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RFP#: 10-327 Commonwealth Neurotrauma Initiative Trust Fund

1. 12 Consenting person s signature Date 13 Person explaining form title Phone a4 Witness signature if required Phone Witness Address For DRS Use Only Consent has been Revoked in entirety E Partially revoked as follows L specify below Revoked on By check one Letter attach Phone _ In Person date copy LJ Received by Titl Phon e e Office Fax address 65 Form 3 Directions for Filling out and Returning the Release of Information Form The Virginia Department of Rehabilitative Services DRS may provide services to you through the Brain Injury Direct Services BIDS Fund part of the DRS Community Based Services Division We need your written permission to share information among family members and service providers to help plan for and provide services Please review the enclosed Uniform Consent to Exchange Information release of information form carefully and do the following IS If you agree with all of the information on the form including the boxes that are already checked simply fill out the highlighted areas Sign date the form on page 2 OR DO If you want to change any of the information on the form including any of the boxes that area already checked make any changes that you wish and put your initials beside it Then sign and date the form on page 2 Return the form to DRS Brain Injury Services Coordination Unit 8004 Franklin Farms Driv
2. five of the nine organizations additional information from remaining organizations will be available upon award of contract The actual number of records varies by table per example the Progress Notes table has more than 15 000 records just for BIS INC alone The number varies each day as the case managers use the system on a continual work day basis Additionally the number of fields varies by table Some have only 4 5 fields while other tables have dozens of fields The vendor and group that has the data now will work on giving the data to the new vendor Number of Consumers who have Profiles in the current Case Management System BIAV N A BIS INC 1 000 will get specific info BISSWVA 1 000 will get specific info CBIR 38 CFF 27 CSS Didlake 45 MWS 55 VSH 20 10 Informational Requirements Reports additional reporting information below Reports must provide for the following generic reports and provide exportable data for the reports specific to DRS needs e History detail reports e There are additional reports attached with the data elements C ANALYSIS DOCUMENTATION Impacts on Current Environment e Installing an automated system will require increased support by DRS Information Systems personnel e Paper document filing has the potential to diminish e Data analysis and reporting capabilities for BIS Programs and for DRS will be improved e Capability of DRS to conduct program distance auditing will
3. Each program must have write access here to enter the names of all their employees into the system and add delete staff names as needed 7 Reason for Contact Dropdown box INFORMATION REFERRAL CONSULTATION INTAKE APPLICATION 8 Name of Person Making Contact Textbox 9 Referral Source Dropdown box to include Acute Hospital Brain Injury Association CSB MH CSB MR CSB SA Detention Facility DMAS DRS DSS Family Friend Guardian Inpatient Rehab Legal Long term Facility Mental Health Outpatient Rehab Private Insurance Private Practitioner School Self Shelter Support Group Worker s Compensation Other 10 Contact Referring Source Mailing Address Suite Apartment Number Post Office Box Textbox 11 Street Number Textbox 12 City or Town Textbox 13 State Default to VA but can change if needed 14 Zip Textbox 15 Phone Number Textbox able to enter multiple phone numbers 16 E mail Textbox able to enter multiple e mail addresses 35 17 Name of Potential Consumer Textbox 18 Does Person Meet Program Eligibility Criteria Dropdown box YES or NO for eligibility criteria data points such as Age Physical Residence is it within service area of program Citizenship Status Documentation Evidence of Brain Injury Substance Abuse Mental Health Person Needs Wants Case Management Services etc 18 A Club Houses Eligibility Criteria need to check clubhouse or case m
4. The requirements of this Paragraph shall be construed to achieve full compliance with the Information Technology Access Act 2 2 3500 through 2 2 3504 of the Code of Virginia AA OPTIONAL PREBID PREPROPOSAL CONFERENCE An optional prebid preproposal conference will be held from __1 30 3 30 p m on Thursday May 27 2010 at the _ Department of Rehabilitative Services 8004 Franklin Farms Drive Richmond Virginia 23229 conference room 101 The purpose of this conference is to allow potential bidders offerors an opportunity to present questions and obtain clarification relative to any facet of this solicitation While attendance at this conference will not be a prerequisite to submitting a bid proposal bidders offerors who intend to submit a bid proposal are encouraged to attend Bring a copy of the solicitation with you Any changes resulting from this conference will be issued in a written addendum to the solicitation If special needs or accommodations are required please notify within 24 hours of the pre proposal conference date METHOD OF PAYMENT The Commonwealth will pay upon receipt of a valid invoice in accordance with the Virginia Prompt Payment 21 Act Invoices shall be submitted to Department of Rehabilitative Services Commonwealth Neurotrauma Initiative CNI Trust Fund 8004 Franklin Farms Drive Richmond VA 23229 A legally authorized official of the Contractor shall sign all financial and progress reports in
5. currently feel that you have a substance abuse problem such as drinking too much using marijuana or other recreational drugs or using prescription medications in ways other than how prescribed Checkbox YES or NO a If YES Textbox to describe If YES can system automatically insert this into Trigger Sheet Form as a possible goal d List any agencies with whom you are working Textbox Name of agency contact person etc PART I CONSUMER PROFILE NEEDS ASSESSMENT B Consumer Profile Financial Information financial elements need to populate the Financial Eligibility Form FEF 1 SOO eas 11 12 13 14 15 16 17 18 19 20 Employment income amount Textbox populates FEF SSI Checkbox YES or NO SSI Amount Textbox populates FEF SSDI Checkbox YES or NO SSDI Amount Textbox populates FEF Insurance Checkbox YES or NO Insurance Company Textbox Insurance Policy Textbox Medicaid Textbox Medicaid Waiver Checkbox YES or NO If YES Dropdown Box for type of Waiver Elderly or Disabled with Consumer Direction EDCD Individual and Family Developmental Disabilities Supports IFDDS HIV AIDS Technology Assisted Tech Mental Retardation MR Day Support Alzheimer s Assisted Living AAL Medicare Textbox Workers Comp Workers Comp Textbox populates FEF Military Benefits Textbox IF YES what kind If monetary how much populate FEF Pension am
6. 20 years after the expiration or termination of the contract All lease and royalty fees necessary to support this right are included in the initial license fee as contained in the pricing schedule Therefore the DRS Brain Injury Services will own all data and will be able to request data at any given time V TERM OF SOFTWARE LICENSE Unless otherwise stated in the solicitation the software license s identified in the pricing schedule shall be purchased on a perpetual basis and shall continue in perpetuity However the Commonwealth reserves the right to terminate the license at any time although the mere expiration or termination of this contract shall not be construed as an intent to terminate the license All acquired license s shall be for use at any computing facilities on any equipment by any number of users and for any purposes for which it is procured The Commonwealth further reserves the right to transfer all rights under the license to another state agency to which some or all of its functions are transferred W TITLE TO SOFTWARE By submitting a bid or proposal the bidder or offeror represents and warrants that it is the sole owner of the software or if not the owner that it has received all legally required authorizations from the owner to license the software has the full power to grant the rights required by this solicitation and that neither the software nor its use in accordance with the contract will violate or infringe upo
7. Bachelors degree Masters degree or higher i 09 Work Status last week enter circle 1 code from list below Employed w o supports integrated setting Extended employ 2 Self employment i DBVI vending facility 4 Homemaker 5 Unpaid family worker 6 Employed w supports integrated settir Not employed in secondary education 8 Not employed all other students 9 Not employed unpaid trainee intern volunte Not employed other 11 10 Hours Worked for pay in typical wk enter 0 if unpaid work or not employed 11 Weekly Earnings gross pay in typical wk Must exceed 0 if Work Status code is 1 3 or 7 12 Primary Financial Support enter circle 1 code from list below blank if unknown Applicant income Spouse family friends Gov t see description in item 20 3 Other 4 13 Ever had an Individualized Education Plan IEP Y _ N L must be Y if Education is coc 14 Living Arrangement enter circle 1 code from list below Private residence including apartment buildings etc alone or with others 1 Community residential Group home Rehabilitation facility 3 Mental health facility Nursing home 5 Adult correctional facility Halfway house 7 Substance abuse treatment center Homeless or in a shelter Other 10 15 Medical Insurance Co name leave blank if none 16 Policy No 17 Medicaid 18 Medicare 19 Has Medicaid Y _ N _ Medicare Y _ N Workers Comp Y NL Private insurance thru Em
