ESBD_File_290459_Addendum 1 Solicitation Hearing Aids.doc

Texas Workforce Commission (TWC) Procurement # 3202200283 Procurement Name: Hearing Aids and Accessories Note: To open the links within this posting it may be necessary to hold the Control Key when “clicking” on the link.

I. general information A. Contract Type: Hearing Aid (6601) B. Posting

This is a notice of Open Enrollment for Hearing Aids and Accessories to be provided to Vocational Rehabilitation (VR) Customers served by the Texas Workforce Commission (TWC) VR Division on behalf of TWC. Opportunities are available to provide Hearing Aids and Accessories to TWC VR Workforce Solutions offices in all areas of the state. Applicants must meet all requirements and specifications outlined herein to be eligible to provide Hearing Aids and Accessories.

C. TWC Point of Contact

1. Contact the Procurement for questions related to:

· Solicitation:

· Section I GENERAL INFORMATION, Section III PROVIDER ENROLLMENT PACKET SUBMITTAL, or

· Other purchasing related inquires.

Procurement contacts:

a. Rebecca Stone rebecca.stone@twc.texas.gov

b. Mary Kurylowicz mary.kurylowicz@twc.texas.gov

c. Consumer.Procurement@twc.texas.gov

2. Contact the Standards mailbox at: vr.standards@twc.texas.gov for questions related to:

· Solicitation:

· Section II SCOPE OF WORK, Section III PROVIDER ENROLLMENT PACKET, or

· VR-SFP Manual, such as:

· staff qualifications,

· service delivery requirements,

· requirements outlined in the VR-SFP Chapter 3: Basic Standards .

Note: If you prefer to speak with someone, we can schedule a phone meeting when requested via vr.standards@twc.texas.gov.

D. Definitions

a.

Customer Information;

b.

Protected Health Information (PHI), in any form including without limitation, Electronic Protected Health Information or Unsecured Protected Health Information;

c.

Sensitive Personal Information, as defined by Texas Business and Commerce Code, § 521.002(a)(2);

d.

Federal Tax Information;

e.

Personally Identifiable Information (PII) as defined by Texas Business and Commerce Code § 521.002(a)(1);

f.

Social Security Administration Data, including, without limitation, Medicaid information;

g.

All privileged work product; all information designated as confidential under the constitution and laws of the State of Texas and of the United States, including the Texas Health and Safety Code and the Texas Public Information Act, Texas Government Code, Chapter 552;

h. Personally Identifiable Information defined by 2 CFR 200.1;

i. Information deemed confidential under The Rehabilitation Act of 1973, 29 U.S.C. Chapter 16, as amended, and implementing regulations 34 C.F.R. Parts 361 through 396.

E. Open Enrollment Period

a. Start Date: June 23, 2022

b. End Date: November 28, 2022, 3:00 p.m. (CT) F. Certifications

By signing and submitting the Execution of Offer form with the Provider Enrollment Packet, Applicant attests to its compliance with the statements contained in the Applicant Certifications embedded below.

G. Contract Award

TWC intends to award contracts to qualified Applicants throughout the enrollment period and may award multiple contracts within individual counties or groups of counties.

Entities, Applicants and/or individuals that are debarred or excluded by the federal government are excluded from receiving Federal contracts or certain subcontracts, and certain types of financial and nonfinancial assistance and benefits. Entities, Applicants and/or individuals that are debarred or excluded by the State of Texas are excluded from doing business with the state.

TWC may consider past performance when determining whether to award a contract to an Applicant, or any other factor it deems to be in the best interest of TWC or the State of Texas.

Participation in a post-award orientation will be required before any services related to the awarded contract can be performed.

H. Compensation

Contractors must comply with the following sections defined in the VR-SFP- Chapter 6: Hearing Aids and Hearing Aid Accessories Chapter 6: Hearing Aids and Hearing Aid Accessories: Service Descriptions, Staff Qualifications, and Outcomes Required for Payment. Payments made to Contractors will be based on the TWC-VR Price list when all requirements have been achieved.

Contractors must also be in compliance with Chapter 3: Basic Standards of the VR-SFP Manual.

Contractors must comply with the Payment and Terms as well as Contractor Obligations described in their executed contract.

I. TWC Standard Terms and Conditions

Contracts resulting from this solicitation will include the TWC Standard Terms and Conditions for Customers embedded below.

II. Scope of Work J. Provider Requirements, Responsibilities, and TWC Policies

Providers must be knowledgeable about their responsibilities, the service requirements and TWC policies applicable to them.

K. Standards for Providers

Providers under contract with TWC must adhere to currently published VR-SFP Manual for the dates of services during which any services are provided to a Customer.

Notice of upcoming changes to the VR-SFP Manual is published on the Vocational Rehabilitation Providers’ Resources page at least thirty (30) days in advance of the effective date of the changes. Each Provider is contractually responsible for maintaining compliance with the most recent VR-SFP Manual.

A revision list that summarizes any formal changes to the VR-SFP Manual can be found on the Vocational Rehabilitation Standards for Providers Revision Log.

TWC GovDelivery list notifies Contractors and Providers every time revisions are posted to the VR-SFP Manual and other important information. All Contractors should subscribe to TWC GovDelivery to gain these notifications. Visit the TWC GovDelivery website at: https://public.govdelivery.com/accounts/txwc/subscriber/new , enter an email address, and select the topic ‘Vocational Rehabilitation Contractors and Providers News’ to subscribe.

