request for proposals (rfp) therapy.pdf · proposal (rfp) process to provide physical therapy...

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RFP Number: DMR-RFP-MVDC-34 The Ohio Department of Developmental Disabilities (DODD), Mount Vernon Developmental Center is requesting proposals for: Physical Therapy Services MVDC For the Period: State Fiscal Years 2018 (FY18) 2019 (FY19) July 1, 2017 through June 30, 2019 RFP Issued: April 13, 2017 Inquiry Period Begins: April 13, 2017 Inquiry Period Ends: April 21, 2017 at 8:00 AM Proposals Due: April 28, 2017 at 4:00 PM Submit Proposals via e-mail to: Ohio Department of Developmental Disabilities [email protected] This RFP consists of five (5) parts and one (1) attachment, totaling thirteen (14) consecutively numbered pages. Please verify that you have a complete copy. Please submit all inquiries about this RFP through the State Procurement web site at www.ohio.gov/procure. Please refer to Part Three of this RFP, General Instructions, for instructions on submitting inquiries through the State Procurement web site. All responses to inquiries submitted by contractors will be posted on the State Procurement website for viewing by all prospective contractors. REQUEST FOR PROPOSALS (RFP)

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Page 1: REQUEST FOR PROPOSALS (RFP) Therapy.pdf · Proposal (RFP) process to provide Physical Therapy services to individuals. It is the intent of this document that vendors provide a single

RFP Number: DMR-RFP-MVDC-34 The Ohio Department of Developmental Disabilities (DODD), Mount Vernon Developmental Center is

requesting proposals for:

Physical Therapy Services MVDC

For the Period: State Fiscal Years 2018 (FY18) – 2019 (FY19) July 1, 2017 through June 30, 2019

RFP Issued: April 13, 2017

Inquiry Period Begins: April 13, 2017 Inquiry Period Ends: April 21, 2017 at 8:00 AM

Proposals Due: April 28, 2017 at 4:00 PM

Submit Proposals via e-mail to:

Ohio Department of Developmental Disabilities

[email protected]

This RFP consists of five (5) parts and one (1) attachment, totaling thirteen (14) consecutively numbered pages. Please verify that you have a complete copy. Please submit all inquiries about this RFP through the State Procurement web site at www.ohio.gov/procure. Please refer to Part Three of this RFP, “General Instructions”, for instructions on submitting inquiries through the State Procurement web site. All responses to inquiries submitted by contractors will be posted on the State Procurement website for viewing by all prospective contractors.

REQUEST FOR PROPOSALS (RFP)

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RFP: Physician Services RFP Number: DMR-RFP-MVDC-13 Page 2

PART ONE: STRUCTURE OF THIS RFP

PARTS Part One Structure of this RFP Part Two Information on requested services Part Three General Instructions Part Four Evaluation of Proposals Part Five Contract Award ATTACHMENTS Appendix 1 – Contractor Information Form

o Contractor Information Form must be completed and submitted with the proposal.

PART TWO: SERVICES REQUESTED INFORMATION

I. BACKGROUND

Mount Vernon Developmental Center (DC) is a Medicaid-certified Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), operated by the Ohio Department of Developmental Disabilities (DODD), serving approximately 80 individuals with developmental and other disabilities.

II. PURPOSE

Mount Vernon Developmental Center intends to select an offeror thorough this Request for Proposal (RFP) process to provide Physical Therapy services to individuals. It is the intent of this document that vendors provide a single proposal covering all categories of work for this service. Vendor will provide during Fiscal years 2018 (FY18) and 2019 (FY19) an annual maximum of 1,040 hours of Physical Therapy and 50 hours of Occupational Therapy. Total 2,080 hours of Physical Therapy and 100 hours of Occupational Therapy for 2 fiscal years.