8. Firm Name Address and Type of Goods of Total Phone Number Contact Person or Services Dollar Amounts Contract 25 2 a Participation by Businesses Owned by Women A Offeror certifies that it is is not a women s business enterprise or women owned business For the purpose of this procurement a women owned business is a concern that is at least 51 owned by a woman or women who also control and operate it In this context control means exercising the power to make policy decisions and operate means being actively involved in the day to day management B List businesses owned by women with which the Offeror has contracted or done business and dollar amounts spent with each of these businesses in the most recent 12 month period for which data are available Offerors are encouraged to provide additional information and expand upon the following format Period From To Total Company Firm Name Expenditures Address and Type of Goods for Goods and Phone Number Contact Person or Services Dollar Amounts Services 26 2 b Participation by Businesses Owned by Women Continued C Describe Offeror s plans to involve businesses owned by women in the performance of this contract either as part of a joint venture as a partnership as subcontractors or as suppliers Offerors are encouraged to provide additional
9. Textbox iv Post Injury Textbox v Outcome Description Comments Textbox Additional Information for data elements Support Team Any field that has names of people with the exception of client name will have a radio button to add them as a member of the support team Doctors and therapists to include under Health but distinguish from Professionals that could include Social Workers so as to access necessary Medical info easier for the fields doctor and therapist we want to auto populate these fields once data has started to be entered List of Agencies and Contact Persons we want to auto populate these fields once data has started to be entered Consent to Exchange Information Form automatically populate based on the we want to auto populate these fields once data has started to be entered based on client from consumer profile 45 Post Injury Survey HEALTH ISSUES POST INJURY PHYSICAL Consumer Family Case Manager YES or NO only YES or NO only Textbox to add notes option option detailed information Do you lack strength coordination on the Radio button for Radio button for right side yes Or no yes or no Textbox Do you lack strength coordination on the Radio button for Radio button for left side yes or no yes or no Textbox Radio button for Radio button for Do you lack strength coordination yes or no yes or no Textbo
10. The project plan should be updated on a monthly basis as part of a project status report or other schedule established in writing by the project manager The updated project plan shall be highlighted with appropriate color to indicate e not initiated black e in progress on schedule green e in progress possible delay yellow e in progress overdue red e completed blue Status Reporting A project status report shall be provided to the BICMS Information Specialist on a bi weekly or other basis as mutually agreed upon The first status report is due two weeks after the contract initiation Documents shall contain appropriate identifying information Any changes from previous status should be noted with reason for change Any decision points should be described with alternatives recommendations and outcome impacts expected from decisions Current period activity status Provide a list of activities Activities should have clear links to the project plan issue resolution risk mitigation an identified in the previous report as appropriate Significant accomplishments for the current period Summarize what was achieved from the activities undertaken during the past period Planned activities for the next period This is a review of the project schedule Describe any possible deviations Non technical project issues List and describe management issues that have been identified and not resolved Identify progress toward resolution
11. h Do you need assistance with household chores Checkbox YES or NO i Do you need assistance with managing your time Checkbox YES or NO j Do you need assistance with planning organization Checkbox YES or NO k Do you have any concerns with safety Checkbox YES or NO l What is your current transportation Dropdown Drive own car family friends or relatives public transportation specialized transportation bicycle motorcycle walking m Do you have any transportation needs Checkbox YES or NO n If you ride a bike or motorcycle do you wear a helmet Checkbox YES or NO i If NO do you need assistance purchasing a helmet Checkbox YES or NO o Describe any additional areas of concern Textbox 5 Employment a Are you presently working Checkbox b Describe work Textbox 1 If not working are you interested in working Textbox li Describe interests Textbox ii Do you have a goal to return to work Checkbox iv Describe goal Textbox v Department of Rehabilitative Services family employment agency friends self Community Services Board Clubhouse Case manager Supported Employment agency One Stop Employment Office Textbox 1 Ifyou have selected YES above describe assistance Also describe any other issues strengths and or weaknesses related to employment Textbox c Job History Table format i Occupation Dates Textbox ii Pre or Post Case Management Textbox 44 iii Pre Injury
12. when necessary expert reviewers will assist in the evaluation process 2 Screening Criteria Proposals will be evaluated as follows 1 Experience Creating Disability Case Management Applications 15 Points 2 Secure Hosting Services for the Web Site and for the Database 10 Points 3 Budget Budget Justification and Sustainability 20 Points 4 Timetable for deliverable clear and concise 15 Points 5 Adherence to Business Definition and Specified Data Elements 20 Points 6 Small Women Owned and Minority Business Participation 5 Points 7 Accessibility 10 Point 8 Experience Creating Brain Injury Case Management Applications 5 Points 100 Points Offerors will be notified by the Department of Rehabilitative Services DRS or the Commonwealth Neurotrauma Initiative CNI Trust Fund regarding the status of their proposals Proposals deemed qualified for further consideration may be asked to provide additional clarifying information prior to the contract negotiation process 3 Final Evaluation and Recommendation for Award Following evaluation and rating The Commonwealth Neurotrauma Initiative CNI Trust Fund Advisory Board will award funding to one qualified Offeror whose proposal is deemed most advantageous B Award Selection shall be made of the Offeror s deemed to be fully qualified and best suited based on the evaluation factors included in this RFP as well as those considered to be in the best interests of DRS and the Commonwea
13. 40 If NO or UKNOWN Do you want information on an Advanced Medical Directive Checkbox YES or NO 41 If YES Textbox to document date that information on advanced medical directive was provided and by whom All programs should use a uniform Advanced Medical Directive to be provided by DRS from VA Dept of Health and included in the software system 37 42 Are you registered to vote Checkbox YES NO or UNKNOWN 43 IF NO or UNKNOWN Do you want to register to vote or make sure that you are registered to vote Checkbox YES or NO 44 If YES Do you need assistance in registering to vote Checkbox YES or NO 45 If YES Textbox to document date that voter registration form was completed or mailed to the person and name of staff person who provided assistance All programs should use a uniform Virginia Voter Registration Form to be provided by DRS and included in the software system 46 Have you ever been convicted of a misdemeanor or felony Checkbox YES NO or UNKNOWN 47 If YES or UNKNOWN Textbox entitled Criminal Offender History should pop up so that case manager can enter descriptive information on known arrests convictions dates outcomes etc OR plan to find out this information This textbox should be updatable If NO skip to 47 DRS will investigate the information that it collects and will include it in the software system 48 Primary Staff Person Dropdown box list
14. 75 of its goal to provide goal to provide educational activities educational activities for a specified for a specified number of people by number of people by the target date the target date The program achieved greater than or equal to 75 of its goal to provide Outreach activities for a specified number of people by the target date 50 74 ofits goal to provide Outreach activities for a specified number of people by the target date The program achieved greater than or The program achieved 50 74 of its equal to 75 ofits goal to provide public goal to provide public awareness awareness activities for a specified activities for a specified number of number of people by the target date people by the target date The program achieved greater thanor The program achieved 50 74 of its equal to 75 of its goal to provide goal to provide advocacy activities advocacy activities for a specified for a specified number of people by number of people by the target date the target date 69 Below Expectati The program achieved les equal to 49 of its goal to educational activities fora number of people by the te The program achieved les equal to 49 of its goal to outreach activities for a sp number of people by the te The program achieved les equal to 49 of its goal to awareness activities for a number of people by the te The program achieved les equal to 49 of its goal to advocacy activities for a et number of pe
