Attachment A Application Form.docx

Request for Responses for COVID-19 Isolation and Recovery Site (I&R) Services Attachment A: Application Form

Organizational Overview

Organization Legal Name:

Trade name(s) and any other name(s) under which the Organization does, or has done, business: [ ]

Principal Address:

City: [ ] State: [ ] Zip: [ ]

Telephone: ( ) - FAX: ( ) - URL: [ ]

FEIN: [ ]

MMARS Vendor Customer (VC) Code (if known): [ ]

Type of legal entity (e.g., corporation, limited partnership, nonprofit corporation, etc.): [ ]

Contact Person

Include the following information for the individual who should be contacted for purposes of discussing any aspect of this completed response form submitted by the Respondent:

First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - Email: [ ]

Programmatic Response

Organizational Overview Provide a brief overview of your organization and each of your proposed Subcontractors to include:

a. Formation date, goals and mission.

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b. Current service areas and main funding sources.

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c. Experience collaborating with EOHHS, DPH, DHCD, homeless service providers, healthcare entities community-based organizations, and behavioral health services providers.

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d. If your proposal includes staffing or shelter services, experience providing services to homeless individuals and/or families.

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e. If your proposal includes staffing or shelter services, experience providing services to persons that have tested positive for COVID-19.

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Proposed Programmatic Capacity

1. Please select which service(s) below your organization is proposing to provide to support isolation and recovery need?

☐ Non-congregate or congregate shelter ☐ Staffing support ☐ Management services (i.e., transportation, referral management, linens, food services etc.)

1.1 If yes to “non-congregate or congregate shelter”, please describe:

a. The location of your proposed program.

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b. Description and overview of the physical layout and floor plan.

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c. The minimum and maximum number of beds your site is able to accommodate.

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d. The timeline and costs for operationalizing the proposed I&R location(s) to serve COVID-positive individuals and/or families (if proposing to provide a facility but not staffing support, “operationalizing” means making the I&R location(s) available to serve as a shelter).

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1.2 If yes to “staffing support”, please:

a. Describe the specific services you are proposing to offer, including without limitation client-facing staff, behavioral health providers, recovery support, and medical staffing. For client-facing staff, please be specific as to the skill set that staff would be expected to have and the services they would be expected to perform.

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b. Complete Attachment B to explain your proposed staffing plan and costs, including the staffing ratios per given number of clients and proposed rates per staff member.

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c. The catchment area that your proposed staffing is able to serve.

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d. In the event of a surge in cases, your ability to scale up staffing, what your costs would be to do so, and timeline for scaling staffing to increased demand. Please be specific as to how long it would take to scale up a given number of staff to accommodate a given number of COVID-positive individuals and/or families.

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e. Your organization’s timeline for operationalizing staffing.

1. If submitting a staffing proposal that is not tied to a specific, identified I&R location(s), clearly describe the minimum number of staff you could provide within specified periods of time ranging from one week to one month and the manner in which staff would be connected with and on-boarded at the location(s) to render services.

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2. If submitting a staffing proposal that is tied to a specific, identified I&R location(s), please show proposed staffing for the minimum and maximum number of beds that the location(s) would be able to accommodate.

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1.3 If yes to “I&R management services”, please describe:

a. The specific services that your organization is proposing to offer.

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b. If offering to provide referral management services, your proposed processes for triaging and assessing potential patient referrals.

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c. The minimum and maximum number of individuals and/or families you are able to serve.

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d. A breakdown of the proposed costs for each specific management service offered.

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