DOA-3477 Vendor Information.docx
DOCX document 28 KB Posted
- Solicitation number
- S-0627 DCTS-17
- Issued by
- Wisconsin
About this file
This is a Vendor Information Form (DOA-3477) submitted to the State of Wisconsin Department of Administration, Division of Enterprise Operations, Bureau of Procurement, in response to Bid/Proposal S-0419 DMS-17 for MMIS & FA Services. The form is designed to collect essential vendor information for the Preadmission Screening and Resident Reviews (PASRR) Level II Screens contract opportunity, which requires vendors to conduct Federally mandated PASRR evaluations for prospective and current nursing home residents in Wisconsin who have serious mental illness or intellectual/developmental disabilities on behalf of the Wisconsin Department of Health Services.
The form requires vendors to provide their company name, contact information, and the names and contact details for four key personnel: a primary contact for bid questions, the individual responsible for affirmative action compliance, the point of contact for purchase orders and billing matters, and the CEO or President. Any vendor awarded a contract valued over $50,000 must submit affirmative action information to the department as a condition of award. The document indicates that alternate formats are available for individuals with disabilities upon request, in compliance with accessibility requirements.
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Text version
State of Wisconsin Department of Administration Division of Enterprise Operations Bureau of Procurement
s. 16.765, Wis. Stats.
DOA-3477 (R02/15)
| Bid / Proposal # |
| S-0419 DMS-17 |
| Commodity / Service |
| MMIS & FA Services |
Vendor Information
| 1. |
| BIDDING / PROPOSING COMPANY NAME |
| Phone |
| ( ) |
| Toll Free Phone |
| ( ) |
| FAX |
| ( ) |
| E-Mail Address |
| Address |
| City |
| State |
| Zip + 4 |
| 2. |
| Name the person to contact for questions concerning this bid / proposal. |
| Name |
| Title |
| Phone |
| ( ) |
| Toll Free Phone |
| ( ) |
| FAX |
| ( ) |
| E-Mail Address |
| Address |
| City |
| State |
| Zip + 4 |
| 3. |
| Any vendor awarded over $50,000 on this contract must submit affirmative action information to the department. Please name the Personnel / Human Resource and Development or other person responsible for affirmative action in the company to contact about this plan. |
| Name |
| Title |
| Phone |
| ( ) |
| Toll Free Phone |
| ( ) |
| FAX |
| ( ) |
| E-Mail Address |
| Address |
| City |
| State |
| Zip + 4 |
| 4. |
| Mailing address to which state purchase orders are mailed and person the department may contact concerning orders and billings. |
| Name |
| Title |
| Phone |
| ( ) |
| Toll Free Phone |
| ( ) |
| FAX |
| ( ) |
| E-Mail Address |
| Address |
| City |
| State |
| Zip + 4 |
| 5. |
| CEO / President Name |
This document can be made available in alternate formats to individuals with disabilities upon request.
File details come from the government source that posted it. Updated .