ESBD_383499_1732773330095_2025_Subcontractor Data Sheet_State Services.xlsx
XLSX spreadsheet 27 KB Posted
- Attached to
- STDC South Texas RFP No 25-01. 02. 03.
- Solicitation number
- STDC_SOUTH-TEXAS_RFP-NO_25-01.02.03.
- Issued by
- Cameron County, Texas
About this file
This is a Subcontractor Data Sheet template provided by the South Texas Development Council (STDC) for use in the procurement of HIV care and support services. The sheet requires detailed information about potential subcontractors, including legal name, identification numbers, mailing address, contract amount, and period of performance. The document includes a comprehensive service category table listing various HIV care services such as Early Intervention, Health Insurance Premium Assistance, Medical Case Management, and support services, where providers must specify allocation amounts, percentages, service units, and number of persons to be served.
The document outlines specific funding streams through Ryan White Part B and includes detailed budget allocation requirements for each service category, with all categories currently showing $0.00 allocations as this is a blank template. The form requires certification that the subcontractor is in compliance with DSHS General Provisions and has not been suspended, terminated for cause, had licenses revoked, or voluntarily surrendered any DSHS licenses in the past three years. The document must be signed by an authorized official and includes fields for contact information.
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Text version
Subcontractor Data Sheet
Subcontractor Data Sheet
Instructions: Complete a Subcontractor Data Sheet for each source of funds. Submit the Subcontractor Data Sheet and the budget for the RFP. If any of the information below changes, a revised Subcontractor Data Sheet, subcontractor budget, and TCT contract detail documentation must be submitted to STDC.
| Administrative Agency Name: | Program ID: | Attachment ID: |
| South Texas Development Council | NA | NA |
Subcontractor Information
Subcontractor Legal Name:
Subcontractor Vendor Identification Number or Employer Identification Number:
Subcontractor Mailing Address:
(Street and Unit/PO Box) (City) (State) (Zip) (County)
Subcontractor Type: Subcontractor Budget Type:
(If other) (If other)
| Subcontractor Amount: | Subcontract Period: | ||
| $0.00 | to | ||
| (Start Date) | (End Date) |
| Method of Procurement: |
| Competitive |
Method of Payment: Rate of Payment:
Table 1: Services Priorities, Allocations, and Objectives by Subcontractor
| Administrative Agency: | South Texas Development Council | ||
| HSDA: | Allocation: | $0.00 | |
| Funding Stream: | Fiscal Year: |
Instructions: Complete table for each subcontractor for each funding stream. Contracted amounts, service units, and persons to be served must be final and should match contracts in TCT. In column 4 place the total allocation for that category; this should include service provider administrative costs. Column 5 indicates the percentage of the total contractual among that is allocated to that service category.
| Service Category | Objectives | Service | ||
| Allocation | Percent of |
Total Allocation
| Units | Persons | |||
| Early Intervention Services | $0.00 | 0.00% | ||
| Health Insurance Premium and Cost Sharing Assistance | $0.00 | 0.00% | ||
| Home and Community-Based Health Services | $0.00 | 0.00% | ||
| Home Health Care | $0.00 | 0.00% | ||
| Hospice Services | $0.00 | 0.00% | ||
| Local AIDS Pharmaceutical Assistance | $0.00 | 0.00% | ||
| Medical Case Management | $0.00 | 0.00% | ||
| Medical Nutritional Therapy | $0.00 | 0.00% | ||
| Mental Health Services | $0.00 | 0.00% | ||
| Oral Health Care | $0.00 | 0.00% | ||
| Outpatient/Ambulatory Health Services | $0.00 | 0.00% | ||
| Substance Abuse Outpatient Care | $0.00 | 0.00% | ||
| Child Care Services | $0.00 | 0.00% | ||
| Emergency Financial Assistance | $0.00 | 0.00% | ||
| Food Bank / Home Delivered Meals | $0.00 | 0.00% | ||
| Health Education / Risk Reduction | $0.00 | 0.00% | ||
| Housing Services | $0.00 | 0.00% | ||
| Linguistic Services | $0.00 | 0.00% | ||
| Medical Transportation Services | $0.00 | 0.00% | ||
| Non-Medical Case Management | $0.00 | 0.00% | ||
| Other Professional Services | $0.00 | 0.00% | ||
| Outreach Services | $0.00 | 0.00% | ||
| Psychosocial Support Services | $0.00 | 0.00% | ||
| Referral for Health Care / Support Services | $0.00 | 0.00% | ||
| Rehabilitation Services | $0.00 | 0.00% | ||
| Respite Care | $0.00 | 0.00% | ||
| Substance Abuse (Residential) | $0.00 | 0.00% | ||
| Treatment Adherence Counseling (Non-Medical) | $0.00 | 0.00% | ||
| Subtotal | $0.00 | 0.00% |
| The following services may not be funded with Ryan White Part B funds |
| Other Services -requires prior DSHS approval. |
Maribel Rodriguez: Maribel Rodriguez:
| Attach a separate sheet detailing services to be funded. | $0.00 | 0.00% | |||
| Total Allocation | $0.00 | 0.00% |
I certify that the above subcontractor is in compliance with any existing Department of State Health Services (DSHS) General Provisions/policies/procedures; and that the below information is accurate. Subcontractor has not:
• Been suspended by DSHS/STDC or is delinquent on a repayment agreement to DSHS/STDC;
• had a DSHS/STDC contract terminated for cause;
• had a required license or certification revoked that is required to carry out terms of the contract; or
• voluntarily surrendered any license issued by DSHS within the past three (3) years.
Authorized Official Name:
Authorized Official Signature: Date:
Contact Person Name:
Contact Person Email: Contact Person Phone:
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