Human Resources and/or Student Medical Consultant RFQ September 2, 2014 at 11:00 am

Transcription

1 Human Resources and/or Student Medical Consultant RFQ September 2, 2014 at 11:00 am Direct all communication related to this RFQ to the following contact: Procedural Technical Hector Rodriguez, Elizabeth Guajardo Purchasing Manager Benefits Administrator, Risk Manager (P) (P) (F) (F)

2 I. Notice to Vendors Table of Contents II. III. IV. Checklist Verification Items Proposal Overview Invitation to Propose V. Qualification Instructions VI. VII. VIII. IX. Terms and Conditions Specifications/Duties Required for Human Resources Medical Consultant Specifications/Duties Required for Student Medical Consultant Contract Specimen X. Required Bid Submission Documents Bid Certification Form Qualifications Form Professional Resume/Literature (to be submitted by Provider) Provider Agreements Affidavit of Non-Collusion/Non-Conflict of Interest/Anti Lobbying Form Non-Collusion Statement Felony Conviction Notice Debarment and Suspension Certifying Statement Conflict of Interest Questionnaires (Form CIQ) Deviation/Compliance Form Out of State Certifying Statement Historically Underutilized Business (HUB) Certifying Statement Notice of NO BID Form Certification of Criminal History Record Information Firm and Personnel Conduct Status Form Errors and Omissions Status Form Hold Harmless Agreement

3 To Whom It May Concern: I. NOTICE TO VENDORS Thank you for the submission of your proposal to the Harlandale Independent School District. The District understands and appreciates all of the efforts undertaken in the preparation and submission of a proposal. It is the intent of this administration to conduct a fair and impartial evaluation of these proposals with an emphasis on determining the best value for the District at the lowest possible price. Essential to an impartial objective analysis is that it not be subjected to extraneous influences. The District requests and appreciates that no efforts be undertaken by vendors to independently contact the District s evaluation team for this proposal with the purpose of seeking an unfair advantage. As a matter of fairness, this is necessary in order to provide due and proper consideration to each and every proposal. This request also extends to contact, communications, and/or interactions with the members of the School Board. Independent communications with the Trustees by vendors puts the administration and the Trustees in a very difficult position. It is our experience that such advocacy efforts result in members receiving non-objective information that can result in confusion during the competitive procurement process. When vendors contact members independently, it facilitates the crossing over of those clearly defined and legally required roles of the Board and the Administration. This can result in legal issues and most certainly a compromise in the integrity of the entire proposal process. Please be advised that this administration will not favorably receive any evidence that a vendor has contacted the District staff or members of the Board in an effort to seek an unfair advantage. We anticipate your cooperation in maintaining the integrity of the competitive procurement process and thank you in advance for such efforts. Respectfully, Harlandale Independent School District Business and Finance Department

4 Proposer use ONLY II. Checklist Verification Items YES NO N/A 1. Unless otherwise indicated, has one (1) original and one (1) copy of the proposal been submitted? 2. Has pricing page been enclosed to include any applicable discounts, freight, or installation costs? 3. Have all envelopes, packages, and any other relevant information been properly referenced and labeled with the proposal number? 4. Have you included any other relevant information, which will enable the District to evaluate this proposal? 5. Has the Invitation to Propose been executed and enclosed? 6. Has the Non-Collusion Statement been executed and enclosed? 7. Has the Felony Conviction Notice been executed and enclosed? 8. Has the Debarment and Suspension Certifying Statement been executed and enclosed? 9. Has the Conflict of Interest Questionnaire (Form CIQ) been executed and enclosed? 10. Has the Deviation/Compliance Form been executed and enclosed? 11. Has the Out of State Certifying Statement been executed and enclosed? 12. Has the Historically Underutilized Business (HUB) Certifying Statement been executed and enclosed? 13. Has the Minority Business Enterprises (MBE) Certifying Statement been executed and enclosed? 14. Has the Women Business Enterprises (WBE) Certifying Statement been executed and enclosed? 15. Has the Notice "No Bid" form been executed and enclosed? 16. Has the Certification of Criminal History Record Information been executed and enclosed? Item 15 and 16 are pertainable only to Consultant Related Proposals. 17. Has the Firm and Personnel Conduct form been executed, notarized and enclosed? 18. Has the Errors and Omission Status form been executed, notarized and enclosed? Item 17 is pertainable only to Construction related proposals 19. Has the Statement of Legal, Professional, and Ethical Behavior form been executed, notarized and enclosed? 20. Have any applicable bonds (performance, payment) been enclosed? 21. Have any documents requiring the seal of an engineer and/or architect been enclosed? 22. Have you read and agree to the Sample AIA Construction Contract?

