IMPORTANT NOTICE TO PARTICIPATING … Number: 17-020 Risk Management Incident Reporting System . ... review the MHMR Tarrant website and retrieve all related documents prior to the

IMPORTANT NOTICE TO PARTICIPATING VENDORS

RFP Number: 17-020 Risk Management Incident Reporting System

For your solicitation response to be considered you must return a complete and signed

hardcopy original solicitation along with any other documentation requested in the solicitation

Standard Terms/Conditions, Special Terms/Conditions and all Amendments/Addendums, must

be completely filled out, signed, and returned with the solicitation by the published due date.

Your solicitation response must be received in the MHMR Purchasing Department prior to the

published due date and time shown on page 1 of the solicitation. Solicitation responses received

after that date and time will be returned, unopened to the sender.

Thank you for your participation in this process.

Jamie Brockway, M.B.A., CPPO, A.P.P.

Purchasing Manager

MHMR of Tarrant

RFP 17-020 RISK MANAGEMENT INCIDENT REPORTING SYSTEM 1 OF 34

MHMR OF TARRANT PURCHASING DEPARTMENT

RFP 17-020

REQUEST FOR PROPOSAL

RISK MANAGEMENT INCIDENT REPORTING SYSTEM

BIDS DUE MARCH 23, 2017 AT 2:00 PM


PRE-PROPOSAL CONFERENCE DATE AND TIME

All vendors must attend the scheduled Pre-Proposal Conference in order to get a clear

understanding of the requirements of this RFP:

DATE: March 8, 2017

TIME: 2:00 P. M.

LOCATION: MHMR Tarrant

Purchasing Department

3840 Hulen ST Suite 200

FORT WORTH, TX 76107

RSVP: Vendors planning to attend the pre-proposal conference should RSVP, in writing, no later

than 12:00 P.M. (Noon), March 7, 2017.

Send RSVP to Purchasing Department fax at (817) 810-3100 or email

[email protected] for schedule.

RSVP:

Company Name: _________________________________________________

Contact Name____________________________________________________

Planning to attend Pre-Bid Meeting: __________YES __________NO

If yes, number of representatives from your company:_______________________________

Tel. No.: _____________________________Fax No.: ______________________________

E-Mail Address:_____________________________________________________________

Interested vendors will be required to sign in at each site. Questions from vendors will be

addressed at the pre-proposal conference. Such applicant who submits a bid and does not attend

the scheduled pre-bid conference waives any right to assert claims due to undiscovered

conditions.

mailto:[email protected]


REQUEST FOR PROPOSAL

INSTRUCTIONS/TERMS AND CONDITIONS

RFP 17-020 Risk Management Incident Reporting System

MHMR of Tarrant (MHMR) is accepting Proposals for furnishing the merchandise, supplies,

services and/or equipment set forth in this Request for Proposal.

THE ORIGINAL AND AN ELECTRONIC (DISC OR FLASH DRVE) COPY

OF

COMPLETED PROPOSAL

MUST BE RECEIVED IN THE

PURCHASING DEPARTMENT

AT 3840 HULEN STREET, SUITE 200

FORT WORTH, TEXAS 76107

ON OR BEFORE 2:00 P.M., MARCH 23, 2017

MHMR of Tarrant invites your firm to submit a Proposal. If you are interest in submitting a

proposal, please adhere to the General Instructions and Requirements as outlined in the enclosed

Request for Proposal.

Vendors shall pay particular attention to all INSTRUCTIONS, REQUIREMENTS AND

DEADLINES indicated in the attached documents and should govern themselves accordingly.

In accepting Proposals, MHMR of Tarrant reserves the right to reject any and all Proposals, to

waive formalities and reasonable irregularities in submitted documents, and to waive any

requirements in order to take the actions, which it deems to be in the best interest of MHMR of

Tarrant, and is not obligated to accept the lowest proposal.

At any time and place established for receipt of the Proposal, MHMR of Tarrant will only release

the names of the Provider(s) and/or Provider Firm(s). No other information will be released until

after MHMR of Tarrant’s Evaluation Team has evaluated the Proposals, and an award has been

made and approved by Executive staff and MHMR’s Board of Trustees.

We greatly appreciate your efforts and look forward to reviewing your submission.

Jamie Brockway

Purchasing Manager

MHMR of Tarrant


SECTION 1 – OVERVIEW

BACKGROUND AND OBJECTIVES

MHMR of Tarrant invites interested and qualified companies herein after referred to as

“Contractors”, “Providers” or “Vendors” to submit Proposals for Risk Management Incident

Reporting System in response to this solicitation.

MHMR has been a provider of quality mental health and intellectual and developmental disability

services in Tarrant since its inception in 1969. It is the second largest community center in Texas,

offering services in the following areas:

Mental health

Intellectual & developmental disabilities

Addiction

Early Childhood intervention

Criminal justice system support

Homelessness

Veterans

Originally a small center offering only mental health services, MHMR now provides services at

more than 100 sites throughout Tarrant and surrounding counties. The staff of more than 2,000

includes psychiatrists, nurses, social workers, therapists, teachers, case managers, dieticians,

volunteers and many others. All committed to providing services in a way that respects the dignity

and basic human rights of the people we serve.

SECTION II – PROPOSAL SCHEDULE (RFP)

Solicitation Packet issue date: Friday, March 3, 2017

Pre-proposal Conference date: Wednesday, March 8, 2017 at 2:00 P.M.

Receive Questions from Prospective Vendors: Friday, March 10, 2017 by 2:00 P.M.

Deadline to Respond to Questions: Wednesday, March 15, 2017 by 4:00 P.M.

Deadline for Submission of RFP: THURSDAY, March 23, 2017 at 2:00 P.M.

Anticipated Award Date: Contingent upon Committee and/or Board Approval


SECTION III – GENERAL INSTRUCTIONS

A. Questions

Deadline for Questions from Vendors: Friday, March 10, 2017 by 2:00 P.M.

Deadline for Response to Questions: Wednesday, March 15, 2017 by 4:00 P.M.

All questions concerning the Proposal specifications must be submitted in writing and emailed to

Jamie Brockway at [email protected]. It is the bidders’ sole responsibility to

review the MHMR Tarrant website and retrieve all related documents prior to the RFP

due date.

B. Submittal Procedure

The Proposal, subject to all conditions and specifications attached hereto, must be signed in INK

by a person or office or the company submitting the Proposal that is authorized to enter into

contractual agreements on behalf of the company. Proposals received unsigned will be deemed

non responsive and therefore; will not be accepted.

