HSS26062-RURALCHHUB_AppC.xlsx
XLSX spreadsheet 27 KB Posted
- Attached to
- Rural Community Health Hubs
- Solicitation number
- HSS26062-RURALCHHUB
- Issued by
- Sussex County, Delaware
About this file
This file comprises vendor submission attachments for a Rural Community Health Hubs solicitation issued by the State of Delaware, Office of Management and Budget, Government Support Services. The document package includes standardized forms that all responding vendors must complete as part of their bid submission process. The attachments establish the framework for vendor participation and include requirements for vendor information documentation, non-collusion certification, exceptions handling, confidentiality declarations, business references, and subcontractor identification.
The vendor submission package requires all responding vendors to provide company information, diverse vendor certifications (both state and federal), designated primary and secondary contacts, and a business capability statement. Vendors must execute a non-collusion statement certifying that they have not engaged in any collusive activity or agreements in restraint of free competitive bidding, and must affirm whether their firm or any affiliates have been subject to government suspension or debarment within the past five years. The forms also permit vendors to submit exceptions to solicitation terms and conditions, designate confidential or proprietary information in accordance with Delaware Freedom of Information Act provisions, provide a minimum of three business references of similar size and scope, and identify any proposed subcontractors with corresponding certifications and work descriptions. All subcontractor forms require signatures from both the proposing vendor and the subcontractor organization.
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Other files
| File | Type | Posted |
|---|---|---|
| HSS26062-RURALCHHUB_AppD.pdf | ||
| HSS26062-RURALCHHUB_rfp.pdf | ||
| HSS26062-RURALCHHUB_AppF.pdf | ||
| HSS26062-RURALCHHUB_AppE.pdf |
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Text version
Attachment2Vendor Info Sheet
| Vendor Information Sheet | ||
| Company Name | ||
| DBA (if applicable) | ||
| Purchase Order Address | ||
| Website | ||
| Diverse Vendor Self-Identification | ||
| State Certified (select drop down of "Yes" or "No") | If yes, which State(s): | |
| Federal Certified (select drop down of "Yes" or "No") | ||
| Desginated Contacts | Primary | Secondary |
| Contact Name | ||
| Role/Title | ||
| Phone Number | ||
| Business Capability Statement | ||
| (Provide a short capability statement about your business and its capabilities and skills to advertise who you are and what you do.) |
&F&A &P
Attachment3Non-Collusion Stmt
| Non-Collusion Statement | |
| This is to certify that the undersigned Vendor has neither directly nor indirectly, entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this solicitation, and further certifies that it is not a sub-contractor to another Vendor who also submitted a bid/proposal as a primary Vendor in response to this solicitation submitted this date to the State of Delaware, Office of Management and Budget, Government Support Services. | |
| It is agreed by the undersigned Vendor that the signed submission of this bid/proposal represents, subject to any express exceptions set forth on the Exception form, the Vendor’s acceptance of the terms and conditions of this solicitation including all specifications and special provisions. | |
| NOTE: Signature of the authorized representative MUST be of an individual who legally may enter his/her organization into a formal contract with the State of Delaware, Office of Management and Budget, Government Support Services. | |
| Company Name | |
| DBA (if applicable) | |
| Name of Authorized Representative | |
| Title | |
| Phone Number | |
| Email Address | |
| Company Address | |
| Phone Number | |
| Email Address | |
| Tax ID Number | |
| AFFIRMATION: Within the past five (5) years, has your firm, any affiliate, any predecessor company or entity, owner, Director, officer, partner or proprietor been the subject of a Federal, State, Local government suspension or debarment? | |
| Select "Yes" or "No" from the drop down menu | |
| If yes, explain |
&F&A &P
Attachment4Exceptions Form
| Exceptions Form | |||||
| Responding Vendors may elect to take minor exceptions to the terms and conditions of this solicitation. All exceptions must be submitted below. Exceptions found elsewhere in the solicitation response will not be considered. Government Support Services maintains sole discretion to reject any exceptions. | |||||
| Exceptions | |||||
| Paragraph & Page # of Document | Current Language stated in the document | Proposed Alternative language | Justification for proposed change | State of Delaware's response | Bidder's response |
If addition space is needed, please copy the format of this worksheet and attach as an additional file in your submission
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Attachment5Confidentiality Form
| Confidentiality Form |
| Responding vendor may elect to designate sections of their proposal as confidential, intellectual property, trade secrets, and other confidential business information. Vendor shall explain below how the redacted information is not “public record” as defined by 29 Del. C. § 10002. The State shall independently determine the validity of any vendor designation as set forth in this section. Any vendor submitting a bid/proposal herein expressly accepts the State’s absolute right and duty to independently assess the legal and factual validity of any information designated as confidential business information. |
| Confidential Information (select "Yes" or "No" on the dropdown) |
| Confidentiality and Proprietary Information |
If addition space is needed, please copy the format of this worksheet and attach as an additional file in your submission
&F&A &P
Attachment 6Business References
| Business References |
| List a minimum of three business references of similar size and scope. Please do not list any State Employee(s) as a business reference. If Subcontractors are identified, a minimum of three business references must also be provided for each subcontractor. |
| Reference One |
| Contact Name |
| Contact Title |
| Business Name |
| Address |
| Phone |
| Current Vendor? |
| Work Performed |
| Reference Two |
| Contact Name |
| Contact Title |
| Business Name |
| Address |
| Phone |
| Current Vendor? |
| Work Performed |
| Reference Three |
| Contact Name |
| Contact Title |
| Business Name |
| Address |
| Phone |
| Current Vendor? |
| Work Performed |
&F&A &P
Attachment7Subcontractor Form
| Subcontractor Form | |
| Are you proposing the use of any subcontractors in the fulfillment of the requirements as outlined in the solicitation? (Please select "Yes" or "No" in the drop down meniu) | |
| If yes, complete this form. | |
| Responding Vendor Information | |
| Company Name | |
| DBA (if applicable) | |
| Company Address | |
| Subcontractor Information | |
| Company Name | |
| DBA (if applicable) | |
| Company Address | |
| Diverse Vendor Self-Identification | |
| State Certified | If yes, which State(s): |
| Federal Certified | |
| Description of Work by Subcontractor |
| Once completed, this form must be signed by both vendors. | |
| Proposing Vendor | Subcontractor |
| Authorized Signature: | Authorized Signature: |
| Name: | Name: |
| Title: | Title: |
| Date: | Date: |
DropDowns
| YES |
| NO |
| YES - Vendor is providing any information they declare to be confidential or proprietary for the purpose of production under 29 Del. C. Ch. 100, Delaware Freedom of Information Act. |
| NO - Vendor is not providing any information they declare to be confidential or proprietary for the purpose of production under 29 Del. C. Ch. 100, Delaware Freedom of Information Act. |
| YES - Vendor is submitting exceptions for consideration. |
| NO - Vendor is not submitting any exceptions to the specifications, terms, or conditions found in this solicitation. |
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