Attachment 3 - DHHS Interpreter Information Request - Firm.pdf

ATTACHMENT 3

INTERPRETER INFORMATION REQUEST - FIRM

Name:

1. LINGUISTIC ABILITY

In the table below, please list the language(s) and dialect(s) and indicate the level of proficiency the bidder can interpret or translate in language(s). Refer to Attachment 4 – Proficiency Levels. Bidders should also present evidence of proficiency in his/her resume. Bidder can add more lines if necessary.

Language Dialect Interpretation

Level of Proficiency Translation Level of Proficiency

2. ADDITIONAL INFORMATION

Are you willing to work and travel to the following location(s):

DHHS Facility: ______________ DHHS Office: ______________ Client’s Home: ______________

Are you regularly or periodically availability during any of the following timeframes?

After 5 pm on Weekdays: __________ On Weekends: __________ On Holidays: __________

Are you willing to accept Medicaid fund related referrals, subject to the provisions of Service Attachment B? Y / N

3. COUNTIES

In the table below, please indicate with an ‘X’ in the appropriate box any county you are willing to work.

If you are able to work in ALL counties, indicate with an ‘X’ here: _____________

Adams: Cheyenne: Furnas: Johnson: Nuckolls: Sheridan:

Antelope: Clay: Gage: Kearney: Otoe: Sherman:

Arthur: Colfax: Garden: Keith: Pawnee: Sioux:

Banner: Cuming: Garfield: Keya Paha: Perkins: Stanton:

Blaine: Custer: Gosper: Kimball: Phelps: Thayer:

Boone: Dakota: Grant: Knox: Pierce: Thomas:

Box Butte: Dawes: Greeley: Lancaster: Platte: Thurston:

Boyd: Dawson: Hall: Lincoln: Polk: Valley:

Brown: Deuel: Hamilton: Logan: Red Willow: Washington:

Buffalo: Dixon: Harlan: Loup: Richardson: Wayne:

Burt: Dodge: Hayes: Madison: Pock: Webster:

Butler: Douglas: Hitchcock: McPherson: Saline: Wheeler:

Cass: Dundy: Holt: Merrick: Sarpy: York:

Cedar: Fillmore: Hooker: Morrill: Saunders:

Chase: Franklin: Howard: Nance: Scotts Bluff:

Cherry: Frontier: Jefferson: Nemaha: Seward:

4. FIRM IDENTIFICATION AND INFORMATION

The firm should provide the full company or corporate name, address of the company's headquarters, entity organization (corporation, partnership, proprietorship), state in which the bidder is incorporated or otherwise organized to do business, year in which the bidder first organized to do business and whether the name and form of organization has changed since first organized.

5. FINANCIAL STATEMENTS

The bidder should provide financial statements applicable to the firm. If publicly held, the bidder should provide a copy of the corporation's most recent audited financial reports and statements, and the name, address, and telephone number of the fiscally responsible representative of the bidder’s financial or banking organization.

If the bidder is not a publicly held corporation, either the reports and statements required of a publicly held corporation, or a description of the organization, including size, longevity, client base, areas of specialization and expertise, and any other pertinent information, should be submitted in such a manner that proposal evaluators may reasonably formulate a determination about the stability and financial strength of the organization. Additionally, a non-publicly held firm should provide a banking reference.

The bidder must disclose any and all judgments, pending or expected litigation, or other real or potential financial reversals, which might materially affect the viability or stability of the organization, or state that no such condition is known to exist.

The State may elect to use a third party to conduct credit checks as part of the corporate overview evaluation.

6. CHANGE OF OWNERSHIP

If any change in ownership or control of the company is anticipated during the twelve (12) months following the proposal due date, the bidder should describe the circumstances of such change and indicate when the change will likely occur.

Any change of ownership to an awarded vendor(s) will require notification to the State.

7. OFFICE LOCATION

The bidder’s office location responsible for performance pursuant to an award of a contract with the State of Nebraska should be identified.

