RFP_HD159049_Required_Attachments.pdf

ATTACHMENT 1

REQUIRED ATTACHMENT CHECK LIST

A complete proposal or proposal package will consist of the items identified below.

Complete this checklist to confirm the items in your proposal. Place a check mark or “X” next to each item that you are submitting to the State. For proposals to be responsive, all required attachments must be returned. This checklist should also be returned with your proposal package.

Attachment Attachment Name/Description

_____ Attachment 1 Required Attachment Check List

_____ Attachment 2 Cover Sheet

_____ _____ Attachment 3 Cost Sheet

_____ _____ Attachment 4 Proposer Business References

_____ _____ Attachment 5 Payee Data Record (STD. 204)

_____ _____ Attachment 6 Copy of Small Business Certification (if applicable)

_____ Attachment 7 Bidder Declaration

_____ Attachment 8 Darfur Certification

_____ _____ Attachment 9 Copy of Certificate of Liability Insurance and

Workers’ Compensation

_____ _____ Attachment 10 DDS’ Sexual Harassment Prevention Policy

_____ _____ Attachment 11 Contractor Certification Clauses (CCC-307)**

_____ _____ Attachment 12 Confidentiality Statement

_____ _____ Attachment 13 Voluntary Statistical Data Sheet (return is voluntary)*

_____ _____ Attachment 14 Statement of Assurances for Protection of Personal

Information (HIPAA)**

*This document will be sent to the Contractor upon award and shall be returned at their discretion.

** These documents are not required with the Proposal package but are required upon award of the contract.

ATTACHMENT 2 – COVER SHEET

The submission of this quote does not obligate the Department of Developmental Services to fund the proposed contract. If the quote is approved for funding, a contract will be executed between the State of California and the Contractor. When funding is authorized, the Contractor will be expected to adhere to the terms of the executed Contract.

The undersigned Contractor hereby proposes to furnish all labor, materials, tools and equipment, to provide services in accordance with the specifications and provisions received with the RFP.

1. Full Legal Name of Contractor’s Organization:

2. Mailing Address:

Street City State Zip

Telephone FAX Email

3. Federal Taxpayer Identification Number: ______________________________________________

4. Principal who is authorized to bind the Contractor:

Typed Name Title

Original Signature Date

5. Contractor’s contact person shall be: _________________________________________________

(Name and Phone Number)

ATTACHMENT 3

SALARIES COST SHEET

List all individuals the entity anticipates utilizing in this contract, grouped by area of expertise. At a minimum, the professional categories shall include the entity’s administrators, trainers, and consultants.

DIRECT LABOR

JOB TITLE (x # of positions) JOB DESCRIPTION HOURS RATE TOTAL

Project Manager 1 ____________________ _______ @ _________ ______________

RHIA 1 ____________________ _______ @ _________ ______________

RHIT 2 ____________________ _______ @ _________ ______________

CCS 6 ____________________ _______ @ _________ ______________

(List Any Additional Staff) ____________________ _______ @ _________ ______________

SUBTOTAL: $_____________

FRINGE BENEFITS

Fringe Benefits Rate @ ___________% $_____________

SUBTOTAL: $_____________

Anticipated Travel Costs* $_____________

TOTAL COSTS: $______________

*See California Department of Human Resources’ Website for the allowed reimbursement rates:

http://www.calhr.ca.gov/employees/pages/travel-reimbursements.aspx http://www.calhr.ca.gov/employees/pages/travel-reimbursements.aspx

ATTACHMENT 4

PROPOSER REFERENCES

Submission of this attachment is mandatory. Failure to complete and return this attachment with your proposal shall cause your proposal to be deemed nonresponsive and rejected.

Please provide three (3) professional references for services performed within the last five years, which are similar to the scope of work to be performed in this contract.

REFERENCE 1

Name of Firm:

Street Address City State Zip Code

Contact Person: Telephone Number:

Dates of Service: Value or Cost of Service:

Brief Description of Service Provided:

REFERENCE 2

Street Address City State Zip Code

Contact Person: Telephone Number:

REFERENCE 3

Street Address City State Zip Code

Contact Person: Telephone Number:

ATTACHMENT 5

PAYEE DATA RECORD (STD. 204)

http://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf http://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf

ATTACHMENT 6

PROPOSER’S SMALL BUSINESS CERTIFICATION (IF APPLICABLE)

ATTACHMENT 7

BIDDER DECLARATION

http://www.documents.dgs.ca.gov/pd/poliproc/MASTEr-BidDeclar08-09.pdf http://www.documents.dgs.ca.gov/pd/poliproc/MASTEr-BidDeclar08-09.pdf

ATTACHMENT 8

DARFUR CERTIFICATION

Found on following page:

http://www.documents.dgs.ca.gov/pd/pestatus/Forms/Darfur%20Contracting%20Act%20Attachment.pdf http://www.documents.dgs.ca.gov/pd/pestatus/Forms/Darfur%20Contracting%20Act%20Attachment.pdf

ATTACHMENT 9

COPY OF VALID CERTIFICATE OF LIABILITY INSURANCE AND WORKER’S

COMPENSATION

Contractor must provide proof of valid Liability Insurance and Worker’s Compensation evidencing required insurance coverage of no less than $1,000,000 per occurrence and no less than $3,000,000 aggregate.

ATTACHMENT 10

DDS SEXUAL HARASSMENT PREVENTION POLICY

(To be provided to Contractor upon award)

ATTACHMENT 11

All Entity’s must sign the first page of the Contractor Certification Clauses, CCC 307.

CONTRACTOR CERTIFICATION CLAUSES CCC 307

http://www.documents.dgs.ca.gov/pd/masters/EPAY/Elavon/ElavonExhibitC-

CertificationCCC-307.pdf http://www.documents.dgs.ca.gov/pd/masters/EPAY/Elavon/ElavonExhibitC-CertificationCCC-307.pdf http://www.documents.dgs.ca.gov/pd/masters/EPAY/Elavon/ElavonExhibitC-CertificationCCC-307.pdf

ATTACHMENT 12

CONFIDENTIALITY STATEMENT

As an authorized representative and/or corporate officer of the company named below, I warrant my company and its employees will not disclose any documents, diagrams, information, and information storage media made available to us by the State for the purpose of responding to this RFP or in conjunction with any contract arising therefrom. I warrant that only those employees who are authorized and required to use such materials will have access to them.

I further warrant that all materials provided by the State will be returned promptly after use and that all copies or derivations of the materials will be physically and/or electronically destroyed. I will include with the returned materials, a letter attesting to the complete return of materials, and documenting the destruction of copies and derivations. Failure to so comply will subject this company to liability, both criminal and civil, including all damages to the State and third parties. I authorize the State to inspect and verify the above.

I warrant that if my company is awarded the contract, it will not enter into any agreements or discussions with a third party concerning such materials prior to receiving written confirmation from the State that such third party has an agreement with the State similar in nature to this one.

(Signature of representative) (Date)

(Typed name of representative)

(Typed name of company)

ATTACHMENT 13

VOLUNTARY STASTICAL DATA SHEET

http://www.documents.dgs.ca.gov/pd/smallbus/reportspage/VSDS.pdf

(This form is voluntary in nature and need only be returned with your response at your discretion.)

http://www.documents.dgs.ca.gov/pd/smallbus/reportspage/VSDS.pdf

ATTACHMENT 14

STATEMENT OF ASSURANCES FOR PROTECTION OF

PERSONAL INFORMATION (HIPAA)

Upon award, Contractor must sign the last page of the Statement of Assurances for Protection of Personal Information (HIPAA)

(See SAMPLE CONTRACT, Exhibit F)