Attachment E CMD LBE Form 2A_1.pdf

PDF 315 KB Posted

Attached to
DPH | Radiology Registry
Solicitation number
SFGOV-0000012046
Issued by
San Francisco County, California

About this file

This is a Contract Monitoring Division (CMD) Attachment 2 form issued by the City and County of San Francisco for Architecture, Engineering, and Professional Services contracts. The form serves as the CMD Contract Participation Form that must be submitted with proposals for the Department of Public Health's Radiology Registry Request for Proposals. The RFP seeks qualified firms to provide professional temporary radiology technologists and radiology support staff to the San Francisco Health Network, including Zuckerberg San Francisco General Hospital & Trauma Center, Laguna Honda Hospital, Jail Health Services, and SFHN Ambulatory Care sites. All referred staff must be credentialed and competent per the Scope of Work requirements. The proposal deadline is September 16, 2026 at 2:00 PM PT, with the deadline for questions set for September 8, 2026, and an estimated Q&A addendum posting on September 11, 2026. The estimated contract start date is January 1, 2027, with an estimated award announcement in October 2026 and Health Commission presentation in December 2026.

The form requires proposers, joint venture partners, subconsultants, vendors, and lower sub-tier entities to document their participation and identify their Local Business Enterprise (LBE) status across multiple categories including Micro, Small, and SBA-LBE classifications. Specific LBE sub-participation requirements must be met, with the RFP/RFQ identifying which LBE size categories apply. The form includes rating bonus options ranging from 2% to 10% for qualifying LBE participants, joint ventures, and neighborhood/zip code LBE programs for contracts estimated between $400,000 and $10,000,000. Proposers must declare under penalty of perjury the accuracy of consultant utilization and work portions listed, and all LBE firm vendor numbers must be verified through the CMD LBE website at http://www.sfgov.org/cmd.

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Other files

File Type Posted
Attachment G HCAO Declaration Form_1.pdf PDF
Attachment A Contact Information Cover Sheet.docx DOCX document
Attachment M City's Contract Terms_1.pdf PDF
Attachment H First Source.docx DOCX document
Attachment B Non-Collusion Affidavit Form_1.docx DOCX document
Attachment C Reference Form_1.docx DOCX document
DPH___Radiology_Registry.xml XML file
Attachment D 12L Compliance_1.docx DOCX document
Attachment D 12L Compliance.docx DOCX document
RFP_12046_Radiology_Registry.pdf PDF
Attachment B Non-Collusion Affidavit Form.docx DOCX document
Attachment E CMD LBE Form 2A.pdf PDF
Attachment F MCO Declaration Form.pdf PDF
Attachment I Cost Proposal Form_1.xlsx XLSX spreadsheet
Attachment I Cost Proposal Form.xlsx XLSX spreadsheet
Attachment C Reference Form.docx DOCX document
Attachment M City's Contract Terms.pdf PDF
Attachment F MCO Declaration Form_1.pdf PDF
Attachment N Performance Improvement Plan and Performance Measure Grid.pdf PDF
Attachment A Contact Information Cover Sheet_1.docx DOCX document
Attachment N Performance Improvement Plan and Performance Measure Grid_1.pdf PDF
Attachment H First Source_1.docx DOCX document
DPH___Radiology_Registry.pdf PDF
Attachment G HCAO Declaration Form.pdf PDF
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Text version

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11/01/2025

CITY AND COUNTY OF SAN FRANCISCO

CONTRACT MONITORING DIVISION

CHAPTER 14B

CMD ATTACHMENT 2

Architecture, Engineering, and Professional Services

FORM 2A: CMD CONTRACT PARTICIPATION FORM

Section 1: This form must be submitted with the proposal or the proposal may be deemed non-responsive and rejected. Proposer, each Joint Venture partner, Subconsultants, Vendors, and lower sub tiers must be listed on this form. The RFP/RFQ will state which LBE size category (e.g., Micro, Small, and/or SBA-LBE) can be used to meet the LBE sub participation requirement(s). All LBE Proposers/JVs with LBE participation must meet the LBE sub participation requirement(s). Any LBE Proposer/JV with LBE participation may not count its participation towards meeting the LBE sub participation requirement(s). Be sure to check the appropriate box for Rating Bonus under Section 2. If more space is needed for Section 1, attach additional copies of this form.

*Type: Identify if Prime (P), JV partner (J), Subconsultant (S), or Vendor (V)

TY

PE

Firm

Portion of Work

(Describe Scope(s) of

Work)

% of Work

Indicate LBE or Non-LBE. If LBE, Micro, Small, or

SBA.

% of LBE Subwork (Carry-Over from % OF

Work Column)

Micro Small SBA

Total % of Work: 100% Total LBE Sub Participation: % % %

I declare, under penalty of perjury under the laws of the State of California, that I am utilizing the above Consultants for the portions of work and amounts as reflected in the proposal for this Contract.

Owner/Authorized Representative (Signature): _____________________ Date: _________________________

Print Name and Title: _____________________________________________________________________________

** See CMD website: http://www.sfgov.org/cmd for each firm’s status

Contract No.:

Contract Title: LBE SUBPARTICIPATION REQUIREMENT(S)

Firm: Micro and Small-LBE Sub Requirement – ___%

Contact Person: Micro, Small, SBA-LBE Sub Requirement – ___%

Address: Micro-LBE Sub Requirement - ___%

City/ZIP: Small-LBE Sub Requirement – ___%

Phone, Email: SBA-LBE Sub Requirement – ___%

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Section 2. Rating Bonus

Check applicable boxes.