III. SCOPE OF WORK

Perform the following under the direction of the Medical Director: Conducts individual evaluations and updates performance records/evaluations accordingly; selects, develops, and modifies and/or adapts specialized evaluations/assessments methods; interprets evaluation results for individual, staff and IPP teams. Assures all items mentioned are within ICF/IID guidelines for certification. Plans, establishes and directs physical and occupational therapy treatment plans to provide guidance to staff working with individuals or for individuals with unusual, complex or persistent disabilities or as deemed necessary by the IPP team. Assures compliance with ICF/IID guidelines. Must have experience in ICF/IID guidelines, policies, and procedures, which will assure compliance with ICF/IID certification. Provides and coordinates physical therapy group or individual treatment for individuals with

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unusual, complex or persistent disabilities or as deemed necessary by the IPP team; demonstrates treatment methods and approach for MVDC staff. Evaluates need for and makes referrals for orthotic devices. Monitors use and repair of all orthotic devices. Evaluates need for, identifies and designs individual's adaptive devices or equipment. Works with outside vendors to coordinate individual's needs with their services. Monitors use and maintains good repair of all adaptive equipment and devices. Observes, records and reports individual behavior, treatment, progress and evaluation results. Documents status of treatment as services are provided. Documents time spent with each individual for Medicaid reports and maintains audit trail for same. Completes a monthly summary of treatment status and recommendations for modifications. The documentation falls within ICF/IID guidelines. Participates in annual team meetings as needed; provides written input to relevant annual team meetings. Serves as team member for those individuals receiving direct therapy services. Consults with professional personnel regarding individual programming, general program development, treatment goals, etc.; makes treatment related recommendations to physicians, other professional personnel, and IPP team members. Provides in-services training to professional and non-professional staff regarding physical therapy treatment and philosophy, individual physical therapy goals, use of orthotic devices, adaptive equipment, and information related topics with regard to individual’s overall needs. Works with workshop settings, day programs and temporary medical placements to ensure coordination of services and follow on discharge plans. Provides formalized training and functionally supervises MVDC staff in physical therapy programs. Requisition supplies and equipment, and maintain records as needed. Continue to demonstrate current professional practices and principles of physical therapy as indicated by work performance, through practice demonstrated and interaction with individual-staff and professionals from the community. Maintain a reciprocal professional and cooperative relationship with Mount Vernon Developmental Center Staff. Services are to be provided by the primary therapist up to 20 hours per week for FY18 and FY19 during the daily hours of Monday through Friday from 8:00 a.m. to 4:30 p.m. It is preferred that direct services be scheduled at those times individuals are not at the workshop. This may require that therapist be scheduled to work some late afternoon/early evenings and weekend hours for direct delivery of therapy services. Emergency admissions will require therapy evaluation within 12 hour of admission. Daytime hours may be required for meetings, paperwork, etc. Contractor will work out a specific schedule with the Medical Director. Contractor’s schedule may be modified with the approval of the Medical Director. Services are to be provided by the Occupational Therapist as needed for up to 50 hours per year during each FY18 and FY19. Provides specialized professional services for facility individuals having wheelchairs. These services may include, but are not limited to, periodic evaluations/assessments, seating, positioning, organization/supervision of wheelchair clinics, and working directly with wheelchair individuals. Provide necessary documentation for 3rd party billing of adaptive equipment and wheelchairs as required by physician’s order. The contractor will provide on-going supervision of the facility (physical) therapy program by a single qualified Physical Therapist. On-site supervisory visits must be performed at a minimum

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of one (1) time per month by the supervising therapist. Supervisory duties may include, but are not limited to, coordination of contractor and the facility Medical Director. Because of the responsibilities involved, the supervising therapist should have a minimum of four (4) years adult DD experience. The contractor is responsible for assuring all therapists providing services under this contract maintain current Ohio license/certification and pursue continuing education, etc. as needed to stay current in their field. In addition, the contractor is responsible for monitoring that the therapists provide quality services to the individuals of MVDC. The contractor will be responsible for assuring all therapists providing service at MVDC are knowledgeable of standards of regulatory/licensing agencies related to the delivery of physical therapy services and implement therapy/documentation accordingly. The contractor shall submit to the Medical Directory by the first (1st) working day of each month statistics regarding therapy services delivered for the previous month. These statistics shall include hours of service delivered by the therapist(s) including direct therapy services, meetings, consultations, etc. as well as number of individuals receiving services and any other physical therapy information requested by the Program Director. The contractor will designate an Administrator to be responsible for the direction of its contract responsibilities under this contract. This designee must be available by phone during reasonable business hours (Monday-Friday; 8:00 a.m.-4:30 p.m.) to discuss areas of concern with the Program Director or Medical Director of MVDC. Provide services at Mount Vernon Developmental Center, utilizing the Center’s equipment.