Deadline to submit proposal is Thursday, March 23, 2017 at 2:00 P.M. The original Proposal,

signed in ink, and an electronic copy (Disc or Flash Drive) shall be submitted in a SEALED

ENVELOPE and delivered to the attention of:

MHMR TARRANT

PURCHASING DEPARTMENT

ATTN: JAMIE BROCKWAY, PURCHASING MANAGER

3840 HULEN STREET, SUITE 200

FORT WORTH, TEXAS 76107

RFP 17-020 Risk Management Incident Reporting System

DO NOT OPEN UNTIL THURSDAY, MARCH 23, 2017 AT 2:00 P.M.

No proposal will be accepted after the stated deadline. Respondents may mail or personally

deliver their Proposals to the Purchasing Office of MHMR at the above address. MHMR will

not be responsible from any Proposal(s) that is (are) lost in the mail or not delivered to the

Purchasing Department by the stated deadline for any reason.

C. Proposal Opening

Submitted proposals will be opened at a Public Proposal Opening at 2:00 P.M., on Thursday,

March 23, 2017 at 3840 Hulen Street, Suite 200, Fort Worth, Texas 76107.

D. Proposal Format

Submittals shall be on 8 ½ inch by 11 inch, bound, stapled, or in a binder, with a Table of

Contents and all pages numbered. Each section shall be clearly identified and tabbed. For

mailto:[email protected]

http://www.mhmrtc.org/Business-Opportunities/Bids


proper comparison and evaluation, MHMR requests that proposals follow the format outlined

below.

Tab 1 - Cover Letter - A brief introductory letter of representation.

Tab 2 - Executive Summary – A brief summary highlighting the most important points

of the Proposal. The Summary should not exceed five (5) pages.

Tab 3 - Contractor Background Information - This section should include a

description of the proposer experience with other services similar to the one described

herein.

a. Submit company background information including principal place of business,

length of existence, breadth of experience and expertise, management structure,

and any other information that demonstrates relative qualifications and

experience.

b. Project Manager – Identify the proposed Project Manager and include a resume.

Include an organization chart of the proposed Management Team including key

personnel and their specific roles.

c. Address any performance related litigation that your firm may be, or has been,

involved in over the last five (5) years. Identify if your firm has had any contracts

terminated due to non-performance over the last five (5) years. Identify adverse

actions sanctioned by any regulatory authorities over the last five (5) years.

Tab 4 - Financial Consideration - Include a copy of your latest annual report or other

comparable documentation. As evidenced by the financial information requested of

each vendor, indication that the vendor, or vendors, are financially stable and able to

provide related services in its entirety. W-9 and Certificate of Insurance as required

herein.

Tab 5 - References – Proposer shall submit with this proposal a list of at least three (3)

references that pertain to this type of service or similar project performed by the firm,

preferably for government agencies. Include name of firm, name of representative,

address, telephone number, email address.

Tab 6 - Scope

a. Include a statement that all products and services quoted in proposal are in full

accord with the specifications or a brief listing of all those specification sections

to which the proposer takes exception. All comments shall be listed and numbered

in order of the respective article of the specification. This statement is required

even if no exceptions are noted.

b. Proposer’s participation and responsibility must be clearly defined. Your firm’s

methodology and project management for implementing a successful project


should be itemized for all phases. Clearly define the planning, design and

implementation process.

c. MHMR’s participation and responsibility must be clearly defined.

d. Include a proposed project schedule identifying tasks, responsibilities and

estimated time commitments from the Agency. Identify all critical milestones.

e. Include Schedule 1, Technical Questionnaire

Tab 7 – Descriptive Literature – Illustrative or descriptive literature, brochures,

specification, drawings, diagrams etc., that provide additional Proposer/product

information with regard to issues addressed in other areas of Proposer’s proposal.

Tab 8 - Proposal Pricing/Delivery - Pricing shall be itemized for all items requested in

this proposal. Brief notes referencing specific line items may be included, if necessary,

for explanation. MHMR will select and award the products and services that best meets

its needs. Vendor Acknowledgement and Proposal Form as required herein.

E. Non-Discrimination Policy Statement

MHMR of Tarrant does not discriminate against any individual or Vendor/Provider with respect

to his/her compensation, terms, conditions, or award of contract because of race, color, religion,

sex, national origin, age, disability, political affiliation, or limit, segregate, or classify candidates

for award of contract, in any way which would deprive or tend to deprive any individual or

company of business opportunities or otherwise adversely affect status as a Vendor/Provider

because of race, color, religion, sex, national origin, age, disability, or political affiliation.

F. Immigration Reform and Control Act of 1986

By submitting their proposals, Offerors certify that they do not and will not during the

performance of this contract employ illegal alien workers or otherwise violate the provisions of

the federal immigration reform and control act.

G. References and Experience

All interest parties are required to submit with their Proposal a comprehensive list of references.

Interested parties are required to provide a minimum of three (3) references where interested

party has provided services (within the last twelve (12) months) that pertain to this type of

services preferably for a government agency. References shall include company names,

address, telephone number, fax number, contact person and an email address. The interested

parties must agree to authorize client to furnish any information required by MHMR to verify

references provided, and for determining the quality and timeliness of previous work performed.

H. Proposal Guarantee/Award Procedure

It is anticipated that a recommendation for award for this Proposal will be made no more than

thirty (30) days after the PROPOSAL DUE DATE. All interested parties are required to


guarantee their Proposals as an irrevocable offer valid for one hundred twenty (120) days after

the Proposal due date. MHMR of Tarrant in its sole and absolute discretion shall have the right

to award Proposal for any or all items/services listed in each Proposal, shall have the right to

reject any and all Proposals as it deems to be in its best interest, to waive formalities and

reasonable irregularities in submitted documents, shall not be bound to accept the lowest

Proposal and shall be allowed to accept the total Proposal of any one vendor.

I. Permits

Any and all permits as required by authorities having jurisdiction, local, state, county, and/or

federal, are the total responsibility of the interested parties/Vendor/Provider.

J. Financial Information

Vendor/Provider must submit a copy of their last AUDITED financial statement. A letter from

your CPA is an acceptable alternative for Non Public companies, but must include a statement

that financial solvency is adequate to meet expenditures for a least a year.

K. Invoicing/Payments

The bidder shall be paid upon the completion of all of the following: 1) submission of an

original properly itemized invoice showing the proposal and/or purchase order number, 2)

delivery and acceptance of the commodities/services and 3) proper and legal processing of the

invoice. Proposals with payment terms of less than thirty (30) days will not be accepted.

