Community_Empowerment_Crisis_Response_Application_Form_(2).docx

Community Empowerment and Crisis Response Services Master Agreement Request for Application

DMH-2024-3029-01

APPLICATION FORM

APPLICATION RESPONSE FORM, INSTRUCTIONS, AND CHECKLIST

General Instructions:

1. All applicants must complete and submit this Application Form and the Cost Response Workbook included in the Bid’s COMMBUYS file.

2. Except as provided in General Instruction 3, below, applicants must respond to each question and request for information set forth in the Application Form. Responses must demonstrate that the applicant understands and can meet the requirements of the RFA.

3. If the applicant has submitted a previous Application Form and is currently on the Master Agreement for a Community Empowerment and Crisis Response Service, this should be indicated in the Application Overview (Part 1) of the Application Form. There is a check box for this purpose. The applicant after completing Part 1 can then proceed to Part III of the application; Part II does not need to be completed.

4. If the applicant is applying to be qualified for more than one service in an Application Form (as indicated in the Application Overview (Part I), then the applicant must submit a separate Proposed Service (Part III) for each service. This is also necessary if the Application Form is being filed to qualify for two or more CORE Service “Other Activities.”

5. Applicants must save and upload this file and all approved attachments to COMMBUYS using the file naming conventions identified in Section 3.1.2. of the RFA. Applicants are advised to allow adequate time for submission by considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume.

Formatting Instructions:

This document was prepared using Microsoft Word’s forms feature. Complete the form on your computer using Microsoft Word.

1. TO COMPLETE THIS FORM, YOU MUST FIRST SAVE IT TO YOUR COMPUTER.

Enter your responses in the text box, moving between the text boxes using the tab key on your keyboard. Enter your response in the text boxes using Microsoft Word.

1. Responses to check boxes are made by clicking once on the check box. To remove the X from a check box, click on the check box again.

1. Text responses are limited to a maximum number of characters and the limits are noted in each question. Once the maximum character limit is reached, MS Word will not allow more than this limit. Please note that a space is counted as a character, and using the enter key to begin a new line in a response is also counted as a character. It is not recommended that applicants insert graphics into the responses. Spell-check does not work in text boxes.

1. Those with visual impairments may use an electronic text reader by unlocking the Application Response Form.

1.

RFR #______

APPLICATION RESPONSE COVER PAGE

Make this the first page of your proposal.

Community Empowerment and Crisis Response Services Master Agreement Request for Application DMH Document #

Organization Organization or Individual Name: DMH-2024-3029-01

Address:

City: [ ] State: [ ] Zip: [ ]

State Vendor Customer Code (if applicant currently has one): [ ]

Website (if applicable): [ ]

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ]

Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

RFA Community Empowerment and Crisis Response Services RFR A note about the text boxes: Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc. are counted as characters. The spell-check feature does not work in a text box.

Part I Application Overview

a. Service(s) Being Offered (check all that apply)

Other Activities Supporting Mental Wellness, Healing Resilience:

Name of activity: [ ] Name of Activity: [ ] Name of Activity: [ ]

b. Indicate if the applicant is currently on the Master Agreement for Community Empowerment Crisis Response Services.

|_| YES Proceed to Part III (Part II from precious application will apply to this one ) |_| NO Proceed to Part II

c. Re-application. If this is a re-application for a Service previously denied, briefly describe what changes you have to the original submission regarding the Service. Text input limit 1,250 characters, approximately 225 words).

Enter text here; text limit 1,250 characters

Part II Applicant’s Background

a. Type of organization (check all that apply);

|_| Sole Proprietorship. Indicate name of individual and Doing Business As name (DBA), if different than individual’s name:

|_| Partnership. Indicate name(s) of Partners: [ ]

|_| Corporation. Indicate type (e.g., |_|For Profit, |_|Non-Profit, |_|Limited Liability

