DOA-3478 Vendor Reference.docx

This is a Vendor Reference form issued by the State of Wisconsin Department of Administration, State Bureau of Procurement, Division of Enterprise Operations, in connection with Bid/Proposal S-0419 DMS-17 for Preadmission Screening and Resident Reviews (PASRR) Level II Screens. The form requires vendors to provide detailed information on four or more prior installations with requirements similar to those in the solicitation document. Vendors must supply company names, addresses, contact persons, telephone numbers, email addresses, and a comprehensive list of products and/or services used for each reference. If a vendor proposes any arrangement involving a third party, the named references must also demonstrate involvement in similar third-party arrangements.

The form serves as a qualification and evaluation tool to assess vendor experience and capability in performing PASRR Level II screens for prospective and current nursing home residents in Wisconsin on behalf of the Department of Health Services. This reference documentation is mandatory for bid submission and allows the State to verify that vendors have successfully completed comparable work evaluating individuals with serious mental illness or intellectual and developmental disabilities. The form is available in accessible formats for qualified individuals with disabilities upon request.