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4.5 PROPOSAL QUESTIONS AND EVALUATION CRITERIA

In your Proposal, please respond to the questions in each of the following Sections 4.5.1 through 4.5.6.

Overall Assessment – 200 Maximum Points Possible

Question Service Area Points Possible4.5.1 Program Services 95 Section Points

1 Program Mission, Philosophy and General Description 25

2 Target Service Population 5

3 Admission and Intake Criteria 5

4 Program Size and Capacity 5

5 Client Fee Schedules 5

6 Program Services 35

7 Medical Services and Oversight 5

8 Coordination of Community Services 10

4.5.2 Quality Assurance and Evaluation 15 Section Points1 Quality Assurance System 10

2 Evaluation Practices 5

4.5.3 Program Management 40 Section Points1 Program Supervisory Structure 5

2 Staffing Qualifications and Ratio 10

3 Staff Development Plan 5

4 Cultural Competence 5

5 Handling of Synthetic Opiates 5

6 State Site Review(s) 5

7 Prior Experience in Providing Synthetic Opiate Outpatient Treatment or Related Service

5

4.5.4 Sustainability Questions 50 Section Points1 Proposer General Sustainable Practices (10%) 20

2 Social Equity (10%) 20

3 Employee Healthcare and Other Benefits (5%) 10

TOTAL POINTS POSSIBLE 200 Total Points

4.5.1 PROGRAM SERVICES 95 Section Points Possible

1. Program Mission, Philosophy and General Description 25 Points Possible

State your agency’s or organization’s overall mission and purpose, and explain how the Synthetic Opiate Outpatient Treatment Services detailed in this RFPQ are appropriate for your agency or organization. Describe how this effort will complement any other service modalities offered by your agency or organization. Please describe your synthetic opiate outpatient treatment program including the goal(s) and philosophy(-ies) of your treatment program; your approach to concepts of abstinence and recovery; how you address community re-integration including issues related to employment readiness, employment, and housing; and how you collaborate with other systems.

Evaluation Criteria:The Proposer:

Has stated the agency’s or organization’s mission and purpose.

Demonstrated that their agency/organization is appropriate to offer the services outlined in this RFPQ, describing any relation to other services offered by the agency.

Demonstrates active commitment to alleviating alcohol, tobacco, and other drug (ATOD) problems for individuals, families, and the community.

Describes a philosophy that reflects treatment that is client-focused, sensitive to personal and cultural issues of the clients, and supports long-term success in recovery.

Operates a treatment program that aligns with the County goal of providing outpatient synthetic opiate treatment services to eliminate opiate use; improve the person’s ability to function within society including employment readiness, employment, and stable housing; and minimize the medical and social complications of drug abuse.

Discusses the program’s philosophy informing the design of the continuum of services; stabilization, transitional, and maintenance phases of treatment; and any follow-up support for those clients who choose to transition to recovery without the use of medication.

Describes how services are arranged to meet treatment goals in addition to the elimination of illicit opiate use, and how issues are addressed that affect the client’s potential for achieving long-term recovery. Services are built around healthy client re-integration into the community, and reflect collaboration with other clinical service providers and with other social/human service systems.

2. Target Service Population 5 Points Possible

Describe the target treatment population you plan to serve including characteristics, geographical distribution, needs, issues, and treatment requirements.


Provides a well-defined description of the treatment population to be served, and articulates the needs of the population including the needs, issues, and treatment requirements of special population sub-groups such as pregnant women, ethnic and sexual minorities, homeless persons, deaf and hearing-impaired persons, offenders, and non- or limited-English speaking clients.

3. Admission and Intake Criteria 5 Points Possible

Describe your admissions policy and intake criteria and how those criteria will determine the inappropriateness of the client for other treatment modalities; determine the person's physiological dependence on opiates; and prevent multiple enrollments in other agencies.


