S-10000-00018293 Att C - Applicant Questionnaire and Service Selection.pdf

RFA # S-10000-00018293 – Disaster Human Services Vendors Attachment C (Agency Internal #6323)

ATTACHMENT C

APPLICANT QUESTIONNAIRE AND SERVICES SELECTION

Submit this completed form with your Application Packet

1. Applicant’s Point of Contact for Price Agreement Negotiations:

Name

Title

Phone

Email

2. Applicant’s Business Name:

Name of Business

Physical Address of Business Location

City, State, Zip

Note: If Applicant has more than one business location relevant to the Services selected, list additional locations on a separate sheet and attach it to this Attachment C.

3. Applicant Service Selection:

Please select each Track and optional capability Applicant is applying to provide.

Applicants may select one or more.

a. Service Selection: (Applicants may select one or more)

• Track 1 - Community Human Services Support YES NO Direct support to individuals, households, and communities, including Resource Navigation, Referrals, Outreach, basic Casework, emergency assistance, resource distribution, and support through Resilience Hubs or other community locations.

• Track 2 - Human Services Network Coordination YES NO Coordination of organizations and services across a community or region, including convening partners, mapping resources, coordinating Referrals and resources, identifying service gaps, and supporting continuity from response through recovery.

• Track 3 - Individual Assistance Implementation and Disaster Case Management YES NO Disaster Case Management and implementation of Individual Assistance authorized by ODHS, including assessment, Recovery Planning, sustained case coordination, household assistance, and required documentation.

• Flexible Funds / Household Assistance Administration

YES NO

Administration of ODHS-authorized household assistance through approved payments or purchases to Providers on behalf of Households, with required documentation and financial controls.

• Training and Capacity Building Capability

YES NO

Training, coaching, facilitation, consultation, technical assistance, exercises, or other capacity-building support related to disaster human services. (For Applicants with relevant Track 3 experience only)

4. Service Area and Capabilities:

a. List Applicant's Primary Service Area (counties, Tribal jurisdictions, or other geographic area):

b. Is Applicant willing to provide Services outside its Primary Service Area when requested by ODHS? YES NO If no or limited, describe any geographic limitations:

c. Identify communities or populations Applicant regularly serves, including culturally specific, linguistically specific, rural, Tribal, or other community relationships relevant to the selected Services:

5. Applicant Service Rates.

List Applicant’s current rate or rates for the Services it is applying to provide.

Attach a rate sheet if additional space is needed.

Is Applicant willing to negotiate with Agency the rate or rates provided?

YES NO

Service Rates:

6. Key Person: Specify at least one (1) key person to serve as Contractor’s primary point of contact for Service requests, performance, and billing.

7. Application Criteria Narrative: Applicant must separately submit the narrative required by Section 3.1 of the RFA. See Section 3.1 for requirements and page limit.

Applicant Signature: ____________________________ Date: ___________________________

Printed Name: _________________________________ Title: ___________________________