ESBD_File_267623_HHS0011287_PCS-102OS_Package 3.xlsx
XLSX spreadsheet 30 KB Posted
- Attached to
- Supplemental Caregiver Services
- Solicitation number
- HHS0011287
- Issued by
- Travis County, Austin City, Texas
About this file
The document provided is a form titled "PCS-102SV" used by the Texas Department of Family and Protective Services (DFPS) to list the staff, subcontractors, and volunteers working under a specific contract to provide Supplemental Caregiver Services. The contract opportunity, issued by the Health and Human Services Commission (HHSC) on behalf of DFPS Child Protective Services (CPS), is an Open Enrollment to enroll Contractors who will provide qualified Supplemental Caregiver Services statewide to support the safety of children and youth receiving supervision and aid Department employees in the caring and appropriate monitoring of children and youth. The contract will cover services in Travis County and the cities of Austin.
The form requires the listing of all personnel involved, including their positions, background check status, training completion, and other relevant information. The authorized signatory must certify the accuracy of the information provided and understand the reporting requirements. The DFPS Contract Manager must approve the listed personnel, with any exceptions noted.
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Text version
PCS-102SV
Legal Entity Contract or Procurement Number
| Fiscal Year | Region | ||||||
| List contracting entity and all names(s) of key personnel, staff, subcontractors and volunteers working under this contract. | |||||||
| Names of all Staff, Subcontractors and Volunteers to work under this contract | Role: Check All | ||||||
| that Apply | Position | Background Check | |||||
| Commercial General Workplace Liability | Crime Policy | Providing DFPS Supervision Services |
Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
This applies to Contractors providing DFPS Supervision Services, either as a stand alone contract or the contract was amended to add service. If Yes, please fill out section to the right of the form regarding additonal training required. If no, no additional information is needed. Verified Driver's License or ID showing that Contract Observer is 21 or older Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
Copy of the Contract Observer's DL or ID must be attached Required DFPS Training Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
Include completion date for each training listed below for each Contractor Observer that will be providing direct client services. Copies showing verificaton must be attached. CWOP Contractor Agreement Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
Signed and dated copies must be attached for each Contractor Observer that will be providing direct client services
| Off-Site Services | Volunteer | Subcontractor | Employee | Direct Provider | Key Personnel | |
| List Position or Title |
Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
List Position Title:
| Key Personnel Title, Observer, Supervisor Observer or Contractor Observer | ABCS | |
| Check Date | Entered by DFPS: | |
| ABCS Recheck Date | Expiration | |
| Date | Crime Policy Expiration Date | Y/N |
Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
Use drop down in box below. Y/N Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
Use drop down in box below.
Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
Include completion date for each training listed below for each Contractor Observer that will be providing direct client services. Copies showing verificaton must be attached.
Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
Signed and dated copies must be attached for each Contractor Observer that will be providing direct client services Gonzalez,Vanessa (austin) (DFPS): Gonzalez,Vanessa (austin) (DFPS):
List Position Title:
| Key Personnel Title, Observer, Supervisor Observer or Contractor Observer | DFPS Recognizing and Reporting Child Sexual Abuse Training | Trauma Informed Care | Reporting Suspected Abuse or Neglect of a Child: A Guide for Professionals Training | Human Trafficking Foundations for Child Watch Support Coordinators Training | Date Form Was Signed by Contractor Observer | |||
| 1 | ||||||||
| 2 | Y | Case Management | ||||||
| 3 | N | Evaluation/Testing | ||||||
| 4 | Home Study/HSEGH | |||||||
| 5 | Monitor | |||||||
| 6 | Post Adopt | |||||||
| 7 | Training | |||||||
| 8 | Treatment | |||||||
| 9 | Other | |||||||
| 10 |
| I certify that as of the Acknowledgment Date this list accurately represents the persons working under this contract and that all applicable credentials including insurance for persons working under this contract are current and on file. Furthermore, I understand that I must report any new persons associated with this contract to the DFPS Contract Manager using Form PCS-102 in accordance with reporting requirements specified in the contract. Form PCS-102 is located at http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp#General_Documents. I also understand that I must submit a background check through ABCS initially for each person and every 24 months thereafter and at the sole discretion of DFPS in any applicable situation as required in the contract. | |
| Name of the authorized Signature Designee certifying this document: | Typed Name; do not print/sign |
| Title: | Typed Title |
| Date of certification: | Typed Date |
| Name of approving DFPS Contract Manager: | Typed Name; do not print/sign |
| Date approved: | Typed Date |
| Approval Exceptions - To be completed by DFPS Contract Manager, if applicable: |
| The following service providers (identified by line number above) are not approved to work under this contract: |
&8Texas Department of Family and Protective Services &"Arial Black,Regular"&12Contracting Entity and List of Staff, Subcontractors and Volunteers &8PCS-102SV June 2021
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