Attachment I_Application Requirements & Application Form.docx

ATTACHMENT I: APPLICATION REQUIREMENTS & APPLICATION FORM

REQUIRED – MUST SUBMIT THESE ITEMS WITH APPLICATION

INSTRUCTIONS:

The Bidder must follow the detailed instructions below and submit the Application electronically using the UMass BuyWays Portal.

The Bidder must respond to each item below in the order in which it appears in the RFA and shall use headings and numbering to match the corresponding section from the RFA.

Using the UMass BuyWays Portal, the Bidder must submit certain required forms, as well as a PDF version of its Application Form – as further described below. If you have attachments or supplementary materials, you must consolidate the material into one file and include it at the end of your Application Form.

Please submit the following information with your Application:

A. PREREQUISITES / FORMS. Complete and submit each form below as instructed on UMass BuyWays Portal:

· Consent Declaration

· Supplier Record Authorization

· Certification of Non-Collusion (Attachment D)

· Proposer Representation Form (Attachment F)

B. APPLICATION FORM. Complete and submit the Application Form that begins on the next page, and any supplementary materials, as one PDF file labeled as Attachment I (B):

Attachment I (B): Application Form

Bidders should refer to the instructions above in Attachment I when completing this Application Form. For more information about the general process for submitting Applications, please refer to Attachment G, Section 3(F): Application Process.

The Bidder’s Application Form must indicate the specific job position(s) for which the Bidder is applying and able to provide. A Bidder selected as a Qualified Consultant is eligible to be offered services pursuant to this RFA for only those positions listed on its Application Form, unless the Qualified Consultant informs UMass Chan that there have been substantive changes to its qualifications, and such changes are reviewed and approved by UMass Chan.

1. BIDDER INFORMATION: Note: To be eligible to apply, the Bidder must be an individual (i.e., sole proprietor serving as an independent consultant) or Small Consulting Firm with ten (10) or fewer employees as defined in Attachment G, Section 3 (A).

Indicate whether you, the Bidder, are applying as an individual sole proprietor or a Small Consulting Firm, and provide full legal name:

|_| Individual Sole Proprietor; and my full legal name is: .

or

|_| Small Consulting Firm; and the firm’s full legal name is: ; and the name and title of the individual completing this Application is: .

[Name and Title]

Address(es):

Website (if any):

Business Phone:

Other Phone:

Email Address:

I.D. No. from Corporations Division of the Massachusetts Secretary of State, if applicable:

Approximately how many years has Bidder’s organization been in operation? _______ years.

2. ADDITIONAL CONTACT PERSON(S): This section is only required for Small Consulting Firms.

CONTACT #1

Name:

Title:

Address:

Phone:

Email Address:

CONTACT #2

Name:

Title:

Address:

Phone:

Email Address:

3. BIDDER’S HISTORY AND EXPERIENCE

(A) How many years has Bidder been in the business of providing consulting services?

YEARS

(B) Does the Bidder have any relevant experience working with state or federal government entities, with specific knowledge of the Medicaid program?

NO: YES:

(C) Describe Bidders’ clients for whom it has provided consulting services by checking-off the applicable fields below.

· Industry (e.g., public, higher education, financial services, insurance, health care):

_______ Higher Education

_______ Insurance Company

_______ Other (please list below)

Other:

· Size of Client Organizations (check all applicable):

4. POSITIONS AND EXPERTISE EXPECTED (CHECK ALL THAT APPLY): The Bidder must indicate whether it is submitting an Application to this RFA in order to be deemed eligible to provide services as an Executive Advisor, Project Manager, Project Coordinator, and/or General Consultant. The Bidder may apply for multiple positions listed below, however, the Bidder must meet the requirements and qualifications for each specific position to which the Bidder is applying as outlined in Attachment H: Positions Available Under the RFA.

5. For each of the positions checked-off in QUESTION # 4 above, describe how your education, experience, skill set, and background sufficiently meet the Required Skills/Qualifications for each separate position. Closely review Attachment H: Positions Available Under the RFA before responding. Do not include the same response for each position. Indicate “N/A” in the box below if you are not applying for a certain position.

Please limit each response to 250 words.

Executive Advisor:

Project Manager:

Project Coordinator:

General Consultant:

6. HOURLY RATES: The Bidder shall complete the following table by providing hourly rates for each of the positions for which the Bidder is applying. These rates shall apply to the full period of the anticipated term of the MSA resulting from this RFA. In any MSA or SOW resulting from this RFA, the selected Qualified Consultant shall be bound by the terms in this Section 6 of its Application, and the rates shall not exceed those included in the table below. UMass Chan reserves the right to negotiate a different rate than that proposed by the Bidder, including but not limited to a deliverable-based rate specific to the Statement of Work if the project permits.

Indicate “N/A” where necessary.

7. SPECIALTY(IES) & AREAS OF EXPERTISE (CHECK ALL THAT APPLY). Note: You will be asked to respond to specific questions, based on selected areas below:

|_| Information Technology (IT): Strategy, operations, solution design, deployment

|_| Business/Product Development: Life cycle management, business strategy, market and competitor analysis

|_| Policy: Analysis, formation, and implementation

|_| Data Analytics & Visualization

|_| Strategic Operations & Process Improvement

|_| Population Health Program Design & Administration

|_| Evaluation & Study Design: Statistical, econometric, epidemiological methods

|_| Survey Design, Sampling, Data Analysis

|_| Data Science: Transcription & Translation Services

|_| Cost & Budget Analysis

|_| Continuous Improvement: Lean Six Sigma Black Belt methodology

|_| Project Management & Program Development

|_| Federal Contracting & Acquisitions

|_| Justice Reform and Systems Alignment

|_| Social Security Regulations

8. For each specific area of subject matter expertise checked-off in QUESTION # 7 above please describe how your experience, skill set, and background demonstrates proficiency and qualifications in each area identified. Closely review Attachment H: Positions Available Under the RFA before responding. Do not include the same response for each area of subject matter expertise.

