Attachment B - Client References Form.xml

Attachment DOC- B: Client References Form Respondent is required to fill out S ection 1 for a minimum of three references to Client s who received services similar to those called out in this RFP and return it with their proposal . Respondent shall then complete S ection 2 for each reference being requested and email the form to the referenced client to complete section 3 . H ave the client return the form directly to the Commonwealth in accordance with the Technical Proposal Evaluation Section of the RFP . The Commonwealth may contact all of the references listed to inquire about Respondent’s services, performance, and degree of Client satisfaction. Full points for references will not be awarded unless S ection s 2 and 3 are returned by email directly from referenced c lients. Section 1. Client References Client #1 : FORMTEXT Address: FORMTEXT Reference Name: FORMTEXT Current Phone: FORMTEXT Client #2 : FORMTEXT Address: FORMTEXT Reference Name: FORMTEXT Current Phone: FORMTEXT Client #3 : FORMTEXT Address: FORMTEXT Reference Name: FORMTEXT Current Phone: FORMTEXT Client #4 : FORMTEXT Address: FORMTEXT Reference Name: FORMTEXT Current Phone: FORMTEXT Client #5 : FORMTEXT Address: FORMTEXT Reference Name: FORMTEXT Current Phone: FORMTEXT Section 2. Client & Contract Information Respondent Name: FORMTEXT Respondent Contact/Name: FORMTEXT Respondent Email: FORMTEXT Respondent Contact Phone: FORMTEXT Client Organization: FORMTEXT Client Contact Name: FORMTEXT Client Email: FORMTEXT Client Phone: FORMTEXT Client Address: FORMTEXT Client Fax: FORMTEXT Contract Dates of Service : FORMTEXT Contract included which of the following services (Check all that apply) : FORMCHECKBOX Adult Correctional Health Care and Mental Health Care Total number of separate institutions served under the contract : FORMTEXT Total number of offenders served under the contract: FORMTEXT Original Value o f Contract: FORMTEXT Current Value of Contract : FORMTEXT Reason(s) for Change in Value: FORMTEXT Section 3. Past Performance Reference Check TO BE COMPLETED BY THE CLIENT REFERENCE Step 1: Please review the information provided by the Respondent of your project in Section 2 of this Offeror Experience Reference Form and validate that the information is or is not correct. If the information is not correct, please indicate (in Section3: Validation of this evaluation form) what is not correct and why. Step 2: Please rate the Respondent ’s performance in the questions below. Circle the number, which corresponds to the performance rating for each category according to the rating scale described below. In addition, comments are appreciated, but will not be scored. Once you have completed the form, please email the response to GalenA.Benassi @ky.gov . A confirmation of receipt will be provided. The Commonwealth of Kentucky appreciates your participation and may contact you regarding the information that you provided. A. Validation of Referenced Project Data Provided by Offeror in Section 2 Please review and validate the information provided by the Respondent in Section 2 above and provide comments to correct or clarify any information provided . Comments from Client Reference FORMTEXT B. Past Performance Reference Please provide a performance rating for each criteria utilizing the rating guidelines below. Please explain ratings of 1, 2, or NA in the Comments section below the table. RATING GUIDELINES Selection Rating 5 Significantly exceeded your expectations. 4 Somewhat exceeded your expectations. 3 Met your expectations. 2 Somewhat below your expectations. 1 Significantly below your expectations. Criteria Rating Not Applicable 1. The Respondent provided sufficient staff resources with appropriate skill sets to meet all service requirements . Choose an item. ☐ 2. The Respondent effectively managed its project staff to achieve all service requirements . Choose an item. ☐ 3. The Respondent met all performance requirements of the contract . Choose an item. ☐ 4. The Respondent met all required standards for service and maintained all accreditations throughout the life of the contract . Choose an item. ☐ 5. The Respondent satisfactorily documented, communicated and addressed identified service issues . Choose an item. ☐ 6. The Respondent worked cooperatively with other contracted service providers to provide comprehensive services . Choose an item. ☐ 7 . The Respondent worked cooperatively with the State to ensure quality services were being provided . Choose an item. ☐ 8 . The Respondent provided timely and accurate reporting to the State. Choose an item. ☐ Comments: For Criteria With Ratings of 1, 2 or N/A: FORMTEXT General Comments: FORMTEXT As a representative of the Client Reference listed above, I approved the responses to the previous statements about the performance of the Respondent identified in Section 2 of this Client Reference Form. Printed Name: FORMTEXT Printed Title: FORMTEXT Signature: Date: FORMTEXT attachment doc-b rfp 26*380 Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. DocumentLibraryForm DocumentLibraryForm DocumentLibraryForm

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REQUEST FOR PROPOSAL dgunders Seger, Tonya R (DOC) 4 2017-08-22T20:12:00Z 2026-03-20T15:14:00Z 2026-04-07T14:12:00Z Normal 4 5 723 4936 Microsoft Office Word 0 41 11 false Title 1 REQUEST FOR PROPOSAL Dts, State of Utah false 5648 false false 16.0000 0x0101002F79A5B7196BC5488593F9CCC1E69EC6 Document