8-DHHS26105 Attachment F Past Perfomance.docx
DOCX document 19 KB Posted
- Attached to
- Residential Treatment Services
- Solicitation number
- DHHS26105
- Issued by
- Utah
About this file
This is a Past Performance Minimum Requirements Form for the Utah Department of Health and Human Services (DHHS) contract opportunity DHHS26105 regarding Residential Treatment Services for persons with serious emotional or behavioral disorders. The form establishes mandatory eligibility criteria that offerors must satisfy to be considered responsible and proceed in the competitive evaluation process. Offerors must disclose any DHHS or equivalent licenses in other states that have been suspended, revoked, or denied for health or safety reasons within the past five years, as well as any State of Utah contracts terminated for cause due to health or safety reasons during the same period. Additionally, offerors must report any moratorium placements by DHHS for health or safety reasons. The form requires offerors to list all relevant licenses and contracts with issuing entities, states, license types, license numbers, and effective dates.
Offerors who affirmatively answer "yes" to any of the three minimum requirements questions—regarding license actions, contract terminations for cause, or contract terminations resulting from health or safety moratoriums within the past five years—will be determined non-responsible and eliminated from further consideration. The evaluator will verify all offeror responses through issuing entities, contracting agencies, and DHHS monitoring records. A signed attestation with printed name and title is required, with the form containing space for documentation on additional sheets if necessary to list multiple licenses or contracts.
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Other files
| File | Type | Posted |
|---|---|---|
| 5-DHHS26105 Attachment A DHHS Client Service Terms.docx | DOCX document | |
| 6-DHHS26105 Attachment B Scope of Work.docx | DOCX document | |
| 9-DHHS26105 Attachment D Facility Service Selection Template 6.26.docx | DOCX document | |
| 12-DHHS26105 RFP Template Residential 6 2026.docx | DOCX document | |
| 2-DHHS26105 Form 3 Conflict of Interest Disclosure Statement.pdf | ||
| 4-DHHS26105 Form 1 - DHHS Data Sheet.pdf | ||
| 13-DHHS26105 Score Sheet.xlsx | XLSX spreadsheet | |
| 11-DHHS26105 Document Submission Checklist.pdf | ||
| 7-DHHS26105 Attachment E Facility Org Chart.docx | DOCX document | |
| 1-DHHS26105 Attachment C Established Rates for Residential Treatment Services 2026.docx | DOCX document | |
| 3-DHHS26105 Form 2 W-9 Form.pdf | ||
| 10-DHHS26105 Attachment G Medicaid Services Attachment.docx | DOCX document |
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Text version
ATTACHMENT F
PAST PERFORMANCE MINIMUM REQUIREMENTS FORM DHHS26105
1. Within the past 5 years, has the Offeror had any DHHS/OL licenses, or equivalent licenses in another state suspended, revoked, or denied for health or safety reasons?
· Yes, there have been licenses, including facility licenses that have been suspended, revoked, denied for health or safety reasons within the past 5 years.
· No, continue completing list of licenses below.
Evaluator will verify Offeror’s answer through the issuing entity. Offerors who have had a license suspended, revoked, or denied for health or safety issues within the past 5 years will be determined non-responsible and will be eliminated from further consideration.
List all DHHS/OL licenses, or equivalent licenses in another state issued to the Offeror within the past 5 years (attach additional sheet if necessary):
| Issuing Entity and State |
| Type of License |
| License Number |
| Effective Dates |
2. Within the past 5 years, has the Offeror had any State of Utah contract terminated for cause due to health or safety reasons?
· Yes, the Offeror has had contracts with the State of Utah terminated for cause due to health or safety reasons within the past 5 years.
· No, continue completing list of contracts below.
Evaluator will verify Offeror’s answer through the contracting agency. Offerors who have had a contract with the State of Utah terminated for cause due to health or safety reasons within the past 5 years will be determined non-responsible and will be eliminated from further consideration.
List all contracts the Offeror has had with the State of Utah within the past 5 years (attach additional sheet if necessary):
| Contracting Agency |
| Contract Number |
| Effective Dates |
ATTACHMENT F
PAST PERFORMANCE MINIMUM REQUIREMENTS FORM DHHS26105
3. Within the past 5 years, has the Offeror been placed on a moratorium by DHHS for health or safety reasons?
· Yes, and the Offeror’s contract was terminated.
· Yes, but the moratorium was resolved so that the Offeror could continue contracting OR the moratorium has not yet been resolved.
· No.
Evaluator will verify Offeror’s answer through DHHS monitoring records. Offerors who have had a moratorium for health or safety reasons resulting in a contract termination, within the past 5 years, will be determined non- responsible and will be eliminated from further consideration.
REQUIRED SIGNATURE:
| Signature: |
| Date: |
Print Name and Title:
File details come from the government source that posted it. Updated .