IV. SPECIAL CONSIDERATIONS

A. The contractor will provide specific services to MVDC to include the following: Licensed Physical Therapist (LPT), Licensed Physical Therapist Assistant (LPTA), and Licensed Occupational Therapist (OT). The LPT/LPTA will be contracted for up to 20 hours per week during Fiscal Years 2018 and 2019; the OT will be contracted for a maximum of 50 hours annually during each of the above fiscal years.

Contractor must have a minimum of two (2) years adult development disability wheelchair experience is required, and a minimum of 30 hours professional training in wheelchair seating/assessment. Contractor shall provide proof as requested to the department director regarding prior experience in delivering direct physical therapy services to adult DD individuals. A minimum of four (4) years experience is required. Provide proof as requested to the Department Director regarding prior experience of eight (8) hours minimum regarding Intrathecal Baclofen Therapy including selection of appropriate candidates using the Ashworth, Spasm and Hygiene scales and physical therapy treatment following ITB pump implantation.

B. Shall have not been found guilty of, or pleaded guilty to, any offense set forth in Section

5123..08(1), (2), or (3) of the Ohio Revised Code; nor employ any person to provide services under this RFP who has been found guilty of, or pleaded guilty to any offense set forth in Section 5123.081(1), (2), or (3) of the Ohio Revised Code. The person(s) providing services

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under this RFP will be subject to a criminal background check prior to performing any services at Mount Vernon Developmental Center.

C. Contractor shall perform all services rendered in accordance with all applicable state of Ohio,

Ohio Department of Developmental Disabilities (DODD) regulations/licensure requirements, federal and state Medicaid (ICF/IID) regulations, Mount Vernon Developmental Center (MVDC) policies and procedures, and any and all other regulatory statutes and/or procedures MVDC desires to institute at any time during the contract period.

D. Contractor shall perform all services rendered in accordance with the service provider’s

licensure/certification requirements and the code of ethics established by the discipline/profession and/or State of Ohio licensing board.

E. Contractor shall certify that all of its employees, while working at Mount Vernon

Developmental Center, will not purchase, transfer, use, be under the influence of, or possess illegal drugs or alcohol, or abuse prescription drugs in any way.

F. Contractor shall comply with all applicable provisions of the Rehabilitation Act of 1973 and the

Americans with Disabilities Act (ADA), both in the provision of specified services and in its employment practices.

G. All services provided under this RFP shall meet the appropriate standards of the Federal

Medicaid program for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID).

H. Contractor shall not be subject to an “unresolved” finding for recovery under Section 9.24 of

the Ohio Revised Code. If there is a finding for recover, the Contractor’s proposal will be rejected.

V. ETHICAL AND CONFLICT OF INTEREST REQUIREMENTS

No contractor or individual, company or organization seeking a contract shall promise or give to any DODD employee any item of value that is of such character as to manifest a substantial and improper influence upon the employee with respect to his or her duties. No contractor or individual, company or organization seeking a contract shall solicit any DODD employee to violate any of the conduct requirements for employees. Any contractor acting on behalf of DODD shall refrain from activities that could result in violations of ethics and/or conflicts of interest. Any contractor or potential contractor who violates the requirement and prohibitions defined Section 102.03 or Section 102.04 of the Ohio Revised Code is subject to termination of the contract or refusal by DODD to enter into a contract. By submitting a signed proposal for this service, the Contractor affirms that, as applicable to the Contractor, parties listed in Division (I)(3) or (J)(3) of Section 3517.13 of the Ohio Revised Code or spouse of such party are in full compliance with Divisions (I)(1) and (J)(1) of the Ohio Revised Code in regards to campaign contributions.

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PART THREE: GENERAL INSTRUCTIONS The following sections provide a calendar of events, details on how to respond to this RFP and how to get more information about this RFP. All responses must be complete and in the prescribed format.

I. CALENDAR OF EVENTS & ON-LINE INFORMATION

The schedule for this RFP is given below and is subject to change. DODD may change this schedule at any time. If DODD changes the schedule before the Proposal Due Date, it will do so through an announcement on the State Procurement web site area for this RFP at the following link: http://procure.ohio.gov/proc/index.asp. The web site announcement will be followed by an addendum to this RFP, which also will be made available through the same State Procurement web site.

It is each prospective Contractor’s responsibility to check the State Procurement web site’s question-and-answer area for this RFP for current information and the calendar of events scheduled through award of any contract.

