Attachment_II_-_Forms_A-D.xlsx

XLSX spreadsheet 44 KB Posted May 4, 2026

Attached to: Rapid Antiretroviral Therapy (ART) Protocol
Solicitation number: 042-3068503-KL
Issued by: Orange County, San Francisco City, California

About this file

Written by GovTribe AI · Jun 25, 2026

This is an application preparation checklist and supporting forms document for Orange County, California's Health Care Agency Request for Applications (RFA) No. 042-1673278-KL for Rapid Antiretroviral Therapy (ART) Protocol Development and Routine Opt-Out Testing Services. The RFA, released May 20, 2024, seeks applications from licensed hospital emergency departments to develop practical, evidence-based protocols for initiating antiretroviral therapy within seven days of HIV diagnosis, disclosure, or re-engagement in care. The solicitation focuses on protocol development and implementation planning rather than direct clinical service delivery, with the goal of improving linkage to HIV care in emergency settings and reducing treatment delays. Selected applicants will collaborate with the Health Care Agency to design patient-centered procedures integrated into existing clinical operations.

The application materials include four required forms: Form A (Application Preparation Checklist), Form B (Agency Description), Form C (Applicant Certifications), and Form D (Board of Directors). Applicants must provide comprehensive documentation including articles of incorporation or state licensing, bylaws, board resolutions, financial statements, audits or inspection reports, business licenses and certifications, IRS W-9 forms, organizational charts, and conflict of interest disclosures. Applications must remain valid for a minimum of 365 calendar days from the due date. Applicants must certify their ability to provide required insurance coverage, demonstrate understanding of county assumptions regarding contract representations, and disclose any financial or business relationships with the county or related entities that could impact service outcomes. The forms request detailed information on organizational leadership, current operating budgets broken down by funding source, and comprehensive board member information including terms of service and other affiliations.

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Other files

File	Type	Posted
Rapid_Antiretroviral_Therapy_(ART)_Protocol_(Addendum_#3_Revision).pdf	PDF	Jul 15, 2026
Rapid_Antiretroviral_Therapy_(ART)_Protocol_(Addendum_#2_Revision).pdf	PDF	Jul 9, 2026
Rapid_Antiretroviral_Therapy_(ART)_Protocol.pdf	PDF	May 28, 2026
Rapid_ART_Model_Contract.docx	DOCX document	May 28, 2026
Rapid_ART_Model_Contract,_5.14.26.docx	DOCX document	May 14, 2026
Attachment_III_-_Proposed_Costs.xlsx	XLSX spreadsheet	May 4, 2026

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Cover Page Attachment II

Forms A-D

RFP No.: 042-1673278-KL Rapid Antiretroviral Therapy (ART) Protocol Development and/or Routine Opt-Out Testing Services

Released May 20, 2024

Form A - Checklist Use this checklist to identify whether or not all items requested have been included. This form is to be completed and included in the uploaded OpenGov.com file. Failure to provide the requested information and/or documentation may result in disqualification of your Application.

Organization Name:

	Upload File				Item(s) Enclosed/
Completed			Page and Section Number
	A.	Cover Page/Executive Summary
	B.	Agency Description (Form B - Attachment II)
	C.	Bidder Certifications (Form C - Attachment II)
	D.	Board of Directors (Form D - Attachment II)
	E.	Campaign Contribution Form
	F.	Reference Letters
	G.	Documentation
		1.	If incorporated:
			a.	Articles of Incorporation
			b.	By-Laws
			c.	Resolution empowering Corporate Officer
		2.	If not incorporated: Documentation empowering

Authorized Representative

	3.	Fictitious Business Name statement and Proof
	4.	Partnership Papers/joint Venture Agreements
	5.	Evidence of Federal/State tax status
	6.	IRS W-9 Form
	7.	Business License/Certifications/CUP (as applicable)
	8.	Table of Contents from P&P manual
	9.	Corporate Organizational Chart
	10.	Unique Entity Identifier (UEI)
H.	Recent Financial Statement
I.	Audits/Reviews/Inspection Reports
J.	Active Litigation, Resolution, and Performance Issues
K.	Past/Current/Threatened Litigation, Liens, and Claims
L.	Services Questionnaire
M.	Budget

FORM A - APPLICATION PREPARATION CHECKLIST

Form B - Agency Description

1.	Organization Legal Name:
		(As Specified in The Articles of Incorporation or State License)
	Business Address:

2.	Contract Signature Authority - Identify below the person empowered to sign a contract:
	Corporate Officer or Authorized Representative Name and Title:
	Corporate Officer or Authorized Representative

Email address:

	Corporate Officer or Authorized Representative
Telephone:		Fax:

3. Date Organization Established:

4. Type of Business (Check One)

Nonprofit Corporation Other (Specify):

5. Current Annual Operating Budget:

	Operating Budget Generated From:
	Non-Orange County
Government Contracts:		$			ERROR:#DIV/0!
	Orange County
Government Contracts:		$			ERROR:#DIV/0!
	Non-Governmental Contracts:		$			ERROR:#DIV/0!
	Donations:		$			ERROR:#DIV/0!
	Participant Fees:		$			ERROR:#DIV/0!
	Other (Specify): _______________		$			ERROR:#DIV/0!
	Other (Specify): _______________		$			ERROR:#DIV/0!
	TOTAL:		$	0.00		ERROR:#DIV/0!

6.	Solicitation Contact Person - Identify below the person who will represent the organization during the solicitation evaluation process:
	Solicitation Contact Name and Title:
	Solicitation Contact Email Address:
	Solicitation Contact Telephone:

Solicitation Submittal Authority:

The undersigned hereby acknowledges: "I have read and understand the contents of, and have authority to submit the attached proposal/application on behalf of the above-named organization. It is correct to the best of my knowledge and represents the organization's proposal/application for the provision of the requested services."

Corporate Office or Authorized Representative Date Telephone

FORM B - AGENCY DESCRIPTION

Form C - Applicant's Cert.

Organization Name:

Validity of Application

The County requires that all applications be valid for at least 365 calendar days from the application due date. Submissions not valid for at least 365 calendar days from the application due date will be considered non-responsive. The applicant shall state the length of time for which the submitted application shall remain valid below:

Validity of RFA (in days) (Signature Required)

Certification of Understanding

The County assumes no responsibillity for any understanding or representation made by any of its officers, employees or agents during or prior to the execution of any Contract resulting from this solicitation unless:

1.	Such understanding or representations are expressly stated in the Contract, and;
2.	The Contract expressly provides that the County therefore assumes the responsibility.

Representations made but not expressly stated and for which liability is not expressly assumed by the County in the Contract shall be deemed only for the information of the applicant.

By signing below, applicant certifies that such understanding has been considered in this response.

(Signature Required)

Certificate of Insurance

The applicant shall certify its willingness and ability to provide the required insurance coverage and certificates as set forth in Section I.O of the Request for Applications (RFA) by signing below.

(Signature Required)

Conflict of Interest

Attach the following on a separate piece of paper and include with Form C:

Provide a description of your organization’s conflict of interest systems and procedures that are in place and apply to the services to be provided to the County.

Disclose any financial, business or other relationship with the County, any other entity that the County Board of Supervisors governs or with the city and county in which the service locations are located, which may have an impact, effect or influence on the outcome of the services you propose to provide. Provide a list of current clients, employees, principals or shareholders (including family members) who may have a financial interest in the outcome of the services you propose to provide (If applicable).

Disclose any financial, business or other relationship within the last three (3) years with any organization or member of any organization who may have a financial interest in the outcome of the work. If you believe that no conflict of interest exists or would exist, sign below.

(Signature Required)

Minimum Submission Requirements Statement

Applicant shall certify that it meets all minimum submission requirements set forth above in this Section II by signing below.

(Signature Required)

Statement of Compliance

A statement of compliance with all parts of this RFA or a listing of exceptions and suggested changes must be submitted in response to this RFP:

1. This response is in strict compliance with said RFA, including the terms and conditions set forth in the Contract and its Attachment(s), and no exceptions thereto are proposed.

(Signature Required)

2. This response is in strict compliance with said RFA, including the terms and conditions set forth in the Contract and its Attachment(s), except for those proposed exceptions listed in a separate attachment hereto.

(Signature Required)

Attachment for each proposed exception must include

1) The RFA page number and section of the provision applicant is taking exception to;

2) The complete provision applicant is taking exception to;

3) The applicant's suggested rewording;

4) Reason(s) for submitting the proposed exception; and,

5) Any impact the proposed exception may have on cost, scheduling, or other areas.

FORM C Applicant Certifications

Form D - Board of Directors

Organization Name:
Provide the following information about your Board of Directors
Number of Members:	Term Length:	Meeting Dates:
Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

Current Office:	Membership Commenced:
Name:	Membership Expires:
Address:	Board Term Commenced:
State/Zip:	Board Term Expires:
Telephone:	FAX:
Occupation:	Subcommittees:
	Other Affiliations:

FORM C - BOARD OF DIRECTORS

File details come from the government source that posted it. Updated Jun 25, 2026.