HSS28001-FY28HFAC_appC.xlsx
XLSX spreadsheet 26 KB Posted
- Solicitation number
- HSS28001-FY28HFAC
- Issued by
- Delaware
About this file
This file is a Vendor Information Sheet attachment for the Delaware Health Fund FY 2028 Health Programs and Services contract opportunity with the State of Delaware. The document serves as a vendor registration form requiring participating companies to provide essential business information including company name, doing business as (DBA) designation if applicable, purchase order address, and website details. The sheet is designed to collect vendor qualification and identification data as part of the bidding process for health programs and services contracting.
The form includes fields for vendors to self-identify as diverse vendors and to indicate state certification status, which suggests the procurement may include set-asides or preferences for certified diverse-owned businesses or state-certified service providers. This vendor information collection is a standard component of the competitive bidding process, enabling the State of Delaware to maintain an accurate vendor database and verify eligibility of bidders participating in the FY 2028 health programs and services solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| HSS28001-FY28HFAC_appD.docx | DOCX document | |
| HSS28001-FY28HFAC_rfp.pdf | ||
| HSS28001-FY28HFAC_appB.pdf | ||
| HSS28001-FY28HFAC_appE.docx | DOCX document |
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Text version
Attachment2 Vendor Information
| Vendor Information Sheet | ||
| Company Name | ||
| DBA (if applicable) | ||
| Purchase Order Address | ||
| Website | ||
| Diverse Vendor Self-Identification | ||
| State Certified | <--Please select "Yes" or "No" on the | |
| dropdown menu | If yes, which State(s): | |
| Federal Certified | <--Please select "Yes" or "No" on the |
dropdown menu
| 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.) |
Attachment3 Non-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, Department of Health and Social Services-Office of the Secretary-Administration (DHSS-OSEC). |
| 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, DHSS-OSEC-Admin.
| 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? | |
| <--Please select "Yes" or "No" on the dropdown menu | |
| If yes, explain | |
| THIS PAGE SHALL BE SIGNED FOR YOUR BID/PROPOSAL TO BE CONSIDERED. | |
| Authorized Representative | |
| Note: |
Signature of Authorized Representative Please sign electronically or If signed manually (NOT electronically), complete the form, print so it can be signed manually and upload as a .PDF file under "Manually Signed Non-Collusion Statement"
Attachment4 Business 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 |
| Note: If you have more than 3 references, please make a copy of this tab and label as "Attachment4 Buiness References2", etc. |
Attachment5 Exceptions 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 | <--Please select "Yes" or "No" on the dropdown menu | |||
| Paragraph & Page # | Current Language | Proposed Alternative | Justification | Note: |
| The language of the RFP cannot be changed since it is a public document applicable to ALL potential bidders | ||||
| Exceptions are related to the Templates noted in Appendix D - Templates of the: PSA, BAA and DTI T&Cs | ||||
| Exceptions can possibly result in a delay or non-award in the contract award process |
Attachment6Confidentiality 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 | <--Please select "Yes" or "No" on the dropdown menu | Note: | |
| If submitting a "redacted" confidential form, please also submit an "unredacted" form so DHSS can review content | |||
| Confidentiality and Proprietary Information | If a FOIA is requested, the "redacted" version will be used | ||
| Subject | Detail | ||
| If you nave more than 10 Confidential items, please make a copy of this tab and label it as "Attachment6Confidentiality Frm2", etc. |
| If you submit a "redacted" version of this form, please also provide an "unredacted" version so we can view the information. |
| The "redacted" version will be used for FOIA requests. |
Attachment7 Subcontractor 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" on the dropdown menu |
| 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 | <--Please select "Yes" or "No" on the dropdown menu | If yes, which State(s): |
| Federal Certified | <--Please select "Yes" or "No" on the dropdown menu | |
| Description of Work by Subcontractor |
| Once completed, this form must be signed by both vendors. | ||
| Proposing Vendor | Subcontractor | |
| Authorized Signature: | Authorized Signature: | Note: Signature of Authorized Representative: |
Please sign electronically or If signed manually (NOT electronically), complete the form, print so it can be signed manually and upload as a .PDF file under "Manually Signed Subcontractor Form"
| Name: | Name: |
| Title: | Title: |
| Date: | Date: |
| NOTE: | |
| If additional SUBCONTRACT(S) is/are used, please copy this worksheet and create a copy and label as "Attachment7 Subcontractor Frm2", etc. |
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. |
File details come from the government source that posted it. Updated .