15. Coordination Unit 8004 Franklin Farms Drive Richmond VA 23229 Phone 804 662 7615 or 800 552 5019 Fax 804 662 7663 E mail patti goodall drs virginia gov Important Information I understand that different agencies provide different services and benefits Each agency has specific information needs By signing this form I am allowing the agencies listed to work more effectively to provide or coordinate services or benefits I understand that if I have reached the age of 18 and am not under a legal guardianship conferred by the court that my parents cannot have access to my case file or to any confidential information related to me and cannot discuss my case with DRS or make decisions regarding my case without my express written consent I also understand that the release of information provided by other agencies is subject to that agency s terms of release a I consenting person s name am signing this form for full name of consumer of consumer address 2 consumer birthdate 3 Consumer SSN optional 4 Relationship to consumer check one Self E Parent C Power of attorney C Legal Guardian 5 I want the following information about the consumer to be exchanged Drug and alcohol treatment information cannot be released through signature on this form The release of such information requires use of the Interagency Consent to Release Information for Alcohol or Drug Patients A yes or
16. Virginia Contractors who utilize access or store personally identifiable information as part of the performance of a contract are required to safeguard this information and immediately notify the agency of any breach or suspected breach in the security of such information Contractors shall allow the agency to both participate in the investigation of incidents and exercise control over decisions regarding external reporting Contractors and their employees working on this project may be required to sign a confidentiality statement K CONFIDENTIALITY Contractor The contractor assures that information and data obtained as to personal facts and circumstances related to patients or clients will be collected and held confidential during and following the term of this agreement and will not be divulged without the individual s and the agency s written consent Any information to be disclosed except to the agency must be in summary statistical or other form which does not identify particular individuals Contractors and their employees working on this project will be required to sign the Confidentiality statement in this solicitation L DEFINITION EQUIPMENT As used herein the terms equipment product or system shall include hardware and software when applicable and any materials or supporting documentation Such documentation may include but is not limited to users guides operations manuals with part lists copies of all applicable w
17. Zip Textbox MAILING ADDRESS Suite Apartment Number Post Office Box If same as PHYSICAL RESIDENCE ADDRESS automatically populate 9 through 14 with PHYSICAL RESIDENCE ADDRESS maybe have a small checkbox at top that says Check here if same as PHYSICAL RESDIENCE ADDRESS If different from PHYSICAL RESIDENCE ADDRESS then Textbox to allow information to be filled in 10 Street Number Textbox 11 City or Town Textbox VONDA 36 12 State Default to VA but can change if needed 13 Zip Textbox 14 County of Residence Dropdown box Need to decide if each program will have write access and can list all the counties of residence within their service areas OR if the system should list ALL COUNTIES IN VA and each program can indicate which ones they want to see for their program with ability to check a county outside of their service area if necessary 15 Phone Number Textbox with ability to enter multiple telephone numbers 16 E mail Textbox with ability to enter multiple e mail addresses 17 Emergency Contact Relationship Phone Textbox 18 Date of Birth Textbox 19 Gender Checkbox MALE FEMALE OTHER 20 Marital status Dropdown box SINGLE MARRIED SEPARATED DIVORCED WIDOWED 21 Race Checkbox or Dropdown box Will conform to DRS info collected 22 Ethnicity Checkbox or Dropdown box Will conform to DRS info collected 23 Citizenship Checkbox or Dropdown Box W
18. based to be hosted by the DSA suitable for modifications as needed by the Vendor and the DSA At a minimum each document should be assigned a unique identification number a document name and the date the document was printed hard coded date If the document is part of a series the series shall be identified and the document given a series sequence number If the document is an update the document shall refer to the original document number it is updating and the update sequential number for the original document revision number If the document contains information about a problem or problem resolution the unique problem log number shall be referenced All content of manuals is subject to review and approval by the DSA Requirements The System Must e have the ability to email items directly from the system via an email function and if possible upload Outlook Contacts e be able to generate a daily work log for managers administrators of the caseloads that are being worked on any given day e tie specifically into the Scorecard each of the nine 9 state funded Brain Injury Services BIS Programs collects information on individual service goals for the people served That information is then rolled up and reported in aggregate to DRS This is reported on the SCORECARD website at http www vadrs org cbs apps outcomes by having outcomes and indicators added to the client screen with check boxes and cleared at the end of
19. based on the data elements provided in this document see Attachment C The application will be designed based on the information provided in the Business Definition Please provide a schema design and testing schedule based on these elements in the response to the Request for Proposal 6 Small Women Owned and Minority Business Participation not counted in 15 page limit The Offeror must submit the following three sets of data for small business women owned business and minority owned business a ownership b utilization of small women owned and minority owned businesses for the most recent 12 months and c planned involvement of small businesses women owned businesses and minority owned businesses on this procurement Forms for submission of this data are provided as Attachment A 7 Vendor Data Sheet not included in 15 page limit The Offeror must complete sign and submit the Vendor Data Sheet Form for submission of this data is provided as Attachment B EVALUATION AND AWARD CRITERIA The proposal to be funded under this Request For Proposals RFP is contingent on the availability of funds and nature of proposals received A Evaluation 1 Proposal Review Proposals submitted in response to this Request For Proposals RFP may be evaluated by a review panel appointed by the Department of Rehabilitative Services DRS and the Commonwealth Neurotrauma Initiative CNI Trust Fund Advisory Board As appropriate and
20. determine costs or savings Any claim for an adjustment in price under this provision must be asserted by written notice to DRS within thirty 30 days from the date of receipt of the written order from DRS If the parties fail to agree on an amount of adjustment the question of an increase or decrease in the contract price or time for performance shall be resolved in accordance with the procedures for resolving disputes provided by the Disputes Clause of this contract or if there is none in accordance with the disputes provisions of the Commonwealth of Virginia Vendors Manual Neither the existence of a claim nor a dispute resolution process litigation or any other provision of this contract shall excuse the Contractor from promptly complying with the changes ordered by DRS CNI Trust Fund or with the performance of the contract generally DEFAULT In case of failure to deliver goods or services in accordance with the contract terms and conditions the Commonwealth after due oral or written notice may procure them from other sources and hold the Contractor responsible for any resulting additional purchase and administrative costs This remedy shall be in addition to any other remedies which the Commonwealth may have INSURANCE By signing and submitting a bid or proposal under this solicitation the bidder or Offeror certifies that if awarded the contract it will have the following insurance coverage at the time the contract is awarded For construc
21. funded out of a separate fund not the CNI Trust Fund Please include in your narrative a cost estimate for each of these items these items cannot be a part of the 180 000 CNI Trust Fund award o hosting web and database o maintenance will begin after implementation of the two year grant at year 3 o data conversion activities Testing Overview All testing will be in accordance with the BICMS Information Specialist AccVerify will be used as the approved Agency Test Tool The unit will be tested and evaluated for all requirements including but not limited to the following criteria e Security e Local site access e Remote site access as appropriate e Mobile site access as appropriate e Simultaneous access for multiple sites as appropriate Accessibility pertaining to section 508 guidelines e Process load Response time e Program area content workflow and business rules e Business function content workflow and business rules e Printing as appropriate e Simultaneous printing as appropriate Sequential printing as appropriate Documentation and Reporting For each criterion the unit will go through the following stages e The BICMS Information Specialist will test each unit as defined by the Software Development Life Cycle e The BICMS Information Specialist will work with the user test groups with the Brain Injury Services BIS Programs set up by the DRS Director of Brain Injury amp Spinal Cord I
