Exhibit_A_Proposal_Certification_of_Intent_to_Meet_RFQ_Requirements.pdf

Sacramento County DHS/OFCA: RFQ No. OFCA/028 | EXHIBIT A

Proposers are required to complete this Exhibit A, RFQ No. OFCA/028 Proposal/Certification of Intent to

Meet RFP Requirements.

For the purposes of this document, the proposer is defined as the organization.

Instructions: Proposers must: A) Respond to all sections of this Exhibit; B) Concisely include applicable, essential, and specific information; attach supplementary sheets as necessary; C) Not alter, delete, or otherwise change any section in the form; D) Include this Exhibit in your organization’s proposal packet with authorized signature. Electronic or scanned authorized signature will be accepted.

A. ORGANIZATION’S INFORMATION

1. Organization Name 2. Federal Tax ID#

3. Organization Address

4. Parent Corporation Name

5. Parent Corporation Address

6. Contact Person & Title Phone Email

7. Person/Title Authorized (per Board Resolution) to sign on organization’s behalf

Phone Email

8. Number of years organization has been in business under present business name:

9. List contracts, for operational assessment and technical oversite, that were successfully completed in the past three

(3) years:

Contract

Term(s)

(ex: 2025- 2026)

Legal Contract Name Service Description Fund

Source(s) Contract Value

EXHIBITA: OPERATIONAL ASSESSMENT AND MEDICAL TRAINING

REQUEST FOR QUALIFICATIONS OFCA/028

PROPOSAL/CERTIFICATION OF INTENT

TO MEET RFQ REQUIREMENTS

10. List contracts that were terminated prior to end of term in the past three (3) years. Attach supplementary sheets if necessary.

Contract

Term

Legal

Contract Name

Service

Description

Fund

Source(s)

Contract

Value

Reason for

Termination

11. List active contracts or other commitments (e.g. consulting arrangements). Attach supplementary sheets if necessary.

Contract

Term Legal Contract Name Service Description Fund Source(s) Contract Value

12. Describe any litigation involving the organization and/or principal officers thereof. Please include details about resolution/conclusion.

13. Does the organization hold financial interest in any other business?

If yes, list business(es):

14. Does the organization hold a controlling interest in any other organization?

If yes, list organization(s):

15. Is the organization owned or controlled by any other person or organization?

If yes, list person(s) or organization(s):

16. List name of persons with whom the prospective organization has been associated in business as partners or business associates within the past three (3) years:

B. ORGANIZATION’S ELIGIBILITY TO APPLY/MINIMUM REQUIREMENTS

1. Have demonstrated subject-matter expertise and experience in delivery of correctional healthcare delivery and process improvement.

Yes or No

Yes or No

Yes or No

2. Be able to provide the identified services outlined in this RFQ on-site at both Sacramento County correctional facilities and other County-identified locations.

3. Ability to develop strong relationships with Sheriff/custody leadership and staff, court-appointed subject matter experts, legal counsel, and County leadership.

Yes or No

4. Ability to bring key subject-matter expertise to fit the identified needs of the program.

Examples may include quality assurance, death reviews, emergency medical response, medical staff efficiencies, and managing high-acuity populations.

6. Possession of a clinical license (such as Nurse Practitioner or Registered Nurse) and specialized certification in correctional healthcare for at least some of the consulting team is

HIGHLY DESIRABLE.

Yes or No

Yes or No

5. Ability for staff assigned to the project to pass Sheriff background clearance for the County's jail system.

Certification:

I certify that all statements in this Operational Assessment RFQ No. OFCA/028 Proposal are true and that all eligibility to apply/minimum requirements in this RFP are satisfied. This certification constitutes a warranty, the falsity of which shall entitle Sacramento County Department of Health Services to pursue any remedy authorized by law, which shall include the right, at the option of the County, of declaring any contract made as a result thereof to be void.

I agree to provide the County with any other information the County determines is necessary for the accurate determination of the organization’s qualification to provide services.

I certify that ( ) will comply with all requirements specified in the RFP. I agree to the right of the County, state, and federal government to audit ( )’s financial and other records.

Electronic or Scanned Signature of Organization’s Authorized Agent Date

Print Name/Title

Untitled