8. RELATIONSHIPS WITH THE STATE

The bidder should describe any dealings with the State over the previous two (2) years. If the organization, its predecessor, or any Party named in the bidder’s proposal response has contracted with the State, the bidder should identify the contract number(s) and/or any other information available to identify such contract(s). If no such contracts exist, so declare.

9. BIDDER'S EMPLOYEE RELATIONS TO STATE

If any Party named in the bidder's proposal response is or was an employee of the State within the past twelve (12) months, identify the individual(s) by name, State agency with whom employed, job title or position held with the State, and separation date. If no such relationship exists or has existed, so declare.

If any employee of any agency of the State of Nebraska is employed by the bidder or is a Subcontractor to the bidder, as of the due date for proposal submission, identify all such persons by name, position held with the bidder, and position held with the State (including job title and agency). Describe the responsibilities of such persons within the proposing organization. If, after review of this information by the State, it is determined that a conflict of interest exists or may exist, the bidder may be disqualified from further consideration in this proposal. If no such relationship exists, so declare.

10. CONTRACT PERFORMANCE

If the bidder or any proposed Subcontractor has had a contract terminated for default during the past two (2) years, all such instances must be described as required below. Termination for default is defined as a notice to stop performance delivery due to the bidder's non-performance or poor performance, and the issue was either not litigated due to inaction on the part of the bidder or litigated and such litigation determined the bidder to be in default.

It is mandatory that the bidder submit full details of all termination for default experienced during the past two (2) years, including the other Party's name, address, and telephone number. The response to this section must present the bidder’s position on the matter. The State will evaluate the facts and will score the bidder’s proposal accordingly. If no such termination for default has been experienced by the bidder in the past two (2) years, so declare.

If at any time during the past two (2) years, the bidder has had a contract terminated for convenience, non-performance, non-allocation of funds, or any other reason, describe fully all circumstances surrounding such termination, including the name and address of the other contracting Party.

11. SUMMARY OF BIDDER’S CORPORATE EXPERIENCE

The bidder should provide a summary matrix listing the bidder’s previous experience providing translation and/or interpreting services and the language(s) in which it can provide translation and/or interpreting services

a. Contractor and Subcontractor(s) experience should be listed separately. Narrative descriptions submitted for

Subcontractors should be specifically identified as Subcontractor projects.

b. If the work was performed as a Subcontractor, the narrative description should identify the same information as requested for the Contractors above. In addition, Subcontractors should identify what share of contract costs, project responsibilities, and time period were performed as a Subcontractor.

12. SUMMARY OF BIDDER’S PROPOSED PERSONNEL/MANAGEMENT APPROACH

The bidder should present a detailed description of its proposed approach to the management of the project.

The bidder should identify the specific professionals who will work on the State’s project if their company is awarded a contract resulting from this RFQ. The names and titles of the team proposed for assignment to the State project should be identified in full, with a description of the team leadership, interface and support functions, and reporting relationships. The primary work assigned to each person should also be identified.

The bidder should provide resumes for all personnel proposed by the bidder to work on the project. The State will consider the resumes as a key indicator of the bidder’s understanding of the skill mixes required to carry out the requirements of the RFQ in addition to assessing the experience of specific individuals. Resumes should indicate if the individual is a native speaker of any language(s).

Resumes should not be longer than three (3) pages. Resumes should include, at a minimum, academic background and degrees, professional certifications, understanding of the process, and at least three (3) references (name, address, and telephone number) who can attest to the competence and skill level of the individual. Any changes in proposed personnel shall only be implemented after written approval from the State.

13. SUBCONTRACTORS

If the bidder intends to Subcontract any part of its performance hereunder, the bidder should provide:

a. name, address, and telephone number of the Subcontractor(s);

b. specific tasks for each Subcontractor(s);

c. percentage of performance hours intended for each Subcontract; and

d. total percentage of Subcontractor(s) performance hours.