22. information and expand upon the following format Firm Name Address and Type of Goods of Total Phone Number Contact Person or Services Dollar Amounts Contract 27 3 a Participation by Businesses Owned by Minorities A Offeror certifies that it is is not a minority business enterprise or minority owned business For the purpose of this procurement a minority owned business is a concern that is at least 51 owned and controlled by one or more socially and economically disadvantaged persons Such disadvantages may arise from cultural racial chronic economic circumstances or background or other similar cause Such persons include but are not limited to blacks Hispanic Americans Asian Americans American Indians Eskimos and Aleuts B List businesses owned by minorities with which the Offeror has contracted or done business and dollar amounts spent with each of these businesses in the most recent 12 month period for which data are available Offerors are encouraged to provide additional information and expand upon the following format Period From To Total Company Firm Name Expenditures Address and Type of Goods for Goods and Phone Number Contact Person or Services Dollar Amounts Services 28 3 b Participation by Businesses Owned by Minorities Continued C Describe Offeror s plans to involve minor
23. no response must be indicated for each category 1 Assessment Info Yes No L 4 Medical Diagnosis Yes Nol 8 Educational Records Yes Nol 2 Financial Info Yes No L 5 Mental Health Diagnosis Yes Nol 9 Psychiatric Records Yes No L 3 Benefits Services Needed 6 Medical Records Yes K No L 10 Criminal Justice Records Yes No L Planned or Rec d Yes K Nol 7 Psychological Records Yes K No CL 11 Employment Records Yes No O Other Information write in 6 I want the Virginia Department of Rehabilitative Services through Patricia Goodall Director of Brain Injury amp Spinal Cord Injury Services and the following other agencies and or individuals to be able to exchange provide the following information attach extra sheets if necessary Name of Agency Individual Address Phone Type of Info Patricia Goodall DRS Brain Injury Services 8004 Franklin Farms 1 above through Coordination Unit and Brain Injury Direct Services Drive 11 BIDS Fund and Carolyn Turner DRS Community Richmond VA 23229 Rehabilitation Case Management CRCM Services 804 662 7615 800 552 5019 Family Members list all with whom information can 1 above through be shared 7 I want information to be shared through the following means or mechanisms check all that apply Written Information x In Meetings or by Phone x Computerized Data 64 Form 2 2 of 2 Uniform Consent to Exchange Information 8 I want this information to be e
24. of color selections capable of producing a range of contrast levels shall be provided k Software shall not use flashing or blinking text objects or other elements having a flash or blink frequency greater than 2 Hz and lower than 55 Hz 1 When electronic forms are used the form shall allow people using assistive technology to access the information field elements and functionality required for completion and submission of the form including all directions and cues Web based Intranet and Internet information and applications if applicable a A text equivalent for every non text element shall be provided eg via alt longdesc or in element content b Equivalent alternatives for any multimedia presentation shall be synchronized with the presentation 55 c Web pages shall be designed so that all information conveyed with color is also available without color for example from context or markup d Documents shall be organized so they are readable without requiring an associated style sheet e Redundant text links shall be provided for each active region of a server side image map f Client side image maps shall be provided instead of server side image maps except where the regions cannot be defined with an available geometric shape g Row and column headers shall be identified for data tables h Markup shall be used to associate data cells and header cells for data tables that have two or more logical levels o
25. of quality based industry standards such as ISO International Standards Organization C Proposal Development Content and Format Requirements Proposals should be as thorough and detailed as possible so that the Department of Rehabilitative Services and a review panel if used may properly evaluate the Offeror s capabilities to provide the required services Proposals should not be longer than fifteen 15 pages double spaced with page numbers using Times New Roman 12 Font the fifteen pages do not include the mandatory reporting forms the RFP cover sheet resumes letters of recommendation support and other attachments or appendices needed Address the following in the proposal 1 Experience Developing Case Management Applications for Working with People with Disabilities Preferably to Brain Injuries two pages List the specifications for software systems that have been designed by your group for use by programs providing services to people with brain injury Provide at least two references for the product and for services rendered 2 Secure Hosting Services for the Web Site and for the Database two pages Since the vendor is responsible for the database server web server and all elements involved in hosting and maintaining the data please list the name of the hosting provider and describe how the data will be secured including all certificates and specific standards for securing the data The following should also be addres
26. of t or actions required to resolve the issues 53 Technical project issues List and describe technical issues that have been identified and not resolved Identify progress toward resolution of the i actions required to resolve the issues Action items Report on actions assigned and executed to resolve issues Describe what the issue was what action was taken who wa responsible and results Risk status Identify changes in probability of occurrence or impact List and describe any new risk event identified during the repor period Identify mitigation plans and assign responsibility for monitoring risk Resource Usage Provide staff hours expended during the past reporting period DSA Project Team Hierarchy The project team consists of more than 4 DSA staff personnel e The BICMS Information Specialist BICMS Manager and IS Designee will review documentation phases and discuss potential problems They will also address how to move to the next Phase The BICMS Manager will designate three Program Users to work with this team e The BICMS project is coordinated through the BICMS Information Specialist Requirements decisions and other information is passed in either direction as based on the information above The Department of Rehabilitative Services IS Project Manager will be kept informed by the DSA Project Team of all developments e Any communication between the Vendor and the BICMS project team shall first be coordinated be
27. should be addressed as directed on Page 1 of the solicitation Proposals may be hand delivered to the designated location in the office of DRS issuing the solicitation No other correspondence or other bids proposals should be placed in the envelope F SMALL WOMEN AND MINORITY OWNED BUSINESSES SUBCONTRACTING AND REPORTING Where it is practicable for any portion of the awarded contract to be subcontracted to other suppliers the Contractor is encouraged to offer such business to small women and or minority owned SWAM businesses The Contractor agrees to report the use of SWAM subcontractors by providing DRS at a minimum the following information name of firm phone number total dollar amount subcontracted category type small women or minority owned and type of product service provided Names of firms may be available from DRS and or from the Division of Purchases and Supply Additional information regarding certified SWAM vendors is available at www eVA state va us 17 G PRIME CONTRACTOR RESPONSIBILITIES The Contractor shall be responsible for completely supervising and directing the work under this contract and all subcontractors that he she may utilize using his her best skill and attention Subcontractors who perform work under this contract shall be responsible to the prime Contractor The Contractor agrees that he she is as fully responsible for the acts and omissions of his her subcontractors and of persons employe
28. to and use of information and data that is comparable to the access and use by Federal employees who are not individuals with disabilities unless an undue burden would be imposed on the agency Section 508 also requires that individuals with disabilities who are members of the public seeking information or services from a Federal agency have access to and use of information and data that is comparable to that provided to the public who are not individuals with disabilities unless an undue burden would be imposed on the agency If the product does not pass accessibility requirements as stated by the aforementioned Section 508 this may result in nonpayment to the vendor Federal Standard Applications and operating systems a When software is designed to run on a system that has a keyboard product functions shall be executable from a keyboard where the function itself or the result of performing a function can be discerned textually b Applications shall not disrupt or disable activated features of other products that are identified as accessibility features where those features are developed and documented according to industry standards c Applications also shall not disrupt or disable activated features of any operating system that are identified as accessibility features where the application programming interface for those accessibility features has been documented by the manufacturer of the operating system and is available to the pr