Discounts will be considered and taken if earned. Invoices must be submitted to MHMR, P.O.

Box 2603, Fort Worth, Texas 76113. L. Price Adjustments

Vendor/Provider will be required to honor their proposed prices for the term of the contract

period.

M. Historically Under-Utilized Business (HUB)

This Agency shall make a good faith effort to utilize Historically Underutilized Business

(HUB’S) in contracts for construction, services, (including professional and consulting

services), and commodities. Please submit proof of Historically Underutilized Business “HUB”

state certificate.

If your firm is not certified, please submit Attachment A, if you intend to subcontract services. If

not, write “None” on Attachment A and submit it. N. Minority/Women and/or Disadvantaged Business The Agency shall make a good faith effort to utilize Minority/Women and/or Disadvantage

Businesses (M/W/DBE’s) in contracts for construction, services (including professional and

consulting Services), and commodities. Please submit proof of M/W/DBE certificate.


O. Direct or Indirect Assignment

The successful Vendor/Provider will not be permitted to directly or indirectly assign rights or

duties under the contract without express approval from MHMR. P. Form W-9 Vendors are to complete For W-9 and Submit with Proposal Documents.

http://www.irs.gov/pub/irs-pdf/fw9.pdf

SECTION IV – PROPOSAL STIPULATIONS AND REQUIREMENTS

A. Modification or Withdrawal of Proposals Any Proposal may be modified or withdrawn prior to the deadline, provided such modification

or withdrawal is submitted prior to the deadline. Any modification received after the deadline

shall be deemed late and will not be considered.

B. Errors or Omissions:

The bidders will not be allowed to take advantage of any errors or omissions in the

specification. Where errors or omissions appear in the specifications, the bidder shall promptly

notify MHMR in writing of such error or omission it discovers. Any significant errors,

omissions or inconsistencies in the specifications are to be reported no later than five (5) days

before time for the proposal response is to be submitted. C. Offer and Acceptance Period

All Proposals must be an irrevocable offer valid for 120 days after the Proposal opening. D. Late Proposals

Proposal received after the stated deadline shall be deemed late and will not be considered.

E. Irregularities in Proposals Except as otherwise stated in this Request for Proposal, evaluation of all Proposals will be based

solely upon information contained in the Vendor/Provider’s response to this Proposal. MHMR

shall not be held responsible for errors, omissions or oversights of a material nature may

constitute grounds for rejection of any Proposal.

MHMR shall have the right to reject Proposals containing a statement, representations, warranty

or certification which is determined by MHMR and its council to be materially false, incorrect,

misleading or incomplete. Additionally, any errors, omissions, or oversights of a material nature

may constitute grounds for rejection of any Proposal.

The inability of a Vendor to provide one or more of the required components or specified

features or capabilities required by this Proposal may constitute grounds for rejection.

http://www.irs.gov/pub/irs-pdf/fw9.pdf


F. Oral Presentations

Any Vendor/Provider that submits a Proposal in response to this request may be required to

make an oral presentation for further clarification upon MHMR’s request.

G. Amendments to the Proposal

If it becomes necessary to revise any part of this Proposal package or if additional information is

necessary to clarify any provision, the revision and/or additional information will be provided to

each Vendor/Provider via faxed amendment or email. H. Availability of the Proposal

After opening, each Proposal, except those portions for which a Vendor/Provider has included a

written request for confidentially (e.g. proprietary information), shall be open to public

inspection.

I. Retention of Proposals

All Proposals considered by MHMR shall become the property of MHMR and shall not be

returned.

J. Notice “No Bid” Form

Vendors must respond to the Proposal request whether they can or cannot provide the products,

supplies, and/or services listed in the Proposal request (See Attachment B Notice “No Bid”

Form). K. Incurred Expenses

MHMR shall not be responsible for expenses incurred by a Vendor/Provider in the

preparation and submission of a Proposal. This provision also includes any costs involved

in providing an oral presentation of the Proposal.

L. Deviation Form

Each response to this Solicitation shall contain a Deviation Form, which states the

prospective contractor’s commitment to the provisions of this Solicitation and Sample

Contract. An individual authorized to execute contracts must sign the Deviation Form.

Any exceptions taken to the terms and conditions identified in this Solicitation Package

must be expressly stated in the Deviation Form. (See Attachment C)

M. Subcontractors All provisions and/or stipulations within this Request for Proposal also apply to any

authorized subcontractors.


N. Term of Contract

The intent of the RFP is to award this contract to the qualified vendor(s) who can

provide and meet all specified requirements of this request for proposal.

The contract period shall commence upon award date and issuance of Purchase Order until

completion and acceptance of the project by authorized MHMR personnel. Project is not

complete until authorized MHMR personnel has inspected and accepted in writing all

services related to this proposal.

O. Licensure

The vendor shall submit, with their Proposal, a copy of any other license(s), certification(s),

registration(s), permit(s), etc. as required by authorities having jurisdiction: local, state,

county, and/or federal.

P. Pricing

Each vendor shall provide responses to “Acknowledgement and Proposal” page with total

pricing.

SECTION V – INSURANCE REQUIREMENTS

Proof of insurance MUST be submitted with the bid response, failure to do so will disqualify the bid.

Upon award of the contract, the successful contractor’s insurance agent will provide a Certificate of

Insurance naming MHMR as an also insured, and will expressly provide for thirty (30) days prior

written notice of cancellation to all insured parties. The Contractor shall take out, pay for and maintain at all times during the prosecution of the work

under the contract, the following forms of insurance, in carriers acceptable to and approved by

MHMR.

1. Workers’ Compensation/Employer’s Liability

a. Workers' Compensation - statutory

b. Employer's liability - $500,000

2. Comprehensive Commercial General Liability:

a. Bodily Injury/Personal Injury- $1,000,000 per occurrence

$2,000,000 aggregate

b. Property Damage - $1,000,000 aggregate

3. Automobile liability:

a. Bodily injury - $500,000 minimum combined single limit

4. Contractual liability — same limits as above. The MHMR reserves the right to review the insurance requirements of this section during the

effective period of the contract and to require adjustment of insurance coverage and their limits

when deemed necessary and prudent by the Agency based upon changes in statutory law, court

decisions, or the claims history of the industry as well as the Contractor.

Required Provisions:


1. Proof of Carriage of Insurance - All certificates of insurance will be required in duplicate and

filed with the Purchasing Manager at 3840 Hulen St, Suite 200, Fort Worth, Texas 76107.

