RFA 5407-0 Final tlh Attachment 1 5-13-22.docx

OREGONBUYS NUMBER S-44300-00003094 OHA-RFA-5407

ATTACHMENT 1: APPLICATION

OHA Application – Trauma Hospital Surveyor to Conduct:

Site Reviews and Focused Reviews for Oregon Hospitals Seeking Designation, Re-Designation, Accreditation or Re-Accreditation as Trauma Centers (Read RFA before completing. Print or Type all entries.)

1. Name:

2. Physical Location Address:

3. Mailing Address (if different):

City State Zip

City State Zip

4. Area Code - Phone #:

6. Email:

7. Federal Tax ID#/SSN #

8. Required Insurance Professional Liability Insurance Company:

Policy #: Expiration Date:

Commercial General Liability Insurance Company:

Policy #: Expiration Date:

Automobile Liability Insurance Company:

Policy #: Expiration Date:

Workers’ Compensation: Does Contractor have any subject workers, as defined in ORS 656.027? (Check one box): |_| YES |_| NO If YES, provide the following information:

Workers’ Compensation Insurance Company:

Policy #: Expiration Date:

*Note: Workers Compensation Insurance is required in the circumstances described in Exhibit C (Insurance Requirements) to Contract to RFA # 5407.

*Note: For more information about these business entity types, please review http://www.sba.gov/smallbusinessplanner/start/chooseastructure/START_FORMS_OWNERSHIP.html Please also complete the information requested in this Attachment 1, pages 4-10 of this Applicant Application Form.

By signing this page and submitting an Application, the signor certifies that the following statements are true:

1. Applicant understands and accepts the requirements of this RFA. By submitting an Application, Applicant agrees to be bound by the Contract terms and conditions in Attachment A and as modified by any Addenda.

2. Applicant acknowledges receipt of any and all Addenda to this RFA.

3. If awarded a Contract, Applicant agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Contract.

4. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

5. Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin.

6. Applicant and Applicant’s employees, agents, and subcontractors are not included on:

a. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or

b. the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/

7. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Applicant, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFA. If any changes occur with respect to Applicant’s status regarding conflict of interest, Applicant shall promptly notify the State in writing.

8. Applicant certifies that all contents of the Application (including any other forms or documentation, if required under this RFA) and this Application Certification Sheet are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.

9. Applicant understands that any statement or representation it makes, in response to this RFA, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Contract being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

10. Applicant acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment A at the time of Contract execution.

APPLICANT

By: Title: Date:

Printed Name:

APPLICANT’S DOCUMENTATION RE:

COMPLIANCE WITH SECTION 2. MINIMUM QUALIFICATIONS

1. Experience and Qualification Criteria All Applicants must meet one or more of the following in order to be considered for a Contract:

· Trauma Surgeon

· General Surgeon

· Emergency Physician

· Registered Nurse with expertise in Trauma Program Management Applicants Qualifications

2. Responsible Applicants As an Applicant, meet the “responsible Applicant” requirements identified in Oregon Revised Statutes and Oregon Administrative Rules (ORS 279B.005, 279B.110 and Oregon Administrative Rules (OAR 125-247-0640)). Access to the rule can be achieved at the following website: http://www.leg.state.or.us/ors/279b.html.

3. Other Requirements Applicable to All Providers:

a. Insurance: Each Provider must possess the insurance coverage specified in Exhibit C of the Sample Work Order (Attachment 2, Exhibit A);

b. Photo ID: Each Provider must possess a valid form of photo identification; and

c. Email and Phone Service: Each Provider must possess email and phone services for responding to OHA in a timely fashion.

d. Conflict of Interests Disclosure: Each Provider must be willing and able to identify any actual or potential conflicts of interest with hospitals being reviewed (on a Conflict of Interest Disclosure form provided by OHA) prior to issuance of a Work Order to that Provider.

4.

Trauma Surgeon/General Surgeon Qualifications

a. Licensed Physician in the Applicant’s state of residence;

b. Board certified or Board eligible General Surgeon;

c. Expertise in trauma systems, trauma care, and trauma program functions at or exceeding the accreditation level of the hospitals to be surveyed;

d. In-depth expertise in Quality Improvement; and

e. Other requirements of Section 3 regarding; insurance, photo ID, email, phone service, and Conflict of Interest Disclosure.

Applicant’s Response to above requirement Trauma Surgeon/General Surgeon Applicant Qualifications

Does Applicant meet the above requirements of Sections 2.1 and 2.2.1? (Check one box): Yes: No:

Applicant’s Physician License #: __________ Applicant’s License Expiration Date: ___________________ Applicant’s Board Certification in General Surgery #: __________ Applicant’s Board Certification in General Surgery Expiration Date: ________________ Describe Applicant’s Status as Board Eligible General Surgeon: ____________________

Knowledge and expertise in trauma systems, trauma care, and trauma program functions (check the applicable level): Level 1: Level 2: Level 3: Level 4:

Applicant has in-depth expertise in Quality Improvement (check one box): Yes: No:

Attach Curriculum Vitae to Application to document Applicant’s qualifications stated above.

5.

5. Emergency Physician Applicant Qualifications

a. Licensed Physician in the applicant’s state of residence;

b. Board certified or eligible Emergency Physician;

c. Expertise in trauma systems, trauma care, and trauma program functions at or exceeding the accreditation level of the hospitals to be surveyed;

d. In-depth expertise in Quality Improvement; and

e. Other requirements of Section 3 regarding; insurance, photo ID, email, phone service, and Conflict of Interest Disclosure.

Applicant’s Response to above requirement Emergency Physician Applicant Qualifications

Does Applicant meet the above requirements of Sections 2.1 and 2.2.3? (Check one box): Yes: No:

Applicant’s Physician License #: __________ Applicant’s License Expiration Date: ___________________ Applicant’s Emergency Physician Certification#: __________ Describe Applicant’s Status as Board Eligible Emergency Physician:

Applicant’s Emergency Physician Certification Expiration: Date: ______________ Knowledge and expertise in trauma systems, trauma care, and trauma coordinator functions (check the applicable level): Level 1: Level 2: Level 3: Level 4:

Attach Applicant’s Curriculum Vitae to Application to document Applicant’s qualifications stated above.

6.

Registered Nurse with expertise in Trauma Program Management Applicant Qualifications

a. Licensed Registered Nurse in the applicant’s state of residence;

b. Expertise in trauma systems, trauma care, and trauma program functions at or exceeding the accreditation level of the hospitals to be surveyed;

c. In-depth expertise in Quality Improvement; and

d. Other requirements of Section 3 regarding; insurance, photo ID, email, phone service, and Conflict of Interest Disclosure.

Applicant’s Response to above requirement Registered Nurse with expertise in Trauma Program Management Applicants Qualifications:

Does Applicant meet the above requirements of Sections 2.1 and 2.2.4? (Check one box): Yes: No:

Applicant’s Registered Nurse License #: __________ Applicant’s License Expiration Date: ___________________ Knowledge and expertise in trauma systems, trauma care, and trauma coordinator functions (check the applicable level): Level 1: Level 2: Level 3: Level 4:

Attach resume to Application to document Applicant’s qualifications stated above.