Questions related to the content found in the VR-SFP Manual can be sent to vr.standards@twc.texas.gov.

L. Required Insurance

Insurance can provide protection to contractors from claims of negligence made by Customers. Currently on June 1, 2022 there are no insurance requirements, but this can be subject to change after proposed changes have been posted at least 30 days on the Vocational Rehabilitation Providers’ Resources page.

M. Warranty and Maintenance

Warranty information below can be found in Chapter 6: Hearing Aids and Related Accessories and is subject to change after proposed changes have been posted at least 30 days on the Vocational Rehabilitation Providers’ Resources page.

Currently a Hearing Aid Contractor must:

· provide a minimum three-year loss damage warranty for hearing aids; and

· provide a minimum one-year warranty for hearing aid accessories.

All warranties have no deductibles or shipping costs.

N. Hearing Aids and Hearing Aid Accessories Scope of Work Applicant must be a hearing aid manufacturer and cannot be a distributor.

Guidelines for the Scope of Work for Hearing Aids and Hearing Aid Accessories Contractors and minimum qualifications are outlined and can be located in VR-SFP Chapter 6: Hearing Aids and Hearing Aid Accessories and is subject to change after proposed changes have been posted at least 30 days on the Vocational Rehabilitation Providers’ Resources page.

For information on returned products, see VR-SFP, 6.3 Returns.

The above content is subject to change at any time and the contractor will be responsible for the most recent published content in the VR-SFP Chapter 6: Hearing Aids and Hearing Aid Accessories.

An Applicant applying for a contract must comply with the following VR-SFP Manual chapters as well.

· Chapter 1: Introduction to Vocational Rehabilitation

· Chapter 2: Obtaining a Contract for Goods and Services

· Chapter 3: Basic Standards O. Service Areas This is a statewide open enrollment solicitation. All Texas counties are included in this solicitation.

III. Provider Enrollment Packet Submittal

P. Completed Enrollment Packets

Completed enrollment packets may be submitted at any time during the enrollment period. All forms must be completed in their entirety. For qualified Applicants that submit complete applications, contracts will be developed as they are approved. The volume of applications may vary during the enrollment period, and contracts may take three months or more to be finalized, depending upon volume and workload.

Submittal of Enrollment Packets must be made via email transmission to: consumer.procurement@twc.texas.gov.

Hard copy applications will not be accepted nor processed.

Q. Encrypted Format

3. Important: All emailed submissions must be received by TWC in an encrypted format to protect the content from being read by entities other than the intended recipients.

No mailed or hand delivered application will be accepted.

If you do not have encryption software, email the procurement TWC Point of Contact listed in Section I. C. 1. TWC Point of Contact and request that an email be sent to you. Submitting your application to the TWC Point of Contact by return email will cause your submission to be received by TWC in an encrypted format when all required steps are followed.

TWC is not responsible for applications sent to an address other than that stated in the solicitation, an application submitted after the closing date, illegible, incomplete, corrupted, or otherwise considered disqualified due to failure of electronic equipment or operator error. Failure to submit an application in accordance with the requirements of the solicitation may result in disqualification.

4. Email Subject Line shall read: Hearing Aids and Accessories OE Application.

5. Enrollment Packet Contents and Organization (Attachments):

Attached documentation shall include all required information delineated in Section III. C Provider Enrollment Packet Submittal below. Submit each document/form as a separate document in the email as an attachment.

Application will be rejected if the Applicant does not submit documents separately as described below.

Organize the application following the defined order and use the naming conventions for each attachment as described in Section III. C Provider Enrollment Packet Submittal.

ALL emailed attachments MUST BE SCANNED IN PDF FORMAT FOLLOWING THE DIRECTIONS in Section III. C Provider Enrollment Packet Submittal.

R.

Provider Enrollment Packet Submittal (Contents and Organization)

TAB 1: Execution of Offer

Complete the Execution of Offer form.

Naming Convention for submission:

T1_Applicant’s Legal Name_Execution of Offer TAB 2: W-9 and Direct Deposit Form (VR1020)

EMBED AcroExch.Document.DC VR1020 and the VR1020 instructions are embedded above.

Alternative W-9 forms will NOT be accepted.

If using an EIN, a copy of the IRS letter assigning the Federal Tax ID# must be included.

If the VR1020 lists a “Doing Business As” (DBA) Designation, a copy of the County DBA Registry letter or Texas Secretary of State DBA Registration, as applicable, must be included.

Complete the TWC W-9 and Direct Deposit Form.

Naming Convention for submission:

T2_ Applicant’s Legal Name_ W-9

TAB 3: Child Support Certification

EMBED Word.Document.12 \s VR1305 and the VR1305 instructions are embedded above or click here to access the VR1305 or here for the VR1305 Instructions to access the forms directly from the forms catalog.

Complete this form.

Provide the name and social security number (SSN) of the individual or sole proprietor, or if not a sole proprietorship, of each partner, shareholder, or owner with an ownership interest of at least twenty-five (25) percent of the business entity.

If no one person owns twenty-five (25) percent or more of the business, state Not Applicable (N/A) in the Name/SSN field and complete the remaining sections.