Other than by adherence to the RFP Inquiry process, set forth below, no contact related to this RFP shall be made with DODD until a contract award is announced. Notwithstanding this prohibition, DODD, at its sole discretion, may request additional information as part of the review process outlined below. Firm Dates

RFP Issued: April 13, 2017 Inquiry Period Begins: April 13, 2017

Inquiry Period Ends: April 21, 2017 at 8:00 AM Proposals Due: April 28, 2017 at 4:00

Estimated Dates

Contract Award Notification: May 5, 2017 Issuance of Purchase Order: To be determined

II. PROPOSAL FORMAT

Proposals must be prepared in accordance with the information in this document.

A. Proposals shall be in writing and signed by the person providing services (or in the case of companies an authorized representative on company letterhead).

B. All proposals shall be submitted on the basis of an hourly rate for each hour of service to be

provided. Contractor will provide up to 1,040 hours Physical Therapy and 50 hours Occupational Therapy per fiscal year 2018 (FY18) and 2019 (FY19). Travel expenses and travel time will not be paid. A separate quotation shall be submitted for each fiscal year period. Any modifications, variations or addendums to the above specified duties or services shall result in the immediate disqualification of that bid. All proposals shall be guaranteed. The services consist of all items listed herein for Mount Vernon Developmental Center, including all required labor, transportation, materials and equipment (including items not specifically

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noted or shown as required for complete service, subject to any exclusions listed below). It is the intent of this document that vendors provide a single proposal covering all categories of work for this service. All proposals shall be in accordance with information provided in this document. Mount Vernon Developmental Center reserves the right to interview all persons providing services under the provisions of this RFP to determine the best responsible vendor. Interviews will be after the proposal deadline and conducted on the premises of Mount Vernon Developmental Center. All proposals shall be in writing and signed by the person providing services (or in the case of companies, by an authorized representative on company letterhead). The provider must invoice the facility within 30 days of service provision. If services cannot be provided due to unforeseen circumstances, notification of the facility is mandatory and preferably one (1) hour prior to start time. The contractor will not invoice for services unless mutually agreed upon or as noted in this contract until such personnel are in place. The Superintendent or Medical Director shall approve or disapprove potential candidates for all positions specified in this contract. Any modifications, variations or addendums to the specified duties or services included herein shall result in the immediate disqualification of that bid.

C. Proposals shall include a statement of the contractor’s ability to meet the minimum

requirement qualifications. D. Proposals shall include a statement of the contractor’s ability to perform the responsibilities

listed above. E. Proposals shall state the years of experience the Contractor has serving people with

developmental disabilities. F. Proposals shall state the years of experience the Contractor has providing service under

ICF/IID standards. G. Proposals shall include the name, vitae, and license numbers(s) of all individuals to provide

services under the provisions of this RFP. H. Proposals shall include a list of previous services performed to include facility name, complete

address, telephone number, contact person, and dates service was performed. I. Proposals should include any accommodation or special needs of any person providing

services under the provisions of this RFP.

III. PROPOSAL SUBMITTAL

Proposals must be submitted in the following manner:

Proposals must be submitted via e-mail by no later than April 28, 2017 at 4:00 PM EST to [email protected].

Subject of email should be “Physical Therapy MVDC”

Contractor Information form completed and submitted with proposal

Contractors are advised there will be no opportunity to correct mistakes or deficiencies in their submitted materials after the proposal due date. Proposals that are incomplete or otherwise missing required information may not be evaluated.

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It is the Contractor’s responsibility to ensure timely submission of a complete Proposal. Late Proposals will not be scored. DODD is under no obligation to consider a Proposal which is received after the proposal due date or that is incomplete. DODD reserves the right to:

Accept or reject any and all Proposals and/or bids if DODD determines that it is in the best

interests of the State to do so. Rebid this RFP, requesting new Proposals from qualified firms. Waive or modify minor irregularities in Proposals received. Negotiate with Contractor(s), within the requirements of this RFP, to best serve the

interests of the State of Ohio. Not make an award at the end of the evaluation process; this RFP is not to be interpreted

or construed to guarantee that one or more Contractors submitting responses will be awarded contracts.

Adjust the RFP Calendar of Event dates for whatever reason it deems appropriate. Contact Contractor to clarify any portion of the Contractor’s submittal.

