Attachment J - Qualification Application fillable form.docx

Attachment J Qualifications Application form

1. Applicants name (Name of firm, entity, or organization)

1. Number of years in business under this name.

1. Federal Employer Identification Number

1. Non Profit organization:

☐ Yes ☐ No

1. Facility address where services will be rendered

1. Facility Mailing Address

1. Hours of Operation

1. Facility Telephone Number

1. Facility Fax Number

1. Facility Email Address

1. Name and Title of Facility’s Contract Person

1. Facility’s Contact Person’s Telephone Number

1. Facility’s Contact Person’s Email Address

1. Name of Medical Director (if applicable)

1. Medical Director Emil (If applicable)

1. Applicant’s Organizational Structure ☐ Corporation ☐ Partnership ☐ Proprietorship ☐ Joint Venture ☐ Other (Explain below)

1. If Corporation, date incorporated:

1. State incorporated

1. State registered as a foreign corporation

1. Applicant’s services or business activities other than what this RFQ requests.

Additional Information/Requirements Narrative Summary

1. Indicate the number of years and dates (example: 2019 to 2023) of experience with conducting health-related needs assessments. Include the most recent project titles and names of organizations with which you have contracted to complete similar projects, if applicable. Also include referral contact information for these organizations.

1. Briefly describe the overall experience and work you/your facility have/has done related to conducting STD and HCV testing, including experience with engaging the community and collaboratives/advisory groups, data gathering, data analysis, and preparation of summary analysis and reports.

1. Indicate what kind of assistance you/your facility expects to need from DPH in-kind support when working with individuals who engage in high-risk behaviors of contracting an STD or HCV and providing them testing, linkage to care, etc.

1. Indicate if any formal grievances/complaints have been filed against you/your agency. If yes, provide a brief summary indicating the general location and circumstances of the grievances/complaints as well as dates/timeframes. Also include the current status of the grievances/complaints and if they have been resolved. If none, indicate as such.

1. Please provide an overview of the processes your facility will implement to accommodate public health staff needs, i.e. workspace, internet connection, electronic health record (EHR) access, etc., while also adhering to the previously mentioned eligibility requirements at the start of this application.

1. Please outline how you plan to utilize the in-kind staffing support made available through this partnership.

1. On a weekly basis, how much support staff is needed, what is the anticipated number of service hours of each support staff, and level of staff assistance required for the following activities: promoting STD and HCV testing, providing sexual health education, educating on STDs and HCV, conducting case investigations, and facilitating linkage to care through in-kind support staff services?

1. Please describe the range of services offered at your facility and the way they are provided to your individuals.

1. Please provide information on the specific STD and HCV testing methods currently utilized at your facility i.e. rapid STD/HCV testing, blood draws, take home HIV tests, etc.

1. Is your organization interested in expanding its testing services for the communities you serve? If so, please explain your rationale and specify which tests you would like to focus on increasing.

1. To which populations do you routinely provide services (check all that apply?)

1. ☐ Young Adults (15-24 years old)

1. ☐ Women of Childbearing Age (15-49 years old)

1. ☐ Pregnant Persons

1. ☐ LGBQT+

1. ☐ Sexually Active

1. ☐ Individuals Interested in Starting Pre-Exposure Prophylaxis (PrEP)

1. ☐ Current Intravenous Drug Users

1. ☐ Past Intravenous Drug Users

1. ☐ Unhoused

1. ☐ Recently Incarcerated 1.

1.

1. On average, how many individuals do you serve each month from the following populations

1. Young Adults (15-24 years old):________

1. Women of Childbearing Age (15-49 years old):_________

1. Pregnant Persons:_________

1. LGBQT+:_________

1. Sexually Active:_________

1. Individuals Interested in Starting Pre-Exposure Prophylaxis (PrEP):_________

1. Current Intravenous Drug Users:_________

1. Past Intravenous Drug Users:__________

1. Unhoused:_________

1. Recently Incarcerated:__________

1. Does your program provide any of the following prevention materials or services:

☐ PrEP ☐ Condoms ☐ Expedited Partner Therapy ☐ Harm reduction services (e.g. syringe exchange) ☐ Take home HIV testing ☐ HCV educational materials ☐ STD educational materials ☐ Peer support or counseling ☐ Insurance assistance

1. How many of the following tests did your facility perform within the last twelve-month period and how many tests does your facility estimate will be performed within the coming twelve months? Please enter a number.

1. HIV within the last twelve months:__________

1. HIV within the coming twelve months:__________

1. Syphilis within the last twelve month:__________

1. Syphilis within the coming twelve months:__________

1. Chlamydia within the last twelve months:__________

1. Chlamydia within the coming twelve months:__________

1. Gonorrhea within the last twelve months:__________

1. Gonorrhea within the coming twelve months:__________

1. HCV within the last twelve months:__________

1. HCV within the coming twelve months:__________

1. Explain the rationale behind your estimated number of tests to be conducted within the coming twelve months.