Must be signed by the Parent Company’s legal authorized representative.

Naming Convention for submission:

T3_ Applicant’s Legal Name_VR1305

TAB 4: Form VR3444, Conflict of Interest Certification

VR3444 is embedded above or click here to access the form directly from the forms catalog.

Complete this form.

Must be signed by the Parent Company’s legal authorized representative.

Naming Convention for email submittals:

T4_Applicant’s Legal Name_VR3444

TAB 5: Form VR3443, TWC VR Standards for Provider Certification

VR3443 is embedded above or click here to access the form directly from the forms catalog.

Must be signed by the Parent Company’s legal authorized representative.

Naming Convention for submission:

T6_ Applicant’s Legal Name_VR3443

TAB 6: VR3440A Goods and Equipment Part A- Parent Company Information

VR3440A is embedded above or click here to access the form directly from the forms catalog.

Parent company is the business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers

Complete this form.

Must be signed by the Parent Company’s legal authorized representative.

Naming Convention for submission:

T7_ Applicant’s Legal Name_VR3440A

TAB 7: Form VR3440B, Good and Equipment Part B-Local Business Location Information

VR3440B is embedded above or click here to access the form directly from the forms catalog.

Local Business is a business that is part of the Parent Company or a Parent Company that only operates one location which provides goods and equipment to TWC-VR customers

Complete this form.

Make sure to attach supporting documentation including copies of staff licenses, certifications and resumes with description of experience.

Naming Convention for submission:

T8_ Applicant’s Legal Name_VR3440B

TAB 8: Form VR3437, Hearing Aids and Accessories Certification

VR3437 is embedded above or click here to access the form directly from the forms catalog.

Must be signed by the Parent Company’s legal authorized representative.

Naming Convention for submission:

T8_ Applicant’s Legal Name_VR3437

_1717476764.pdf

TWC Substitute W-9 and Direct Deposit Form (1/2020) Page 1 of 2

TWC Substitute W-9 and Direct Deposit Form

(Print or type in text fields)

Box 1

Legal Name (as shown on your tax return):

Box 2 Business Name (if different from Box 1):

Box 3 Tax Information Mailing Address:

City: State: Zip:

Box 4 Payment Address (if different from Tax Address):

City: State: Zip:

Phone: Fax: Email:

Box 5 Taxpayer Identification Number:

Note: Enter the same number used filing your tax return

Social Security Number (SSN)

Employer Identification Number (EIN)

Box 6 Federal Tax Classification/ Business Designation:

T=Texas Corporation; C=Professional Corporation; or T/O= Limited Liability Company

A=Professional Assoc.

L=Limited Partnership

P=General Partnership

O=Out-of-State Corporation

S=Sole Owner

G=Government Entity

I=Individual Recipient

F=Financial Institution

R=Foreign Corporation

U=State Agency/University

E=State Employee

N= Other

If Other, please explain:

Box 7 Profit Status: Profit Non-Profit

Box 8 Corporation Info: State of Jurisdiction: File or Charter Number:

Box 9 Sole Ownership Info:

Sole Owner Name and SSN:

Box 10 General Partnership Information:

Partner 1 Name and SSN/EIN:

Partner 2 Name and SSN/EIN:

Box 11 Backup Withholding:

Please see IRS Website

Exempt from Backup Withholding

*Authorized signature is required on page 2.

TWC Substitute W-9 and Direct Deposit Form (1/2020) Page 2 of 2

Direct Deposit Information (Response Required)

Box 12 New Account Information (Setups and Changes)

I am currently on Direct Deposit and wish to continue. I decline Direct Deposit at this time.

New Set-up Change in Direct Deposit Information Cancel My Direct Deposit

Financial Institution Name: City: State: Zip:

Financial Institution Routing Number: Type of Account:

Account Number: Checking Savings

Box 13 Existing Account Information (Complete only for direct deposit information change)

Financial Institution Routing Number:

Type of Account:

Account Number: Checking Savings

Box 14 Will payments be forwarded to a financial institution outside the United States? Yes No

Box 15 Certification of TWC Substitute W-9 and Direct Deposit Form

Under penalties of perjury, I certify that:

1) I have provided my correct taxpayer identification number and that;

2) I am not subject to backup withholding as specified on the instruction page for this form and that;

3) I am a US citizen or other US person and that;

4) For Direct Deposit Authorization Setup, Changes or Cancellation

I authorize the Texas Comptroller of Public Accounts to deposit my payments from the State of Texas to my financial institution electronically. I understand that the Texas Comptroller of Public Accounts will reverse any payments to my account in error.

I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association’s rules. For further information on these rules, please contact your financial institution.

