Exhibit N, Work Order Request and Response Form Template.pdf

RFQ No. HHS0016852 Exhibit N

Work Order Request and Response Form Template

This form has three sections. Section I, Work Order Request Requirements, is to be completed by the System Agency Contract Manager and comprises the requirements associated with the specified individual Work Order. Section II, Work Order Request Response, is to be completed by the Contractor. Section III, Negotiated Work Order Request, is to be completed by the System Agency Contract Manager and comprises the requirements associated with the specified individual Work Order that is to be awarded via Work Order Agreement.

SECTION I. WORK ORDER REQUEST REQUIREMENTS

A. GENERAL INFORMATION AND TIMELINE

1. Work Order Request Information

Solicitation #: [Enter Number]

Solicitation Title: [Enter Title]

Work Order #: [Enter

Number]

Work Order Request Project Title:

[Enter Title]

2. Work Order Request Timeline

This Work Order Request solicits Work Order Responses from eligible Contractors according to the timeline below.

Work Order Request Release Date: [Enter date]

Contractor Questions Deadline: [Enter date] at [Enter time a.m./p.m.] Central Time

Responses to Questions Distributed to Contractors: [Enter date]

Work Order Response DUE DATE: [Enter date] at [Enter time a.m./p.m.] Central Time

Response Evaluation Period ☐ Yes [Enter month and year] ☐ Not applicable

Work Order Negotiation Meeting [optional]: ☐ Yes [Enter month and year] ☐ Not applicable

Estimated Work Order Award Date [optional] ☐ Yes [Enter date] ☐ Not applicable

Estimated Work Order Start Date: [Enter date]

Estimated Work Order End Date: [Enter date]

All dates are subject to change at the System Agency’s discretion and Contractors will be notified in writing if there are changes to this timeline.

B. WORK ORDER REQUEST POINT OF CONTACT AND QUESTIONS

1. System Agency Point of Contact

All communications and submission of documents required under this Work Order Request will be conducted by email. All communications for this Work Order Request must be directed to the Work Order Request Point of Contact at the following email address:

Agency Contact: [Enter Name] Agency

Contact Title: [Enter Title]

Agency Contact Email: [Enter Email Address]

Agency Contact Phone: [Enter Phone #]

Failure to comply with this requirement may result in disqualification of Contractor from being selected for this Work Order Request.

2. Questions

Any questions by Contractors regarding the Work Order Request must be submitted to the System Agency Work Order Request Point of Contact by the “Contractor Questions Deadline” provided in Section I.A2, Work Order Request Timeline. Responses to questions will be emailed to all Contractors receiving this Work Order Request. The Work Order Request System Agency Point of Contact may combine duplicative or similar questions and provide one response. Also, the System Agency reserves the right not to respond to submitted questions that it determines are not relevant to the Work Order Request.

C. WORK ORDER REQUEST SCOPE OF WORK

1. Description of Services and Contractor Requirements

Under this Work Order Request, Contractor must provide the following Services to the System Agency:

2. Work Order Request Deliverables

The Contractor will be responsible for submitting the following Deliverables under the resulting Work Order Agreement (additional rows can be added as required):

No. Deliverable Description Deadline

1. [Description of Deliverable 1] [Deadline for Deliverable 1]

2. [Description of Deliverable 2] [Deadline for Deliverable 2]

3. [Description of Deliverable 3] [Deadline for Deliverable 3]

4. [Description of Deliverable 4] [Deadline for Deliverable 4]

5. [Description of Deliverable 5] [Deadline for Deliverable 5]

[Describe all audit services that Contractor must provide under this specific resulting Work Order Request and resulting Work Order Agreement. Ensure that the detailed services are consistent with the Master Contract.]

6. [Description of Deliverable 6] [Deadline for Deliverable 6]

7. [Description of Deliverable 7] [Deadline for Deliverable 7]

8. [Description of Deliverable 8] [Deadline for Deliverable 8]

9. [Description of Deliverable 9] [Deadline for Deliverable 9]

10. [Description of Deliverable 10] [Deadline for Deliverable 10]

3. Liquidated Damages Associated with Deliverables (if applicable):

If applicable, will this Work Order Agreement require liquidated damages in addition to those of the Master Contract? ☐ Yes ☐ No ☐ Not Applicable

If “No” or “Not Applicable” move to next section of this form.

If “Yes” insert liquidated damages specific to this project below.

[Describe any required liquidated damages.]

4. Compensation Method

The resulting Work Order Agreement will utilize the following compensation structure set forth in the Master Contract (check one option only):

☐ Lump Sum / Fixed Fee for this project is: [$0.00]

☐ Time & Materials with a not-to-exceed amount of: [$0.00]

5. Payment and Invoicing

a. All payments under a resulting Work Order Agreement shall comply with the Master Contract including, but not limited to, travel expenses.

b. Payment for Services related to this Work Order Request will be tied to specific Deliverables. Contractor must identify the invoice for each Deliverable. See SECTION II, WORK ORDER RESPONSE.

c. Contractor is not authorized to perform Work or invoice for Work performed until a Work Order Agreement is signed by both parties and the purchase order is issued for this Work Order.