2. All certificates shall provide MHMR with an unconditional thirty days written notice in case

of cancellation or any major change.

3. As to all applicable coverage, certificates shall name MHMR and its officers, employees, and

elected representatives as an additional insured.

4. All copies of the certificates of insurance shall reference the project name and bid number for

which the insurance is being supplied.

5. The Contractor agrees to waive subrogation against MHMR, its officers, employees, and

elected representatives for injuries, including death, property damage, or any other loss to the

extent the loss, if any, is covered by the proceeds of insurance.

The Contractor/Vendor is responsible for making sure any sub-contractor(s) performing work under

this agreement has the required insurance coverage(s) and supplies MHMR with the proper

documents verifying the coverage.

A CURRENT “CERTIFICATE OF INSURANCE”

MUST ACCOMPANY ALL PROPOSALS


SECTION VI – PROPOSAL EVALUATION PROCESS

Not all evaluation factors are equal in importance and each factor is weighted in accordance with its

importance to MHMR. Each item has been assessed a percentage upon which the final score will

determined. A total of one hundred percentage (100%) points for the following items will be considered a

perfect score.

The following will be significant factors in evaluating proposals, but the evaluation will not be

limited to these items when making a final recommendation.

A. Overall Program

Capabilities 30%

Incident reporting system capabilities that meet MHMR

requirements. The vendor has a well-defined concept and program

structure for all components of service desired by MHMR.

(Including equipment, availability and start-up time)

B. Project Management

Methodology 25%

Indications of Project Management capabilities for large scale data

center; focus on solution and timeline, and achieve desired result.

Detail of tasks, schedule, dependencies, duration, etc.

C. Understanding 5%

Indication that the vendor understands the nature a n d s c o p e

of MHMR services and guidance as a Local Mental Health

Authority and that the vendor has thoroughly analyzed MHMR’s

needs and requirements.

D. Financial Condition 10%

Include a copy of your latest annual report or other comparable

documentation. As evidenced by the financial information

requested of each vendor, indication that the vendor, or vendors,

are financially stable and able to provide related services in its

entirety.

E.

History/Description

of Firm

Credentials of Staff

5%

Provide a brief history and description of your firm. The

description should include the size (number of employees) and

areas of specialization. Describe any special expertise your firm has

working with the products and/or services required for this

projects’ scope. Employment duration and Certifications of firm’s

staff who will be assigned to this project.

F. References 10%

Provide the names, telephone numbers, emails and addresses of

at least three business references; preferably, from similar not-for-

profit entities located in Texas. Issues that will be addressed

include contract performance, quality of the personnel,

responsiveness, etc.

G. Cost 15%

Final cost may be negotiated with the successful Vendor. Cost

may only become a determining factor when all other conditions are

equal.


SECTION VII – SPECIALIZED SERVICES TO BE PERFORMED OVERVIEW

MHMR Tarrant is soliciting proposals for Risk Management Incident Reporting System

Services. The purposes of a comprehensive Risk Management Incident Reporting (IR)

framework are to:

Establish risk identification which aligns with other healthcare organizational standards,

procedures, and guidance,

Identify key risks to MHMR performance and solvency,

Utilize trending, tracking, and data analysis to implement controls of manageable risks,

and

Build an agency framework and culture with increased resilience and resistance,

manageable risk, hazards, and untoward events.

CURRENT PROCESSES

Current risk elements are being tracked through three (3) separate repositories. Two of the

repositories utilize an internal Share Point site while the third system uses Excel.

PROJECT SCOPE

1. Vendor shall assess MHMR’s existing Incident Reporting systems a. Identify current Reportable Occurrences in accordance with processes and guidance,

b. Report gaps for Industry Reportable Occurrences and manageable risks; and

recommendations for corrective action;

c. Incorporate agreed upon steps to address gaps.

d. Conduct an audit for compliance to guidance and precertification for credentialing in

accordance with CARF: 1.C.1-3, 1.A.8 , 1.G.1-2,1.H.9-10, CMS Guidance to

Surveyors ICF IDD – App. J, Federal Register Vol. 81 No. 180 Friday September 16,

2016: §441.184(b), §483.475(a)(1), §485.920(b), FEMA – Comprehensive

Preparedness Guide 101 (2010), NFPA-1600, TAC Title 40 Part 1 Chapter 9

Subchapter E Division 4, HSPD 5,8,21 or other IR standards.

2. Vendor shall develop a Statement of Work (SOW) to include:

a. Collaboration with MHMR Department of Emergency Management Environmental -

Safety to develop a project plan that will include both the agreed upon benchmarks

and a schedule from project initiation to project close.

b. Indicate what work will be done on site vs remotely.

c. Travel and expenses will not be paid by MHMR.

d. Indication of the various phases, duration, assumptions, responsibilities, and payment

criteria.

3. Vendor shall categorize Incidents with granular detail and cross routing elements:

EXAMPLE(S):


911 Calls: Police, Fire, and EMS

Abuse/Neglect

Department of Family Protective Services (DFPS)

Beneficial Elements (Acts of Kindness, Suggestions)

Emergency Preparedness Functions

Human Element

Suicide Ideation / Threat / Completion

Homicide Ideation / Threat / Completion

Health and Medical

Immanent Threat(s)

Life Safety Code

Natural Hazards

Occupational Safety Elements

Technological Hazards Elements

Vehicle Incidents (injuries, staff, non-staff)

Violation of Contractual Requirements or Policy

4. Vendor shall construct Technical Platform

a. Cloud-based (preferred). Please complete Schedule 1: Technical Questionnaire.

b. Offline and mobile reporting accessibility.

c. Accessible and operational using various device types such as desktops, laptops,

tablets, and cell phones.

d. Configurable reporting elements for data analysis forms, tables, and dashboard(s).

e. Able to interface with software applications as needed (MS Outlook, Excel, etc.).

f. Multi-platform incident notification such as text message, and email.

g. Link to Active Directory Sync to automatically setup and manage users.

h. Training/Testing module in separate environment (preferred).

5. The System shall have reporting capabilities:

a. Centralized reporting system to document incidents in real time.

b. Documentation of original report, details of incident, including witnesses, and contact

information (phone number, email address);

c. Creation of an incident report on behalf of another user, contractor, or other external

entity;

d. Assigns a unique identification number to each incident report;

e. Tracks original entry of incident, subsequent entries, edits, and or updates to incident

by user, date, and time;

f. Display and report history of incident report from original report to resolution,

including updates and edits;

g. Require information based on incident type(s) selected. (Example: A property

damage incident vs. a medication error incident);

h. Enter and track status of incident. (Examples include open, investigation pending,

resolved);


i. Search, select, and display incident(s) in system. (Examples include incident number

(s), incident type(s), individual(s) involved (client, staff), entity, date range, and

program); and

j. Scan and attach or link documents to incident report. Access to view scanned

documents is based on security settings.