5 III. PROPOSAL PROCESS OVERVIEW 1.0 The proposals are released to the potential proposer. 2.0 Deadline for submitting the Proposals. 3.0 The Harlandale Independent School District reviews all Proposals and selects the Proposals reasonably qualified for selection of award. 4.0 The Harlandale Independent School District and proposer(s) enter into discussions, negotiations, and clarification of Proposals as necessary. 5.0 A recommendation to the Harlandale Independent School District Board of Trustees for Proposal award. 6.0 A purchase order/contract is executed with the successful proposal.

6 IV. INVITATION TO PROPOSE REPRESENTATIONS: By execution and submission of this proposal, the undersigned authorized representative of the contracting company indicated below hereby represents and warrants to the Harlandale Independent School District as follows: That said person is authorized to enter into contractual relationships on behalf of the contracting company indicated below, and That said person has read and understands this Sealed Proposal, the accompanying General Terms and Conditions, General Proposal Specifications, and Proposal Form(s) and that this proposal is made in accordance with the provided documents, and That said person proposes to supply any products and/or services submitted under this Sealed Proposal at the prices quoted and provided and in strict compliance with the proposal documents and That if any part of this proposal is accepted, said person and company will furnish all products and/or services awarded under this proposal at the prices quoted and provided and in strict compliance with the proposal documents and That the Harlandale Independent School District or any representative or agent of the Harlandale Independent School District is authorized by the undersigned to contact any firm, institution, and/or person to obtain information about the firm s services, financial condition, and/or any other information Harlandale Independent School District may deem necessary. Name of Company Date of Submittal Address Signature of Authorized Representative City, State, Zip Printed Name of Authorized Representative Telephone and Fax No. of Authorized Representative Position or Title of Authorized Representative Delivery Date Payment Terms

7 I. Instructions V. Qualifications Instructions 1. Sealed proposals shall be received in the Office of Hector Rodriguez, Purchasing Manager, at SE Loop 410, San Antonio, TX on or before 11:00 A.M. (CST), Tuesday, September 2, 2014 for the provision of Physician Services. Proposals received after 11:00 A.M. will be returned to sender. Proposals received after designated time will not be considered. The District Purchasing Office will have sole authority to stamp receipt and verification of time received. Fax copies will not be accepted. 2. Each proposal shall be in a sealed envelope plainly marked Request for Qualifications Human Resources Medical Consultant and/or Student Medical Consultant. 3. Proposals shall be submitted in duplicate. 4. Incomplete proposals will be returned without further consideration. 5. It is agreed Request for Qualifications participants will be available to be interviewed by a panel of District staff members. 6. Proposer must complete Bid Certification Form, Affidavit of Non-Collusion, Non- Conflict of Interest, and Anti-Lobbying Form, Felony Conviction Notification Form and Conflict of Interest Questionnaire. 7. Proposer must complete qualifications Form & include Professional Resume. 8. There will be no formal proposal opening. All interested parties submitting a nonfinancial proposal will be notified of the results.

8 VI. Terms & Conditions 1. The District reserves the right to accept or reject any or all submissions, waive any formalities in the process and award to the proposer to best serve the interest of the District and to negotiate with any proposer as deemed advisable or necessary for the best interest of the District. Qualifications of Service Providers must be non-financial in nature. Upon the analysis of all proposals, the District will enter into separate financial negotiations to recommend the best Provider. 2. A professional resume along with a resume of any staff member who will be assigned to the Harlandale ISD account must be submitted along with the request for qualifications. It is an option of the proposer to include brochures and additional information concerning the operation of the health provider. 3. Proposer must also furnish proof of medical malpractice insurance via a certificate of insurance within 30 days after notification of award. 4. Proposer must have local representation with offices in San Antonio, TX. 5. The District is enclosing a summary of services relating to the Human Resources/Student Medical Consultant s responsibilities. These services may be modified based upon the needs of the District. 6. The District will consider either one Provider to service both Human Resources and Student needs, or separate physicians for each of the two types of service. 7. It is understood and agreed between said parties that only designated DISTRICT staff members will be authorized to discuss medical issues with the PHYSICIAN and the PHYSICIAN shall not respond to telephone calls by non-authorized DISTRICT employees. 8. It is agreed all medical personnel in the employ of the PHYSICIAN are considered employees of said PHYSICIAN and are not independent contractors or subcontractors of the PHYSICIAN. Additionally, physician assistants (P.A. s) in the employ of the PHYSICIAN are covered by medical malpractice coverage. 9. It is understood and agreed that this Agreement shall, in no way, be construed as creating an employer/employee relationship between the DISTRICT and PHYSICIAN, and that PHYSICIAN is, and shall remain, an independent contractor.

