ORBuys S-44300-00001995 OHA-RFA-5171 Final Attachment 1 Application Form.doc

OREGONBUYS NUMBER: S-44300-00001995

RFA OHA-5171

Attachment 1 – APPLICATION FORM

Applicants must meet all Requirements, as described in Request for Application (RFA):

OREGONBUYS NUMBER: S-44300-00001995

RFA-OHA-5171

Applicants must comply with the RFA and submit this completed Application Form to be considered for an Agreement.

Applicant info for Quantitative Exposure Assessment, Hazard Assessment, or Alternatives Assessment Review Services

Individual/Organization Name:

Mailing Address:

City: State: County: Zip Code:

Phone:

Facsimile:

Website Address:

Type of Organization

Module(s) Applicant Is Applying to Review (check all that apply. See RFA page 3)

Responsible Proposer Requirements

Yes, Applicant is currently registered with the Oregon Secretary of State business registry.

No, Applicant is not currently registered with the Oregon Secretary of State business registry but will meet requirement prior to Agreement execution.

Applicant Examples

Yes, Applicant has attached no more than four (4) examples within the last seven years evidencing experience with the conduction or review of Quantitative Exposure Assessments, Hazard Assessments, or Alternatives Assessments or similar product assessments. These focus on one or more High Priority Chemicals of Concern for Children’s Health (HPCCCH) under the Oregon Toxic-Free Kids Act.

Yes, Applicant has provided a written summary showing evidence of their understanding of Oregon’s 2015 Toxic Free Kids Act, OHA’s Guidance for a Quantitative Exposure Assessment (QEA) per OAR 333-016-3050 and the Act’s rules as they relate to how HPCCCHs can leach from children’s products and become bioavailable to children under ‘reasonably foreseeable use and abuse of such products’(as that defined in OAR 333-016-2010)possesses the 5 years of experience in assessing exposure to children and developing fetuses posed by these chemicals, particularly from consumer products. [Such rules are found at OAR 333-016-3030(4); OAR 333-016-3050; and OAR 333-016-3060.] Yes, Applicant has provided a written summary or example of 5 years’ experience in assessing exposure by one or more of the HPCCCH chemicals to children and developing fetuses.

Yes, Applicant has provided a written summary or example of their current system/process or one they will use for identifying prior relationships, bias and actual conflicts of interest.

Yes, Applicant has provided a brief summary of Applicant’s current system/process (or one to be used) to track total hours spent on an MCP review broken down into the quarter hour along with job titles of individuals doing the work.

Yes, Applicant has provided a written summary of Applicants system/process for ensuring limited access to individuals directly reviewing the contents of the exemption request and accompanied MCP.

Yes, Applicant has provided a written summary of expertise that they possess that makes them qualified to perform the MCP review services.

Applicant Insurance

Commercial General Liability Insurance

Yes, we currently meet the CGL insurance requirement.

Do not currently meet CGL insurance requirements but will meet requirement prior to Contract execution.

Professional Liability Insurance

Yes, we currently meet the PLI insurance requirement.

Do not currently meet PLI insurance requirements but will meet requirement prior to Contract execution.

Applicant Contract Administrator

Name and Title:

Phone:

Email:

Signature:

Submit application by email to danielle.a.pompe@state.or.us . An email will be sent as confirmation of receipt.

Thank you, Danielle Pompe Oregon Health Authority Office of Contracts and Procurement 635 Capitol St. NE, Suite 350 Salem, Oregon 97301

Phone :971-374-3474 Fax : 503-978-4324