Authorized Signature Required:

Printed Name Required: D a t e Required:

E-Mail completed form to: VndrSetupMaint_W9@twc.state.tx.us or Fax to: 512-936-3514

Box 1 Legal Name (as shown on your tax return)::

Box 2 Business Name (if different from Box 1)::

Box 3 Tax Information Mailing Address::

Box 3 City::

Box 3 State::

Box 3 Zip::

Box 4 Payment Address (if different from Tax Address)::

Box 4 City::

Box 4 State::

Box 4 Zip::

Box 4 Phone::

Box 4 Fax::

Box 4 Email::

Box 6n If Other, please explain::

Box 8 Jurisdiction::

Box 8 File or Charter Number::

Box 9 Sole Owner Name and SSN::

Box 10 Partner 1 Name and SSN/EIN::

Box 10 Partner 2 Name and SSN/EIN::

Box 12f Financial Institution Name::

Box 12g City::

Box 12h State::

Box 13a Financial Institution Rounting Number::

Box 13b Account Number::

Box 15 Printed Name Required:

Box 15 Date Required::

Box 5 Taxpayer Identification Number: (Select one of two): Off

Box 6 Federal Tax Classification/Business Designation: (Select one of thirteen): Off

Box 7 Pofit Status:: Off

Box 11 Backup Withholding: Please see IRS Website: Off

Box 12 Direct Deposit Information: Off

Box 12 Direct deposit Set-up, Change or Cancel (select one of three): Off

Box 12 Type of Account:: Off

Box 14 Will payments be forwarded to a financial institution outside the United States?: Off

Box 5 Taxpayer Identification Number: Enter the same number used when filing your tax return:

Box 12i Zip Code::

Box 12j Financial Institution Rounting Number::

Box 12k Account Number::

Texas Workforce Commission

Vocational Rehabilitation Services

Conflict of Interest Certification

Instructions:

· For response to an Electronic State Business Daily (EBSD) posting follow the instructions in the ESBD posting. All sections must be completed at application.

· For updates to information on file with TWC record the required information and gain signatures. Submit updated forms to the assigned Contract Manager and QASVRS or RPSS.

· Type all information on form using a computer and get all required signatures.

· Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply.

· Keep a copy of the completed application, attachments, and supporting documentation for your records.

Reason for Submission

Date of submission:

|_| Application package

Solicitation ID: 3202200283

|_| Update of information due to change in information on file. For example, qualifications change.

|_| Other: Specify:

Entity’s Information

Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Entity’s legal name:

Entity’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN) (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

Conflict of Interest Certification Acknowledgment and Signature

Contractors and potential contractors must not offer, give, or agree to give TWC staff anything of value. Anything of value includes prepared foods, gift baskets, promotional items, awards, gift cards, meals, or promises of future employment. If a violation occurs, corrective action is required and may include contract termination or disqualification from receiving a future contract with TWC. Real or apparent conflicts of interest might occur when a former VR employee becomes an employee or a subcontractor of a TWC contractor. A contractor must not:

· hire, contract with, or accept as a volunteer any current employees of TWC, VR, or ILS-OIB;

· hire, contract with, or accept as a volunteer any former employees of TWC, VR, or ILS-OIB earlier than 12 months after the separation date, if the former employee will provide contracted services as defined in the VR SFP manual and/or Texas Government Code §572.069; or

· knowingly request or obtain confidential information from a state employee for the benefit of the contractor, personally or professionally.

A customer is acting in a dual role when the Texas Workforce Solutions–VR (TWS-VR) customer’s IPE supports the customer:

· obtaining employment from an existing contractor to provide services to other TWS-VR customers; or

· becoming a TWC-VR contractor to provide services to TWS-VR customers.

When the TWS-VR customer is in a dual role, for a period of 12 months following the closure of his or her case, the customer:

· is prohibited from providing services to any customer who is assigned to the customer’s same TWS-VR counselor; and/or

· may not receive service authorizations from the office to which the customer’s VR counselor is assigned.

An exception may be granted when a VR3472, Contracted Service Modification Request, is approved for any of the following reasons:

· The customer lives in a rural or other area where no other providers are available to serve the customer(s);

· The contractor has a skill or capability that no other available and accessible provider has. For example, in situations where a customer is not proficient in English, the contractor speaks the customer's language as well as English.

The scenarios above do not make up a complete list of real or apparent conflicts of interest. Failure to disclose a conflict of interest can result in contract termination, disqualification from receiving a future contract, and/or recoupment of payments.

Signatures

I, the legally authorized representative, have been named by the entity and have the authority to certify

· the entity acknowledges the conflict of interest statements above,

· the entity recognizes they must comply to any and all conflict of interest content found in the TWC VR Standards for Provider Manual, and/or contract, if awarded,

· the information provided in this form is complete and accurate.

Typed name:

Handwritten Signature:

X

Date:

VR3444 (03/20) Conflict of Interest Certification Page 1 of 2 image1.png

Texas Workforce Commission

Goods and Equipment Part A:

Parent Company Information

· For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS).

· Follow instructions on the form and in the TWC VR Standards for Providers.

· Type all information on form using a computer and get all required signatures.

· Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission

Date of submission:

|_| Application package

Solicitation ID: 3202200283

|_| Update of information due to change in information on file.

|_| Other Specify:

Parent Company Information

Parent company: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Parent company’s legal name:

Parent company’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN): (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

Street address:

City:

County:

State:

ZIP code:

Mailing address: (if different from physical address)

City:

County:

State:

ZIP code:

Remittance address: (if different from mailing and/or physical address)

City:

County:

State:

ZIP code:

Describe your principal line of business. Include a brief description of the types of products and services your business provides.

Email address, if any:

Web address (if applicable):

List the name of each location the parent company will operate.

List any current contracts the entity has with TWC Vocational Rehabilitation:

|_| No contract related to Vocational Rehabilitation has been granted to this parent company.