29. B Company Name Address Contact Person Project Telephone Number Fax Number Dates of Service Value C Company Name Address Contact Person Project Telephone Number Fax Number Dates of Service Value D Company Name Address Contact Person Project Telephone Number Fax Number Dates of Service Value I certify the accuracy of this information Signed Date Title 30 ATTACHMENT C BUSINESS DEFINITION Definitions and Recommendations for a Brain Injury Case Management Software System A PROJECT DEFINITION Introduction The scope of this project includes definition recommendations system purchase installation staff training and ongoing support as a recommendation for the purchase or development of a Brain Injury Case Management Software System Assumptions and Constraints The following are the major assumptions and constraints relevant to this project e The system must service a current group of nine 9 or more groups The number of users may increase over the years and the system should be able to address expansion issues The system must allow the user groups to enter retrieve and store data as individual case management systems for each program e The application must run in an Internet environment e The application must run on IE 6 0 or higher compatible web browsers e The application must be user friendly and accessible per requirements listed above in this RFP e The applicat
30. EEE DEERE EEE EEE EEE EE 68 Form 6 Sample Application amp Referral reem e deg EEN EEN SE ibaa teve E chan 70 Form 7 Sample Authorization and Expenses Form 71 I PURPOSE Il The purpose of this Request For Proposals RFP issued on behalf of the Commonwealth Neurotrauma Initiative CNI Trust Fund is to establish one grant funded contract for the development of a web based case management software system to assist state funded Brain Injury Services BIS contractors The case management system will provide a universal application to store statewide case management brain injury data by organization and will provide a web interface to display and allow for data entry The application must be built so it is secure allow multiple organizations to utilize the system display data specific to each group allow access and reporting on all data and must pass Virginia Standards for Accessibility as defined in Attachment C BACKGROUND AND ELIGIBLE OFFERORS A History Senate Bill 1132 passed by the 1997 Virginia General Assembly established the Commonwealth Neurotrauma Initiative CNI Trust Fund The Fund to support research education and treatment relating to traumatic spinal cord or brain injuries resulting in loss of physical and cognitive functions Originally the Fund was to consist of grants donations and bequests from public and private sources and funds In 1998 Senate Bill 484 was passed by the General Assembly and establish
31. IONS OF OFFERORS The Commonwealth may make such reasonable investigations as deemed proper and necessary to determine the ability of the Offeror to perform the services furnish the goods and the Offeror shall furnish to the Commonwealth all such information and data for this purpose as may be requested The Commonwealth reserves the right to inspect Offeror s physical facilities prior to award to satisfy questions regarding the Offeror s capabilities The Commonwealth further reserves the right to reject any proposal if the evidence submitted by or investigations of such Offeror fails to satisfy the Commonwealth that such Offeror is properly qualified to carry out the obligations of the contract and to provide the services and or furnish the goods contemplated therein TESTING AND INSPECTION The Commonwealth reserves the right to conduct any test inspection it may deem advisable to assure goods and services conform to specifications ASSIGNMENT OF CONTRACT A contract shall not be assignable by the Contractor in whole or in part without the written consent of the Commonwealth CHANGES TO THE CONTRACT Changes can be made to the contract in any of the following ways 13 The parties may agree in writing to modify the scope of the contract An increase or decrease in the price of the contract resulting from such modification shall be agreed to by the parties as a part of their written agreement to modify the scope of the contract DRS may o
32. ORS A bidder offeror or contractor shall not be discriminated against in the solicitation or award of this contract because of race religion color sex national origin age disability faith based organizational status any other basis prohibited by state law relating to discrimination in employment or because the bidder or offeror employs ex offenders unless the state agency department or institution has made a written determination that employing ex offenders on the specific contract is not in its best interest If the award of this contract is made to a faith based organization and an individual who applies for or receives goods services or disbursements provided pursuant to this contract objects to the religious character of the faith based organization from which the individual receives or would receive the goods services or disbursements the public body shall offer the individual within a reasonable period of time after the date of his objection access to equivalent goods services or disbursements from an alternative provider eVA Business To Government Vendor Registration The eVA Internet electronic procurement solution website portal www eVA virginia gov streamlines and automates government purchasing activities in the Commonwealth The eVA portal is the gateway for vendors to conduct business with state agencies and public bodies 15 All vendors desiring to provide goods and or services to the Commonwealth shall participate i
33. Request for Proposals RFP Issue Date May 14 2010 RFP 10 327 Title Commonwealth Neurotrauma Initiative Trust Fund Development of a Web Based Brain Injury Case Management Software System Issuing Agency Virginia Department of Rehabilitative Services Commonwealth Neurotrauma Initiative CNI Trust Fund 8004 Franklin Farms Drive Richmond Virginia 23229 Where Work Will Be Performed Statewide Period of Contract Upon Contract Signature Sealed Proposals Will be Received Until 3 00 P M EST on Monday June 14 2010 For Furnishing The Services Described Herein All inquiries for information should be directed to James Gregory General Services Manager at 804 662 7516 TTY 800 552 5019 FAX 804 662 9525 Questions regarding this Request For Proposals RFP will not be received later than ten 10 business days prior to the closing of the solicitation IF PROPOSALS ARE MAILED SEND DIRECTLY TO ISSUING AGENCY SHOWN ABOVE IF HAND DELIVERED DELIVER TO James Gregory General Services Purchasing Department 8004 Franklin Farms Drive Richmond VA In Compliance With This Request For Proposals And To All The Conditions Imposed Therein And Hereby Incorporated By Reference The Undersigned Offers And Agrees To Furnish The Services In Accordance With The Attached Signed Proposal Or As Mutually Agreed Upon By Subsequent Negotiation Name of Organization Address Contact Person Title please print FEI FIN E mail Address Telephone Fa
34. ability to maintain its own internal data within a safe and secure environment that is accessible to ongoing web hosting and software system maintenance duties This assures that client level data are maintained accurately for each group B Eligible Offerors Responses to this RFP may be made by Virginia based and licensed organizations institutions and companies deemed qualified to provide the services C Small Women Owned and Minority Business Participation It is the policy of the Commonwealth of Virginia to contribute to the establishment preservation and strengthening of small business and businesses owned by women and minorities and to encourage their participation in State procurement activities The Commonwealth encourages Contractors to provide for the participation of small businesses and businesses owned by women and minorities through partnerships joint ventures subcontracts or other contractual opportunities Submission of a report of past efforts to utilize the goods and services of such businesses and plans for involvement on this contract are required for contracts of a 100 000 or more or b over 15 000 where subcontracting opportunities exist By submitting a proposal Offerors certify that all information provided in response to this RFP is true and accurate Failure to provide information required by this RFP will ultimately result in rejection of the proposal For further information please go to http www dmbe vir