Please limit each response to 250 words and include additional text boxes if applying for more than one area.

9. RESUME: The Bidder must submit a current resume by attaching it to the end of this Application Form. For individuals, please submit a copy of your resume. For Small Consulting Firms with multiple staff, please submit a resume for each proposed individual (the firm may only propose up to five (5) individuals for consideration).

· Total Number of Resumes Included:

· List the Names of all Individuals for whom a Resume is Attached:

10. REFERENCES: Please provide three (3) professional or client references from individuals familiar with your work that is related to the scope of services described in this RFA. Each field in the box below is mandatory. If possible, please provide references from three separate organizations.

UMass Chan reserves the right to contact any or all of the Bidder’s references. UMass Chan may independently contact the Bidder’s references without giving prior notice to the Bidder. UMass Chan expects references to respond to inquiries within ten (10) business days from the date of initial contact with the reference. UMass Chan’s inability to contact the Bidder’s references in a timely manner, as noted above, may disqualify the Bidder.

REFERENCE #1

· Reference’s Organizational Name:

· Organizational Address and/or Website:

· Contact Person’s Name and Title:

· Contact Person’s Telephone Number:

· Contact Person’s Email Address:

· Brief Description of Services You Provided:

REFERENCE #2

· Reference’s Organizational Name:

· Organizational Address and/or Website:

· Contact Person’s Name and Title:

· Contact Person’s Telephone Number:

REFERENCE #3

· Reference’s Organizational Name:

· Organizational Address and/or Website:

· Contact Person’s Name and Title:

· Contact Person’s Telephone Number:

11. INSURANCE: Note, the insurance requirements in the MSA will vary depending on the needs and/or requests of UMass Chan and will be determined at the time that any MSA or Statement of Work is offered. For reference, the potential insurance requirements are included in the MSA – see Attachment A, Exhibit 1, Section 6.

Bidders shall complete the table below by indicating the types and amounts of insurance coverage maintained by the Bidder, if any.

Other:

No Insurance:

12. PROPOSER REPRESENTATION FORM: In addition to this Application Form, the Bidder shall complete and submit Attachment F: Proposer Representation Form. By submitting this Application, the Bidder acknowledges this requirement and confirms the Proposer Representation Form has been submitted through the UMass BuyWays Portal.

13. CONFLICT OF INTEREST DISCLOSURE: Upon consideration by UMass Chan to perform a specific project pursuant to this RFA, Bidder shall represent that it is aware of no known actual or perceived conflicts of interest, or any other fact, circumstance or condition that would delay or interfere with its ability to perform the project. Bidders should review the Commonwealth of Massachusetts’s Summary of Conflict of Interest law by visiting the Ethics Commission Website at: https://www.mass.gov/orgs/state-ethics-commission.

Upon consideration by UMass Chan to perform a specific project pursuant to this RFA, the Bidder agrees to:

· Avoid any actual or perceived conflict of interest with the work to be performed under the MSA; and

· Immediately disclose to UMass Chan any actual or perceived conflict of interest that may arise as a result of its involvement in performing the work under the MSA.

14. THIRD PARTY PRIVACY QUESTIONNAIRE: The Bidder shall complete and submit Attachment E: Third Party Privacy Questionnaire. As stated in the instructions, the Bidder must include the attachment at the end of its Application Form and submit it as one consolidated PDF file. By submitting this Application, the Bidder acknowledges this requirement and confirms the Third Party Privacy Questionnaire has been submitted through the UMass BuyWays Portal.

15. DISCLOSURES: The Bidder must disclose any and all significant judgments; pending or expected litigation; investigations, proceedings, arbitration or settlements involving the Bidder; or other real potential financial reversals relative to the Bidder’s organization’s revenue, which might materially affect the viability, stability, or financial standing of the Bidder’s organization; or the Bidder must certify under penalties of perjury that no such condition is known to exist. Details of settlements that are prevented from disclosure by the terms of the settlement may be annotated as such.

Bidder shall check-off the applicable statement below:

No such condition is known to exist:

or Such conditions are known to exist and Bidder has attached a description of such condition(s):

16. SUPPORTING DOCUMENTATION: Although not required, Bidder may provide any supporting documentation that the Bidder believes would be relevant to demonstrating its ability to perform any of the services referenced in Attachment H: Positions Available Under the RFA. Bidders are asked to be brief and concise in responding to this section. If the Bidder submits attachments or supplemental information with its Application, such information shall be submitted at the end of the Application and be clearly labeled as an Appendix.

Bidder shall check-off the applicable statement below:

Supporting Documentation NOT Included:

or Supporting Documentation Included:

17. AGREEMENT TO TERMS & CONDITIONS: By submitting this Application and signing below, the Bidder accepts all terms and conditions of the Master Services Agreement, including the Business Associate Agreement and Nondisclosure Agreement, found in Attachment A, Exhibits 1-3 of this RFA. An electronic signature is acceptable, otherwise the Bidder may print, sign, and scan this signature page for inclusion in its Application.

UMass Chan reserves the right to reject any Application that takes exception to any terms and conditions of the Master Services Agreement.

Signature

Date

Name AND Title

Bidder’s Organization Name, if applicable image1.png