9 10. The District has approximately 2,200 employees and 14,000 students. Our employees are employed in not only educational environments, but in a vast array of support services which include, but are not limited to maintenance, cafeteria, sports, and administrative functions. Our students range in grades from Pre-K through Grade 12 and may have disabilities to be recognized. 11. A multi-year contract will be offered renewable on an annual basis.

10 HUMAN RESOURCES MEDICAL CONSULTANT VII. Specifications Physician agrees to be available to the District and its staff on a priority basis for the following purposes: a. To provide feasible medical advice and consultation to the DISTRICT relative to its employees; b. To assist the DISTRICT in providing the fullest possible opportunity for each DISTRICT with compliance and accommodation under Americans with Disabilities Act; c. To act as an advisor/consultant to medical problems which may affect the performance and well-being of the DISTRICT S employees; d. To assist the DISTRICT in evaluating employee s medical and health matters through physical examination and consultation; e. To consult with the employee s attending physician and/or refer employee to the appropriate medical specialist for consultation and/or treatment; f. To advise and assist the DISTRICT in the establishment or modification of its policies relating to the health of employees; g. To cooperate with local health authorities to control communicable diseases; h. To assist Human Resources in obtaining speakers for in-services and/or workshops relating to employee safety and health issues; i. For the PHYSICIAN to be available to answer questions by telephone with DISTRICT Administrators; j. To make appropriate presentations to staff, Superintendent and Board of Trustees; k. To serve as the DISTRICT S media liaison relative to medical and health matters when needed; l. To cooperate with the local health authorities to control communicable diseases; m. To assist the Health Services staff in obtaining speakers for in-services and workshops; n. To answer questions of Health Services staff by telephone;

11 Human Resources Medical Consultant Specifications Continued o. To make appropriate presentations to the Board of Trustees, parent groups, PTA and other meetings when requested by the Superintendent; p. To perform such other duties as may be assigned by the Superintendent, i.e., attend school health conferences; serve as the Superintendent s and/or District s spokesperson and representative in situations involving severe health problems; represent Harlandale Independent School District health programs at state or local conventions.

12 VIII. Specifications STUDENT MEDICAL CONSULTANT Physician agrees to be available to the District and its staff on a priority basis for the following purposes: a. To provide feasible medical advice and consultation to the DISTRICT relative to its students; b. To assist the DISTRICT in providing the fullest possible opportunity for DISTRICT compliance and accommodation under Section 504 of the Rehabilitation Act of 1973, as amended; c. To act as an advisor/consultant to medical problems which may affect the performance and well-being of the DISTRICT S students; d. To assist the DISTRICT in evaluating student s medical and health matters through physical examination and consultation; e. To consult with the student s attending physician and/or refer student to the appropriate medical specialist for consultation and/or treatment; f. To advise and assist the DISTRICT in the establishment or modification of its policies relating to the health of students; g. To cooperate with local health authorities to control communicable diseases; h. To assist Pupil Personnel Department in obtaining speakers for in-service and/or workshops relating to student safety and health issues; i. For the PHYSICIAN to be available to answer questions by telephone with DISTRICT Administrators and Health Services Staff; j. To make appropriate presentations to staff, Superintendent and Board of Trustees; k. To provide advice and consultation to DISTRICT Health Services staff relative to students with handicaps or physical conditions that require special accommodations; l. To assist the DISTRICT in minimizing student absences due to illness; m. To act as an advisor/consultant to medical problems, including Special Education student needs, through the Health Services Staff; n. To assist the DISTRICT in media communication concerning medical or health matters;

13 Student Medical Consultant Specifications Continued o. To advise and assist the DISTRICT in the establishment of policies relating to the health of school children; p. To conduct in-service meetings with the DISTRICT S Health Services staff at least twice per semester; q. To approve over the counter medications; r. To serve as the DISTRICT S media liaison relative to medical and health matters when needed; s. To advise and assist the DISTRICT in the establishment of policies relating to the health of school children; t. To cooperate with the local health authorities to control communicable diseases; u. To assist the Health Services staff in obtaining speakers for in-services and workshops; v. To answer questions of Health Services staff by telephone; w. To make appropriate presentations to the Board of Trustees, parent groups, PTA and other meetings when requested by the Superintendent; x. To perform such other duties as may be assigned by the Superintendent, i.e., attend school health conferences; serve as the Superintendent s and/or District s spokesperson and representative in situations involving severe health problems; represent Harlandale Independent School District health programs at state or local conventions.