Describes admission policies and intake criteria that are appropriate for and respectful of targeted service population, and procedures that assure that (a) other treatment modalities are considered/tried for the client and deemed inappropriate, (b) the client has demonstrated physiological dependence on opiates, (c) multiple enrollments in treatment programs are prevented, and (d) referrals are made for alternative services for people not admitted to the treatment program.

4. Program Size and Capacity 5 Points Possible

Please describe the total size/capacity of your treatment program and the number of publicly-funded clients that can be served, including OHP-enrolled clients. Separately identify the program size/capacity for County-funded and OHP-funded clients. Detail how County-funded services will complement OHP and private-pay clients, and how you will track funding changes in County-funded versus OHP-funded clients.


Describes the treatment program’s total size/capacity including the number of publicly-funded clients that can be served.

Demonstrates that services can be provided by accessing complementary funding streams.

Describes methods used to track changes in client OHP enrollment status, and related changes in source of public funds being used, i.e. County-funds versus OHP-coverage.

5. Client Fee Schedules 5 Points Possible

Describe your client fee schedule, including how it allows for the admission of low-income clients, and how it is implemented. Explain any difference between the fee schedules used for County-funded clients, OHP-funded clients, and private-pay clients.

NOTE TO PROPOSERS: Attach copies of your client fee schedule and client fee assessment forms as well as any pertinent procedures/protocols (as Attachment 3). Please note the fee schedule, client fee assessment form, and any pertinent guidelines used in applying the fee schedule will not be included in maximum page limitation of this RFPQ.


Describes how a sliding fee scale is implemented and how it allows for the admission of low-income clients.

Describes assurances that no one will be denied admission to the program because of lack of or limited ability to pay for services.

Provides a copy of their fee schedule, client fee assessment form, and any pertinent procedures/protocols used in applying the fee schedule.

6. Program Services 35 Points Possible

Describe your agency’s continuum of treatment services including the specific types of services and stages of treatment offered. Please identify referral and access considerations. Discuss the assessment and treatment planning process, how clients are involved in treatment planning, and how the treatment needs of clients are coordinated with other individuals or agencies involved with the client. Describe how you address the clinical needs of special populations such as those who have co-occurring disorder, those who are pregnant, those with acute medical problems, etc. Discuss how changes in a client’s stage of treatment are determined. Describe how urinalysis testing and results contribute to client interventions and treatment planning determinations. What kinds of referrals are made to external community-based resources, and why? How is nicotine dependency addressed in your program? When is a client considered no longer appropriate for your agency, and what are the processes for both planned service conclusion and involuntary termination? What are you most proud of in terms of how you have designed your services?


Describes a continuum of treatment services which minimally meet OARs requirements. Additionally reflects an awareness of and appropriate use of evidence-based practices, and rigorously combines pharmacological and behavioral interventions.

Describes how services are accessible both by hours of operation and by location, and how provisions are made for services on days the program is closed.

Provides thorough assessment of medical and bio/psycho/social issues. Demonstrates the capacity to provide individualized services as determined by the specific needs of the client and varying according to the stage of treatment.

Reflects knowledge of established best practices as are used to inform client stage of treatment, level of care and placement criteria.

Identifies services addressing the clinical needs of special populations such as those who have a co-occurring disorder, those who are pregnant, those with acute medical problems, etc.

Identifies how clients are involved in on-going treatment planning and in discharge planning processes.

Offers effective strategies for engagement of family and significant others.

Describes active collaboration with such public jurisdictions as the County Department of Community Justice and Oregon State DHS child welfare services.

Demonstrates how urinalysis testing and results contribute to client interventions and treatment planning.

Offers both onsite supportive services as well as referrals to community-based resources which focus on overcoming environmental barriers to long-term recovery.

Describes the process for involuntary termination from the program.

Demonstrates an agency plan to make available nicotine dependence and tobacco cessation services.

7. Medical Services and Oversight 5 Points Possible

Describe how medical oversight is assured, what types of medical services are provided on-site, and how dosages are determined.


