BPM007142_Collaborative_Safety-_ADCS_Sole_Source_Request_Signed.pdf

Page 1 of 2 SPO Form 103 Standard Work (Rev 12.05.23)

Standard Work

Owner State Procurement Office, Compliance Unit

Form Number SPO Form 103 ‐ Sole Source (SS) Procurement Authorization Version Revised 12/5/2023

Form Completion Process

Process Standard Work/Instructions for completion and submittal of the SPO 103 form. The form is available on the SPO website: For Agencies > Resources > Standard Forms and Documents.

No. Action Action Detail/Key Points

Sections I through III to be completed by the requesting State Governmental Unit

SECTION I - State Governmental Unit Request

1 State Governmental Unit Name of the requesting State Governmental Unit (SGU; agency, board, or commission)

2 Requestor Name of the requestor 3 Email Email of the requestor 4 Title Job title of the requestor 5 Telephone Telephone number of the requestor

SECTION II - Background

6 Service(s)/Material(s) Description of service(s)/material(s) or Contract title (eProcurement Label) 7 Supplier Name of supplier(s) 8 Contract ID eProcurement contract number (if available)

9 Sole Source Type Select applicable option:

‐ Authorization request ‐ Authorization modification request

Docusign Envelope ID: C30DF2A9-3F2E-4F22-8CBE-3896CC2E7827

Page 2 of 2 SPO Form 103 Standard Work (Rev 12.05.23)

10 Requesting Term Specify contract term or extension period, as applicable, based on the SS 11 Estimated Cost Forecasted expenditures for the duration of the SS Term or extension period

SECTION III - Justification

12 Rationale Select applicable option in accordance with R2‐7‐E301(A):

‐ There is only a single source for the material(s) or service(s) ‐ No reasonable alternative source exists

Provide details of the procurement need, reason for the single source, and how the proposed procurement is advantageous to the State

Detail information regarding the rationale selected in the previous section; State Governmental Unit use of the material(s) or service(s); if mandatory state contracts were explored; the limitation which led to sole source; and how the State would benefit from the procurement.

Describe the procurement process, efforts to locate other sources/evidence of one source, and determination that the price is fair and reasonable. Include the sole source notice and number (BPM00XXXX) and attach a copy to the determination.

Detail strategy for the proposed procurement, considered competition, reason for selecting specific supplier, and negotiations strategy.

A notice was posted in the State's eProcurement system to registered vendors with an invite to comment on the sole-source request for three (3) working days, and it was determined that no reasonable alternative source exists for the procurement need. A copy of the notice is attached.

Check the box confirming the sole source request notice was posted in the State's eProcurement system for three (3) working days prior to the request.

16 Signature Signature of the authorized requestor 17 Date of Request Specify the date of request

Section IV to be completed by the Procurement Authority:

SECTION IV - Approval

18 Determination

Select applicable option in accordance with A.A.C R2-7-E301(D):

- Request Authorized Pursuant to R2-7-E301

- Request Authorized with Conditions/Restrictions R2-7-E301

- Request Returned for Additional Information

- Request Denied

19 Approved Expiration Date Specify date or term of expiration

20 Comments, conditions, or restrictions (as applicable) Complete as needed

21 Print Name Printed name of the approver 22 Title Job title of the approver 23 Signature Signature of the approving authority 24 Date of Approval Specify the date of approval 25 Use section as necessary Used by any party in case the fields within the form were insufficient

STATE GOVERNMENTAL UNIT NOTICE: This is an official written determination in response to a procurement authorization request.

A copy of the form shall be maintained by the State Governmental Unit and the State Procurement Office.

Upon completion, Requestor shall forward the signed form to the Contract Owner.

Contract Owner shall upload the signed approval version of this form in the eProcurement system.

If anticipated expenditure is above State Governmental Unit's delegation, forward document to SPOCompliance@azdoa.

gov.

Page 1 of 4 SPO Form 103 - Sole Source Procurement Authorization (Rev 12.05.23)

Procurement Determination:

Sole Source Authorization A.A.C. R2-7-E301

SECTIONS I THROUGH III MUST BE COMPLETED BY THE REQUESTOR

USE ADDITIONAL PAGE AS NECESSARY

SECTION I - State Governmental Unit Request

1. State Governmental Unit

2. Requestor 3. Email

4. Title 5. Telephone

SECTION II - Background

6. Service(s)/Material(s)

7. Supplier

8. Contract ID

9. Sole Source Type

10. Requesting Term 11. Estimated Cost

Docusign Envelope ID: C30DF2A9-3F2E-4F22-8CBE-3896CC2E7827

Victoria.Wride@azdcs.gov

BPM007142

Contract ID: TBD

Victoria Wride

Arizona Department of Child Safety (ADCS)

Collaborative Safety LLC

8161 Hwy 100 #206 Nashville, TN 37221

916-548-5041 sm@collaborative-safety.com

Sr. Procurement Specialist 602-255-2863

2 years $200,000

‐ Authorization request

Technical assistance and Leadership Labs for ADCS Leaders, Supervisors and Managers, utilizing the Collaborative Safety model, to implement Safety Science.