35. ages in activities in the community outside of their residential setting Residential Goals RS1 Individual moves to a less restrictive residential setting RS2 Individual in an at risk situation moves to or receives supports that provide a safer more stable setting RS3 Individual who is homeless or in a shelter moves to a more stable residential setting An example of the community data after it was collected Cit Education C12 Outreach and on line information C13 Public Awareness events etc UI Advocacy This is reported on the SCORECARD website at http www vadrs org cbs apps outcomes The program conducts or sponsors presentations workshops and or conferences designed to expand or improve services The program develops or expands support groups forms relationships and builds coalitions with community partners identifies and facilitates development of and referral to community resources develops or improves access to written The program develops conducts sponsors or participates in activities that increase the community s general knowledge of brain injury print broadcast activities health fairs awareness The program develops and provides information training and resources that assist survivors caregivers and others to become effective selfand systems advocates Exceeds Expectation Meets Expectation The program achieved greater thanor The program achieved 50 74 of its equal to
36. anagement first Clubhouse drop down yes or no Wants clubhouse services drop down yes or no Health and Safety Risk drop down yes or no Independent in ADL drop down yes or no Ability to independently administer meds drop down yes or no Over 18 drop down yes or no 19 Outcome of Contact Textbox 20 Is this Contact an Information Referral a Consultation or an Intake Application Checkbox If Consultation skip to the Consultation Form live link if Intake Application continue to PART I CONSUMER PROFILE NEEDS ASSESSMENT below On line manual for Definition of Consultation Professional Consultation Staff provides guidance to another professional on specific case Consumer Consultation Individual requires immediate assistance but may not be eligible for services staff provides limited case management i e intervention assistance to prevent institutionalization etc PART II CONSUMER PROFILE NEEDS ASSESSMENT A Consumer Profile General Demographic Information 1 ID Number Automatically generated by system Last Access to this Consumer Profile Date and Name of Staff Person automatically generated by system each time the file is accessed NAME First name Maiden Middle Name Last Name Textbox PHYSICAL RESIDENCE ADDRESS Suite Apartment Number Textbox Street Number Textbox City or Town Textbox State Default to VA but can change if needed
37. ara EE 9 VI REPORTING AND DELIVERY INSTRUCTION 10 VII GENERAL TERMS AND e AT EE 10 VIII SPECIAL TERMS AND CONDITIONS EAR ee ee Eege EEN EEN ees 16 IX METHOD OF PAYMENT Sr ce hac Pa Ne eS eh hs ect aD aah Ts Ole a te ie ile ath 21 X EE Eiere een et E 22 ATTACHMENT A Participation in State Procurement Tronsgctiong 23 ATTACHMENT B Vendor Data SHEGE sissc sicisaceiacasasiceesaseatntsaan sen sanccbananassatacsukecawebodcguved ceeasa ues aetabanceseanete 30 ATTACHMENT C Business Definitions amp Recommendations for a BI Case Management System 31 ATTACHMENT D BIS Programs Case Management Software System Data Elements c cccccecseeeeees 35 RRE EE 51 ATTACHMENT F Project Management PLOW acacia Sats can aout int bina eer 53 EE EE Ee ege 53 Project Plan nd Schedule oo Eege 53 Status Reportin geed erdeelt eda 53 DSA Projeced CGM TICrancny EE 54 Accessibility Requirements eegeeegA deeg EESEE E E asses A E EA EEE EA ai 54 Description Overview General Information 57 E tee 59 POINTES Responsibilities EE 6l TEE EE 61 FREE OPTS ANDI TO RIED oe Sek Be EE 62 Form 1 Substance Abuse Agreements rucas saci gepuciabnsievianshiiotae uecacdads AE BEE eet eg 62 Form 2 Consent to Exchange Information csisscsscsatiietiesaei en iestagal Gv aes cae 63 Form 3 Directions for Filling Out Release Form 66 FOr 4 ClOSUIC e dE A sta e ORAS OE ARE EAI A a NEE hae eB ats 67 Form 5 Scorecard ASSCSSMEN1 0 6 6 6 ccc EEE EEE EEE EEE EE EEE E
38. area unless significant changes are implemented after levels 2 3 or 4 testing BICMS Testing Organization Testing activities are coordinated with the BICMS Information Specialist Each program area is represented by an IS customer analyst and a functional program representative For each area testing scripts schedules and all other testing activities shall be coordinated through the BICMS Information Specialist and the functional program customer analyst and representative The DRS Brain Injury Manager has final review and approval authority Testing Scripts Depending on the module there are at least two levels of testing that are required before acceptance e Level one tests specific functions of the unit module At this level specific screen edits are tested for completeness e Level two tests the interaction between modules for a complete functional program At this level a complete case is processed from pre intake to post closure as applicable Testing varies according to requirements of a specific functional program Testing also includes authorization invoice payment budgets and management information Testing shall also include print functions Testing shall also include simultaneous processing from multiple remote locations e Level three tests the integration of the Vendor system with any external system At this level interactions data exchanges between different systems are tested Testing varies according to requirement
39. arranties and any other pertinent information necessary for the proper operation and maintenance of the equipment being acquired M DEFINITION SOFTWARE As used herein the terms software product or software products shall include all related materials and documentation whether in machine readable or printed form 18 N MAINTENANCE Upon expiration of the initial three year Commonwealth Neurotrauma Initiative CNI Trust Fund grant and at the Commonwealth s option the contractor shall provide a one year period of maintenance including labor parts and travel at the prices set forth in the pricing schedule Maintenance shall not include external electrical work providing supplies and adding or removing accessories not provided for in the contract Maintenance shall also not include repairs of damage resulting from acts of God transportation between state locations negligence by state personnel or other causes not related to ordinary use in the production environment in which installed Each successive year of maintenance may be ordered by the Commonwealth in writing at least 30 days prior to expiration of the existing maintenance period O RENEWAL OF MAINTENANCE Maintenance of the hardware or software specified in the initial three year CNI Trust Fund contract may be renewed by the mutual written agreement of both parties for an additional two 2 one year period s under the terms and conditions of the original contract except as n
40. asis of race age color gender or national origin and shall be subject to the same rules as other organizations that contract with public bodies to account for the use of the funds provided however if the faith based organization segregates public funds into separate accounts only the accounts and programs funded with public funds shall be subject to audit by the public body Code of 10 Virginia 2 2 4343 1E In every contract over 10 000 the provisions in 1 and 2 below apply 1 During the performance of this contract the Contractor agrees as follows a The Contractor will not discriminate against any employee or applicant for employment because of race religion color sex national origin age disability or any other basis prohibited by state law relating to discrimination in employment except where there is a bona fide occupational qualification reasonably necessary to the normal operation of the Contractor The Contractor agrees to post in conspicuous places available to employees and applicants for employment notices setting forth the provisions of this nondiscrimination clause b The Contractor in all solicitations or advertisements for employees placed by or on behalf of the Contractor will state that such Contractor is an equal opportunity employer c Notices advertisements and solicitations placed in accordance with federal law rule or regulation shall be deemed sufficient for the purpose of meeting these require
41. ate Checkbox vii Are you participating in school sponsored extra curricular activities Checkbox YES or NO viii Do you want to participate in school sponsored extra curricular activities Checkbox YES or NO If YES can system automatically populate TRIGGER SHEET as possible goal 5 List any other areas of concern related to school Textbox PART II CONSUMER PROFILE NEEDS ASSESSMENT A Consumer Needs Assessment Functional Assessment Information 1 Physical Sensory 42 2 3 4 a Do you have problems with strength coordination on the right side Checkbox YES or NO b Do you have problems with strength coordination on the left side Checkbox YES or NO CG Do you have problems with strength coordination Checkbox YES or NO d Do you have problems with balance Checkbox YES or NO e Do you have problems with mobility Checkbox YES or NO f Do you have problems with vision Checkbox YES or NO g Do you have problems with hearing Checkbox YES or NO h Do you have problems with taste Checkbox YES or NO i Do you have problems with smell Checkbox YES or NO j Do you have problems with speech Checkbox YES or NO k Do you have problems with swallowing Checkbox YES or NO L Do you have problems with sleeping Checkbox YES or NO m Do you have problems with pain Checkbox YES or NO n Describe any additional areas of concern Textbox Cognitive a Do you have problems with attenti