Parent Company Management Team

Legally authorized representative: Person who is authorized to sign contracts and official documents for the parent company.

Last name:

First name:

Title:

Phone number: ( )

Alternate phone number: ( )

Fax number:

Email address:

Point of contact The person appointed by the legally authorized representative as the primary contact for routine TWC communication and is responsible for meeting all TWC VR Standards for Providers manual and contract requirements. If the legally authorized representative is serving as the point of contact, they must complete this section.

Point of contact last name:

Point of contact first name:

Title:

Phone number: ( )

Alternate phone number: ( )

Fax number:

Email address:

Authorized Representative Acknowledgments and Signature

I, the legally authorized representative, have been named by the parent company and have the authority to certify acknowledgement:

· the information provided in this form is complete and accurate;

· the application includes the following forms:

· VR1020, W9 and Direct Deposit Form;

· VR1305, Child Support Certification Form;

· VR3443, Standards for Providers Certification;

· VR3444, Conflict of Interest Certification;

· VR3440A, Goods and Equipment Part A, Parent Company Information;

· VR3440B, Goods and Equipment Part B, Local Business Location Information; and

· VR3437, Hearing Aids and Accessories Certification or VR3438, Vehicle Modification Certification, or VR3439, Durable Medical Equipment Certification.

· the business must keep all forms listed above up to date with TWC-VR submitting to the assigned Quality Assurance Specialist (Q) or Regional Program Support Specialist (RPSS);

· the applicant must be in compliance with all the terms in the Electronic State Business Daily Agency posting notice, TWC VR Standards for Provider Manual, and/or contract, if awarded.

Authorized Representative’s typed name:

Handwritten signature:

X

Date:

Agency Use Only

Comments:

Name and initials of each reviewer(s) of the application. Date each entry.

VR3440A (02/21) Goods and Equipment Part A: Parent Company Information Page 2 of 3

Texas Workforce Commission

Goods and Equipment Part B:

Local Business Location Information

· For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and Contract Manager.

· Follow instructions on the form and in the TWC VR Standards for Providers.

· Type all information on form using a computer and get all required signatures.

· Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission

Date of submission:

|_| Application package

Solicitation ID: 3202000283

|_| Update of information due to change in information on file.

|_| Other. Specify:

Parent Company Information

Parent company: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Parent company’s legal name:

Parent company’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN): (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

Local Business Location

Local Business: The business that part of the parent company or parent company that only operates one location or is manufacturer that provides goods and equipment to TWC-VR customers.

Local Business Description

Local Business legal name:

Local Business “doing business as” (DBA) name:

Street address:

City:

County:

State:

ZIP code:

Mailing address: (if different from physical address)

City:

County:

State:

ZIP code:

Number of years in present business:

Business Hours:

Sunday Monday Tuesday Wednesday

Thursday Friday Saturday

Business Accessibility:

A business must meet each customer’s individual accessibility needs.

Note: Use the ADA Checklist for Existing Facilities, for accessibility definitions.

|_| Business does not serve customers at the business location at any time. If selected, skip remaining questions in this section.

· Business has accessible/handicapped parking

|_| Yes |_| No

· Exterior route to enter the building is accessible (i.e. ramps, curb cuts, level)

|_| Yes |_| No

· Interior space of building used by customers is accessible (i.e. level, wheelchair seating area, elevator, wide aisles and doors)

|_| Yes |_| No

· Bathroom(s) accessible

|_| Yes |_| No

· Counters at accessible height

|_| Yes |_| No

· Alarm Systems Standards

|_| Yes |_| No

· Braille signage

|_| Yes |_| No

If any question above is answered no, describe how the business will meet the accessibility needs of TWS customers.

Business Safety

A business must ensure the safety of all customers by maintaining documents of proof at their location and/or physical presence of safety equipment. Failure to answer questions below accurately could result in adverse consequences such as contract termination or the return of funds.

|_| Business does not serve customers at the business location at any time. If selected, skip remaining questions in this section.

· Business has local building or occupancy permit

|_| Yes |_| No

· Fire inspections are in compliance with city/county requirements

|_| Yes |_| No

· Business has working fire extinguisher or fire sprinkler system

|_| Yes |_| No

· Visible and audible fire alarms

|_| Yes |_| No

· Interior exit signs and routes posted

|_| Yes |_| No

· Policy and procedure for evacuation of customer during emergency

|_| Yes |_| No

If any question above is answered no, describe how the business will ensure the safety of TWS customers.

Comparable Benefits the Business Accepts:

Record any insurance or funding accepted. Check all that apply.

|_| Applicant or contractor is a manufacturer therefore does not accept comparable benefits.

|_| Aetna

|_| BlueCross

|_| Cigna

|_| Medicaid

|_| Medicare

|_| United Health Care

|_| Veteran’s Administration

|_| Worker’s Compensation

|_| None

|_| Other:

|_| Other:

|_| Other:

Staff Members

Record the name of each staff person as applicable.:

Note: Proof of qualification such as copy of license, certifications or resume with description of experience must be attached.

|_| Applicant or contractor is a manufacturer therefore has no staff related to application or contract.

