Model SOW CIR CORE RFA.doc

Department of Mental Health

COMMUNITY EMPOWERMENT CRISIS RESPONSE MASTER AGREEMENT

Statement of Work

Contractor Information:

Name:

DMH MA Contract Number:

DMH MMARS Doc ID (SOW):

Contact Person:

Name

Email

Telephone:

DMH Purchaser Information (Area/Central Office Division):

DMH Area/Central Office Division:

Contract Person:

Name:

Email

Telephone:

Reports / Invoices are to be sent:

Area Offices bbnhs@invoices@mass.gov Central Office Tayla.wiggins@mass.gov

Project

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New FORMCHECKBOX Continuation *Anticipated Effective Date of Amendment:

Service to be provided: (check all that are applicable to this SOW and for which the Contractor has been determined qualified to provide service and is on the Master Agreement as such)

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CIR: Individual & Group Counseling

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CIR: Public Education

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CIR: Community Outreach & Engagement

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CIR: Assessment & Referrals

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CIR: Training, Resources, & Consultation for Community Organizations

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CORE: Public Education

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CORE: Community Outreach & Networking

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CORE: Capacity Analysis

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CORE: Training, Resources, & Consultation for Community Organizations

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CORE: Other Activities Promoting Healing, Resilience, Empowerment, Community, & Mental Wellness

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Other:

Dates of Service: New Anticipated Start Date: End Date: _

Continuation Original Start Date: Current End Date:

New End Date:

Scope of Services: FORMCHECKBOX Attachment must be provided. The scope of service must address the following as this detail is not set forth in the RFA.

(1) Specific details as to the services to be provided (what, when, where and how much (e.g., a set of deliverables or details as to volume (e.g., expected number or hours per week; set number of persons served, set number of defined events, etc.)), (2) the required staffing, (3) the populations and communities to be served (e.g., school; a neighborhood, town, etc.); (4) service location(s); (5) service goals and/or performance measures, (5) the required reporting and invoicing. If any of the details described above vary depending on the different services/Service Components being proving that must be clear in this description.

For Continuation ONLY: FORMCHECKBOX Scope of Services amended FORMCHECKBOX No Change to Scope of Services

Payment Mechanism. Invoices must include itemized details of the Service Component, Date of Service, and Deliverable (if deliverable based). If providing invoices for Service Components to be billed separately, attach a document that explains how each will be paid.

If only one service is being provided under the SOW or all services are to be billed jointly, proceed to complete this section:

Billing Options (check applicable category):

Choose one method from below. It is important that the budget(s)/rate(s)/deliverables are developed based on the Cost Proposal Workbook submitted with the Contractor’s response to the RFA. Questions should be directed to the Central Office Contract Unit.

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Deliverable Project:

Specify the Deliverables. For each deliverable indicate (1) due date; (2) acceptance process; (3) acceptance criteria; and (4) amount payable upon the deliverable being accepted

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Cost Reimbursement Project:

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Budget attached for duration less than or equal to 12 months.

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Budget attached for duration greater than 12 months per fiscal year.

A line-item budget which must justify the cost for the entire duration must be attached.

Expenditures must be made in accordance with the approved budget for this engagement and the terms and conditions of the MA contract. Payments will be made upon the submission of invoices that are complete, align with the submitted budget, and that include appropriate documentation in accordance with the terms of the service scope and governing contract. If travel reimbursement is allowed, the details must be outlined in the budget.

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Rate Project:

Detail the applicable rate amount and the applicable unit of service, which unless otherwise approved by the Director of Contracts, will be 1 hour billed against the maximum number of units specified for the State fiscal year as is applicable Billable Rate

Billable Unit

Maximum Number of Billable Units (SOW Specific)

New Total budget for engagement $

Continuation

Current Total budget for engagement $ Amendment Amount (+ or -) for engagement $ New Total budget for engagement $

Funding: Funding for this engagement is subject to the appropriation of funds by the Massachusetts Legislature or the Federal Government for the year(s) in which services are delivered.

Changes to Scope and/or Terms: Any changes to this engagement must be agreed upon in writing in advance by both parties.

Termination: The Department, upon prior written notice, may terminate this engagement without cause and without penalty, or may terminate or suspend an engagement if the vendor breaches any material term or condition or fails to perform or fulfill any material obligation required by this engagement, or in the event of an elimination of an appropriation or absence of sufficient funds for the purposes of an engagement, or in the event of an unforeseen public emergency mandating immediate department action.

Authorizing Signature for the Vendor

Authorized Vendor Signature and Date

Print Name and Title

Authorizing Signatures for the Department

Authorized Signature and Date

Print Name and Title

*The effective start date of this Engagement or Amendment shall be the latest date this document has been executed by an authorized signatory of the Vendor, the Department or a later Engagement or Amendment start date specified above.