Has or will have a Medical Director on staff or on contract no later than the start date of services for this RFPQ (July 1, 2011).

Articulates who is in charge of the synthetic opiate treatment services including determining dosages, dispensing of synthetic opiates, monitoring client effects, documentation in client records.

Provides the following minimum on-site services: Routine urine testing; emergency medical services; tuberculosis, HIV, and Hepatitis C risk awareness and risk assessment; communicable disease evaluation and follow-up, and coordination of prenatal services.

8. Coordination of Community Services 10 Points Possible

Describe when, where, and how you communicate with other service systems and familiarity with community resources, and how this coordination contributes to individual client outcomes.


Describes systems established to provide regular care coordination efforts with partner agencies or organizations.

Describes the parameters of working with other alcohol/drug service providers.

Demonstrates a close working relationship with the criminal justice system; describes how case planning is coordinated with DHS systems.

Demonstrates familiarity with community-based resources and describes how service coordination occurs.

4.5.2 QUALITY ASSURANCE AND EVALUATION 15 Section Points Possible

1. Quality Assurance System 10 Points Possible

Please describe your data collection system, and how it relates to quality assurance. Address the elements of your quality assurance/evaluation plan which describe what is evaluated, the procedures and who is responsible for carrying them out, and the schedule for implementation.


Describes the quality assurance/evaluation plan, and its elements and related processes and procedures; identifies the number and roles of staff assigned to the function of quality assurance.

Provides details about their data collection system and its use in managing service capacity and utilization, cost data, access and retention, etc.

Describes the means of maintenance and review of licensing, certification(s) and contract requirements for services and facility(-ies); identifies how staff certification/licensing active status is monitored.

Articulates how well their program is doing in achieving its stated agency goals and service outcomes.

2 Evaluation Practices 5 Points Possible

Describe an actual experience where quality assurance/evaluation practices were used, how they were used, and the outcome(s).


Articulates at least one example of previous experience with quality assurance/evaluation practices that demonstrates the agency’s or organization’s ability to carry out quality assurance and evaluation practices that result in improved service delivery.

4.5.3 PROGRAM MANAGEMENT 40 Section Points Possible

1. Program Supervisory Structure 5 Section Points Possible

Please describe the synthetic opiate outpatient treatment services program's supervisory structure, qualifications, and process. Describe how administrative supervision is provided, to whom, and by whom (identify staff roles). Describe how clinical supervision is provided, to whom, and by whom.


Describes the program’s administrative supervision function, and who is involved.

Describes the qualifications of the Clinical Supervisor; identifies how this person is sufficiently experienced in synthetic opiate addiction treatment to guide clinical practices.

Describes how at a minimum of two (2) hours per month of clinical supervision is provided to clinical staff, and if direct observation of service delivery plays a role.

Identifies the specifics of any other relevant supervision functions.

2. Staffing Qualifications and Ratio 10 Points Possible

Please describe the synthetic opiate outpatient treatment services program staffing structure for all program roles, and address considerations about staff experience and qualifications. Describe the proposed treatment counselor-to-client ratio for each phase of treatment.


Describes a service model that provides adequate levels of trained and experienced staff in the different program roles and in accordance with relevant OARs. Addresses program philosophy about staff in recovery.

3. Staff Development Plan 5 Points Possible

Please describe your staff development plan. Identify how staff is supported in their professional development efforts. Does the agency provide onsite training, and if so, on what training topics? Does the agency provide a budget and/or agency release time for external training opportunities? Provide relevant specifics, and address any staff coverage or scheduling issues.


Describes a sound staff development plan.

Identifies internal and/or external training opportunities, whether the program provides a budget and/or agency release time, and how staff schedule issues are handled.

4. Cultural Competence 5 Points Possible

Please describe your agency’s or organization’s cultural competency plan for staff and clients. How does this plan advise the delivery of services which are culturally appropriate? Address how the plan is implemented, monitored, and updated as needed.


