3-HSS-26-026 Drug Court Diversion Services - Attachment 6 - Subcontractor Information Form.docx

DOCX document 126 KB Posted

Attached to
Syringe Services Program
Solicitation number
HSS-26-026
Issued by
Delaware

About this file

This document is a Subcontractor Information Form for the Delaware Health and Social Services (DHSS) Division of Substance Abuse and Mental Health, specifically for Contract No. HSS-26-026. The form is designed to capture detailed information about potential subcontractors, including their business classification status (such as Women Business Enterprise, Minority Business Enterprise, Disadvantaged Business Enterprise, and Veteran Owned Business Enterprise). The form requires vendors to provide comprehensive details about subcontractors, including their name, mailing address, description of work, and authorized signatory information.

The form is part of a broader solicitation for Syringe Services Program, which aims to provide harm reduction programming for people who use drugs (PWUD) and injection drug users (IDU). The context suggests this is part of Delaware's public health strategy to address HIV/AIDS, which affected 3,786 people in the state as of 2021. The document provides a template for vendors to disclose subcontractor information, emphasizing transparency and potentially promoting diversity and inclusion through the various business enterprise classifications that can be noted on the form.

View the file

Other files

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file

Text version

Delaware Health and Social Services

Division of Substance Abuse and Mental Health d

Delaware Health and Social Services

Division of Substance Abuse and Mental Health d

Attachment 6

SUBCONTRACTOR INFORMATION FORM

PART I – STATEMENT BY PROPOSING VENDOR

1. CONTRACT NO.

HSS-26-026

2. Proposing Vendor Name:

3. Mailing Address

4. SUBCONTRACTOR

a. NAME

4c. Company OSD Classification:

Certification Number: _____________________

b. Mailing Address:

4d. Women Business Enterprise |_| Yes |_| No 4e. Minority Business Enterprise |_| Yes |_| No 4f. Disadvantaged Business Enterprise |_| Yes |_| No 4g. Veteran Owned Business Enterprise |_| Yes |_| No 4h. Service Disabled Veteran Owned Business Enterprise |_| Yes |_| No

5. DESCRIPTION OF WORK BY SUBCONTRACTOR

6a. NAME OF PERSON SIGNING

7. BY (Signature)
8. DATE SIGNED

6b. TITLE OF PERSON SIGNING

PART II – ACKNOWLEDGEMENT BY SUBCONTRACTOR

9a. NAME OF PERSON SIGNING

10. BY (Signature)
11. DATE SIGNED

9b. TITLE OF PERSON SIGNING

* Use a separate form for each subcontractor image1.png image2.png

File details come from the government source that posted it. Updated .