QuarterlyTemplateReport_Sales_and_SDP_Form3_Etzel_6_7_13.xlsx
XLSX spreadsheet 31 KB Posted
- Attached to
- HSP40 Medical Commodities
- Solicitation number
- BD-14-1080-OSD01-OSD10-00000000422
- Issued by
- Massachusetts
About this file
This document is a template for a Quarterly Revenue Report and Supplier Diversity Program (SDP) Spending Report required for a state contract in Massachusetts. The report covers information on purchases and environmental purchasing data made during the fiscal year period, as well as the contractor's SDP spending commitment and status. The report requires the contractor to provide details such as the purchasing entity, delivery date, product or service description, unit of measure, purchase price, quantity ordered, list price, and any environmental purchasing information. The SDP Spending Report section requires the contractor to report quarterly on their spending with certified SDP partners and demonstrate compliance with their annual spending commitment percentage. The related state contract opportunity is for HSP40 Medical Commodities, issued by the state of Massachusetts.
The pricing and savings information is based on an established rate chart or price schedule, with the report capturing any savings realized. Contractors must submit the completed report to the Strategic Sourcing Manager within 45 days of the end of each quarter. The report includes attestation by the contractor regarding the accuracy of the information provided.
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Other files
| File | Type | Posted |
|---|---|---|
| sdp-plan-form-1-commitment.docx | DOCX document | |
| c-tc.doc | DOC document | |
| eppform.doc | DOC document | |
| EFT_FORM.pdf | ||
| RFR HSP40 Rev A 10-30-14.doc | DOC document | |
| consig contractor authorized signatory.doc | DOC document | |
| RFR HSP40 6-3-14.doc | DOC document | |
| ppd.doc | DOC document | |
| sdp-plan-form-3-reporting.xlsx | XLSX spreadsheet | |
| sdp-plan-form-2-declaration.docx | DOCX document | |
| w_9.doc | DOC document | |
| Reference_Letter_Template_HSP40.docx | DOCX document | |
| RFRHSP40_RFRChecklist Rev 1.doc | DOC document | |
| HSP40_VENDORNAME_CATALOG.xlsx | XLSX spreadsheet | |
| standard_contract_frm HSP40.doc | DOC document | |
| Units of Measure.xlsx | XLSX spreadsheet |
Show all 16
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Text version
Cover Page
| CONTRACT TITLE and Number: (Insert Contract Number and Name by clicking on Cell A1) |
| Contract Category / SubCategory (where applicable): |
| CONTRACTOR INFORMATION |
| Company Name: (Click on Cell A5 and overtype this informaiton with Company Name) |
| Contact Person: (Click on Cell A6) |
| Contact Person's Phone Number/Email: (Click on Cell A7) |
Reporting Quarter Date: (Click on Cell A9)
| Completing the Report - Vendor Instructions | ||
| The Quarterly Revenue Report covers the Fiscal Year period indicated above. | ||
| The first worksheet contains the required reporting data to assess the purchases made during this period and capture environmental purchasing information. | ||
| The second worksheet pertains to your company's Supplier Diversity commitment and the status of that commitment by the end of the fiscal year. | ||
| Contract vendors must provide information in all the columns indicated in the report and return the completed form to the Strategic Sourcing Manager at OSD | ||
| For questions, contact: | peter.etzel@state.ma.us | |
| Email all completed reports to: | peter.etzel@state.ma.us |
mailto:peter.etzel@state.ma.usmailto:peter.etzel@state.ma.us
1. Standard Product Report Data
| CONTRACT TITLE and Number: (Insert Contract Number and Name by clicking on Cell A1) | ||
| Contract Category / SubCategory (where applicable): | Entity Classification (Column B) | |
| Authority | ||
| CONTRACTOR INFORMATION | Executive Agency | |
| Company Name: (Click on Cell A5 and overtype this informaiton with Company Name) | Higher Education | |
| MassDOT | ||
| Reporting Quarter Date: (Click on Cell A7 to enter reporting quarter period) | Municipality | |
| Non-Profit / POS | ||
| Entity Classification (Column B) - Vendors will choose one to best describe the purchasing entity | Other | |
| Drop Down Options | Savings is based on the difference between an established rate chart or price schedule and the pricing charged to the State. | |
| Authority (includes MWRA, MassPort, Housing Authorieis, legislative branch, etc.) | ||
| Executive Agency (State agencies) | ||
| Higher Education | ||
| MassDOT (Formally MTA and MassHighway) | ||
| Municipality (includes Schools, Fire, Police, DPWs, other city/town depts.) | ||
| Non-Profit / POS (Purchase of Service) | ||
| Other (Not included in the Above List) |
Name of Purchasing Entity (e.g. agency, authority, city or town, college, school, non-profit, other) Entity Classification Delivery Zip Code Date of Purchase or Order Delivery Date Product Brand Name or Supply Brand Product Mfr. and/or OEM Name Service/Product Description (include item size where applicable) Unit of Measure (UOM) e.g. hours, gal, cs, ea, sq yrd, etc. UOM Purchase Price or Hourly Rate UOM Quantity Ordered or Hours Total Purchase / Order Amount List Price (non-contract price) List Price Total Savings EPP Product Description (eg: recycled paper content, low toxicity, energy efficient, 3rd party certified, water conservation, etc.)
