7-HSS-26-007 Emergency Response System - Attachment 6 - Subcontactor Information Form.docx

DOCX document 131 KB Posted

Attached to
Emergency Response Systems State and local contract opportunity
Solicitation number
HSS-26-007
Issued by
Delaware

About this file

This document is a Subcontractor Information Form for Delaware Health and Social Services (DHSS), specifically the Division of Services for Aging and Adults with Physical Disabilities, related to Contract No. HSS-26-007 for Emergency Response Systems. The form is designed to capture detailed information about potential subcontractors who may participate in providing emergency response technology services. The contract appears to be focused on implementing an Electronic Response System (ERS) that enables high-risk participants to quickly secure help during physical, emotional, or environmental emergencies by activating a help button that signals a response center.

The form includes sections for vendor identification, subcontractor details, and certification of business classifications such as Women Business Enterprise, Minority Business Enterprise, Disadvantaged Business Enterprise, and Veteran Owned Business Enterprise. While specific pricing terms are not detailed in this document, the form suggests a comprehensive approach to identifying and qualifying subcontractors who can support the emergency response system's implementation. The underlying contract aims to promote participant safety by providing a technological solution that reduces the need for extensive in-home supervision and allows for rapid emergency response, potentially preventing institutionalization for vulnerable populations.

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Text version

Delaware Health and Social Services

Division of Services for Aging and Adults with Physical Disabilities d

Delaware Health and Social Services

Division of Services for Aging and Adults with Physical Disabilities d

Attachment 6

SUBCONTRACTOR INFORMATION FORM

PART I – STATEMENT BY PROPOSING VENDOR

1. CONTRACT NO. HSS-26-007

TITLE: Emergency Response Systems

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 .