6. System shall have alert channel of responsibility and authority to resolve situation

capabilities:

a. Routing with line of succession to appropriate authority for intervention,

investigation, and resolution.

b. Electronic notification of incident occurs in real time by system dashboard, email,

text, and/or Instant Messenger (IM).

c. System shall allow staff supervisor to be notified by email when incident is opened.

d. System tracks confirmation of notifications.

e. System shall allow users to decline a task with documented reason(s).

7. System shall have investigating compatibilities:

a. Immediate email notification with specialized alert for critical incidents or life safety

concerns (Examples include: Critical events requiring sheltering, evacuation,

lockdown; Death – Suicide/Homicide; Homicide threat or attempt; Homicide –

Perpetrator; Litigation threats; Missing person (police report filed); News coverage

media likely;

b. Active task management dashboards;

c. System shall allow user to document task completion with notification to originator of

task;

d. Ability to document investigative actions and discovery by the incident for both

internal and external entities. Investigative details are limited to users based on

security settings. Include relevant details such as date, time, staff, entity, etc.;

e. Ability to classify notes pertaining to assigned groups to ensure ease of reference.

Examples include Risk Management, Client Rights, Medical, Property Management,

Human Resources; and,

f. Ability to store outside entity identifying information relevant to a Tarrant incident.

(Examples include: DFPS#, Police Report#, Hospital ID#; and

outside reporting Authority.

8. System shall have Analyses Data Tracking, Trending, and Resolution functions:

a. Ability to set status of incident as closed or resolved, based on security settings;

b. Configurable data analysis. (Examples may include date range, incident type(s), staff,

program, assigned staff, status of incident);

c. Ability to tap historic reports in the system for annual reporting or longitudinal

comparisons;

d. Real time trends and reports;


e. Ability to alert of potential risk based on multiple reports or continued escalation of

incidents for program, staff, client, incident type; and,

f. Ability to generate reports from system to view, print, and/or download to external

applications (such as Excel) for analysis.

9. System shall have security capabilities:

a. Security settings of system to allow or limit access to entry of, search, view, edit/add

capabilities based on security settings and or user roles;

b. System allows local maintenance of assigning user licenses and maintaining user

accounts and security settings;

c. System has ability to create and maintain user accounts electronically and manually;

and,

d. System tracks when users are activated, deactivated, and/or security changes occur.

EXERCISE AND TRAINING

1. Exercise

a. Vendor will work with MHMR project leaders to complete configuration of system.

b. Vendor will work with MHMR project leaders to complete functional testing.

c. MHMR and Vendor shall perform Technical Exercise and Testing of Full System to

include Agents, Analyzers, and selected End Users

d. Deliver an after-exercise report highlighting all successes and identified gaps and

inconsistencies with the System. Develop a corrective course of action based on the

results of the exercise.

e. Give a presentation to executive management on the system capabilities.

2. Training

Vendor shall provide training as follows:

a. Administrative (including configuration, security, maintenance);

b. Tracking Trending Agents;

c. Agents and Analyzers / End Users;

d. Support and learning portal; and,

e. Training Manuals (paper or electronic).

DELIVERABLES

1. Final Project Deliverables will include, but are not limited to:


a. Routing Map of MHMR key personnel to be notified in life safety and critical

incidents;

b. Single agency wide repository for reporting incidents;

c. Tracking and trending reports for analysis;

d. Immediate and automatic routing notification for the responsible person(s) to take

investigative action or intervention action(s) in a life safety hazard and or critical

events;

e. A “close the loop” element to report resolution of the incident;

f. Security level/layered accessibility for restricted access to sensitive data;

g. Time-phased implementation procedures to activate various components of the IR;

h. Training and exercise materials package; and,

i. Provide a project plan in electronic format that can be maintained by MHMR.

PROPOSED TIMELINE

IR system is expected to be completed and accepted based on agreed upon project schedule.

It is preferred that once contract is awarded the IR system will be completed in a six (6) month

period.

At present the recommendation for service agreement is expected to be completed in time for

funding to be incorporated into the FY 18 Budget.

MHMR PROJECT MANAGEMENT TEAM

MHMR will be responsible for operational decisions. MHMR will provide staff in the following

roles:

MHMR Project Lead

MHMR Director of Emergency Management Environmental Safety

OUT OF SCOPE

MHMR will not require vendor to convert past incident report history into the new system.

BACKGROUND CLEARANCE CHECK

Certain contracts may require vendors to enter sensitive secure areas. These may include, but are

not limited to, the locations listed above.

If a particular contract requires vendor personnel to enter such a location the following may

apply.


1. The successful bidder shall provide information, including, but not limited to, name, date

of birth, and driver’s license number for each individual who will be performing work on

MHMR Tarrant property.

2. Vendor personnel who perform work on MHMR Tarrant property must submit to and

pass a background clearance check. That status must be maintained by all vendor

personnel entering MHMR Tarrant buildings for the duration of the contract.

3. Background clearance checks conducted by vendor’s firm may or may not be accepted by

MHMR Tarrant. MHMR Tarrant reserves the right to conduct additional background

checks as it deems necessary.

4. Award of a contract could be affected by a vendors’ refusal to agree to these terms.

Award could also be affected if vendor is unable to supply personnel who can pass a

background clearance check.

NOTE: The background clearance check applies to the individual and not the

company.


RFP 17-020 RISK MANAGEMENT INCIDENT REPORTING SYSTEM

ACKNOWLEDGEMENT AND PROPOSAL

Having read and understood the instructions to bidders, terms and conditions, the specifications

and special provisions, we submit the following proposal:

1. Contractor shall include a breakdown and itemized description of products and services to be

performed.

2. Contractor shall include total cost.

3. Contractor shall include ongoing annual support cost.

4. Contractor shall include a breakdown of MHMR Tarrant and Contractor responsibilities.

5. Contractor should include a sample copy of Master Service Agreement or Statement of Work,

as applicable.