Mount Vernon Developmental Center reserves the right to interview all individuals providing services under the provisions of this RFP to determine the best responsive contractor. Interviews will be after the proposal deadline and conducted on the premises of Mount Vernon Developmental Center. The Contractor shall bear the cost of travel to any scheduled interview.

In accordance with federal and state statutes and DODD policy, no person shall be excluded from participation or subject to discrimination in the RFP process on the basis of race, color, age, sex, national origin, military status, religion, or disability.

IV. INQUIRIES

From the issuance date of this RFP, until a contract is awarded to a contractor, there may not be communications concerning the RFP between any supplier who expects to submit a proposal and any employee of DODD involved in the issuing of the RFP. The only exception is provided through the submission of written requests for clarification/interpretation via the state procurement website during the inquiry period.

Prospective Contractors may make inquiries or seek clarifications regarding this RFP any time during the inquiry period listed in the RFP Calendar of Events. To make an inquiry, prospective Contractors must use the following process:

1. Access the State Procurement web site at http://www.procure.ohio.gov. 2. From the Navigation Bar at the top, select “for Suppliers”. 3. Under the title “Bid Opportunities”, select “All Opportunities”. 4. Enter the RFP Number found on Page 1 of this document as the “Document/Bid Number”. 5. Click the “Search” button. 6. Select this RFP. 7. On the document information page, click the “Submit Inquiry” button. 8. On the document inquiry page, complete the required “Personal Information” section by

providing the following: a. First and last name of the prospective contractor’s representative who is

responsible for the inquiry;

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b. Name/Company/Business of the prospective contractor; c. Representative’s business phone number; and d. Representative’s e-mail address.

9. Type the inquiry in the space provided, making certain to include the following: a. A reference to the relevant part of this RFP; b. The heading for the provision under question; and c. The page number of the RFP where the provision can be found. d. Enter the Security Number.

10. Click the “Submit” button.

Prospective Contractors submitting inquiries will receive an immediate acknowledgement by e-mail that their inquiry has been received. The prospective contractor who submitted the inquiry will not receive an e-mail response to the question, but will need to view the response on the State Procurement web site where it will be posted for viewing by all prospective contractor. Prospective Contractors may view inquiries using the following process:

1. Access the State Procurement web site at http://www.procure.ohio.gov. 2. From the Navigation Bar at the top, select “for Suppliers”. 3. Under the title “Bid Opportunities”, select “All Opportunities”. 4. Enter the RFP Number found on Page 1 of this document as the “Document/Bid Number”. 5. Click the “Search” button. 6. Select this RFP. 7. On the document information page, click the “View Q & A” button to display all inquiries

with responses submitted to date.

DODD will try to respond to all properly posed inquiries within 48 hours, excluding weekends and state holidays. DODD will not respond to any inquiries received after 8:00 a.m. on April 21, 2017. Prospective Contractors who attempt to seek information or clarifications verbally will be directed to reduce their questions to writing in accordance with the terms of this RFP and state purchasing policy. No other form of communication is acceptable, and use of any other form of communication or any attempt to communicate with DODD staff or any other agency of the State to discuss this RFP may result in the contractor being deemed ineligible.

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PART FOUR: EVALUATION OF PROPOSALS

I. EVALUATION PROCESS

Mount Vernon Developmental Center’s (MVDC) evaluation process of responses submitted to this request may consist of up to four distinct phases:

1. MVDC’s initial review of all proposals for timely submission; 2. An evaluation committee review of the proposals for defects and scoring; 3. MVDC’s request for clarifications or interviews; and, 4. Negotiations or best offer requests.

At its sole discretion, MVDC will determine whether phases three and/or four are necessary under this RFP, reserving for itself the ability to eliminate or add phases three or four at any time during the evaluation process. DODD may add or remove sub-phases to phases 2 through 4 at any time if DODD believes doing so will improve the evaluation process.

