IWWTI Grant Response Form - Attachment B.docx

ATTACHMENT B

RESPONSE FORM

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF VETERANS’ SERVICES

THE INVISIBLE WOUNDS OF WAR TRAINING INITIATIVE GRANT APPLICATION

Grant Application #: DVS_IWWTIApplicationFY18

ISSUED: May 10, 2018

SUBMITTED BY (Respondent):

Identification of Respondent

Respondent’s Name: [ ]

Respondent’s Principal Address:

City: [ ] State: [ ] Zip: [ ]

Telephone: ( ) - E-mail: [ ] URL: [ ]

Respondent FEIN: [ ]

Respondent Vendor Customer (VC) Code : [ ]

Respondent’s Point of Contact

Include the following information for the individual who should be contacted for purposes of discussing any aspect of the Respondent’s completed Response Form:

First Name: [ ] Last Name: [ ]

Title: [ ] Organization: [ ]

Telephone: ( ) - E-mail: [ ]

BUSINESS RESPONSE

Provide the information requested below and attach the required documents.

A. COVER LETTER

Attach a Cover Letter that clearly states the name of the Respondent, principal address, and the name, address, e-mail, fax and telephone number of the Respondent’s contact person. The letter must:

a. Include a statement that clearly articulates that the Respondent accepts the terms of this Grant Application, without substantive change;

b. Include a statement that the Response will remain in effect until a Grant Agreement resulting from the Grant Application is executed;

c. Include a statement affirming that Respondent is a non-profit entity authorized to conduct business within the Commonwealth of Massachusetts; and

d. Be signed by an authorized signatory of the Respondent.

|X| Cover Letter attached.

B. CONFLICT OF INTEREST

The Respondent or any subgrantee/subcontractor shall not have any interest that will conflict with the performance of services required under any Grant Agreement resulting from this Grant Application, or that may be otherwise anti-competitive, as determined by DVS, for the duration of the Grant Agreement.

To demonstrate freedom from conflicting interests, the Respondent agrees that:

|X| No interest will conflict with the performance of services required under the Grant Application and envisioned Grant Agreement. Check box to the left to acknowledge this stipulation.

|X| The Respondent will submit any additional information requested by DVS that may be relevant to the Respondent’s financial, legal, contractual, or other business or personal interests as they relate to the Grant Application and envisioned Grant Agreement. Check box to the left to acknowledge this stipulation.

C. SUBAWARDS / SUB CONTRACTS

1. Acknowledge that all agreements with all subgrantees / subcontractors and other financial and programmatic agreements or arrangements will be in writing, and will contain terms consistent with all terms and conditions of the Grant Application and Grant Agreement. Check box below to acknowledge this stipulation.

|X| Check to acknowledge.

2. Acknowledge that the Respondent shall not be relieved of any legal obligations under any Grant Agreement resulting from this Grant Application as a result of any subaward/subcontract and that it shall be fully responsible for all subgrantee’s / subcontractor’s performance.

|X| Check to acknowledge.

D. REQUIRED FORMS AND CERTIFICATIONS

Submit the Commonwealth-required forms and certifications below. All of the Commonwealth-required forms may be downloaded from the “File Attachments” section of this solicitation on the COMMBUYS website:

1. |_| W-9 Form (Massachusetts Substitute W-9 Format - Request for Taxpayer Identification Number and Certification) (New Grantees only);

2. |_| Cover Letter;

3. |_| Authorization for Electronic Funds Transfer Form (New Grantees only);

4. |_| Grantee Authorized Signatory Listing;

5. |_| Program Services Matrix;

6. |_| Commonwealth Standard Contract;

7. |_| Commonwealth Terms and Conditions;

8. |_| Organizational Chart;

9. |_| Curriculum Vitae of Key Personnel;

10. |_| Budget;

11. |_| Budget Narrative;

12. |_| SDP Plan Form 1;

13. |_| List of References;

14. |_| References Authorizations;

15. |_| Veteran Employment Certification; and

16. |_| Commitment Letters, if applicable.

E. PROPOSED PROGRAM

Provide your response as directed below. You cannot exceed the specified character limit for each response box or page limit for each attachment.

Your response must demonstrate your ability to assume all programmatic requirements set forth in the Grant Application. If you are unable to provide the information required in a specific submission requirement, expressly identify which information is not being submitted, and why. Submit the most comparable information you have available and explain, in accordance with this section, how you will have the capability to perform all Grant responsibilities.