42. automatically insert this into TRIGGER SHEET Form as a possible goal 8 Describe your social and recreational activities Textbox strengths weaknesses and educational needs Textbox 9 Are there any needs related to your social and recreational activities Checkbox YES or NO If YES can system automatically insert this into TRIGGER SHEET Form as a possible goal 10 Describe your family support system include strengths weaknesses and educational needs Textbox 11 List any agencies with whom you are working Textbox Name of agency contact person etc PART II CONSUMER PROFILE NEEDS ASSESSMENT D Consumer Profile Education Information 1 Are you currently attending school Checkbox YES or NO i If YES Textbox name of school public or private address phone fax contact persons Ability to list multiple schools ii If YES grade in school Dropdown Pre K 2 If NO what is your highest level of education Dropdown Pre K 3 Do you have an Individualized Education Plan IEP Checkbox YES or NO 4 If YES Textbox members of IEP team contact information 5 Do you have 504 accommodations Textbox i What is your special education category Textbox il What is your classroom setting Textbox lil Is your school placement appropriate Checkbox iv Are your classroom supports adequate Checkbox v List your educational strengths needs Textbox vi Is your school transportation adequ
43. be areas of concern Textbox Textbox Textbox COGNITIVE Consumer Family Case Manager Radio button for Radio button for Do you have problems with attention yes or no yes or no Textbox Do you have problems with Radio button for Radio button for concentration yes or no yes or no Textbox 46 Radio button for Radio button for Do you have problems with memory yes or no yes or no Textbox Radio button for Radio button for Are you unable to manage time yes or no yes or no Textbox Do you have difficulty with planning Radio button for Radio button for and or organization yes or no yes or no Textbox Radio button for Radio button for Do you have any other cognitive needs yes or no yes or no Textbox If yes describe Textbox Textbox Textbox Describe cognitive strengths and weaknesses Textbox Textbox Textbox BEHAVIORAL Consumer Family Case Manager Radio button for Radio button for Do you feel irritable yes or no yes or no Textbox Radio button for Radio button for Do you feel anxious yes Or no yes or no Textbox Radio button for Radio button for Do you feel angry yes or no yes or no Textbox Radio button for Radio button for Do you feel aggressive yes or no yes or no Textbox Financial Reporting 47 El ee EE ETH TE Commonwealth of Virginia Department of Rehabilitative Services Vocational Rehabilitation Program Client Financial Statement 1 Primar
44. be enhanced File and Processing Requirements File requirements can be roughly estimated using previous data The application must be a multi user system with record sharing capabilities 34 ATTACHMENT D BRAIN INJURY SERVICES BIS PROGRAMS CASE MANAGEMENT SOFTWARE SYSTEM DATA ELEMENTS After each item is the type of interface control and additional information that we would like provided PART I INFORMATION REFERRAL CONSULTATION and INTAKE 1 Contact Number Automatically generated by system 2 Contact Date Automatically generated by system 3 Contact Method Dropdown box PHONE INTERNET WRITTEN IN PERSON 4 If information is taken over the PHONE or IN PERSON the staff person handling the contact MUST determine if this is a medical emergency or if the individual is at risk of harm to self or others Checkbox YES NO or NOT SURE 5 If YES or NOT SURE then staff person handling the contact MUST ask Are you able to call 911 or Adult Protective Services for assistance If YES NO or NOT SURE Textbox for documentation that staff directed individual to call 911 or called 911 or Adult Protective Services on behalf of the individual as appropriate also include name of staff person date and time information was relayed any other relevant information Jn program manual include reference to Code of VA that requires employees to report etc 6 Staff Person Handling the Contact Dropdown box of ALL EMPLOYEES
45. blue ink Financial expenditure reports and progress reports shall be submitted to the above address X PRICING SCHEDULE The Offeror shall provide the services in accordance with the solicitation requirements terms and conditions contained herein and as reflected in the Offeror s budget proposal The Offeror agrees to perform all services as described herein for amount noted below Initial two year CNI Trust Fund grant not to exceed 90 000 year XI ATTACHMENTS A Participation in State Procurement Transactions by Small Business and Businesses Owned by Women and Minorities B Vendor Data Sheet C Business Definition D Data Elements E Flow Diagram F Project Management Plan 22 ATTACHMENT A Participation in State Procurement Transactions by Small Businesses Businesses Owned by Women and Businesses Owned by Minorities The following definitions will be used in completing the information required by one or more of the three categories of businesses contained in this Attachment as applicable to your firm 1 Participation by Small Businesses 2 Participation by Businesses Owned by Women and 3 Participation by Businesses Owned by Minorities For additional information on certified SWAM business go to www eVA state va us Definitions Period is the specified 12 month period for which the information provided in this list is applicable and valid The period will be specified as month and year Firm Name A
46. chnology used by other individuals with whom any blind or visually impaired user of the technology interacts iii Nonvisual Access Technology shall be integrated into any networks used to share communications among employees program participants or the public and iv the Technology for nonvisual access shall have the capability of providing equivalent access by nonvisual means to telecommunications or other interconnected network services used by persons who are not blind or visually impaired Compliance with the foregoing nonvisual access standards shall not be required if the head of the using agency institution or political subdivision determines that i the Technology is not available with nonvisual access because the essential elements of the Technology are visual and ii nonvisual equivalence is not available Installation of hardware software or peripheral devices used for nonvisual access is not required when the Technology is being used exclusively by individuals who are not blind or visually impaired but applications programs and underlying operating systems including the format of the data used for the manipulation and presentation of information shall permit the installation and effective use of nonvisual access software and peripheral devices If requested the Contractor must provide a detailed explanation of how compliance with the foregoing nonvisual access standards is achieved and a validation of concept demonstration
47. cumentation and support a Product support documentation provided to end users shall be made available in alternate formats upon request at no additional charge b End users shall have access to a description of the accessibility and compatibility features of products in alternate formats or alternate methods upon request at no additional charge c Support services for products shall accommodate the communication needs of end users with disabilities Virginia Standard for Web Based Intranet and Internet Information and Applications includes Federal standard and extensions cited within this section Overview Any BICMS form shall meet the standards established by the Commonwealth of Virginia This has been recently announced as part of the Technology Plan See http www vita virginia gov docs pubs covStrategicPlan index cfm and http vita virginia gov docs websiteStandards cfm Word Wide Web Consortium W3C Web site references A more comprehensive checklist to which the DSA complies may be found at the World Wide Web Consortium Web Site at http www w3 org TR 1999 W AI WEBCONTENT 19990505 full checklist html DSA Web Sites are designed specifically to obtain the highest possible level of Web Accessibility as defined by 56 the standards set by W3C at http www w3 org TR 1999 WAI WEBCONTENT 19990505 wai pageauth html Cascading Style Sheets CSS The DSA will adopt CSS as a standardized backbone for all HTML and ASP T
48. d agency or other reliable source has reason to believe that you have a problem with alcohol or other drugs you will be required to see a substance abuse counselor for an evaluation We may also request that you agree to be screened for the use of alcohol marijuana cocaine amphetamines barbiturates or other drugs while being served by the BIS program Case management services may be discontinued if you refuse to see a substance abuse counselor as requested The results of the evaluation will determine whether or not you should be referred for substance abuse treatment services If you are referred to a treatment program case management services will continue as long as you comply with the treatment program Failure to participate in a treatment program will be grounds for BIS to discontinue case management services L have read the above and understand that BIS will refer me to a substance abuse counselor if it is believed that I have a problem with alcohol or other drugs Participation in any recommended treatment or counseling will mean that BIS will continue case management services Signed Consumer s Signature and Date Parent Guardian Parent Guardian s Signature and Date Witness Witness s Signature and Date 62 Form 2 1 of 2 Consent to Exchange Information Uniform Consent to Exchange Information 3 06 CBS DIV Return the requested information to Patricia Goodall Ed S Director Brain Injury Services
