Leadership Staffing MA RFR_Attachment A Application~1.docx

ATTACHMENT A:

LEADERSHIP STAFFING SERVICES APPLICATION

Each Bidder must complete the following application in accordance with all submission instructions and submit the completed application, along with any attachments, as part of its response to the RFR. Please see Section 6.1.B. of the RFR.

SECTION 1: BACKGROUND INFORMATION

A. Bidder Organization or Individual:

Bidder Name (including DBA, if applicable):

Principal Address:

Local (Greater Boston) Address (if applicable, and if different from principal address):

E-mail address of Bidder’s contact for this Application:

Telephone number of Bidder’s contact:

Contact Person to receive requests for services under this Contract:

E-mail Address of Contact Person:

Phone Number of Contact Person:

Contract Manager for Standard Contract Form (if different from Contact Person):

E-mail Address of Contract Manager:

Phone Number of Contract Manager:

B. Leadership Staffing Services for which Bidder seeks to be considered:

Each Bidder must check the category or categories of Leadership Staffing Services described in Section 4 of the RFR for which it seeks to be considered.

☐ Section 4.1: Leadership Search Services, Category 1 ☐ Section 4.2: Interim Leadership Services, Category 2

INSTRUCTIONS FOR SECTIONS 2-5

Each Bidder must satisfy all submission requirements listed below in accordance with the corresponding submission instructions. Please clearly label all attachments with the section number of this Bidder Application to which the attachments apply. Unless otherwise noted, each Bidder must check the box to the left of each submission requirement to indicate its compliance with the requirement.

SECTION 2: RESPONDENT INFORMATION

B. Bidder’s Organizational Chart/Key Personnel:

1. Provide the Bidder’s organizational chart, showing Bidder’s staff who are expected to manage the Contract. The organizational chart should include the names, titles, and reporting relationships of all key organization officers, as well as any subsidiary relationships and subcontractors. If this requirement is not applicable because Bidder is an individual or sole proprietor, please indicate as much in the response. indicating their respective areas of expertise and qualifications; and

2. The résumés of staff designated as key personnel who are likely to be responsible for fulfilling the requirements of the Contract and any Statements of Work requested thereunder.

Submit as attachments

C. Entity Requirements

1. A copy of the Bidder’s Dept. of Labor Standards certificate of licensure, required in RFR Section 3.1.1.

2. Statement of number of years in business. (Section 3.1.2.)

3. Statement of number of years experience in each category of services for which Bidder is applying. (Section 3.1.3.)

1. Submit as attachment 2.&3. Submit as a brief statement.

D. Financial Condition:

Bidders’ Dunn and Bradstreet number; or if not available or provided, a Certification of Good Standing from the Mass. Department of Revenue and a statement of gross income for the last three financial periods, and a list of any outstanding contingencies and liabilities, such as lawsuits or other claims or charges against the Bidder.

A copy of the Bidder’s audited financial statement for the Bidder’s last fiscal year; or in the absence of such an audited statement, an unaudited financial statement for the Bidder’s last fiscal year, with a letter from the Bidder’s Chief Financial Officer certifying to the solvency of the Bidder.

A statement confirming the Bidder has not been in bankruptcy under the U.S. Bankruptcy Code and/or state or federal receivership within the 7 calendar years preceding this response. A disclosure, if applicable, of any solvency proceedings consistent with Section 3.2.2. of the RFR.

A statement confirming their financial business model will be able to support and fund their daily business as a Qualified Vendor under any contract awarded from this RFR, and that the Bidder has at least four months of adequate reserves.

A statement confirming Bidder is in good standing and compliance with the filing requirements of its state of incorporation and the Commonwealth of Massachusetts, if applicable.

A certificate from the taxing authority of the state in which the Bidder has its principal office, attesting that the Bidder is not in default of any obligation under its tax laws. Corporations with principal offices in Massachusetts may satisfy this requirement by submitting a “Certificate of Good Standing” issued by the Massachusetts Department of Revenue (DOR). For instructions on obtaining the DOR certificate, visit: https://www.mass.gov/info-details/dor-certificate-of-good-standing-andor-corporate-tax-lien-waiver-faqs.

A statement confirming Bidder is not subject to a federal or state debarment order or aware of an investigation that could result in a debarment.

Submit as attachments

E. Liability Coverage

1. A copy of Bidders statement of insurance sufficient to meet the requirements of RFR Section 3.3.1 for Categories 1 and/or 2.