6. Contractors are requested to include a tentative schedule with milestone as applicable.

MHMR TARRANT IN ITS SOLE AND ABSOLUTE DISCRETION SHALL HAVE THE

RIGHT TO AWARD CONTRACTS FOR ANY OR ALL MATERIALS LISTED IN EACH

PROPOSAL, SHALL HAVE THE RIGHT TO REJECT ANY AND ALL PROPOSALS, AND

SHALL NOT BE BOUND TO ACCEPT THE LOWEST PROPOSAL AND SHALL BE

ALLOWED TO ACCEPT THE TOTAL PROPOSAL OF ANY ONE VENDOR, OR AS

OTHERWISE STATED IN THIS PROPOSAL. THIS SUBMISSION IS GUARANTEED AS AN IRREVOCABLE OFFER VALID FOR 120

DAYS AFTER THE PROPOSAL OPENING DATE.

BY RETURNING THIS BID PROPOSAL COMPLETED, THE BIDDER CERTIFIES THAT

THE PROPOSAL SPECIFICATIONS ARE UNDERSTOOD AND COMPLIED WITH.

PROPOSAL MAY BE CONSIDERED INVALID IF NOT RETURNED.

Name and Address of Company: Authorized Representative:

___________________________________ ______________________________________

Company Name Authorized Signature

___________________________________ ______________________________________

Number/Street Address Typed or Printed Name

___________________________________ ______________________________________

City, State, Zip Code Title

___________________________________ _______________________________________

Telephone Number Fax Number

E-mail address


SCHEDULE 1

Technical Questionnaire

Note: This series of questions are optional for the initial

submission of the RFP. However, vendors will be required to

complete this list if selected to move to the next round for

consideration.

Vendor Response

("N/A" if Not Applicable)

Upgrades and Maintenance

1

Does your service have regular maintenance windows, and if so,

what are they? What services are impacted or unavailable

during these times?

2

Do you have a regular update and patching cycle? If so please

outline the general cycle and schedule and describe the types of

changes typically released in major and minor revisions.

3 Can clients opt in or out of service pack upgrades? Are some

upgrades mandatory and others optional?

4

What measures are in place to prevent upgrades from breaking

client integrations? Do you issue release notes and

recommendations in advance of each upgrade (for example:

guidelines on where, when, and how to perform regression

testing)?

Logging and System Management

5

Explain what configuration options your solution provides for

logging end-user and administrator actions. Please address the

general types of events that can be logged (or not logged),

options for setting formatting and logging levels, options for

setting retention policies, purging, and so on.

6 How could MHMR get direct access to logs if desired or

required?

7

Can all logged events be trapped and sent as notifications to

MHMR managed systems, dashboards or other correlation

systems?

8

Is there a standard set of usage statistics that you provide to

your customers, accessible via a dashboard? If yes, please

describe the general characteristics of the statistic set and/or

provide example dashboard screenshots in the Exhibits section

of the RFP.


9

Can MHMR administrators create their own system

management dashboards and/or populate them with their own

composed metrics?

10

Are there any types of standard limitations on log sizes and log

retention windows that pertain to your customers? Are there

any special charges for modifying such standard limitations? If

so, can log files be sent to MHMR for retention by MHMR

itself?

Hosting Infrastructure, Backup and Disaster Recovery

11

Please describe the types of data center facilities in which your

solution is located. Are your data center facilities rated using

Uptime Institute tier ratings? If so: 1) describe the ratings they

have achieved, and 2) identify the party who conducted the

rating and provide a website or other contact information for

that party in your response.

12

Are third parties involved in your provisioning of data center

services? If yes, please identify those third parties and provide

websites and/or other contact information.

13 Are clients permitted to visit and tour your data center facilities

with advance notice?

14

What documented plans do you have for recovering data center

operations and network connectivity in the event of a local or

regional disaster? How often are your DR plans refreshed and

updated? Can you provide any third-party corroboration or

certification of your DR plan quality?

15

What are the Recovery Time Objectives (RTOs) and Recovery

Point Objectives (RPOs) for your SaaS solution customers’

hosted instances?

16 What is the schedule and the format for backups from your

solution?

17 Are restorations from backup regularly tested? With what

frequency and with what validation?


Integration, Data Import, Export and Location

18

Does your solution support web services (JSON, SOAP, REST,

XML) for exchanging structured information both into and out

of your system? Explain the general mechanism and standards

supported. What data elements can be manipulated via web

services?

19

What approach do you most recommend for sending inbound

data to your service from MHMR systems and/or 3rd party

providers?

20

Does your solution support one or more secure varieties of file

transfer? Explain the general mechanism and standards

supported.

21 What types of Application Programming Interfaces (APIs) does

your solution expose for data extraction?

22 Please identify other general functional areas exposed via your

solution’s APIs.

23 What technical documentation can you provide clients for your

solution’s APIs?

24

Can your clients export data from your solution to their own

cloud solutions and if so how (e.g., do you use a docker based

approach, or something else)?

25

Please indicate if data in your solution is ever stored or moved

outside the US, and if so what type of data is stored outside the

US (e.g. images, cached data, data in transit).

26 Do you supply a certification of data destruction upon contract

termination?

27

Does your solution support bulk load for initial data population

or bulk extraction for return to MHMR upon request or

termination of contract? Is there a fee for such services? What

formats and secure protocols are supported to enable this

functionality?


Performance and Benchmarking

28

What published performance benchmarks does your solution

have for any or all of the following?

• Application response times (separate by module if

appropriate)

• Speed of individual transactions

• Speed of mass transactions

• Speed of mass data imports and data exports

• Data storage limits

• Other

If benchmarks are available, for each benchmark please cite the

benchmarking organization, the date and other relevant details

and assumptions.

Architecture and Supported Platforms

29

What client PC/laptop operating systems (Windows, Macintosh,

etc.) does your solution support? Differentiate by OS version

if/where appropriate.

30

What client PC/laptop browsers (Internet Explorer, Firefox,

Safari, etc.) does your solution support? Differentiate by

browser version if/where appropriate.

31

What client smartphone and tablet operating systems (iPhone,

iPad, Droid, Android, etc.) does your solution support?

Differentiate by smartphone and tablet OS version if/where

appropriate.

32

What server operating system(s) (Windows, Linux, other

flavors of UNIX, other) does your SaaS solution run on?

Differentiate by OS version if/where appropriate. Are certain

application functions limited to certain platforms?

33

What application server environment(s) (WebLogic,

WebSphere, other) does your solution run in? Differentiate by

application server version if/where appropriate.

34 What web server(s) (Apache, IIS, other) does your solution run

on? Differentiate by web server version if/where appropriate.


35

What database management system(s) (Oracle, SQL Server,

DB2, other) does your solution run on? Differentiate by DBMS

version if/where appropriate.

