Schedule 1 - Vendor Checklist.docx
DOCX document 43 KB Posted
- Solicitation number
- S-0627 DCTS-17
- Issued by
- Wisconsin
About this file
This is a vendor checklist document associated with a Request for Bid (RFB No. S-0627 DCTS-17) issued by the Wisconsin Department of Health Services for Preadmission Screening and Resident Reviews (PASRR) Level II Screens. The Department seeks to contract with qualified vendors to provide a team of professionals to conduct Federally required PASRR Level II screens for prospective and current nursing home residents in Wisconsin who have a serious mental illness or intellectual/developmental disability. The services are intended to evaluate residents on behalf of the state's health services agency. The checklist serves as an organizational tool for bidders to ensure complete submission of all required documentation and materials.
The vendor checklist requires bidders to submit multiple supporting documents organized into seven tabs, including the completed Request for Bid Form, Budget Form (Schedule 2), Qualifications and Requirements Matrix (Schedule 3), Work Plan and staffing documentation (Schedules 4-5), evaluation summaries for named individuals (Schedule 6), and various certification and compliance forms. Required certifications include the Designation of Confidential and Proprietary Information Form (DOA-3027), Vendor Reference Form (DOA-3478) demonstrating prior experience with State PASRR entities within the last three years, Vendor Information Form (DOA-3477), Certification Regarding Debarment and Suspension (F-01788), U.S. Department of Agriculture Drug-Free Workplace Certification (Form FNS-730), and disclosure statements. Bidders must acknowledge compliance with all submission requirements by marking checkboxes; omission of required materials may result in bid rejection.
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Text version
Preadmission Screening and Resident Review (PASRR) Level II Screens
Schedule 1 – Vendor Checklist
Bidding Company Name
Instructions: Use this checklist to organize the bid submittal. Complete this form by marking the check boxes. By marking these boxes, you are acknowledging compliance with these items. Omission of any required materials may result in the rejection of your Bid.
| TAB A |
| Included |
| Request for Bid Form (the first page of this RFB) |
| |_| Completed and signed |
| Schedule 1 – Vendor Checklist (this document) |
| |_| Completed and signed |
TAB B
| Schedule 2 – Budget Form (entire workbook) |
| |_| Completed |
TAB C
| Schedule 3 – Qualifications and Requirements Matrix |
| |_| Completed and signed |
TAB D
| Schedule 4 – Work Plan, Organization, and Staffing |
| |_| Included |
TAB E
| Schedule 5 – Key Personnel |
| |_| Included |
| Resumes and photocopies of educational degrees, and relevant profession certifications and licensures. |
| |_| Included |
| Copies of professional services contract(s) or other written agreements. |
| |_| Included or |
|_| Not needed
TAB F
| Schedule 6 – Evaluation Summary and Notice of Appeal Rights for John Doe |
| |_| Completed and signed |
| Schedule 7 – Evaluation Summary and Notice of Appeal Rights for Jane Doe |
| |_| Completed and signed |
TAB G
Designation of Confidential and Proprietary Information Form DOA-3027. (If nothing to declare, enter “None”.)
|_| Completed and signed
| Vendor Reference Form (DOA-3478) listing at least one (1) State PASRR entity with whom the Vendor has done business similar in size and scope as required by this RFB within the last three (3) years. |
| |_| Completed |
| Vendor Information Form (DOA-3477) |
| |_| Completed |
| Certification Regarding Debarment and Suspension (F-01788) |
| |_| Completed and signed |
| U.S. Department of Agriculture Certification Regarding Drug-Free Workplace Requirements (Form FNS-730 as posted on VendorNet) |
| |_| Completed and signed |
| Disclosure Statements – see RFB Section 8.2. |
| |_| Included and signed |
Authorized Signature
Date
Above name printed or typewritten
RFB No. S-0627 DCTS-17 Schedule 1 – Vendor Checklist Page 1 of 2
File details come from the government source that posted it. Updated .