14 IX. Contract Specimen HARLANDALE INDEPENDENT SCHOOL DISTRICT HUMAN RESOURCES/STUDENT MEDICAL CONSULTANT QUALIFICATIONS FORM I am applying for position as District Human Resources Medical Consultant I am applying for position as District Student Medical Consultant (Check one or both of the above) Request for Qualifications Personal Data 1. Name (Name of medical group/facility you are employed by or affiliated with) Business Address Telephone # Fax # 2. Provide a professional resume which includes credentials, experience, and any pertinent information pertaining to you and your staff. 3. Do you currently provide services to any employer in the capacity of medical consultant? If so, please include as a reference below. 4. Please include a brief statement regarding your interest in providing services to Harlandale Independent School District as its Human Resources Medical Consultant. What considerations should be given on an individual basis which is not reflective in your professional resume? (Please address in separate letter form). References Name Address Phone #

15 BID CERTIFICATION The undersigned proposer does hereby declare that he/she has read the specifications for the Harlandale Independent School District Human Resources and/or Student Medical Consultant and with full knowledge of the requirements, does hereby agree to furnish all services in full accordance with the specifications and requirements. The Physician(s) indemnifies the District for any liability because of failure to provide medical/malpractice insurance which is at least equal to that coverage being replaced. Physician s Name (Print or type) Address City, State, Zip Signature of Physician Telephone # ( ) Fax # ( ) Date SPECIMEN COPY ONLY

16 HUMAN RESOURCES MEDICAL CONSULTANT AGREEMENT The Human Resources Medical Consultant Agreement is made and entered into as of by and between the Harlandale Independent School District, hereinafter called DISTRICT, and, a medical doctor licensed to practice medicine in the State of Texas, hereinafter called PHYSICIAN. For and in consideration of the mutual benefits to be derived by the parties hereto, it is expressly understood and agreed as follows, to wit: 1. DISTRICT does, by these present, employ PHYSICIAN in the capacity of HUMAN RESOURCES MEDICAL CONSULTANT for the period of through. 2. As consideration for the services to be rendered to the DISTRICT agrees to pay PHYSICIAN a fee of per month. (To be negotiated after proposal opening) 3. As consideration of the above-mentioned payments and these premises, PHYSICIAN agrees to make himself/herself available to the DISTRICT and its Staff on a priority basis for the following purposes: a. To provide feasible medical advice and consultation to the DISTRICT relative to its employees; b. To assist the DISTRICT in providing the fullest possible opportunity for each DISTRICT with compliance and accommodation under Americans with Disabilities Act; c. To act as an advisor/consultant to medical problems which may affect the performance and well-being of the DISTRICT S employees; d. To assist the DISTRICT in evaluating employee s medical and health matters through physical examination and consultation; e. To consult with the employee s attending physician and/or refer employee to the appropriate medical specialist for consultation and/or treatment; f. To advise and assist the DISTRICT in the establishment or modification of its policies relating to the health of employees; g. To cooperate with local health authorities to control communicable diseases; h. To assist Human Resources in obtaining speakers for in-services and/or workshops relating to employee safety and health issues; SPECIMEN COPY ONLY

17 Human Resources Medical Consultant Agreement Continued i. For the PHYSICIAN to be available to answer questions by telephone with DISTRICT Administrators; j. To make appropriate presentations to staff, Superintendent and Board of Trustees; k. To serve as the DISTRICT S media liaison relative to medical and health matters when needed; l. To cooperate with the local health authorities to control communicable diseases; m. To assist the Health Services staff in obtaining speakers for in-services and workshops; m. To answer questions of Health Services staff by telephone; o. To make appropriate presentations to the Board of Trustees, parent groups, PTA and other meetings when requested by the Superintendent; p. To perform such other duties as may be assigned by the Superintendent, i.e., attend school health conferences; serve as the Superintendent s and/or District s spokesperson and representative in situations involving severe health problems; represent Harlandale Independent School District health programs at state or local conventions. 4. It is understood and agreed between the DISTRICT and PHYSICIAN that this Agreement shall not be construed to require PHYSICIAN to receive or respond to telephone calls by employees of the DISTRICT. 5. This Agreement may be cancelled or terminated by either party with thirty (30) days written notice to the other party, whereupon at the end of said thirty (30) days period, both parties will release from any further obligation hereunder. 6. It is understood and agreed that this Agreement shall, in no way, be construed as creating an employer/employee relationship between the DISTRICT and PHYSICIAN, and that PHYSICIAN is, and shall remain, an independent contractor. AGREED AND ENTERED INTO as of ATTEST: By: HARLANDALE INDEPENDENT SCHOOL DISTRICT By: SPECIMEN COPY ONLY