Describes a written cultural competency plan which addresses both staff and clients, and how the plan informs the degree to which services are delivered in a culturally appropriate manner.

Describes how the plan is implemented, monitored, and updated.

5. Handling of Synthetic Opiates 5 Points Possible

Please describe your agency’s or organization’s policies and procedures for handling your stock of synthetic opiates.


Articulates their policies and procedures for monitoring and controlling their inventory of synthetic opiates, and with what state and/or federal requirements they are in compliance.

6. State Site Review(s) 5 Points Possible

Describe the program’s processes both for maintaining the agency’s or organization's operational policies and procedures in compliance with OARs 415-020-0000 through 415-020-0090, and for keeping staff current on the rules and regulations.

NOTE TO PROPOSERS: Please provide a copy of the report from your last State site review(s). Proposers Site Reviews should be labeled Attachment 4 and will not be counted against the Proposal’s total page count. The Proposer’s organization or agency must have been found in “substantial compliance” with OARs 415-020-0000 through 415-020-0090 by the Oregon Department of Human Services (DHS), Addictions and Mental Health Division (AMH).


Has provided a copy of their State last site review(s) documenting they have been in “substantial compliance” with appropriate Oregon Administrative Rules (OARs) OAR 415-020-0000 through 415-020-0090 by the Oregon Department of Human Services (DHS), Addictions and Mental Health Division (AMH).

Articulates their plan for maintaining operational policies and procedures in compliance with OARs and identifies how staff are kept current on rules and regulations.

7. Prior Experience in Providing Synthetic Opiate Outpatient Treatment or Related Service 5 Points Possible

Please describe your organization's or agency’s experience providing synthetic opiate outpatient treatment or related services. Address compliance with State and federal governmental regulations in providing these services, and identify any relevant accreditation standards which have been met.


Identifies length of experience in providing synthetic opiate outpatient treatment or related services.

Identifies history of compliance with OARs, DEA, etc. Identifies any accreditation certificates which have been awarded, i.e. CARF, etc.

4.5.4 SUSATAINABILITY QUESTIONS 50 Section Points Possible

1. Proposer General Sustainable Practices 20 Points Possible

The County seeks to partner with suppliers who demonstrate a commitment to its Sustainable Purchasing Policy (See Section 1.11). It is expected that the successful Proposer incorporate sustainable practices into daily business operations and will continue to do so while meeting the requirements of a contract resulting from this procurement.

Please describe your organization’s or agency’s sustainability practices both in the delivery of services and through in-house resource conservation efforts. Practices might include use of

recyclable materials in dosing procedures; encouragement of client and/or staff use of public transportation resources; video and/or teleconferencing; use of electronic medical records; electronic invoicing; duplex printing; use of post-consumer recycled copier and printer paper; in-house recycling programs (paper, cans/bottles/plastic, organic waste, etc); use of energy-efficient fluorescent lighting and/or motion sensor lighting; and/or use of green cleaning products.


Describes a variety of sustainable practices currently in use in the delivery of services, and/or near-future implementation plans for sustainable business practices.

2. Social Equity 20 Points Possible

The County is committed to extending contracting opportunities for State of Oregon certified Minority, Women and Emerging Small Businesses (MWESBs). In order to promote economic growth, the County seeks to maximize the participation of MWESB consultants, partners, contractors, and suppliers throughout the duration of the project as well as a diverse workforce.

Describe your firm’s commitments to providing equal employment opportunities including your organization’s or agency’s efforts to develop an internally diverse workforce; internal on-the-job training, mentoring, technical training and/or professional development opportunities addressing diversity; and the process(es) used to recruit women and minorities.


Describes the agency’s or organization’s commitment to providing equal employment opportunities.

Describes efforts used to develop an internal diverse workforce.

Describes internal diversity mentoring, training, and/or professional development opportunities.

Describes process(es) used to recruit women and minorities into the organization or agency.