D. WORK ORDER REQUEST RESPONSE SUBMISSION REQUIREMENTS

Failure to adhere to the requirements of this section may result in disqualification of Contractor’s Work Order Response.

1. Work Order Response Contents and Format Contractor must fully complete SECTION II, WORK ORDER REQUEST RESPONSE, and the submission must adhere to the requirements of this Work Order Request. Contractor must not modify the form in any way, including, but not limited to, changing font, font size, margins, section order, or headers. Contractor’s Work Order Response must be clearly legible.

a. The Narrative, Response identified at SECTION II, WORK ORDER REQUEST RESPONSE is limited to [# (Number)] pages in length and excludes any HUB Subcontracting Plan (HSP) updates, supporting documentation, resumes, and budget information.

b. Contractor shall submit any updates to its HUB Subcontracting Plan in a separate document.

For assistance updating HSP forms, call (512) 406-2570 or send an email to hhschuboutreach@hhsc.state.tx.us.

2. Work Order Response Submission Method

Contractor shall submit its Work Order Request Response using any of the selected options below:

(Select all that apply)

☐ Email Contractor will attach this Work Order Request, and its completed Work Order Response to an email and submit to the Point of Contact identified in SECTION I(B)(1). The subject line in Contractor’s email should include the Work Order Request number.

☐ USB Drive Contractor will submit an electronic copy of this document including its completed Work Order Response on one USB drive in a sealed package. Delivery address is as follows:

Click or tap here to enter text.

☐ Paper Submission with USB Drive Contractor will submit one original and four copies of this document including its completed Work Order Response. Contractor must also submit an electronic copy of its submission on one USB drive. Contractor must ensure that all information is in both the hard and electronic copies. Delivery address is as follows:

Click or tap here to enter text.

Note: Telephone or facsimile responses will not be accepted.

3. Work Order Response Deadline

The completed Work Order Response must be received no later than the Work Order Response DUE DATE specified in SECTION I(A)(2) of this Work Order Request.

E. WORK ORDER REQUEST RESPONSE EVALUATION

1. Evaluation Criteria

The System Agency will evaluate and select the Work Order Request Response offering best value using the following criteria:

mailto:hhschuboutreach@hhsc.state.tx.us

2. Negotiations, if required

The selected Contractor(s) must be prepared to participate in a Work Order Agreement negotiation meeting(s) if required by Section I.A. 2, Work Order Request Timeline.

F. GENERAL REQUIREMENTS

This Work Order Request and the resulting Work Order Agreement are subject to the terms and conditions of the Master Contract. The terms of the Master Contract may not be amended by a Work Order.

G. APPENDICES

As applicable, the following Appendix/Appendices is/are attached hereto, incorporated herein, and made part of the Work Order Agreement for all purposes.

1. Appendix A - [Insert Name, as applicable]

2. Appendix B - [Insert Name, as applicable]

3. Appendix C - [Insert Name, as applicable]

{Criteria shall match the original procurement criteria of Article IV, Section 4.2.5 of the RFQ}

SECTION II. WORK ORDER REQUEST RESPONSE

A. NARRATIVE RESPONSE

1. Contractor’s General Information

Contractor Name: [Enter Name] Contact: [Enter Contractor’s

Contact Name]

Address: [Enter Contractor Address] Contact Title:

[Enter Contact’s Phone

Phone: [Enter Contractor’s General Phone #]

Contact Phone:

[Enter Contact’s Phone

Email: [Enter Contractor’s General Email #]

Contact Email: [Enter Contact’s Email]

Master Contract Number:

[Enter Master Contractor#]

2. Contractor’s Fulfillment of Work Order Request Requirements

3. Contractor’s Proposed Deliverable Timeline/Project Schedule

Contractor must propose a timeline/project schedule to meet the “Estimated Work Order End Date” identified at Section I(A)(2) of the Work Order Request. Contractor may use the table, below, to submit this information. (Rows can be added as required.)

Note: “Deliverable” column must be filled in exactly as stated in Section I.C(2) in the Work Order Request above.

Deliverable Assigned Contractor Staff

Submission Deadline

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Description of Deliverable] [Staff] [Deadline]

[Contractor must describe how it will fulfill the requirements identified in the Work Order Request]

B. CONTRACTOR’S PROPOSED PRICING

1. Contractor’s Projected Expenditures under Work Order by Deliverable

a. Contractor’s Work Order Response must provide the projected expenditures for each Deliverable identified in the Work Order Request using the table, below.

b. Contractor must use the table, below, and must not modify it in any way including, but not limited to, changing font, font size, margins, section order, or headers.

c. The System Agency will evaluate the Contractor’s proposed pricing provided in this Work Order Request Response.

d. Submission of proposed pricing information on a Work Order Request Response does not guarantee funding, unless, and until, a Work Order Agreement is signed by the Contractor and System Agency.

e. Contractor must identify its proposed staff for each Deliverable. For each member of its proposed staff, Contractor must identify the staff member’s hourly rate, the number of hours the staff member is expected to work on the identified Deliverable, and the total cost associated with that staff member for the identified Deliverable.

f. Contractor’s proposed pricing may not exceed any established rates identified in its Master Contract.