18 STUDENT MEDICAL CONSULTANT AGREEMENT The Student Medical Consultant Agreement is made and entered into as of by and between the Harlandale Independent School District, hereinafter called DISTRICT, and _, a medical doctor licensed to practice medicine in the state of Texas, hereinafter called PHYSICIAN. For and in consideration of the mutual benefits to be derived by the parties hereto, it is expressly understood and agreed as follows, to wit: 1. DISTRICT does, by these present, employ PHYSICIAN in the capacity of STUDENT MEDICAL CONSULTANT for the period of _ through _. 2. As consideration for the services to be rendered to the DISTRICT agrees to pay PHYSICIAN a fee of per month. (To be negotiated after proposal opening) 3. As consideration of the above-mentioned payments and these premises, PHYSICIAN agrees to make himself/herself available to the DISTRICT and its Staff on a priority basis for the following purposes: a. To provide feasible medical advice and consultation to the DISTRICT relative to its students; b. To assist the DISTRICT in providing the fullest possible opportunity for DISTRICT compliance and accommodation under Section 504 of the Rehabilitation Act of 1973, as amended; c. To act as an advisor/consultant to medical problems which may affect the performance and well-being of the DISTRICT S students; d. To assist the DISTRICT in evaluating student s medical and health matters through physical examination and consultation; e. To consult with the student s attending physician and/or refer student to the appropriate medical specialist for consultation and/or treatment; f. To advise and assist the DISTRICT in the establishment or modification of its policies relating to the health of students; g. To cooperate with local health authorities to control communicable diseases; h. To assist Pupil Personnel Department in obtaining speakers for in-services and/or workshops relating to student safety and health issues; SPECIMEN COPY ONLY

19 Student Medical Consultant Specifications Continued i. For the PHYSICIAN to be available to answer questions by telephone with DISTRICT Administrators and Health Services Staff; Student Medical Consultant Agreement Continued j. To make appropriate presentations to staff, Superintendent and Board of Trustees; k. To provide advice and consultation to DISTRICT Health Services staff relative to students with handicaps or physical conditions that require special accommodations; l. To assist the DISTRICT in minimizing student absences due to illness; m. To act as an advisor/consultant to medical problems, including Special Education student needs, through the Health Services Staff; n. To assist the DISTRICT in media communication concerning medical or health matters; o. To advise and assist the DISTRICT in the establishment of policies relating to the health of school children; p. To conduct in-service meetings with the DISTRICT S Health Services staff at least twice per semester; q. To approve over the counter medications; r. To serve as the DISTRICT S media liaison relative to medical and health matters when needed; s. To advise and assist the DISTRICT in the establishment of policies relating to the health of school children; t. To cooperate with the local health authorities to control communicable diseases; u. To assist the Health Services staff in obtaining speakers for in-services and workshops; v. To answer questions of Health Services staff by telephone; w. To make appropriate presentations to the Board of Trustees, parent groups, PTA and other meetings when requested by the Superintendent; x. To perform such other duties as may be assigned by the Superintendent, i.e., attend school health conferences; serve as the Superintendent s and/or District s spokesperson and representative in situations involving severe health problems; represent Harlandale Independent School District health programs at state or local conventions. SPECIMEN COPY ONLY

20 Student Medical Consultant Specifications Continued 4. It is understood and agreed between the DISTRICT and PHYSICIAN that this Agreement shall not be construed to require PHYSICIAN to receive or respond to telephone calls by employees of the DISTRICT. 6. This Agreement may be cancelled or terminated by either party with thirty (30) days written notice to the other party, whereupon at the end of said thirty (30) days period, both parties will release from any further obligation hereunder. 6. It is understood and agreed that this Agreement shall, in no way, be construed as creating an employer/employee relationship between the DISTRICT and PHYSICIAN, and that PHYSICIAN is, and shall remain, an independent contractor. AGREED AND ENTERED INTO as of ATTEST: By: HARLANDALE INDEPENDENT SCHOOL DISTRICT By:

21 PROPOSER S AFFIDAVIT OF NON-COLLUSION, NON-CONFLICT OF INTEREST, AND ANTI-LOBBYING FOR DISTRICT HUMAN RESOURCES/STUDENT MEDICAL CONSULTANT STATE OF TEXAS COUNTY OF BEXAR Affiant, being first duly sworn, deposes: By submission of this proposal, the undersigned certifies that: (1) Affiant does neither the proposer nor any of proposer s officers, partner, owners, agents, representatives, employees, or parties in interest, has in any way colluded, conspired, or agreed, directly or indirectly with any person, firm, corporation or other proposer or potential proposer any money or other valuable consideration for assistance in procuring or attempting to procure a contact or fix the prices in the attached proposal or the proposal of any other proposer, and further states that no such money or other reward will be hereinafter paid. (2) Affiant further states they have neither recommended or suggested to HISD or any of its officials or employees, any of the terms or provisions set forth in their request for proposal and subsequent agreement, except at a meeting open to all interested proposers, of which proper notice was given. (3) Affiant, further states their officers, employees, or agents have not, and will not, attempt to lobby, directly or indirectly, the Harlandale Independent School District Board of Trustees between proposal submission date and award by the Harlandale Independent School District Board of Trustees. (4) Affiant further states no officer, or stockholder of the proposer is a member of the staff, or related to any employee of the Harlandale Independent School District. The undersigned certifies that he/she is fully informed regarding the accuracy of the statements contained in this certification, and that the penalties herein are applicable to the bidder as well as to any person signing in his/her behalf. Signature/Title Printed Name Company Name Date:

22 NON-COLLUSION STATEMENT The undersigned affirms that they are duly authorized to execute this contract, that this company, corporation, firm, partnership, or individual has not prepared this proposal in collusion with any other Proposer, and that the contents of this proposal as to prices, terms, or conditions of said proposal have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business prior to the official opening of this proposal. VENDOR ADDRESS PHONE AND FAX PROPOSER (SIGNATURE) PROPOSER (PRINT NAME) POSITION WITH COMPANY SIGNATURE OF COMPANY OFFICIAL AUTHORIZING THIS PROPOSAL COMPANY OFFICIAL (PRINT NAME) OFFICIAL POSITION

23 FELONY CONVICTION NOTICE Texas Education Code, Section , Notification of Criminal History, Subsection (a) states a person or business entity that enters into a contract with a school district must give advance notice to the district if the person or owner of operator of the business entity has been convicted of a felony. The notice must include a general description of the conduit resulting in the conviction of a felony. Subsection (b) states, a school district may terminate a contract with a person or business entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The district must compensate the person or business entity for services performed before the termination of the contract. THIS NOTICE IS NOT REQUIRED OF A PUBLICLY HELD CORPORATION. I, the undersigned agent for the firm named below, certify that the information concerning notification of felony convictions has been reviewed by me and the following information furnished is true to the best of my knowledge. COMPANY NAME: AUTHORIZED COMPANY OFFICIAL S NAME: **SIGN ONLY A, B, OR C** (PRINT OR TYPE) (PRINT OR TYPE) A. My firm is a publicly held corporation; therefore, this reporting requirement is not applicable. SIGNATURE OF COMPANY OFFICIAL B. My firm is not owned nor operated by anyone who has been convicted of a felony. SIGNATURE OF COMPANY OFFICIAL C. My firm is owned or operated by the following individual(s) who has/have been convicted of a felony. Details of Conviction: SIGNATURE OF COMPANY OFFICIAL

24 DEBARMENT AND SUSPENSION CERTIFYING STATEMENT In accordance with Executive Order 12549, Debarment and Suspension, 7 CFR Part 3017, Section the contracted certifies that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal Department or Agency. The Harlandale Independent School District hereby agrees to abide by the aforementioned terms and conditions. VENDOR NAME ADDRESS TELEPHONE NUMBER FAX NUMBER COMPANY OFFICIAL (SIGNATURE) COMPANY OFFICIAL (PRINT NAME) POSITION WITH COMPANY

25 CONFLICT OF INTEREST QUESTIONNAIRE (FORM CIQ) FOR VENDOR OR OTHER PERSON DOING BUSINESS WITH LOCAL GOVERNMENTAL ENTITY This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. By law, this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section , Local Government Code. A person commits an offense if the person violates Section , Local Government Code. An offense under this section is a Class C misdemeanor. 1. Name of person doing business with local governmental entity. 2. Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section (a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3. Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money. 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local governmental entity that is the subject of this questionnaire. 5. Name of local government officer with whom filer has affiliation or business relationship (Complete this section only if the answer to A, B, or C is YES.) This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or business relationship. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? YES NO B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? YES NO C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of ten percent (10%) or more? YES NO D. Describe each affiliation or business relationship. 6. Describe any other affiliation or business relationship that might cause a conflict of interest. 7. SIGNATURE OF PERSON DOING BUSINESS WITH THE GOVERNMENTAL ENTITY DATE (PRINT OR TYPE NAME AND TITLE)

