Attachment 2.pdf

ATTACHMENT 2

SUBMISSION CHECKLIST

Solicitation of Interest (SOI) 1147 Dialectical Behavior Therapy

Applicant: __________________________________________________________________

Please indicate whether the following statements described in the solicitation apply to your organization:

Yes

No*

The applicant agrees to provide the services requested in the Scope of Work section of the SOI announcement document.

Yes

No*

The applicant attests that at least four consultants have completed adherent DBT training to include DBT intensives and advanced training in DBT and possess a minimum of three years of follow-up training.

Yes

No*

The applicant provided a narrative (Attachment 1 – Letter of Interest) describing a brief plan to meet the program requirements/deliverables noted in the Scope of Work section of the SOI.

Yes

No*

The applicant included a brief narrative (Attachment 1 – Letter of Interest) identifying the organization’s 5+ years of experience providing DBT implementation, consultation, and training to staff in juvenile justice facilities for court-adjudicated youth.

Yes

No*

The applicant is eligible to do business with New York State.

Yes

No

The applicant certifies under penalty of perjury that, by submission of this proposal, each proposer and each person signing on behalf of any proposer, and in the case of a joint proposal each party thereto as to its own organization, has and has implemented a written policy addressing sexual harassment prevention in the workplace and provides annual sexual harassment prevention training to all of its employees, and that such policy does, at a minimum, meet the requirements of section two hundred one-g of the labor law? Please note that a proposal will not be considered for award nor will any award be made to a proposer who is not able to make this certification in compliance with State Finance Law section 139-l; provided, however, that if the proposer cannot make the foregoing certification, such proposer shall so state and shall furnish with the proposal a signed statement which sets forth in detail the reasons therein.

Yes

No*

The applicant certifies under penalty of perjury that they are not a Russian entity or Russia supporting entity as those terms are defined in Executive Order No. 14 dated February 27, 2022?

Yes

No*

The applicant certifies under penalty of perjury that your organization is not conducting business operations in Russia, as those terms are defined in Executive Order No. 16 dated March 17, 2022?

Yes

No*

The applicant certifies that no organization staff members that would provide these services are currently or have ever been a NYS agency employee OR the applicant has disclosed this information. If applicable, the applicant has included with their submission a signed statement with the NYS employee name(s) and the NYS agency(ies) they work for or previously worked for.

* A response of “no” to any question marked with an asterisk will disqualify the applicant.

ATTACHMENT 2

SUBMISSION CHECKLIST

Submit the following completed documents prior to the deadline via email to RFP@ocfs.ny.gov:

□ Attachment 1 – Letter of Interest

□ Attachment 2 – Submission Checklist

□ Resumes for at least four consultants who have completed adherent DBT training to include

DBT intensives and advanced training in DBT and possess a minimum of three years of follow-up training.

By signing below, I attest that I have express authority to sign these statements on behalf of the applicant and am authorized by law to bind the applicant contractually.

Print Name: __________________________________________________________________

Signature: __________________________________________________________________

Title: __________________________________________________________________

Organization: __________________________________________________________________

Address: __________________________________________________________________

Email: _______________________ Phone: _________________________

FEIN/TIN: _______________________ Date: _________________________

SFS Vendor ID (if applicable): _____________________________________________________

Please indicate the name and email address of an additional contact person below:

mailto:RFP@ocfs.ny.gov