1. BACKGROUND / EXPERIENCE

Please state with particularity the Respondent’s background and experience including, but not limited to, the following:

a. Working with military veterans, proving services for veterans, and assessing and addressing the needs of veterans residing within the Commonwealth;

b. Collaborating with agencies of the Commonwealth of Massachusetts, community-based organizations, behavioral health services providers, etc.;

c. Providing management services, administrative coordination, implementation planning, project management and/or capacity building for organizations, training programs, projects or initiatives;

d. Participating in initiatives similar to IWWTI;

e. Employing measurable outcomes to evaluate performance; and

f. Serving the community and ability to ensure cultural, linguistic, and socio-economic sensitivity and respect;

g. Significant experience administering large public programs; and

h. Prior experience training diverse populations at diverse locations throughout the Commonwealth.

(Maximum 1,000 words)

Enter narrative here.

2. OVERVIEW

Please provide a brief overview of the Respondent including, but not limited to the following:

a. Formation date, goals and mission;

b. Number of employees;

c. Management structure;

d. Latest annual budget;

e. Current service areas and funding sources;

f. Familiarity with evidence-based models of service;

g. Discuss how the organization’s experience, contractual relationships and staff expertise relate to the key activities.

3. PROGRAM STRATEGY

Please provide a summary of the Program you propose including, but not limited to goals, design, structure, time tables and milestones, marketing, operations, use of best practices, diversity of training locations, performance measures, performance reporting to DVS, etc.

(Maximum 3,000 words)

a. Attach a completed Program Matrix for your proposed Program in the form and format posted on COMMBUYS. (no page/character maximum)

|X| Program Services Matrix attached.

b. Attach an Organizational Chart showing the relationships between the Respondent and any/all other subgrantees and/or subcontractors identified in the Program Services Matrix. Show contractual relationships, staff roles, FTEs and names, where known. (no page/character maximum)

|X| Organizational Chart attached.

c. Attach letters of commitment from the proposed subgrantee/subcontractors subcontractors listed in the completed Program Services Matrix, and describe the timelines and capacity to do so. (maximum 1 page per letter)

|X| Letters of commitment from subgrantees, and/or subcontractors attached.

d. Program Locations

Provide details of your proposed program locations, as identified in the completed Program Services Matrix. Discuss the appropriateness of the locations for the services being provided and Clients being served

4. KEY EMPLOYEES AND PROPOSED STRUCTURE

Please identify the key employees who will lead this project, their qualifications for doing so, and their anticipated roles in executing Respondent’s IWWTI program.

a. Key Personnel

Attach brief bios of the Key Personnel identified earlier in the Response (maximum 1 page per individual; 2 pages total)

|X| Curriculum Vitae of Key Personnel attached.

b. Attach a statement certifying the percent of Respondent’s total current workforce that are military veterans and who have been employed by Respondent for at least the past six (6) months.

|X| Certification document.

5. REFERENCES

As discussed and required by the Grant Application (which is incorporated herein by reference), please identify the required minimum of three (3) references. Please provide each individual’s name, business name, business title, business address, business telephone number, and business email address. By submitting its Response, the Respondent expressly authorizes DVS to contact each reference as contemplated herein and discuss any and all matters concerning the Respondent, the Grant Application and the Response. Prior to submitting its Response, the Respondent shall send written authorization to each reference permitting him/her to cooperate fully with DVS’ investigation and evaluation of the Response. Copies of these authorizations must be included with the Response. Respondents are cautioned that they alone are responsible for obtaining each reference’s cooperation with DVS’ inquiry. DVS shall have no obligation to contact the Respondent and report that a reference refused to cooperate with DVS.

|X| Reference list attached.

|X| Copies of authorizations attached.

6. BUDGET AND NARRATIVE

A. Attach a completed budget. Note the budget must reflect all activities from the grant start date. (No page maximum)

|X| Budget attached.

B. Attach a budget narrative to support your proposed budget. Describe each line item and include supporting calculations as appropriate. Provide a breakdown of all costs, including salaries and fringe benefits. Payroll expenses should specify staff titles and staff role in IWWTI Program, and time allocations (FTEs). Indicate if fringe calculations are based on a rate or actual expenses for each person. For all expenses, indicate how the expenses contribute to the implementation of IWWTI.

|X| Budget narrative attached.

DVS – IWWTI Grant Application Response Form – Attachment A Page 9