3. Employee Healthcare and Other Benefits 10 Points Possible

The County recognizes that contracting with Proposers who offer Healthcare and Other Benefits to their employees demonstrates responsible community stewardship.

*Note to Evaluators: Evaluation Points for the two questions below have been pre-determined; please score accordingly

3.1 Employee Healthcare 4 Points Possible

Please select one applicable statement from the three below:

(1) Proposer offers health insurance with a primary care benefit to employees that is equal or above the prioritized list for the Oregon Health Plan (available online at http://www.oregon.gov/OHPPR/HSC/current_prior.shtml).

Yes ___ (4 pts) No ___ (0 pts)OR(2) Proposer offers health insurance without a primary care benefit to employees that is equal

or above the prioritized list for the Oregon Health Plan (available online at http://www.oregon.gov/OHPPR/HSC/current_prior.shtml).

Yes ___ (2 pts) No ___ (0 pts)OR(3) Proposer offers no health insurance benefit to employees or health insurance with or

without a primary care benefit to employees that is below the prioritized list for the Oregon Health Plan (available online at http://www.oregon.gov/OHPPR/HSC/current_prior.shtml).

Yes ___ (0 pts) No ___ (N/A)

3.2 Other Benefits 6 Points Possible

Please select yes or no for each of the three items below:

(1) Proposer offers sick leave to all full-time employees.

Yes ___ (2 pt) No ___ (0 pts)OR(2) Proposer offers vacation benefits to all full-time employees.

Yes ___ (2 pt) No ___ (0 pts)OR(3) Proposer offers retirement benefits to all full-time employees.

Yes ___ (2 pt) No ___ (0 pts)

http://www.oregon.gov/OHPPR/HSC/current_prior.shtml



4.6 PROPOSER CHECKLIST

Following is a checklist of attachments and forms that are available for your use by downloading them from the County Purchasing Website at: www.multcopurch.org.

The checklist is for Proposer use, and does not need to be submitted with the Proposal. It is to help the Proposer visualize what elements / attachments need to be returned with your Proposal. Please organize your Proposal in the following order:

Document Name

Return With

Proposal

WordOr

PDF DocumentOfferor Representations and Certifications – Signed – See Section 4.1.5

Yes Word Attachment 1

Proposal Response Cover Page:See Section 4.1.6


Proposal ResponseSee Section 4.2

Yes Word Proposer to Place their Proposal submission between attachments 2 and 3.

Client Fee Schedule, Assessment Form and Pertinent Fee Schedule GuidelinesSee Section 4.5.1 Question 5


State Site Review(s)See Section 4.5.3 Question 6


Qualified Vendor Application Package (QVAP)*See Part 3

Yes* Word Attachment 5*

Exceptions to Contract Terms and Conditions**See Section 5.2.1

Yes** Word Attachment 6**

Sample Multnomah County DCHS MHASD Services ContractSee Section 5.2.1

No PDF Attachment 7Informational Only

NOTE: A FULL COPY OF THE ATTACHMENTS ARE AVAILABLE ELECTRONICALLY FROM Purchasing – See the Purchasing website at www.multcopurch.org, click on the “Bid & Proposal Opportunities” link on the left side of the screen, then click on “Go to current bid and proposal opportunities”, then scroll down to Procurement R11-10416.

*Attachment 5—QVAP must be submitted at the time of Proposal response AND must be submitted in a separate envelope from Proposal response.

**Attachment 6—Exceptions to Contract Terms and Conditions is only required if Proposer has any exceptions.

http://www.multcopurch.org/

http://www.multcopurch.org/

Solicitation ATTACHMENT 1

OFFEROR REPRESENTATIONS AND CERTIFICATIONS

FAILURE OF THE OFFEROR TO COMPLETE AND SIGN THIS FORM MAY RESULT IN REJECTION OF THE SUBMITTED OFFER

The undersigned, having full knowledge of the specifications for the goods or services specified herein, offers and agrees that this offer shall be irrevocable for at least 30 calendar days after the date offers are due or as stated in the solicitation, and if accepted, to furnish any and/or all goods or services as described herein at the prices offered and within the time specified.