26 DEVIATION/COMPLIANCE FORM The Harlandale Independent School District requires that if the undersigned bidder/proposer intends to deviate from either General Terms and Conditions General Bid/Proposal Specifications Bid/Proposal Specifications Sample Contract for Applicable Construction Methodology All such deviations must be listed on this page, with complete and detailed conditions and information included or attached. The Harlandale Independent School District shall consider any deviations in its bid/proposal award decisions, and the Harlandale Independent School District reserves the right to accept or reject any bid/proposal based upon any deviations indicated below or in any attachments and/or inclusions. In the absence of any deviation entry on this form, the bidder/proposer assures the Harlandale Independent School District of their full compliance with the General Terms and Conditions, General Bid/Proposal Specifications, Construction Contract and all other information pertinent and contained in this Bid/Proposal. DEVIATIONS (Check One) YES, please list below NO List any and all deviations submitted by your company below (if additional space is required please provide attachments): NAME OF COMPANY DATE OF SUBMITTAL ADDRESS SIGNATURE OF AUTHORIZED REPRESENTATIVE CITY, STATE, ZIP PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE AND FAX NUMBER OF AUTHORIZED REPRESENTATIVE POSITION OR TITLE OF AUTHORIZED REPRESENTATIVE

27 HISTORICALLY UNDERUTILIZED BUSINESS (HUB) CERTIFYING STATEMENT Proposing companies that have been certified by the Texas Building and Procurement Commission (TBPC) as Historically Underutilized Business (HUB) entities are encouraged to indicate their HUB status when responding to this proposal. (Check one) I certify that my company has been certified by the Texas Building and Procurement Commission (TBPC) as a Historically Underutilized Business (HUB), and I have attached a copy of our HUB Certification to this form. (Please provide documentation for recognition as a HUB). My company has NOT been certified by the Texas Building and Procurement Commission (TBPC) as a Historically Underutilized Business (HUB), NAME OF COMPANY DATE OF SUBMITTAL ADDRESS SIGNATURE OF AUTHORIZED REPRESENTATIVE CITY, STATE, ZIP PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE AND FAX NUMBER OF AUTHORIZED REPRESENTATIVE POSITION OR TITLE OF AUTHORIZED REPRESENTATIVE

28 MINORITY BUSINESS ENTERPRISES (MBEs) AND WOMEN BUSINESS ENTERPRISES (WBEs) CERTIFYING STATEMENT A continuing goal of the District is to increase the participation by Minority Business Enterprises (MBEs) and Women Business Enterprises (WBEs) in all phases of the District s procurement practices and to provide them equal opportunities. The term minority business enterprise means a business, at least 51 percent of which is owned, controlled and managed by minority group members. Minority group members are Blacks, women, Spanish-surnamed Americans, American Indians, Aleuts, Asians and other socially or economically disadvantaged groups. (Check One) I certify that my company is recognized as a Minority Business Enterprise (MEB) (Please provide documentation for recognition as a MBE). I certify that my company is recognized as a Women Business Enterprise (WBE). (Please provide documentation for recognition as a WBE). I certify that my company is not recognized through neither affiliations listed above NAME OF COMPANY DATE OF SUBMITTAL ADDRESS SIGNATURE OF AUTHORIZED REPRESENTATIVE CITY, STATE, ZIP PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE AND FAX NUMBER OF AUTHORIZED REPRESENTATIVE REPRESENTATIVE POSITION OR TITLE OF AUTHORIZED

29 Dear Vendor: HARLANDALE INDEPENDENT SCHOOL DISTRICT NOTICE OF NO BID FORM If at this time your company will be submitting a NO BID for this proposal please check the appropriate box below, complete the remainder of this form, and only return this form to the address listed below PRIOR to the scheduled DATE and TIME. Our company cannot provide the products, supplies and/or services listed in this request. Please REMOVE our name and address to the following category (ies) so that we may propose at a later date. Category(ies): We have chosen NOT to submit a proposal at this time but would like to remain on your list for this category. We did not submit a proposal because: Reason(s): Please REMOVE our name from all Harlandale ISD lists until further notice. Reason(s): COMPANY NAME: ADDRESS AND PHONE: REPRESENTATIVE (PLEASE PRINT): AUTHORIZED SIGNATURE: NAME OF PROPOSAL: Please mail this form to: HARLANDALE INDEPENDENT SCHOOL DISTRICT NOTICE OF NO BID SE LOOP 410 San Antonio, TX VENDORS WHO RESPOND TO THIS INVITATION WITH A COMPLETED PROPOSAL FORM WILL REMAIN ON OUR MAILING LIST. VENDORS MAKING NO RESPONSE AT ALL MAY BE REMOVED FROM THAT LISTING.