Submit as an attachment

F. Conflict of Interest: To demonstrate freedom from conflicting interests, the Bidder shall submit the following:

1. A statement of any and all of the financial, legal, contractual, and other business interests of the Bidder and any material subcontractor, its affiliates, partners, parent(s), subsidiaries, and related organizations, if any, that may impact its performance under the Contract. In cases where such relationships or interests exist or appear to exist, describe how a potential or actual conflict of interest will be avoided or remedied;

2. Any other information requested by EOHHS that, in EOHHS’s judgment, is relevant to the Bidder’s financial, legal, contractual, or other business interests.

If EOHHS determines that a Bidder possesses a conflicting interest, EOHHS reserves the right to propose or consider the Bidder’s proposal of any measures to eliminate or mitigate such conflicting interest to EOHHS’ satisfaction.

Submit as attachments:

1. Statement not to exceed one page

2. Additional documents, only if requested by EOHHS.

SECTION 3: PROGRAMATIC RESPONSE

1. Category 1: Describe Bidder’s experience performing Leadership/Executive Searches for healthcare organizations. Include examples of successful assignments of directly hired individual identified as a result of the Bidder’s leadership search.

2. Category 2: Describe Bidder’s experience providing Interim Leader candidates to healthcare leadership positions for temporary assignment. Include the types of positions and entities the Bidder has helped with in the past.

Submit as an attachment a narrative of not more than one page for each of the RFR categories for which the Bidder seeks to be considered.

B. Examples of Experience and References: Examples of projects demonstrating the Bidder’s qualifications and expertise to perform the work described in Section 4 of the RFR. Include as project references individuals who have direct knowledge of the services the Bidder provided for the reference organization. EOHHS staff may be included as a reference.

(Note: EOHHS reserves the right to contact any of the references Bidder includes in its response.)

Submit no more than three specific examples in total using the table below

1.

Name of Project:

Contracting Entity:

Project Reference Contact Information (Name, address, e-mail, phone):

2.

Name of Project:

Contracting Entity:

Project Reference Contact Information (Name, address, e-mail, phone):

3.

Name of Project:

Contracting Entity:

Project Reference Contact Information (Name, address, e-mail, phone):

C. Largest Customers: List up to five customers in the following categories, consistent with the requirements in RFR Section 3.5:

1. Three largest customers;

2. Largest government customer and/or

3. Largest customer in Masaschusetts.

Bidders may indicate additional out of state customers to reach the five customer limit, if the Bidder so wishes.

For each entity listed include a description of the scope of services provided, and duration of service relationship/contract.

Submit as an attachment.

(1 page or less)

SECTION 4: ADDITIONAL RESPONDENT QUALIFICATIONS

Category 1 – Narrative Description The Bidder shall provide a narrative description for contract implementation as set forth below. The Bidder should not simply recite or restate requirements. The Bidder shall include:

1. A description of the steps or processes Bidder would use to conduct leadership searches upon EOHHS request;

2. A description of Bidder’s pre-screening and interviewing processes; and

3. A description of Bidder’s processes to verify licensure, educational background, and background checks.

Submit as attachment (one page or less)

Category 2 – Narrative Description The Bidder shall provide a narrative description for contract implementation for Category 2 services, as set forth below. The Bidder should not simply recite or restate requirements. The Bidder shall include:

1. A description of Bidder’s recruitment processes to identify Interim Leader candidates;

2. A description of Bidder’s pre-screening and interviewing processes; and

3. A description of Bidder’s processes to verify licensure, educational background, and background checks.

Submit as attachment (one page or less)

SECTION 5: COST RESPONSE (Respond only for applicable Category(ies))

Category 1 – Leadership Search: Cost Response

1. Bidder shall provide their rate card for Category 1 search services consistent with the Maximum Rates set forth in Exhibit 1 of the RFR.

2. The Rate Card must include all (1) fees; (2) costs and expenses; (3) payment schedule; (4) cancellation terms; (5) guarantee terms; (6) and any other Contractor terms.

Submit as attachment

Category 2 – Interim Leader: Cost Response

1. Bidder shall provide their rate card for Category 2 Interim Leadership services consistent with the Maximum Rates set forth in Exhibit 1 of the RFR.

2. Rate Card must include: (i) job title; (ii) daily rate; (iii) conversion schedule; and (iv) direct placement fee; except that Contractor may describe their rate-setting methodology in lieu of quoting a specific rate provided such methodology results in rates that do not exceed the maximum rates set forth in Exhibit 1 of the RFR.

3. Rate Card may include additional rates for travel and any additional terms as may be applicable to services offered.

4. Rate Card must specify for the daily rate, the gross amount paid to the Interim Leader (pay rate) and the amount charged by the Contractor (Contractor mark-up/bill rate).

Submit as an attachment

RFR for Master Agreement for Leadership Staffing Services Attachment A – Bidder Application