DPH 01823 10/5/12 12/17/12 Report, Consulting, Translation N/A Report, Transcript hours $ 125.00 35 $4,375 $290.00 $10,150 $5775 - See above 25 cases of paper with 40% recycle content.
Contractor Revenue Report - PRODUCTS Draft Template for Annual Reporting
EDITION 6/29/11 &P
2. SDP for Products
| CONTRACT TITLE and Number: (Insert Contract Number and Name by clicking on Cell A1) | |
| Contract Category / SubCategory (where applicable): | Entity Classification (Column B) |
| Authority | |
| CONTRACTOR INFORMATION | Executive Agency |
| Company Name: (Click on Cell A5 and overtype this informaiton with Company Name) | Higher Education |
| MassDOT | |
| Reporting Quarter Date: (Click on Cell A7 to enter reporting quarter period) | Municipality |
| Supplier Diversity Program (SDP) Spending Report |
| SDP Plan Form #3 |
| Document Number/Name: |
| Instructions: This form must include information on your company's spending with your Supplier Diversity Program (SDP) Partner(s) and must be completed and submitted |
| within 45 days of the end of each quarter to Commonwealth Contract Manager. |
Part I Contractor Information (Required)
| Contractor Company | Contact Name | Total Supplier Diversity | Quarterly Contract Sales | Fiscal Year | |||
| Name | Spending Commitment %* | Quarter 1 (7/1-9/30) | Quarter 2 (10/1-12/31) | Quarter 3 (1/1-3/31) | Quarter 4 (4/1-6/30) | Total (calculates automatically) | |
| $ - 0 |
Part II SDP Partner Information (Required) (Insert additional lines as needed)
| SDP Partner(s) Company | Email Address** | Certification Type*** | Quarterly Spending with Supplier Diversity Partner(s) | Fiscal Year | |||
| Name | (Choose One) | Quarter 1 (7/1-9/30) | Quarter 2 (10/1-12/31) | Quarter 3 (1/1-3/31) | Quarter 4 (4/1-6/30) | Total (calculates automatically) | |
| $ - 0 | |||||||
| $ - 0 | |||||||
| $ - 0 | |||||||
| $ - 0 | |||||||
| $ - 0 | |||||||
| $ - 0 | |||||||
| Year-To-Date Compliance Check (Do not change this line) | $ - 0 |
If not in compliance, please explain why and what actions will be taken to bring your company to compliance with the annual spending commitment:
Part III By signing below I attest to the accuracy of the information provided in this report:
| Name | Supplier Diversity Certification Acronyms: |
| Title | MBE - Minority Business Enterprise |
| Phone | WBE - Woman Business Enterprise |
| MWBE - Minority and Woman Business Enterprise | |
| Authorized Signature | SDVOBE - Service-Disabled Veteran-Owned Business Enterprise |
| (leave blank if submitted electronically) | |
| Date |
| *This is your company's SDP Plan commitment percentage submitted in your Bid Response or established through negotiation. |
| **The Supplier Diversity Office and contracting department reserves the right to contact SDP Partners at any time to request that they attest to the amounts reported to have been |
| paid to them by the Contractor. |
| ***Certification Status for SDP Partner(s) can be checked at www.mass.gov/sdo |
File details come from the government source that posted it. Updated .