II. PROPOSAL EVALUATION CRITERIA

Scores will be given for each of the following items. The highest possible score is noted with each line item. The award will be given to the Contractor with the highest score. A. Individual(s) to provide services are Ohio-licensed Physical Therapist, Licensed Physical

Therapist Assistant (LPTA), and Licensed Occupational Therapist (OT). (YES = continue to next criteria; NO = proposal rejected)

B. Experience serving individual(s) with developmental disabilities with wheelchairs. (<2 years = 0 points; 2-5 years = 5 points; 5+ years = 10 points)

C. Experience serving individual(s) with developmental disabilities with therapy.

(<4 years = 0 points; 4-9 years = 5 points;10+ years = 10 points)

D. Experience serving individual(s) with developmental disabilities with Intrathecal Baclofen

Therapy. (<8 years = 0 points; 8-12 years = 5 points; 12+ years = 10 points)

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PART FIVE: CONTRACT AWARD

I. CONTRACTUAL REQUIREMENTS

Any contract(s) resulting from this issuance of this RFP are subject to the terms and conditions as provided in the personal services contract. The information contained in the RFP and in the proposal submitted by the selected contractor shall be considered part of the contract. Term of awarded contract shall be for the initial period of fiscal year 2018 (July 1, 2017 thru June 30, 2018) with option to renew for FY19 at the rates included in this proposal. Payments for all services provided pursuant to the contract are contingent upon the availability of state and federal funds. All aspects of the contract apply equally to work performed by all subcontractors. The Contractor, and any subcontractor(s), will not use or disclose any information made available to them for any purpose other than to fulfill the contractual duties specified in the RFP. The Contractor, and any subcontractor(s), agrees to be bound by the same standards of confidentiality including federal and state statutory and regulatory requirements that apply to the employees of DODD and the State of Ohio. Before a contract can be awarded, an Affirmative Action Program Verification Form must be completed using the Ohio Business Gateway Electronic filing website (https://ohiobusinessgateway.ohio.gov). Contractor must have an approved Affirmative Action plan recorded with the State of Ohio Department of Administrative Services.

II. CONTRACT AWARD PROCESS

It is Mount Vernon Developmental Center’s intention to award one contract under the scope of this RFP and as based on the RFP Calendar of Events schedule, so long as DODD determines that doing so is in the State’s best interests and MVDC has not otherwise changed the award date. Any award decision by MVDC under this RFP is final. After MVDC makes its decision under this RFP, all Contractors will be notified (in writing or by phone, at DODD’s discretion) of the final evaluation and determination as to their Proposals. MVDC will issue a notice of contract award to the selected Contractor(s), and finalized contract terms and conditions will be forwarded for signature. Contract will include RFP and attachments and the Contractor’s accepted proposal. Once executed copies of the contract are submitted by the Contractor(s), and pending any further approvals that may be required (e.g., State Controlling Board), DODD will fully execute the contract. Once the contract is fully executed, DODD will issue a purchase order (PO). DODD will issue to the Contractor(s) one (1) copy of the signed instrument and one (1) copy of the PO for its/their files.

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Unless otherwise negotiated and included in the executed contract/scope of work, the selected contractor(s) shall be bound by all outlined services, policies and procedures as contained in the contractor’s submitted and evaluated proposal. Contractor may commence work upon receipt of a state issued purchase order. Payments for services are made thirty (30) days from receipt date of a proper invoice. A proper invoice includes the following:

Contractor’s Name

Contractor’s Address

Date(s) of services rendered

Itemization of services performed

Developmental Center name and address

Agency purchase order number

Invoice Number, assigned by Contractor

Invoice Date III. FUNDING APPROVAL THRESHOLD

In the event that contractual expenditures with the selected Contractor(s) will exceed $50,000 in spending under any contract that results from this RFP, or that otherwise exceed $50,000 in aggregate spending across all contracts between the contractor and DODD, the contract will be subject to the approval of the State of Ohio Controlling Board.

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Appendix 1: Contractor Information Form

The Contractor Information Form must be filled out and returned with a bid response.

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CONTRACTOR INFORMATION FORM

THIS FORM MUST BE SUBMITTED WITH YOUR PROPOSAL

CONTRACTOR NAME:

STREET ADDRESS:

CITY: STATE: ZIP CODE:

AUTHORIZED CONTACT NAME:

PHONE NUMBER: EMAIL:

1. Identify all of contracts currently with the State of Ohio (including DODD).

Total # of Contracts:

State Agency: Amount:

Contracted Services:

Duration of Contract:

(Attach additional sheets if necessary.)

2. Provide current employee information on both a nationwide basis (including Ohio), and

Ohio’s based operations.

NATIONWIDE OHIO

Total # of Employees:

Percent of Women:

Percent of Minorities:

3. Provide OAKS Vendor ID or Tax Identification Number:

4. If your billing address is different than mailing address above, please provide below:

Contractor Name:

Street Address:

City: State: Zip Code:

Authorized Signature Date