OFFEROR NAME:

ADDRESS:

TELEPHONE NUMBER: FAX NUMBER: WEB SITE:

DATE/STATE OF INCORPORATION:

BUSINESS DESIGNATION: Corporation Sole Proprietor Partnership S Corporation Non-Profit Government Other

MWESB CERTIFICATION: Number Minority Owned Woman Owned Emerging, Small N/A

ASSURANCES - The Offeror attests that: 1. The person signing this offer has the authority to submit an offer and to represent Offeror in all phases of this procurement process; 2. The information provided herein is true and accurate;3. The Offeror is a resident proposer, as described in ORS 279A.120, of the State of ______________, [insert State] and has not discriminated against

any minority, women, or emerging small business enterprises in obtaining any required subcontracts, in accordance with ORS 279A.110;"Resident bidder" means a bidder that has paid unemployment taxes or income taxes in this state during the 12 calendar months immediately preceding submission of the bid, has a business address in this state and has stated in the bid whether the bidder is a "resident bidder". ORS 279A.120 (1) (][b);

4. Any false statement may disqualify this offer from further consideration or be cause of contract termination; and5. The Offeror will notify the Department Contracts Officer within 30 days of any change in the information provided on this form.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS - The Offeror certifies to the best of its knowledge and belief that neither it nor any of its principals: 1. Are presently debarred, suspended,

proposed for debarment, declared ineligible or voluntarily excluded from submitting bids or proposals by any federal, state or local entity, department or agency;

2. Have within a five-year period preceding the date of this certification been convicted of fraud or any other criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) contract, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are presently indicted for or otherwise criminally charged with commission of any of the offenses enumerated in paragraph 2. of this certification;

4. Have, within a five-year period preceding the date of this certification had a judgment entered against contractor or its principals arising out of the performance of a public or private contract;

5. Have pending in any state or federal court any litigation in which there is a claim against contractor or any of its principals arising out of the performance of a public or private contract; and

6. Have within a five-year period preceding the date of this certification had one or more public contracts (federal, state, or local) terminated for any reason related to contract performance.

Where Offeror is unable to certify to any of the statements in this certification, Offeror shall attach an explanation to their offer. The inability to certify to all of the statements may not necessarily preclude Offeror from award of a contract under this procurement.

SIGNATURE OF AUTHORIZED PERSONSignature Date

Print Name & Title

Contact Person for this procurement:

Phone Email


PROPOSAL RESPONSE COVER PAGE

REQUEST FOR PROPOSALSFor

RFP No. R11-10416Synthetic Opiate Outpatient Treatment Services

PROPOSER NAME:

Use this Proposal Cover Page as the first page of your Proposal response, directly behind Attachment 1


CLIENT FEE SCHEDULE, ASSESSMENT FORM, AND PERTINENT FEE SCHEDULE GUIDELINES

Reference: See Section 4.5.1 Question 5: Client Fee Schedules

Proposer: Please insert a copy of your client fee schedule(s), client fee assessment form(s), and pertinent guidelines used in applying the fee schedule.


STATE SITE REVIEW(S)

Reference: See Section 4.5.3 Question 6: State Site Review

Proposer: Please insert a copy of the report from your agency’s or organization’s most recent State Site Review(s).


Department of County Human ServicesQualified Vendor Application Package - QVAP

Organizations doing business with Multnomah County must have the capacity to manage and monitor administrative contract requirements. Please submit the information requested here with your proposal response—via separate envelopes. One (1) original and one (1) complete copy of this package are requested. (See Part 3 – QVAP Process)

1. Organizational ChartPlease submit a current organizational chart that indicates lines of authority and communication for all organization's programs. Include on the chart the person-in-charge (e.g., executive director), and the administrative and program management position(s). Clearly identify where administrative contract management responsibilities lie.