Page 2 of 4 SPO Form 103 - Sole Source Procurement Authorization (Rev 12.05.23)

SECTION III - Justification

12. Rationale

13. Provide details of the procurement need, reason for the single source, and how the proposed procurement is advantageous to the State

Docusign Envelope ID: C30DF2A9-3F2E-4F22-8CBE-3896CC2E7827

‐ There is only a single source for the material(s) or service(s)

The Collaborative Safety model, developed by Collaborative Safety LLC is a nationally recognized model that is founded in safety science, behavior analysis, forensic interviewing and is encased in a trauma informed lens.

The Contractor will work directly with ADCS to provide consultation, technical assistance and training services to specific, identified ADCS employees to implement the Collaborative Safety model to support a culture of safety through integration of safety science and development or transformation of review systems, including systemic critical incident reviews.

Implementing this model will enhance organizational function in regards to a safe culture, staff resiliency, equity and improved outcomes for ADCS employees and families served.

Page 3 of 4 SPO Form 103 - Sole Source Procurement Authorization (Rev 12.05.23)

14. Describe the procurement process, efforts to locate other sources/evidence of one source, and determination that the price is fair and reasonable. Include the sole source notice and number (BPM00XXXX) and attach a copy to the determination.

15. A notice was posted in the State's eProcurement system to registered vendors with an invite to comment on the sole-source request for three

(3) working days, and it was determined that no reasonable alternative source exists for the procurement need. A copy of the notice is attached.

16. Signature 17. Date of Request

In accordance with the Procurement Rules, the Arizona Uniform Terms and Conditions must be made a part of all Contracts. If you will be required to sign a software licensing agreement or sign any other agreement containing terms and conditions, these will need additional review to ensure that the terms and conditions do not invalidate the Arizona Uniform Terms and Conditions. Approval of this request does not allow for agencies to exceed their dollar acquisition amount of delegated authority.

11/7/2025

ADCS conducted research to identify a model to support safety science to improve the outcomes of ADCS families.

This award is contingent upon a finalized agreement and signed contract with ADCS to deliver

Collaborative Safety Services through direct service implementation by Collaborative Safety LLC.

ADCS issued a Sole Source Procurement notice; BPM007142 on 10/29/2025. No responses were received by the closing date on 11/3/2025. Based on the finding of the Sole Source Notice, ADCS proposes Collaborative Safety LLC as the most qualified vendor to contract for this service. The price quoted to ADCS by Collaborative Safety LLC is fair and reasonable.

ADCS will move forward with issuing a purchase order to include the Uniform Terms and

Conditions.

Page 4 of 4 SPO Form 103 - Sole Source Procurement Authorization (Rev 12.05.23)

TO BE COMPLETED BY PROCUREMENT AUTHORITY

SECTION IV - Approval

18. Determination

19. Approved Expiration Date

20. Comments, conditions, or restrictions (as applicable)

21. Print Name 22. Title

23. Signature 24. Date of Approval

25. Use section as necessary

STATE GOVERNMENTAL UNIT NOTICE: This is an official written determination in response to a procurement authorization request.

A copy of the form shall be maintained by the State Governmental Unit and the State Procurement Office.

Upon completion, Requestor shall forward the signed form to the Contract Owner.

Contract Owner shall upload the signed approval version of this form in the eProcurement system.

If anticipated expenditure is above State Governmental Unit's delegation, forward document to SPOCompliance@azdoa.gov.

Docusign Envelope ID: C30DF2A9-3F2E-4F22-8CBE-3896CC2E7827

Chief Procurement Officer

Select applicable option in accordance with A.A.C R2-7-E301(D):

November 7, 2025

December 31, 2027

Procurement supports the direction of moving forward with Collaborative Safety LLC to provide

Technical assistance and Leadership Labs for ADCS Leaders, Supervisors and Managers, utilizing the Collaborative Safety model, to implement Safety Science. On the basis that the Single

Source was executed as permitted per ARS § 41-2536. It has been confirmed that process was executed as stated in R2-7-E301(A),(B),(C).

Achilles "Lex" Sargento