A. NO Rating Bonus Requested 0%

B. Contracts with an Estimated Cost in Excess of $400,000 and Less Than or Equal to $10,000,000. See instructions in Sections 2.01 and 2.02.

Micro or Small-LBE 10%

Joint Venture 7.5%

Joint Venture 5%

Joint Venture (Micro or Small-LBEs only) 10%

SBA-LBE 5%

C. Contracts with an Estimated Cost in Excess of the Delegated Purchasing Amount ($20,000 as of July 1, 2024) and Less Than or Equal to $10,000,000. The below rating bonuses DO NOT apply to Chapter 21 contracts and only apply to Chapter 6 contracts, including Chapter 6.40. See instructions in Section

2.01 for details. This Neighborhood/Zip Code LBE Program shall apply to projects located within the jurisdictional boundary of San Francisco. The program shall not apply to Job Order Contracts (JOC), As- Needed contracts, or other contracts where no specific project location is specified at the time of proposal. The RFP/RFQ will clearly state whether the Pilot Neighborhood/Zip Code LBE Program is applicable to the specific project. A Proposer may receive up to a maximum rating bonus of 13% depending on the particular application.

Prime Neighborhood/Zip Code LBE rating bonus:

Prime Neighborhood LBE (or a JV where the Neighborhood LBE JV partner(s)’ participation is at least 40%) 1%

OR

Prime Zip Code LBE (or a JV where the Prime Zip Code LBE JV partner(s)’ participation is at least 40%) 1.5%

Subconsulting Neighborhood/Zip Code LBE rating bonus:

Sub Neighborhood LBE 0.5%

OR

Sub Zip Code LBE 1.5%

D. Contracts in Excess of $10,000,000 and Less Than or Equal to $20,000,000. See instructions in Section 2.01.

Micro, Small, or SBA-LBE 2%

E. Mentor-Protégé Program Bid Discount/Rating Bonus. The Mentor Protégé rating bonus is not applicable to professional services contracts. However, for this CMD Attachment 2, the Mentor Protégé rating bonus/bid discount is applicable for Design-Build and/or CM/GC projects only. See instructions in Section 2.01.

Mentors of the Mentor-Protégé Program 1%

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Section 3. Proposer, Joint Venture Partners, Subconsultant, and Vendor Information

Provide information for each firm listed in Section 1 of this form. Firms which have previously worked on City contracts may already have a vendor number. Vendor numbers of LBE firms are located on the CMD LBE website at http://www.sfgov.org/cmd. Use additional sheets if necessary.

FIRM NAME: VENDOR #:

ADDRESS: FEDERAL ID #:

CITY, ST, ZIP: PHONE: EMAIL:

SERVICE:

Contract No:
Contract Title:
Firm:
Contact Person:
Address:
CityZIP:
Phone Email:
Micro and SmallLBE Sub Requirement: Off
Text30:
Micro Small SBALBE Sub Requirement: Off
Text31:
MicroLBE Sub Requirement: Off
Text32:
SmallLBE Sub Requirement: Off
Text33:
SBALBE Sub Requirement: Off
Text34:
Text201:
FirmRow1:
Portion of Work Describe Scopes of WorkRow1:
Text205:
Indicate LBE or NonLBE If LBE identify MBE WBE or OBE AND Micro Small or SBA:
Text35:
Text39:
Text45:
Text202:
FirmRow2:
Portion of Work Describe Scopes of WorkRow2:
Text206:
Indicate LBE or NonLBE If LBE identify MBE WBE or OBE AND Micro Small or SBA_2:
Text36:
Text40:
Text46:
Text203:
FirmRow3:
Portion of Work Describe Scopes of WorkRow3:
Text207:
Indicate LBE or NonLBE If LBE identify MBE WBE or OBE AND Micro Small or SBA_3:
Text37:
Text41:
Text47:
Text204:
FirmRow4:
Portion of Work Describe Scopes of WorkRow4:
Text208:
Indicate LBE or NonLBE If LBE identify MBE WBE or OBE AND Micro Small or SBA_4:
Text38:
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Text1:
Date:
Print Name and Title:
NO Rating Bonus Requested 0: Off
Micro or SmallLBE 10: Off
Joint Venture 75: Off
Joint Venture 5: Off
Joint Venture Micro or SmallLBEs only 10: Off
SBALBE 5: Off
Prime Neighborhood LBE or a JV where the Neighborhood LBE JV partners participation is at: Off
Prime Zip Code LBE or a JV where the Prime Zip Code LBE JV partners participation is at least: Off
Sub Neighborhood LBE 05: Off
Sub Zip Code LBE 15: Off
Micro Small or SBALBE 2: Off
Mentors of the MentorProtégé Program 1: Off
FIRM NAME:
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ADDRESS:
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FIRM NAME_2:
Text56:
ADDRESS_2:
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FIRM NAME_3:
Text59:
ADDRESS_3:
Text60:
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FIRM NAME_4:
Text62:
ADDRESS_4:
Text63:
Text73:
Text78:
Text64:
Text83:
FIRM NAME_5:
Text65:
ADDRESS_5:
Text66:
Text74:
Text79:
Text67:
Text84:
FIRM NAME_6:
Text68:
ADDRESS_6:
Text69:
Text75:
Text80:
Text70:
Text85:

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