Staff Positions:

VR Verified:

|_| Assistive technology professional (ATP)

Name of staff:

|_| Yes

Initials:

|_| American Welding Society (AWS)

|_| Yes

Initials:

|_| Certified Mechanic

|_| Yes

Initials:

|_| National Mobility Equipment Dealer Association (NMEDA)

|_| Yes

Initials:

|_| Occupational therapist

|_| Yes

Initials:

|_| Physiatrist

|_| Yes

Initials:

|_| Physical therapist

|_| Yes

Initials:

|_| Pulmonologist

|_| Yes

Initials:

|_| Rehabilitation engineer

|_| Yes

Initials:

|_| Technician certified (NMEDA)

|_| Yes

Initials:

|_| Other:

|_| Yes

Initials:

|_| Other:

|_| Yes

Initials:

|_| Other:

|_| Yes

Initials:

Equipment and Goods

Select the equipment and goods your business is requesting to be included in a contract so they can be provided to TWC-VR customers when a service authorization is issued.

Note: When the Standards for Providers requires a staff person of the business meet qualifications to provide the good or equipment, the business must have a least one person who meets the qualification(s) to have the good or equipment included in the contract. Hearing aid manufacturers do have a staff requirement.

Agency Use Only

Yes- indicates the SME, QASVR or RPSS verified qualification and service and can be included in the contract

|_| Assistive devices for the bathroom

|_| Yes Initials:

|_| BiPAP

|_| Yes Initials:

|_| Bone Anchored Hearing Aid (BAHA) Processor & Accessories

|_| Yes Initials:

|_| Cochlear Implant Processor and Accessories

|_| Yes Initials:

|_| CPAP

|_| Yes Initials:

|_| Hearing Aid

|_| Yes Initials:

|_| Hearing Aid Accessories

|_| Yes Initials:

|_| Manual wheelchairs

|_| Yes Initials:

|_| Patient lifts

|_| Yes Initials:

|_| Power wheelchairs

|_| Yes Initials:

|_| Rehabilitation or hospital beds

|_| Yes Initials:

|_| Scooters

|_| Yes Initials:

|_| Seating and positioning systems

|_| Yes Initials:

|_| Vehicle Modification Equipment

|_| Yes Initials:

|_| Other:

|_| Yes Initials:

|_| Other:

|_| Yes Initials:

|_| Other:

|_| Yes Initials:

|_| Other:

|_| Yes Initials:

|_| Other:

|_| Yes Initials:

|_| Other:

|_| Yes Initials:

Counties

· The local business can serve customers in any county included in the solicitation.

· Indicate what counties the local business has the ability to provide the goods and services with a store front or has staff that can serve the customer by traveling to the customer’s location.

· Manufacturers should select “All 254 Texas counties”.

|_| All 254 Texas counties

Vocational Rehabilitation Region 1- Borderplex Workforce Development Board

|_| Brewster

|_| El Paso

|_| Hudspeth

|_| Jeff Davis

|_| Presidio

|_| Culberson

Vocational Rehabilitation Region 1- Concho Valley Workforce Development Board

|_| Coke

|_| Irion

|_| Mason

|_| Schleicher

|_| Sutton

|_| Concho

|_| Kimble

|_| Menard

|_| Sterling

|_| Tom Green

|_| Crockett

|_| McCulloch

|_| Reagan

Vocational Rehabilitation Region 1- North Texas Workforce Development Board

|_| Archer

|_| Baylor

|_| Clay

|_| Cottle

|_| Hardeman

|_| Montague

|_| Wilbarger

|_| Foard

|_| Jack

|_| Wichita

|_| Young

Vocational Rehabilitation Region 1- Panhandle Workforce Development Board

|_| Armstrong

|_| Dallam

|_| Hartley

|_| Oldham

|_| Swisher

|_| Briscoe

|_| Deaf Smith

|_| Hemphill

|_| Parmer

|_| Wheeler

|_| Carson

|_| Donley

|_| Hutchinson

|_| Potter

|_| Castro

|_| Gray

|_| Lipscomb

|_| Randall

|_| Childress

|_| Hall

|_| Moore

|_| Roberts

|_| Collingsworth

|_| Hansford

|_| Ochiltree

|_| Sherman

Vocational Rehabilitation Region 1- Permian Basin Workforce Development Board

|_| Andrews

|_| Ector

|_| Loving

|_| Pecos

|_| Upton

|_| Borden

|_| Gaines

|_| Martin

|_| Reeves

|_| Ward

|_| Crane

|_| Glasscock

|_| Midland

|_| Terrell

|_| Winkler

|_| Dawson

|_| Howard

Vocational Rehabilitation Region 1- South Plains Workforce Development Board

|_| Bailey

|_| Dickens

|_| Hale

|_| Lamb

|_| Motley

|_| Cochran

|_| Floyd

|_| Hockley

|_| Lubbock

|_| Terry

|_| Crosby

|_| Garza

|_| King

|_| Lynn

|_| Yoakum

Vocational Rehabilitation Region 1- West Texas Central Texas Workforce Development Board

|_| Brown

|_| Eastland

|_| Kent

|_| Runnels

|_| Stonewall

|_| Callahan

|_| Fisher

|_| Knox

|_| Scurry

|_| Taylor

|_| Coleman

|_| Haskell

|_| Mitchell

|_| Shackelford

|_| Throckmorton

|_| Comanche

|_| Jones

|_| Nolan

|_| Stephens

Vocational Rehabilitation Region 2- North Central Texas Workforce Development Board