|_| Certified by the Massachusetts Supplier Diversity Office. If so, Indicate applicable certification(s): |_| Minority Business Enterprise (MBE), |_| Minority Non-Profit Organization (MNPO), |_| Women Business Enterprises (WBE), |_| Women Non-Profit Organization (WNPO), |_| Portuguese Business Enterprise (PBE), |_| Service-Disabled Veteran-Owned Business Enterprise (SDVOBE), |_| Veteran Business Enterprise (VBE), |_| Veteran Non-Profit Organization (VNPO), |_| Disability-Owned Business Enterprise (DOBE), |_| Lesbian, Gay, Bisexual, and Transgender Business Enterprise (LGBTBE)

|_| Registered Participant of the Massachusetts Small Business Program

b. Overview of Applicant’s Business: Provide a description of the applicant’s business (e.g., history, years in business, principal services offered, number of current customers; primary customers, service population, number of full and part time employees, hours of operation; licenses and certifications; and awards and recognition in the last 3 years. Text input limit 6,000 characters, approximately 1,000 words)

Enter text here; text limit 6,000 characters

c. General Experience: Describe the Applicant’s experience and expertise related to serving individuals or communities impacted by trauma and traumatic events. Provide specific examples throughout this response. (Text input limit 6.000 characters, approximately 850 words).

d. Culturally and Linguistically Responsive Services: Describe the Applicant’s experience working with diverse participants and the strategies the Applicant has used or intends to use to deliver culturally and linguistically responsive services. (Text input limit 3,000 characters, approximately 500 words).

Enter text here; text limit 3,000 characters

e. Staff: Complete and attach the Staff Demographics Response available in the COMMBUYS Bid file. Please enter percentages as whole numbers (e.g., 2.3% = 2%).

|_| Agency Demographics Response uploaded to COMMBUYS.

f. Fiscal Solvency.

1. Check if EOHHS Qualified |_|. If not EOHHS Qualified provide a copy of one of the following: (1) a current letter of Credit the Applicant has from a bank or other financial institution, (2) a current credit report; or (3) the most recently completed and filed Tax return. DMH may request a bidder to furnish supplementary information as is sufficient, in the opinion of DMH, to assure DMH that the Applicant’s business organization and financial resources are adequate to successfully provide the services as set forth in the response.

|_| Selected Financial Information uploaded to COMMBUYS.

2. Affirm the following:

If one or more of the above boxes are not checked, please explain. Text input limit 1,500 characters, approximately 225 words).

Enter text here; text limit 1,500 characters

Part III Proposed Service If the Application is for more than one Service a separate Section III needs to be provided for each Service. Specify the Service Component being addressed in this PART III: [ ]

It is important for an Applicant to provide sufficient detail in this Part III, so it is clear what the Applicant is offering DMH.

a. Service Abstract: Provide an abstract of the service component the Applicant is seeking to be determined qualified to provide. It must describe (1) the specific service that will be provided (key service elements and service objectives); (2) the intended recipients of the service ( e.g., individuals, community organizations, school administrators or educators, or governmental organizations; etc.); (3) other key stakeholders, if any; (4) how services will be provided; (5) where services will be delivered (e.g. libraries, homes, parks, schools, etc.); (6) the intended duration and frequency of the services (e.g. one time event; daily for a limited duration; once a month for a limited duration, etc.) and (7) the DMH Areas/sites or communities to which you are able and willing to provide services (e.g., statewide, specific DMH Areas, or specific cities or towns).

(Text input limit 6,000 characters, approximately 1000 words)

b. CIR/CORE. If the proposed service is a Critical Incident Response Service (CIR) service component, describe what you have in place that will allow you to respond rapidly if you enter into a SOW and how your services are aligned with standards established by FEMA for the Community Counseling Assistance and Training Program (CCP). If the proposed service is a Community Outreach, Resilience, and Empowerment (CORE) service component describe how the proposed service will empower communities, neighborhoods, and groups so they are better equipped to heal and thrive. (Text input limit 3,500 characters, approximately 600 words)

Enter text here; text limit 3,500 characters

c. Expertise and Experience: In this response, be sure to provide specific details and specific examples that support your response. Describe the experience and expertise of the Applicant and staff in providing the proposed service to the proposed service populations and stakeholders. (Text input limit 3,500 characters, approximately 600 words)

d. Staffing Model. Describe your proposed staffing model and staff plan for the service. Describe oversight and supervision of staff involved in the direct delivery of services. Upload via COMMBUYS job descriptions and qualifications for all proposed staff positions and attach resumes for any position for which there is a known candidate. (Text input limit 3,500 characters, approximately 600 words)

|_| Upload via COMMBUYS job descriptions for all proposed staff (as applicable).

