Attachment B - Application Form.pdf
PDF 104 KB Posted
- Attached to
- New York State Vaccine Program Supply
- Solicitation number
- 2138013
- Issued by
- New York
About this file
This is an Application Form attachment related to an Invitation for Bids issued by the New York State Department of Health to procure vaccines for the Children & Adult programs. The Department seeks qualified organizations to supply vaccines to ensure Child Health Plus enrollees, underinsured children, and underinsured and uninsured adults receive appropriate immunizations as specified in the IFB. All vaccines identified on the Current CDC Vaccine Price List must be covered by the awarded contract or contracts. The Department intends to award one or more contracts from this competitive procurement. The deadline for submission of written questions is August 13, 2026, at 5:00 p.m. ET, with responses posted by approximately August 28, 2026. The bid submission deadline is September 10, 2026, at 5:00 p.m. ET, and the anticipated contract start date is April 1, 2027.
No business enterprises have been awarded an identical or substantially similar procurement contract within the past five years. The Department has established no specific contracting goals for Service-Disabled Veteran-Owned Businesses (0.00%), Minority Business Enterprises (0.00%), Women Business Enterprises (0.00%), or Disadvantaged Business Enterprises (0.00%). Additional details regarding pricing terms, technical specifications, insurance requirements, and other bidding conditions are contained within the complete IFB documentation available at https://www.health.ny.gov/funding/ifb/20792/.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment E - Estimated Order Volume by Vaccine Brand.pdf | ||
| Attachment C - Bid Form.xlsx | XLSX spreadsheet | |
| Attachment D - Bid Form Instructions.pdf | ||
| Invitation for Bids.pdf |
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Text version
NEW YORK STATE DEPARTMENT OF HEALTH
Pediatric and Adult Vaccine Purchase
Attachment B – Application Form
1. APPLICANT INFORMATION
Applicant Organization/Agency Name: ___________________________________________
Main Address: ________________________________________________________________
City: ______________________ State: ________________ ZIP code: ____________________
Name and Title of Contact Persons:
Primary Contact: _______________________________________________________
Telephone: (____) ___________________ E-Mail: ____________________________
Secondary Contact: _____________________________________________________
Telephone: (____) ___________________ E-Mail: _____________________________
2. ELIGIBILITY CRITERIA
YES | NO Able to provide one or more vaccine(s) listed on CDC Vaccine Price List at a price(s) not to exceed the current CDC cost per dose at time of order. (https://www.cdc.gov/vaccines-for-children/php/awardees/current-cdc-vaccine-price-list.html)
YES | NO
YES | NO
Capable of providing the annual quantities of pediatric and adult vaccines, by brand, as identified in Attachment E: Estimated Order Volume by Vaccine Brand.
Able to deliver to the McKesson warehouse at:
170 Clermont Rd.
Shepherdsville, KY 40165
YES | NO Able to deliver within fifteen (15) calendar days from the date of order.
YES | NO Able to provide vaccines with a minimum expiration date of twelve (12) months from the date received by New York State at the McKesson warehouse, with the exception of seasonal influenza and COVID-19 vaccines.
YES | NO Able to include the following items on the enclosed packing slip with each delivery:
a. NDC
b. Lot number
c. Batch number
d. Expiration date
e. Number of doses ordered
f. Name of purchaser (New York State)
g. VTrckS PO number submitted with the purchase order
h. Shipment date.
3. STATEMENT OF PROPOSED RATES
□ The Attachment C – Bid Form is complete and included with the submission.
4. APPLICANT ATTESTATION
All information contained herein is true and accurate.
Contract/Legal Designee: ________________________________________________ Date: ______________________ https://www.cdc.gov/vaccines-for-children/php/awardees/current-cdc-vaccine-price-list.html https://www.cdc.gov/vaccines-for-children/php/awardees/current-cdc-vaccine-price-list.html
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