3. Schedule A - Statement of Work - Services & Commodities.docx

Enter your company name Schedule A – Statement of Work Enter your solicitation type and number Respiratory Protection Program This schedule identifies the anticipated requirements of any Contract resulting from this RFP. The term “Contractor” in this document refers to a bidder responding to this RFP, as well as the Contractor who is awarded the contract. The term “bidder” is used to identify where specific responses to the RFP are required. Yellow fields are also used to identify areas where a bidder response is required.

The Contractor must respond to each requirement or question and explain how it will fulfill each requirement. Attach any supplemental information and reference it appropriately within your response.

Background This is a contractual agreement with the State of Michigan, Michigan Veterans’ Facility Authority (MVFA) for a contractor to perform medical evaluation services for the agency’s respiratory protection program for the Michigan Veteran Homes at Chesterfield Township (MVHCT), Michigan Veteran Homes DJ Jacobetti (MVHDJJ), and Michigan Veteran Homes at Grand Rapids (MVHGR). These are CMS certified facilities.

To facilitate best practice standards and the purpose of this contract, the contractor and their employees providing service must comply fully with all state, federal and local laws and regulations as they relate to this contractual agreement.

Michigan Veteran Homes are long-term assisted care facilities operated by the State of Michigan. The MVH provides skilled nursing care to qualified Michigan veterans and their dependents. The MVH is recognized by the United States Department of Veterans Affairs for maximum capacity of 128 nursing care beds at MVHCT and MVHGR. MVHDJJ has a maximum capacity of 126.

Scope The contractor will provide a Michigan licensed medical professional to perform the preliminary medical evaluation screening of new employees at all three Michigan Veteran Homes. Evaluations will be performed during the onboarding process and/or hiring process of each facility, and if any circumstances arise that require a new evaluation. The purpose of this contract is for MVH employees to safely wear respiratory equipment.

The contractor will not provide the resulting respiratory protection fit testing.

Usage from October 1, 2025 through May 31, 2026 at each facility is 0-MVHDJJ, 313-respiratory health questionnaires, 2-pulmonary function testing days for MVHCT and 148-respiratory health questionnaires for MVHGR.

General Requirements The contractor will be required to comply with the Michigan Occupational Safety and Health Administration’s (MIOSHA) General Industry and Construction Safety and Health Standard Part 451. Respiratory Protection (Attachment A).

The contractor will provide state licensed medical professionals, such as physicians, physician assistants or nurse practitioners to perform the evaluations.

The MVH will provide each employee with a medical evaluation questionnaire (Attachment C). If contractor has a secure method of submitting the questionnaire online, please describe or state the preferred method for receiving forms in compliance with HIPAA in the box below.

The contractor will evaluate and look for;

a.) An employee passing the evaluation, and able to proceed to have a fit test performed.

b.) An employee that exhibits a medical condition that would prevent them from safely wearing a respirator i.e. exhibits abnormal breathing or spirometry results.

c.) The contractor will provide recommendations for alternative protection.

List all exception(s):

Bidder must describe how they comply with the above requirement(s):

ADA Compliance The State is required to comply with the Americans with Disabilities Act of 1990 (ADA), including its accessibility standard for websites, applications, content and documents. All Contract Activities created, provided, or made available by Contractor under this Contract in a digital format, including but not limited to, websites, applications, software, mobile applications, text, images, sounds, videos, controls, animations, links, and documents (including files in the following formats: PDF, word processing, presentation, and spreadsheet) must comply with the accessibility standards provided in the Digital Accessibility Standards, located at SOM Digital Standards.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Timeframes All Contract Activities must be delivered within two (2) business days from receipt of order. The receipt of order date is pursuant to the Notices section of the Standard Contract Terms.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Reporting The Contractor may be requested to submit to the Program Managers or Buyer annual usage reports.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Contractor Program Manager The Contractor must appoint one (1) individual specifically assigned to State of Michigan accounts who will respond to State inquiries regarding the Contract Activities, answer questions related to ordering and delivery, etc. (the “Contractor Program Manager”).

The Contractor must notify the Contract Administrator at least five (5) calendar days before removing or assigning a new Contractor Program Manager.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

Program Manager Information:

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Customer Service Number Bidder Response

The Contractor must specify its customer service number for the State to contact the Contractor Program Manager who must be available for calls during the hours of 8:00a.m. – 4:30p.m. Monday through Friday.

Insert customer service number

Disclosure of Subcontractors If the Contractor intends to utilize subcontractors, the Contractor must disclose the following:

The legal business name; address; telephone number; a description of subcontractor’s organization and the services it will provide; and information concerning subcontractor’s ability to provide the Contract Activities.

The relationship of the subcontractor to the Contractor.

Of the total bid, the price of the subcontractor’s work.

Whether the Contractor has a previous working experience with the subcontractor. If yes, provide the details of that previous relationship.

A complete description of the Contract Activities that will be performed or provided by the subcontractor.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Required Subcontractor information. Bidders must complete the table below for each anticipated subcontractor. Copy the table as many times as needed for each subcontractor. Complete the second table with the percentage of work that will be completed by all subcontractors involved.

The legal business name, address, telephone number of the subcontractor(s).

A description of subcontractor’s organization and the services it will provide and information concerning subcontractor’s ability to provide the Contract Activities.

The relationship of the subcontractor to the Bidder.

Is the subcontractor a GDBE?

Whether the Bidder has a previous working experience with the subcontractor.

A complete description of the Contract Activities that will be performed or provided by the subcontractor.

Of the total bid, the price of the subcontractor’s work.

Work performed by subcontractors

Total percentage of work that will be performed by subcontractors: Insert %

Security The Contractor will be subject the following security procedures: Check in at the front lobby to receive a visitor pass by identifying themselves, their company and their purpose for the visit.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Price Term Pricing is firm for the entire length of the Contract.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Authorizing Document The appropriate authorizing document for the Contract will be a Delivery Order (DO).

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Order Verification The Contractor must have internal controls to verify abnormal orders and to ensure that only authorized individuals place orders.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Invoice Requirements All invoices submitted to the State must include: (a) date; (b) delivery order; (c) quantity; (d) description of the Contract Activities; (e) unit price; (f) vendor-generated invoice number and (g) total price.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

Payment Methods The State will make payment for Contract Activities by Electronic Funds Transfer (EFT) in accordance with Public Act 533 of 2004.

Bidder Response

☐ I have reviewed the above requirement(s) and agree with no exceptions.

☐ I have reviewed the above requirement(s) and have noted any exceptions below.

Exceptions: List all exceptions here

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