30 CERTIFICATION OF CRIMINAL HISTORY RECORD INFORMATION Each Texas public school district must receive certification from any entity with which it contracts to provide services regarding the fact that the entity has obtained the following for all employees who have or will have continuing duties related to contracted services; and have direct contact with students before employing or immediately after employing or securing the services of the individual: A name-based criminal history background check on all employees hired before January 1, 2008; A national criminal history record information review on all employees hired on or after January 1, 2008, which may include fingerprints and photographs. Continuing duties related to contracted services work duties that are performed pursuant to a contract to provide services to a school district on a regular, repeated basis rather than infrequently or one time only. Direct contact with students The contact that results from activities that provide substantial opportunity for verbal or physical interaction with students that is not supervised by a certified educator or other professional district employee. Contact with students that results from services that do not provide the opportunity for unsupervised interaction with an individual student, such as addressing an assembly, officiating a sports contest, or judging an extracurricular event, is not, by itself, direct contact with students. However, direct contact with students does result from any activity that provides the opportunity for unsupervised contact with students such as, without limitation, the provision of individualized coaching, tutoring, or other services. 19 TAC The required criminal history record information can be obtained from either of the following: ÿ A law enforcement or criminal justice agency ÿ A private entity that is a consumer reporting agency governed by the ÿ Fair Credit Reporting Act (15 U.S.C. Section 1681 et seq.) The school district may not allow any employee of the entity or an individual to serve at the district if information obtained through this review verifies that the employee has been convicted of one of the following and at the time of the offense, the victim was under 18 years of age or was enrolled in a public school: (1) A Title 5 felony offense; (2) An offense requiring the individual to register as a sex offender; or (3) An offense under the laws of another state or federal law that is equivalent to a Title 5 felony in the state of Texas or that would require registration in the Texas sex offender databank. Name of Contracting Entity or Individual: Type of service to be performed on school campus:

31 FIRM AND PERSONNEL CONDUCT STATUS FORM Respondent firm and its personnel is in good standing with all applicable licensing and certifying authorities and is not currently under nor ever have been under disciplinary action. I, the undersigned agent for the firm named below, certify that this firm nor its principals or key personnel have ever been under disciplinary action by applicable licensing and certifying authorities. FIRM S NAME: Signature of Company Official: Date Signed: Printed name of company official signing above: If the firm or its personnel is not in good standing, please provide detailed explanation below: I, the undersigned agent for the firm named below, certify the above explanation about the firm s principals or key personnel which have been under disciplinary action by applicable licensing and certifying authorities is true. STATE OF TEXAS COUNTY OF BEXAR This instrument was acknowledge before me on the day of, 20 (NOTARY SEAL) Notary Public, State of Texas

32 ERRORS AND OMISSIONS STATUS FORM List your firm or individual s from your firm who have been involved in any errors or omissions claims within the last 5 years. FIRM S NAME: NATURE OF SERVICES PROVIDED BY FIRM: NAME OF FIRM EMPLOYEE INVOLVED IN CLAIM: DATE OF CLAIM: Describe in detail the nature of the claim, total amount of the claim, and amount paid by your Errors and Omissions Insurance. Signature of Company Official: Date Signed: Printed name of company official signing above: If this does not apply to your firm certify below: I, the undersigned agent for the firm named below, certify that neither this firm nor its principals or key personnel have been party to any claims for errors or omissions within the last five years. STATE OF TEXAS COUNTY OF BEXAR This instrument was acknowledge before me on the day of, 20 (NOTARY SEAL) Notary Public, State of Texas

33 STATEMENT OF LEGAL, PROFESSIONAL AND ETHICAL BEHAVIOR 1. Does your firm have any pending construction or development-related litigation? If so, please describe on a separate page. NO YES 2. Has your firm ever been sanctioned by any State or Federal agencies? Please provide a description of such sanction on a separate page. 3. No person or company shall make any political contributions to any HISD board member from the issuance of the RFP/B and no sooner than 30 days after the contract is awarded. AGREE DO NOT AGREE 4. No person or company shall have contact with any HISD board member from the date of issuance of this RFP/B and no sooner than 30 days after the contract is awarded. 5. The firm submitting the Proposal is responsible to report any board member making contact with the firm to the District's Superintendent. 6. The firm must conduct a criminal background check on any employee that the firm has working on the project who will be coming to school property. 7. The firm must have a statement of no tolerance for any inappropriate conduct by any of the firm's employees with the District's staff members or students. Failure to abide by statement 4-7 may subject your proposal to disqualification. Please submit clarification responses of Yes on questions 1-2 and Do Not Agree in statement 3-7 on a separate page. I hereby certify that the above statements of legal, professional, and ethical behavior are understood and will be addressed and adhered to. Company Representative Signature Date Company Representative (Type/Printed) STATE OF TEXAS COUNTY OF BEXAR This instrument was acknowledge before me on the day of, 20 (NOTARY SEAL) Notary Public, State of Texas