Security

36

In your SaaS implementations, do you typically support

clients’ own internal Single Sign-On (SSO) infrastructures?

What types of SSO mechanisms can you support? Can you

support (ADFS/SAML/LDAP)? Are there any SSO variations

you cannot support?

37 Does your system provide tokens as secondary authentication

for read-and-signs or electronic signatures for certificates?

38

What is the recommended user account management process

for this solution? (Adding, Terminating, access level, passwords

etc.)

39

For client-side implementations of your solution (including

browser version, offline-access version if applicable, tablet and

smartphone versions if applicable), what data is cached client-

side? How is such data deleted or otherwise managed at session

termination? If answer differs for each solution, please provide

all relevant responses.

40

Please describe your general approach to stored data for hosted

solutions. Where is data hosted, on what type of media and

equipment? What strategies do you employ for redundancy,

high availability, business continuity, and disaster recovery of

data? For the latter, please make reference to plans and

procedures, regular testing, routine data backups and offsite

storage.

41

If data is clustered, mirrored, duplicated or otherwise

distributed, can the physical location of data be changed

without MHMR’s knowledge or consent? If so, in the event that

MHMR needs to recall, delete, or otherwise modify distributed

data, can you furnish all the location(s) of all such distributed

data to MHMR for those purposes?


42

What mechanisms, policies and procedures are used to

safeguard stored data? Be sure to cite your use or non-use of

intrusion detection, anti-virus, firewalls, vulnerability scanning,

penetration testing, encryption, data at rest encryption,

authentication and authorization protections and policies,

including those involving passwords, removal of unnecessary

network services, limiting of administrative access, code review,

logging, employee training and other relevant safeguards.

43

What mechanisms are used to transport data? What methods

are used to safeguard data during transport? Be sure to cite

your use or non-use of encryption during transmission,

encrypting wireless traffic, physically securing devices in

transit, network traffic segregation, and other relevant

safeguards. Where relevant, include descriptions of the

encryption protocols and algorithms used.

44

In your approach to storage and transport of data, as described

in questions 37, 39 and 40, do you rank any data in terms of

sensitivity and do you employ any special measures when

handling more sensitive data? If so, in implementing such

measures can you respond and act upon the client’s own

rankings for data sensitivity?

45

Please identify any subcontracted parties who are involved in

your handling of stored data as described in questions 37, 39

and 40. Please provide a website address and/or other contact

information for each.

46

Are your information security controls certified through a

certification body (ISACA, SANS, etc.) audit or similar

methodology? If so, please provide a copy of the latest audit

findings in the Exhibits section of your RFP response.

47

Please identify any compliance frameworks for which your

product has been certified, such as HIPAA, FISMA, FERPA,

PCI, and so on. For each, provide the date of the last

certification.

48 Do you have existing Healthcare or government tenants? What

regulatory compliance frameworks are they governed by?


49

Please describe any controls you use to address the threat of

information being mistakenly disclosed to unauthorized

persons. Your response should refer where applicable to issues

of awareness and training, removal of unnecessary data

(electronic and paper), use of screen savers and lockouts,

limiting storage of confidential data on remote devices,

verification of identity of individuals requesting access, and

other relevant safeguards that enforce the principle of “need to

know.”

50

Please describe any controls you use to address the threat of

information knowingly being misused by your workforce and

contractors. Your responses should refer where applicable to

issues of strong sanctions policy and practice, background

checks, role-based access to information, oversight of data

authorization by supervisor, terminating access to data for

terminated employees and employees changing job functions,

prohibition on sharing passwords, and other relevant

safeguards.

51

Please describe controls you use to address the threat of

physical theft or loss of data. Your responses should refer

where applicable to policies on the storage of confidential data

on laptops, PDAs, USB drives and other portable devices,

encryption of data on portable devices, two factor

authentications, removal of unnecessary information, physical

protection of desktops and servers, and other relevant

safeguards.

52

Please describe controls you use to address community

concerns regarding privacy practices. Your responses should

refer where applicable to privacy statements, opt-in or opt-out

consents, compliance with applicable privacy rules, and other

relevant safeguards.

53

Please describe controls you use to address the use, handling,

protection and sharing of confidential data shared with

subcontractors. Your responses should state any relevant

relationships that may induce additional risk to the safe storage

of sensitive data (such as outsourcing of key services, use of sub-

contractors or cloud services for hosting, etc.) and refer where

applicable to contractual safeguards and reviews of security

programs / practices.

53

Do you require the use of two-factor authentication for the

administrative control of servers, routers, switches and

firewalls?


54

Does your SaaS solution support Secure Sockets Layer (or

other industry-standard transport security) with 128-bit or

stronger encryption and two-factor authentication for

connecting to the application?

55

Do your hosting environments provide redundancy and load

balancing for firewalls, intrusion prevention and other critical

security elements?

56

Do you (or an experienced third-party partner) perform

external penetration tests at least quarterly and internal

network security audits at least annually? Are these audits

structured per the International Organization for

Standardization (ISO) 17799 (transitioning to ISO 27001)

standard?

57

Do you provide protection (or receive protection from a third

party) for denial-of-service attacks against your hosted

solutions?

58

Can you provide documented requirements (and audit

procedures) for network access standards to ensure that other

customers will not accidentally compromise the security of your

environments?

59

Can you provide documented policies for OS hardening for

your web, application, database and other hosting-related

servers?

60

Can you provide validated procedures for configuration

management, patch installation, and malware prevention on all

servers and PCs involved in SaaS delivery?

61

If you have a multi-tenant architecture that extends to the

database level, can you provide a documented set of controls for

ensuring the separation of data and the security of information

between different customers’ SaaS instances?

62

How do you review the security of applications (and any

supporting code, such as Ajax, ActiveX controls and Java

applets) that you develop and use?

63

Do you use content monitoring and filtering or data leak

prevention processes and controls to detect inappropriate data

flows?


64

Can you provide documented procedures for configuration

management (including installation of security patches) for all

applications?

65

Do you perform background checks on personnel with

administrative access to servers, applications and customer

data?

66

Can you provide documented processes for evaluating security

alerts from operating system and application vendors, shielding

systems from attack until patched, and installing security

patches and service packs?

67 Do you use write-once technology to assure the validity of audit

trails and security logs?

68

Can you provide documented procedures for vulnerability

management, intrusion prevention, incident response, and

incident escalation and investigation?

69

How many staff do you have dedicated to application and

infrastructure security? How many average years’ experience

do these personnel have and what security certifications do they

possess?