|_| Upload via COMMBUYS résumés for all positions for which there are known candidates.

e. References. An applicant must provide three professional references prepared to provide examples of similar or comparable services the applicant has provided within the last five years, as applicable. Applicants are encouraged to provide references of government organizations within the Commonwealth. DMH or its agents may contact any individual(s) named as references. Applicants must use the Business Reference Form included in this Bid’s COMMBUYS file for this purpose.

|_| Business Reference Form uploaded to COMMBUYS

f. Subcontractors: If the Applicant intends to use subcontractors in providing the proposed service component, complete and attach the Subcontractor Identification List. All subcontracts are subject to DMH approval and are required to comply with the same conditions as the awarded vendor.

|_| Subcontractor Identification List is uploaded to COMMBUYS (if applicable).

g. Start Up. Indicate any actions, and estimate timeline for such, that your organization will need to take (e.g., hiring) to enter into a SOW with DMH for services. This should address the need to do CORIs as indicated in Subsection 2.3.3 and to ensure that subcontractors, as applicable, are available. (Text input limit 2,500 characters, approximately 400 words)

Enter text here; text limit 2,500 characters

h. Environmental Preferable Products Please indicate which or the following business practices the Applicant has adopted to foster a sustainable approach to conducting their operations. Applicants need to meet at a minimum one of the business practices below, preference will be given to those that meet more than one of the business practices. DMH reserves the right to ask for additional information or documentation.

|_| Uses at least 50% remanufactured toner cartridges in printers.

|_| Uses Green Cleaning products (certified by UL Ecologo, GreenSeal or SaferChoice) in all cleaning or janitorial services.

|_| Purchases appliances and equipment (printers, copiers, microwaves, etc.), that are Energy Star or EPEAT certified models.

|_| Incorporates green building design elements into all construction and renovation projects.

|_| Owns or leases buildings certified to LEED or another green building standard.

|_| Purchases or creates renewable electricity onsite (through solar or wind systems, for example).

|_|Has received a third party energy audit (usually through the utility) and implemented recommendations.

|_| Has received a third party waste audit and implemented recommendations.

|_| Other sustainable initiatives, Indicate initiatives: (e.g., waste reduction programs, green building management programs, other energy efficiency programs, etc., APPLICATION RESPONSE SUBMISSION PAGE

Organization

I affirm, on behalf of the Applicant, that the Applicant will comply with the requirements of this Request for Application and with the terms of this proposal.

Authorized Signatory:

First Name: [ ] Last Name: [ ]

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of Applicant with authority to sign on the Applicant’s behalf and is agreeing all affirmations listed above.

CHECKLIST OF ATTACHMENTS TO THE APPLICATION RESPONSE FORM

All documents listed below must be submitted via COMMBUYS for your response to be considered complete. Files must be uploaded and follow the naming convention indicated in the chart. These attachments are referenced through out the Application Form or in the Cost Proposal Workbook.

Assign when creating documents

Application Form

Cost Proposal Workbook

Scanned documents will be accepted. All scanned documents must be scanned in such a way that they can be read on a computer monitor and printed on 81/2” x 11” paper, unless otherwise specified. Attachments must be uploaded in a zipped file.

Addendums or uploads not specifically requested in this document, the RFR or on the COMMBUYS Bid Solicitation screen will not be reviewed.

APPLICATION INSTRUCTIONS

1. Save, read, and review the completed Application Response Form. Check entries in the text boxes to assure that the input limits did not shorten your response. Proofread text; spell-check does not work in the text boxes.

2. Upload in COMMBUYS the Application Response Form with the attachments according to the application Checklist.

3. Confirm that “No Charge” is checked or a dollar amount entered in the Unit Cost field on the Item screen in COMMBUYS. The “No Charge” selection will not be construed by the Purchaser to mean an offer to provide service or products at no charge.

4. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes) image1.wmf