|_| Collin

|_| Erath

|_| Johnson

|_| Palo Pinto

|_| Somervell

|_| Denton

|_| Hood

|_| Kaufman

|_| Parker |_| Wise

|_| Ellis

|_| Hunt

|_| Navarro

|_| Rockwall

Vocational Rehabilitation Region 2- Tarrant County Workforce Development Board

|_| Tarrant

Vocational Rehabilitation Region 2- Dallas County Workforce Development Board

|_| Dallas

Vocational Rehabilitation Region 2- Texoma Workforce Development Board

|_| Cooke

|_| Fannin

|_| Grayson

Vocational Rehabilitation Region 3- Heart of Texas Workforce Development Board

|_| Bosque

|_| Freestone

|_| Hill

|_| Limestone

|_| McLennan

|_| Falls

Vocational Rehabilitation Region 3- Capital Area Workforce Development Board

|_| Travis

Vocational Rehabilitation Region 3- Rural Capital Area Workforce Development Board

|_| Bastrop

|_| Burnet

|_| Fayette

|_| Lee

|_| Williamson

|_| Blanco

|_| Caldwell

|_| Hays

|_| Llano

Vocational Rehabilitation Region 3- Brazos Valley Workforce Development Board

|_| Brazos

|_| Grimes

|_| Madison

|_| Robertson

|_| Washington

|_| Burleson

|_| Leon

Vocational Rehabilitation Region 3- Central Texas Workforce Development Board

|_| Bell

|_| Hamilton

|_| Milam

|_| Mills

|_| San Saba

|_| Coryell

|_| Lampasas

Vocational Rehabilitation Region 4- Northeast Texas Workforce Development Board

|_| Bowie

|_| Delta

|_| Hopkins

|_| Morris

|_| Titus

|_| Cass

|_| Franklin

|_| Lamar

|_| Red River

Vocational Rehabilitation Region 4- East Texas Workforce Development Board

|_| Anderson

|_| Gregg

|_| Marion

|_| Rusk

|_| Van Zandt

|_| Camp

|_| Harrison

|_| Panola

|_| Smith

|_| Wood

|_| Cherokee

|_| Henderson

|_| Rains

|_| Upshur

Vocational Rehabilitation Region 4- Deep East Texas Workforce Development Board

|_| Angelina

|_| Nacogdoches

|_| Sabine

|_| San Jacinto

|_| Trinity

|_| Houston

|_| Newton

|_| San Augustine

|_| Shelby

|_| Tyler

|_| Jasper

|_| Polk

Vocational Rehabilitation Region 4- Southeast Texas Workforce Development Board

|_| Hardin

|_| Jefferson

|_| Orange

Vocational Rehabilitation Region 5- Gulf Coast Workforce Development Board

|_| Austin

|_| Colorado

|_| Harris

|_| Montgomery

|_| Waller

|_| Brazoria

|_| Fort Bend

|_| Liberty

|_| Walker

|_| Wharton

|_| Chambers

|_| Galveston

|_| Matagorda

Vocational Rehabilitation Region 6- Golden Crescent Workforce Development Board

|_| Calhoun

|_| Goliad

|_| Jackson

|_| Lavaca

|_| Victoria

|_| DeWitt

|_| Gonzales

Vocational Rehabilitation Region 6- Alamo Workforce Development Board

|_| Atascosa

|_| Comal

|_| Guadalupe

|_| Kerr

|_| Medina

|_| Bandera

|_| Frio

|_| Karnes

|_| McMullen

|_| Wilson

|_| Bexar

|_| Gillespie

|_| Kendall

Vocational Rehabilitation Region 6- Lower Rio Grande Valley Workforce Development Board

|_| Hidalgo

|_| Starr

|_| Willacy

Vocational Rehabilitation Region 6- Cameron County Workforce Development Board

|_| Cameron

Vocational Rehabilitation Region 6- Middle Rio Grande Workforce Development Board

|_| Dimmit

|_| Kinney

|_| Maverick

|_| Uvalde

|_| Zavala

|_| Edwards

|_| La Salle

|_| Real

|_| Val Verde

Vocational Rehabilitation Region 6- Coastal Bend Workforce Development Board

|_| Aransas

|_| Duval

|_| Kleberg

|_| Nueces

|_| San Patricio

|_| Bee

|_| Jim Wells

|_| Live Oak

|_| Refugio

|_| Brooks

|_| Kenedy

Vocational Rehabilitation Region 6- South Texas Workforce Development Board

|_| Jim Hogg

|_| Webb

|_| Zapata

Describe the service area if it does not include the entire county for example only within the city limits of Austin.

Agency Use Only

SME, QASVR or RPSS verified the counties listed above are included in the solicitations and can be included in the contract. |_| Yes |_| No Initials:

If no is selected, list counties that cannot be included in the contract.

Agency Use Only

Comments, if any: Date each entry:

Name and initials of reviewers of the application.

VR3440B (05/22) Goods and Equipment Part B: Local Business Location Information Page 2 of 3

Texas Workforce Commission

Hearing Aids and Accessories Certification

Instructions:

· For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS).

· Follow instructions on the form and in the TWC VR Standards for Providers.

· Type all information on form using a computer and get all required signatures.

· Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission

Date of submission:

|_| Application package

Solicitation ID:

|_| Update of information due to change in information on file.

|_| Other Specify:

Parent Company Information

Parent Company: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Business’s legal name:

Business’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN) (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

TWC Acknowledgment and Signature

This acknowledgment is applicable to, and shall be considered active for, the following purposes:

· Processing of the respondent’s application

· Execution of the initial award, if applicable

· Continuation of the contract life through subsequent execution of renewals and/or amendments and/or updating information on file with TWC as applicable

I, the legally authorized representative of the Parent Company named in this application:

· Must answer all questions on the VR3440A and VR3440B true and accurately;

· Acknowledges the Lowest List Price and TWC Discounted Price for all Hearing Aids and Accessories must be provided to TWC-VR;

· Acknowledges the business cannot hold the TWC-VR customer liable for any fees and charges related to the Hearing Aids and Accessories; and

· Acknowledges that the company must provide the manufacture 3-year warranty for hearing aids and 1-year for accessories with no deductible.

Failure to comply with the above statements could result in adverse consequences such as contract termination or the return of funds.

Legally authorized representative’s printed name:

Title:

Legally authorized representative’s handwritten signature:

X

Date:

Agency Use Only

Comments:

VR3437 (06/22) Hearing Aids and Accessories Certification Page 1 of 2

Texas Workforce Commission

TWC VR Standards for Providers Certification

Instructions:

· For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and Contract Manager.

· Follow instructions on the form and in the TWC VR Standards for Providers.

· Type all information on form using a computer and get all required signatures.

· Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission

Date of submission:

|_| Application package

Solicitation ID: 3202200283

|_| Update of information due to change in information on file. For example, qualifications change.

|_| Other: Specify:

Entity’s Information

Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Entity’s legal name:

Entity’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN) (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

TWC Acknowledgment and Signature

This acknowledgment is applicable to, and shall be considered active for, the following purposes:

· Processing of the respondent’s application

· Execution of the initial award, if applicable

· Continuation of the contract life through subsequent execution of renewals and/or amendments and/or updating information on file with TWC as applicable.

I, the legally authorized representative of the entity named in this application:

· certify that the entity staff and I have read and will abide by the TWC VR Providers’ Resource Page, TWC VR Standards for Provider Manual and TWC VR forms;

· certify that that the entity will abide by any requirements prescribed in the Electronic State Business Daily (EBSD) posting for which the entity applied; and

· acknowledge that failure to follow applicable standards in the TWC VR Standards for Provider Manual, notices or publications on the TWC VR Providers’ Resource, instructions on TWC VR forms and requirement in the EBSD posting associated with the entity could cause adverse consequences for the entity, such as denial of payments, recoupment of payments, suspension of service provision to VR customers, loss of an awarded contract or processing of an application from an EBSD posting.

Legally authorized representative’s printed name:

Title:

Legally authorized representative’s handwritten signature:

Date:

Agency Use Only

Comments:

VR3443 (03/20) Standards for Providers Certification Page 1 of 2

Texas Workforce Commission

Child Support Certification

Section 1

Family Code, Section 231.006, Ineligibility to Receive State Grants or Loans or Receive Payment On State Contracts, prohibits the payment of state funds under a grant, contract, or loan to:

· a person who is more than 30 days delinquent in paying child support, and

· a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25 percent.

Section 231.006 further provides that a person or business entity that is ineligible to receive payments for the reasons stated above shall continue to be ineligible to receive payments from the state under a contract, grant, or loan until:

· all arrearages have been paid;

· the person is in compliance with a written repayment agreement or court order as to any existing delinquency; or

· the court of continuing jurisdiction over the child support order has granted the obligor an exemption from Subsection (a) as part of a court-supervised effort to improve earnings and child support payments.

Section 231.006 further requires each bid, or application for a contract, grant, or loan to include:

· the name and social security number of the individual or sole proprietor and each partner, shareholder, or owner with an ownership interest of at least 25 percent of the business entity submitting the bid or application, and

· the statement in Section 3 below.

Section 231.006 authorizes a state agency to terminate a contract if it determines that the statement required below is inaccurate or false. In the event the statement is determined to be false, the vendor is liable to the state for attorney’s fees, costs necessary to complete the contract (including the cost of advertising and awarding a second contract), and any other damages provided by law or contract.

Section 2

In accordance with Section 231.006, the names and Social Security numbers of the individuals identified in the contract, bid or application, or each person with a minimum 25 percent ownership interest in the business entity identified therein are provided below:

Name:

SSN:

Name:

SSN:

Name:

SSN:

Name:

SSN:

Section 3

As required by Section 231.006, the undersigned certifies the following:

“Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment, and acknowledges that this contract may be terminated and payment withheld if this certification is inaccurate.”

Contractor Authorized Representative Printed Name:

Title:

Contractor Authorized Representative Signature:

Date:

VR1305 (11/17) Child Support Certification Page 1 of 1

Texas Workforce Commission

Child Support Certification

VR1305 Instructions

Purpose

The following entities must complete and submit the VR1305, Child Support Certification with their bid or application:

· sole proprietorships,

· partnerships,

· entities with shareholders, or

· entities with an owner who has an ownership interest of at least 25 percent of the business entity.

Copies and Distribution

Consumer Purchasing…