70

Can you provide documented identity management and help-

desk procedures for authenticating callers and resetting access

controls, as well as establishing and deleting accounts when

help-desk service is provided?

Secondary (Non-Production) Environments

71

Do you provide SaaS customers with a standard set of

secondary non-production environments (staging, test, and so

on)? If so, which types of environments? Are there any

limitations on access to and usage of these environments?

72

If you answered yes to question 69, above, can data in these

secondary environments be synched with production data? If

so, is there a fee for this synchronization? If not, what type of

data is provided in these supporting environments?

73

If you answered yes to question 69, above, can changes made in

secondary environments be migrated to production

automatically?


Attachment A MHMR of Tarrant County

Historically Underutilized Business (HUB)/Disadvantaged Business Enterprise (DBE)

HUB Utilization Assessment

Please indicate below any changes to the information provided

Principal Owner Name:_________________________________ Title:__________________________________

Principal Owner Phone:_________________________ Other Phone:______________________________

1. If none of the below applies to your business please initial here____________________, in doing so you

acknowledge that your business will NOT be considered a Historically Underutilized Business or a

Disadvantaged Business Enterprise vendor (you may skip questions 2 and 3).

2. Is your business primarily owned (51% or more) by an individual or individuals that can be classified in

one or more of the following groups? (Please check all that apply from the list below)

4. Please sign and date the form below.

______________________________________________ ______________________________________

Signature Date Print Name

Legal Name of your

Business: ________________________________________________________________

Address: ________________________________________________________________

City: __________________________State:___________Zip:___________________

Women (Check here if you are a self-

employed woman)

African Americans

Hispanic Americans

Native Americans

Asian Americans

Service Disabled Veterans

3. Is your business already certified as disadvantaged or historically underutilized?

[ ] Yes [ ] No

If “Yes”, please indicate the name of the certifying agency:__________________________

Certificate #:_________________________Expiration Date:__________________

If not certified, is your business eligible for certification based on question 2 above? [ ] Yes [ ] No


ATTACHMENT B

NOTICE “NO BID” FORM

Dear Vendor,

Please check the appropriate box below, complete the remainder of this form and return it PRIOR to the scheduled Date and Time:

I/Our Company cannot provide the products, supplies and/or services listed in this request. Please MOVE my/our name and address to the following commodities so that we may submit bids/proposal at a later date:

Commodities: ____________________________________________________________________

I/We have chosen NOT to submit a Proposal at this time, but would like to remain on your list for this Proposal category. We did not submit a Proposal because:

Reason(s): ______________________________________________________________________

________________________________________________________________________________

Please REMOVE my/our name from all MHMR of Tarrant County lists until further notice.

Reason(s): ______________________________________________________________________

________________________________________________________________________________

Company Name: _________________________________________________________________

Representative (Print Name): __________________________________________________________

Address: _______________________________________________________________________

Email: _________________________________________________________________________

Phone Number: ( ______ ) ___________________ Fax Number: ( ______ ) ___________________

PLEASE RETURN THIS FORM ONLY TO:

MHMR Tarrant Purchasing Department

Notice “No Bid” – RFP 17-020 Risk Management Incident Reporting System 3840 Hulen Street, Suite 200

Fort Worth, Texas 76107

Authorized Signature: _____________________________________________________________

Title: ____________________________________ Date: _______________________________

VENDORS WHO RESPOND TO THIS INVITATION WITH A COMPLETED PROPOSAL FORM WILL

REMAIN ON OUR MAILING LIST. VENDORS MAKING NO RESPONSE MAY BE REMOVED FROM THE

MAILING LIST.

Thank you for your time and assistance.


ATTACHMENT C

DEVIATION FORM

All deviations to this Solicitation must be noted on this sheet. In the absence of any entry on this Deviation Form, the prospective contractor assures MHMRTC of their full agreement and compliance with the Specifications, Terms and Conditions.

An individual authorized to execute contracts must sign the Deviation Form. Any exceptions taken to the terms and conditions identified in this Solicitation Package must be expressly stated below.

THIS DEVIATION FORM MUST BE SIGNED BY EACH PROSPECTIVE CONTRACTOR WHETHER THERE ARE DEVIATIONS LISTED OR NOT, AND

SUBMITTED WITH THIS SOLICITATION

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

COMPANY NAME: __________________________________________________________

AUTHORIZED SIGNATURE: ___________________________________________________

PRINTED NAME/TITLE: _______________________________________________________

DATE: ______________________________________________________________________


ATTACHMENT D

NON-COLLUSION AFFIDAVIT OF BIDDER

State of _________________________ County of __________________

_____________________________________________ verifies that:

(Name)

(1) He/She is owner, partner, officer, representative, or agent of

__________________________________, has submitted the attached bid.

(Company Name)

(2) He/She is fully informed in respect to the preparation, contents and

circumstances in regard to attached bid;

(3) Neither said bidder nor any of its officers, partners, agents or employees

has in any way colluded, conspired or agreed, directly or indirectly with

any other bidder, firm or person to submit a collusive or sham bid in

connection with attached bid and the price or prices quoted herein are

fair and proper.

______________________________________

SIGNATURE

______________________________________

PRINTED NAME

Subscribed and sworn to before me this

_________ day of _________________ 2017

______________________________________

NOTARY PUBLIC in and for

___________________________County, Texas.

My commission expires ___________________

THIS FORM MUST BE COMPLETED, NOTARIZED AND SUBMITTED WITH BID


ATTACHMENT E

REFERENCE FORM

All references must be from customers for whom your company has provided similar serves as the

specifications of this bid (Invalid contact information will result in default of references and may cause

the bid to be disqualified.)

Company Name: _______________________________________________________________

Street Address: ________________________________________________________________

City, State & Zip: ______________________________________________________________

Contact Name: ________________________________ Phone: __________________________

E-mail: _______________________________________________________________________

List date and describe work performed: ______________________________________________

______________________________________________________________________________

Company Name: _______________________________________________________________

Street Address: ________________________________________________________________

City, State & Zip: ______________________________________________________________


E-mail: _______________________________________________________________________


______________________________________________________________________________

Company Name: _______________________________________________________________

Street Address: ________________________________________________________________

City, State & Zip: ______________________________________________________________


E-mail: _______________________________________________________________________


______________________________________________________________________________

Company Name: _______________________________________________________________

Street Address: ________________________________________________________________

City, State & Zip: ______________________________________________________________


E-mail: _______________________________________________________________________


______________________________________________________________________________

THIS PAGE MUST BE COMPLETED AND SUBMITTED WITH BID