2. Executive Director/AdministratorPlease identify the name, title, and job description of the position-in-charge (e.g., executive director) for the Provider organization.

3. Administrative OversightPlease identify the name(s) and title(s) of the employee(s) responsible for meeting administrative contract requirements (e.g. insurance, non-discrimination, property management) and overseeing contract corrective action, and describe their job duties as they relate to these functions. Be sure to include these positions on the organizational chart.

4. Personnel PoliciesPlease submit a copy of the Table of Contents for the organization's personnel policies/ procedures manual.

5. Non-Discrimination PolicyPlease submit a copy of the organization’s non-discrimination policy stating that the organization will not discriminate against any individual with respect to employment or provision of services based on that individual's race, color, religion, sex, national origin, age, sexual orientation, political affiliation, marital status, or disability. Please also submit a statement that the organization is willing and able to comply with the following non-discrimination policies should it be awarded a contract (See Non-Discrimination Certificate for use or sample):

o Executive Orders 11246: www.dol.gov/esa/regs/statutes/ofccp/eo11246.htmo Title VI of the Civil Rights Act of 1964, as amended: www.eeoc.gov/laws/vii.htmlo Section 504 of the Rehabilitation Act of 1973:

www.dol.gov/oasam/reg/statutes/sec504.htmo Americans with Disabilities Act: www.usdoj.gov/crt/ada/adahoml.htm

6. Accountability Mechanism Description, Roles, and FunctionsPlease describe the purpose, functions, and structure of the organization’s accountability mechanism, e.g., Board of Directors, Advisory Committee, etc. These may be outlined in by-laws. Be sure to cover what role the governing body or alternative mechanism plays in:

Setting and overseeing business planning and policy development. Planning refers to guiding the future direction of the organization’s business, e.g., identifying areas for program development and innovation. Policy refers to setting the philosophy and values of the organization, and principles and guidelines for making operational decisions. Example: policy on cultural diversity, policy on types of programs appropriate for the organization to operate.

Overseeing the organization’s budget, both its development and the organization's ongoing financial position.

Overseeing operations of the organization. This includes involvement with issues affecting delivery of services as well as personnel matters when organizational policy and procedures are concerned.

Assuring accountability of the organization’s business and operations to funding sources, legal requirements (e.g., tax laws), and the organization’s clientele.

7. Financial StatementPlease provide a current Financial Statement prepared by an independent certified auditor.

8. List of Membership and RepresentationPlease complete the Accountability Membership form. Identify who is currently a member of the governing body or alternative accountability mechanism, their terms, who or what they are representing. If any members are staff or owners of the organization, be sure to identify their number and positions and provide a statement of assurance that management staff does not constitute a quorum.

ACCOUNTABILITY MECHANISM MEMBERSHIP(This is usually your Board of Directors)

Diversity Status:

W=WomenM=Minority: African American, SE Asian, Native American, Hispanic, Pacific IslanderO=Other Diversity Categories; Please Specify:

What Constitutes a Quorum?

Name Representation Term Diversity Status

NON-DISCRIMINATION CERTIFICATE

Provider:

Address:

Telephone:

The organization named above will not discriminate against any individual with respect to employment or provision of services based on that individual's race, color, religion, sex, national origin, age, sexual orientation, political affiliation, marital status, physical or mental disability, gender identity, source of income, familial status, or other protected status.

Additionally, this organization complies with Executive Order 11246, Title VI of the Civil Rights Act of 1964, as amended, Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act.

Contractor: ______________________________________________Authorized Agency Signature

Dated: ______________________________________________


EXCEPTIONS TO CONTRACT TERMS AND CONDITIONS

Reference: See Section 5.2.1

Proposer: Insert text if your agency or organization has any exceptions to Contract Terms and Conditions.

4€¦ · web viewoperates a treatment program that aligns with the county goal of providing...

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