Staff by Deliverable Hourly Rate

Number of Hours

Cost per Staff

Total Cost of Deliverable

Deliverable [#] $ [#] Staff

1: [Staff Name and Title] [Rate] [#] [#]

Staff 2:

[Staff] [Rate] [#] [#]

Staff 3: [Staff] [Rate] [#] [#]

Staff 4: [Staff] [Rate] [#] [#]

Deliverable [#] $ [#] Staff

1: [Staff Name and Title] [Rate] [#] [#]

Staff 2:

[Staff] [Rate] [#] [#]

Staff 3: [Staff] [Rate] [#] [#]

Staff 4: [Staff] [Rate] [#] [#]

Deliverable [#] $ [#] Staff

1: [Staff Name and Title] [Rate] [#] [#]

Staff 2: [Staff] [Rate] [#] [#]

Staff 3: [Staff] [Rate] [#] [#]

Staff 4: [Staff] [Rate] [#] [#]

Staff by Deliverable Hourly Rate

Number of Hours

Cost per Staff

Total Cost of Deliverable

Deliverable [#] $ [#] Staff

1:

[Staff Name and Title] [Rate] [#] [#]

Staff 2: [Staff] [Rate] [#] [#]

Staff 3:

[Staff] [Rate] [#] [#]

Staff 4: [Staff] [Rate] [#] [#]

Deliverable [#] $ [#] Staff

1:

[Staff Name and Title] [Rate] [#] [#]

Staff 2: [Staff] [Rate] [#] [#]

Staff 3: [Staff] [Rate] [#] [#]

Staff 4:

[Staff] [Rate] [#] [#]

Total Costs for Deliverables $ [#]

2. Contractor’s Projected Expenditures under Work Order for Travel

If travel reimbursement is allowed by the Master Contract, the Contractor must list projected travel expenditures by staff member’s title and type of travel, to include length of stay, identification of hotel, location, flight costs, mileage, etc. Contractor acknowledges that System Agency is not authorized to remit payment for travel expenses that do not comply with the Master Contract.

Staff Travel (Contractor must list projected travel costs expenditures by staff title and type of travel).

Projected Travel Expenditures

Staff 1 - [Insert Staff (Member Title]1)

[Staff Name] $ [#]

Flight/Bus/Train Trips

[Description] [#]

Hotel [Description] [#] Mileage [Description] [#]

Car Rental [Description] [#]

Per Diems [Description] [#]

Total Staff 1 $ [#] Staff Travel (Contractor must list projected travel costs expenditures by staff title and type of travel).

Projected Travel Expenditures

Staff (2 - [Insert Staff Member Title])

[Staff Name] $ [#]

Flight/Bus/Train Trips [Description] [#]

Hotel [Description] [#] Mileage [Description] [#]

Car Rental [Description] [#]

Per Diems [Description] [#]

Total Staff 2 $ [#] Staff (3 - [Insert Staff Member Title])

[Staff Name] $ [#]

Flight/Bus/Train Trips [Description] [#]

Hotel [Description] [#]

Mileage [Description] [#]

Car Rental [Description] [#]

Per Diems [Description] [#]

Total Staff 3 $ [#]

Staff (4) [Staff Name] $ [#] Flight/Bus/Train Trips [Description] [#]

Hotel [Description] [#]

Mileage [Description] [#]

Car Rental [Description] [#]

Per Diems [Description] [#]

Total Staff 4 [#] Total Projected Travel Expenditures

C. HISTORICALLY UNDERUTILIZED BUSINESS REQUIREMENTS

Upon execution of a Work Order Agreement, the Contractor will submit an updated HUB Subcontracting Plan to the following email address: HHSCHUB@hhs.texas.gov. Note: Contractor will not be able to proceed with any Work under the resulting Work Order Agreement without obtaining approval from the HHS HUB Program Office.

D. WORK ORDER RESPONSE CERTIFICATION

By signing this Work Order Response Form, Contractor certifies that the information provided in its mailto:HHSCHUB@hhs.texas.gov

Work Order Response is complete and accurate. Contractor further certifies that it meets the requirements and is capable of providing the Services identified in the Work Order Request. The individual whose name and signature appears below, acts with authority to bind Contractor.

[Contractor’s Name]

[Signature] [Date]

Authorized Signature Date [Enter Name]

Printed Name [Enter Signatory’s Title]

Title

SECTION III. NEGOTIATED WORK ORDER REQUEST

A. NEGOTIATIONS

Did negotiations result in modifications to the original Work Order Request? (Select one) ☐ Yes ☐ No ☐ Not Applicable (negotiations were not conducted)

If “No” or “Not Applicable” move to the signature section of this form.

If “Yes” provide the details of the negotiated modifications below.

DOCUMENTED NEGOTIATED WORK ORDER REQUEST CHANGES

Item WO Section & Language

Clarification Required

Response Notes

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]

[#] [Enter Language]

[Clarification] [Response] [Notes]