Service Questionnaire.docx

Attachment 1 – Service Questionnaire

LARIMER COUNTY DEPARTMENT OF HUMAN SERVICES

CORE SERVICES

Certification Form This Application Certification Form only needs to be completed once per applicant.

Instructions:

1. Fill out the Document

a. Click on the fillable fields or use the “Tab” key to navigate.

b. Enter your information and ensure accuracy.

2. Save Changes

a. Click “File” > “Save” or press Ctrl +S (Windows) / Cmd + S (Mac)

3. Save as PDF

a. Click “File” > “Save As.”

b. Choose a location and select “PDF” from the “Save as type” dropdown.

c. Name your file and click “Save.”

4. Submit the PDF

a. Locate the PDF, then attach it to the proposal in Bidnet

AGENCY / NAME:

FEDERAL IDENTIFICATION NUMBER or SOCIAL SECURITY NUMBER:

AUTHORIZED SIGNER PRINTED NAME: TITLE:

WEBSITE:

ADDRESS:

CITY: STATE: ZIP:

TELEPHONE NUMBER:

EMAIL ADDRESS:

SIGNATURE: DATE:

BUSINESS STRUCTURE (Non-Profit, Government, LLC, Sole Proprietor, etc.):

BUSINESS TYPE (Small, Large, Disadvantaged, Minority owned, etc.):

BUSINESS NAME CHANGES IN THE PREVIOUS TEN (10) YEARS:

Provide the following information for the individual who will serve as the primary contact for your organization for technical and contractual clarifications during the RFQ process, if different than the authorized signatory:

Service Questionnaire This Application Narrative only needs to be completed once per applicant. Each question below has a 6,000-character limit unless otherwise noted; approximately 800 words.

A. Experience & Qualifications – 30 Points

1. Provide a brief description of your agency including total staff size, staff and organizational diversity number of years in operation, mission, and history.

2. Is your agency a Medicaid provider?

3. List any professional, state, or required licenses, and accreditations/certifications that are applicable.

4. Provide a statement of related work experience and knowledge providing alcohol and drug testing services.

5. Explain the agency’s experience serving the population specified in this RFQ.

B. Procedures & Policies – 30 Points

1. Provide a detailed description of the agency’s understanding of the program, the goals, objectives, outcomes, and the impact of those programs and services for Larimer County.

2. Describe the client population to be served.

3. Provide a detailed description about the program/services you propose to provide and desired impact of those programs/services.

4. Provide detailed information about the goals, objectives, activities, outcomes, timelines, and staffing for the proposed program/services. Include how you will determine engagement, completion, success and impact of services.

5. Include a comprehensive and sound program design and system delivery.

6. Describe how your organization will monitor and evaluate the quality of the services. Specify process and outcome measurements for program effectiveness.

7. Provide the agency’s documentation, record keeping, data collection and analysis reporting system.

C. Collaboration – 20 Points

1. Describe any partnerships or collaborations in which you are involved and how they may be enhanced or supported by this service.

D. Pricing – 20 Points

1. Cost Proposal – This should be a fee for service rate. Rates must be inclusive of all administrative and overhead costs, including report writing. Cost Proposal spreadsheet is Attachment 2.

Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary Covered Transactions Instructions for Certifications

This form only needs to be completed one time per applicant.

1. By signing and submitting this application, the prospective primary participant is providing the certification set out below.

2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency’s determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.

3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

4. The prospective primary participant shall provide immediate written notice to the department or agency to which this application is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this application is being submitted for assistance in obtaining a copy of those regulations.

CERTIFICATION

1. The prospective primary participant certifies to the best of knowledge and belief, that it and its principals:

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department;

(b) Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federally, State or local) with a commission of any of the offenses enumerated in paragraph (1) (b) or this certification; and

(d) Have not within a three-year period preceding this application had one or more public transactions (Federal, State or local) terminated for cause or default.

2. Where the Prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this application.

Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary Covered Transactions Instructions for Certifications Signature Page –

SIGNATURE: TITLE:

NAME OF AGENCY: DATE:

ADDRESS:

CITY: STATE: ZIP:

Insurance and Contract Attestation Form Larimer County is diligent about enforcing insurance requirements listed in all contracts. This diligence means the County expects all applicants to acknowledge and attest to the following statements.

It is recommended that you confirm with your insurance carrier before submitting your application that your company can meet the insurance requirements published in the solicitation. All Larimer County contracts require the vendor to maintain the defined insurance requirements throughout the contract term; these coverages are purchased at the applicant’s expense. The County’s insurance requirements may necessitate adding or increasing coverage or limits, and those changes may impact pricing for the proposed project. These costs must be included in pricing at the time of submission and will not be permitted to be added later.

(initial) I certify, on behalf of the applicant identified below, that I have reviewed the Insurance Requirements for this solicitation.

(initial) I certify that the applicant currently meets or will obtain all the Insurance Requirements provided in this solicitation before entering a Contract with the County.

(initial) I understand, upon Notice of Award, I will be required to submit a valid Certificate of Insurance meeting the Insurance Requirements published in this solicitation. I understand a valid Certificate of Insurance must be received by Larimer County within ten (10) business days of the Notice of Award and must include Larimer County as Additional Insured and Certificate Holder.

(initial) I further hereby certify, I have read the sample contract attached to the solicitation and understand the terms and provisions contained in that contract, and it is the applicant’s intent to comply with each and every term and provision contained in the sample contract and propose no modifications to the sample contract except as follows (There will be NO modifications to insurance provisions except in regard to the waiver of Workers’ Compensation for sole proprietors and personal auto in place of business auto for those who use personal autos for business use):

(initial) I understand that the modifications stated above, if any, are offered for discussion purposes only, and Larimer County reserves the right to accept, reject, or further negotiate all proposed modifications to the sample contract.

Agency/Name:

Printed Name (Authorized) Signer:

Signature of Authorized Signer:

DORA ATTESTATION AGREEMENT

AGENCY/PROVIDER NAME:

The Department of Regulatory Agencies (DORA) is the state's umbrella regulatory agency, charged with managing licensing and registration for multiple professions and businesses, implementing balanced regulation for Colorado industries, and protecting consumers. As part of the Colorado Code of Regulations, Volume 7, contractors are required by statute to be licensed, registered, or certified to perform the purchased service. As a contractor with Larimer County, you are required to complete the following document to meet the terms of your Contract.

Please check the appropriate box(es):

I attest that I am a professional registered with DORA.

I attest that my employees are professionals registered with DORA.

I attest that I am not registered with DORA.

I attest that my employees are not registered with DORA.

If DORA registration is not applicable, please note why:

Alternative registrations/credentials held:

By signing below, I attest that the above information is accurate, and I agree to notify my Program Quality Assurance Coordinator of any changes in my registration with DORA, including any complaints or disciplinary actions filed relevant to my registration.

Application Checklist This Application Checklist only needs to be completed once per applicant. Your Application will not be considered complete unless all documents are included. Please make certain that you include the following:

Completed Application submitted via BidNet® Completed Application Packet (Attachment 1)

· Primary Covered Transactions

· Instructions for Certifications

· Completed Application Checklist Insurance and Contract Attestation Form DORA Attestation Agreement Application Checklist Project Description and Budget (Attachment 2)

· One (1) per each service applied for

Please place an X next to each item above to indicate that it is included in your submission. You are advised to review your materials to ensure they are comprehensive before you submit it.

I have reviewed this Application and have included all the required information:

PRINTED NAME OF PERSON COMPLETING APPLICATION:

TITLE:

SIGNATURE: DATE:

image1.wmf image2.png