49. d by them as he she is for the acts and omissions of his her own employees H MANDATED REPORTERS FOR ADULT PROTECTIVE SERVICES Contractors who are determined to be mandated reporters for adult protective services according to 63 2 1606 A of the Code of Virginia effective July 1 2004 shall comply with all terms and conditions of the Code Mandated reporting to adult protective services is required of any person employed by or contracted with a public or private agency or facility and working with adults in an administrative supportive or direct care capacity I NO COST EXTENSION OF CONTRACT Contracts awarded under this Request For Proposal RFP may be extended upon approval by the Commonwealth Neurotrauma Initiative CNI Trust Fund Such an extension is subject to the terms of the current contract and should be done within a reasonable period of time prior to the expiration of the contract approximately 60 days No contract funded under this Request For Proposals RFP shall exceed a total funding award of 180 000 J CONFIDENTIALITY OF PERSONALLY IDENTIFIABLE INFORMATION The contractor assures that information and data obtained as to personal facts and circumstances related to patients or clients will be collected and held confidential during and following the term of this agreement and will not be divulged without the individual s and the agency s written consent and only in accordance with federal law or the Code of
50. ddress and Phone Number is the name address and business phone number of the small business women owned business or minority owned business with which the Offeror has contracted or done business with over the specified period or plans to involve on this contract as applicable Contact Person is the name of the individual in the specified small business women owned business or minority owned business who would have knowledge of the specified contracting and would be able to validate the information provided in this list Type of Goods or Services is the specific goods or services the Offeror has contracted for from the specified small women owned or minority owned business over the specified period of time or plans to use in the performance of this contract as applicable The Offeror will asterisk those goods and services that are in the Offeror s primary business or industry Dollar Amount is the total dollar amount in thousands of dollars the Offeror has contracted for or has done business with the listed firm during the specified period or plans to use on this contract as applicable Total Company Expenditures for Goods and Services is calculated by dividing the dollar amount of business conducted or contracted for with the indicated firm over the specified period by the total expenditure of the Offeror over the specified period for goods and services of Total Contract is calculated by dividing the estimated dollars
51. e Richmond VA 23229 ATTN Patricia Goodall Questions Call Patti Goodall at 804 662 7615 or 800 552 5019 or E mail Patti Goodall drs virginia gov Thank you 66 Form 4 Closure Form Auto Populate if Possible Consumer Status Date Case Opened Date of Closure Transition E Date Closure Transition Letter Sent E Summary Financial Resources Utilized rs DRS FAMILY DSS DFS MEDICAID CARE HEALTH INSURANCE PRIVATE PAY OTHER Description if Other Reason for Closure Transition B Assessment of Current Functioning and Continued Needs Recommendations and Referrals Recommendation Referral Contact Phone No recommendations or referrals on file Case Manager Date 67 Form 5 Scorecard Assessment Each of the nine 9 state funded Brain Injury Services BIS Programs collects information on individual service goals for the people served That information is then rolled up and reported in aggregate to DRS This is reported on the SCORECARD website at _http www vadrs org cbs apps outcomes These are the areas that are scored Add Scorecard data elements Number of Goals Achieved amp Total Number of Goals Individualized Service Plan with Short term w long term goals and incorporating the scorecard Progress Notes Community Goals CI1 Education The program conducts or sponsors presentations workshops and or conferences designed to ex
52. e application and data will be backed up hourly from the network to tape or some other external storage process This needs to be confirmed before installation 7 Informational Requirements Database The application must be a multi user system with record sharing capabilities based on program Unique values will needed based on federal reporting Software must include standardized tables for inserting and editing repetitive data 8 Informational Requirements Specific Database Requirements Prefer SQL Server or an enterprise database that can provide secure roles Oracle is okay All Nine Programs will be in one database The tables will reflect the data from the data elements Document will be included We would like to have the data normalized and placed into third normal form There will be an ID for each of the nine programs since each program will not be able to view the others data Security will be based on DRS ADMIN BI ADMIN BI program Users and BI Case Managers There will be several tables for LU tables that will be maintained by one of the administrators At this point we are thinking we would like all the data in the database and no archived data The data will come from the existing system Below is the information we have from the existing site 9 Informational Requirements Data in Existing Application There are 101 tables in the existing application The figures below reflect the number of individuals served by 33
53. e a new record or select from existing list Assign Case Manager Evaluate the Case Manager Clients history and Assessment provide plan for client Scorecard RESIDENTIAL SETTING Determine INDEPENDENT LIVING services to provide IMPACT the client INDEPENDENT ACTIVITY Evaluate Outcomes and determine if goals are achieved Reevaluate goals and give additional goals and time Discharge client 52 Data collected Information about Client Name Address Contact Referral Source Data collected Financial Health History Employment Education Mental Health Substance Abuse Arrest and Convictions From Consumer Profile amp Needs Assessment Wait List Create Case Manager Record Match Case Manager skills with Client Further Assess Needs ATTACHMENT F Project Management Plan Description This is an ongoing task throughout the project Activities are used to provide control and quality assurance for the project establish project reporting and milestones Deliverables include initial and updated project plans Project Plan and Schedule At minimum the project plan should include phases tasks activities and deliverables with estimated time Each activity should have a description projected start end date revised start and end date assigned resources estimated ongoing and actual costs in hours percentage complete Activities should be rolled into tasks Tasks should be rolled into phases
54. e client receives any fee based service see policy for use 6 of RS 13 and RS 25 for schoo training beyond high school Use RS 13 Part 1 for clients who receive General Relief TANF SSI or SSDI even If clientfamily has other Income too Update Part 1 annually o using Section C Use RS 13 Part 2 for ali other clients even if family members but not client receive 9 551 or SSDI Update Part 2 annual using a separate RS 13 each year DEL boii ee sree ok TAL SS SSM e a A I receive General Relief GR Temporary Assistance for Needy Families TANF Supplemental Security Income 551 or cash benefits from Social Security Disability Income This includes parentiguardian receiving GR or TANF for DRS client may lose DRS funding if do not give proof ofthis aid when asked or give false information My counselor will ask for proof atleast once a year agree to tell my counselor of any changes in my financial situation My counselor and must look for comparable benefits medical insurance student federal financial aid etc for certain services Client Name SSN Counselor Name Caseload B Proof of aid is in file check the box O Proof is 2 recent award letter check stub or direct deposit statementreceipt showing type of aid Even if client receives more that one ofthe above types of aid itis only necessary to document one type on the RS 13 _ 29 C Annual Review 30 Enter date client gives updated proof of aid to DRS
55. each quarter when a report is run Issues e Each program should be able to look at a client on a search and only see specific data as designated by the group If the client was to move from one state funded Brain Injury Services program to another the designated brain injury service provider will receive an email and release the client from one group to another The email should come only from the DRS Administrator The rest of the data can be viewed only by the designated programs as agreed e Ad Hoc reporting can only be done on existing data elements Brain Injury Specific Issues for this System e It is expected to test against each requirement after each phase with the Brain Injury Case Management Software System BICMS Information Specialist and the Information Technology Customer Analyst from the Department of Rehabilitative Services will sign off once it is approved e Change management software such as SourceSafe should be in place so that changes can be tracked by the Brain Injury Case Management Software System Information Specialist Scanning Capabilities 58 e The cost of the following item should be included in the Request for Proposals response but written as a separate cost item as it will be ongoing beyond the life of the work on the implementation of the application o scanning capability Other Issues e The Department of Rehabilitative Services is interested in discussing the following cost items that would be
56. each year Keep copy of proof in client file 31 Fa Proofisinfile O 2 Date Proofisinfile O al 3 Date Proofisinfle O A Date Proofisinfile O al 5 Date Proofisinfile O 6 Date Proof is in file O 35 7 Date Proof is in file g 8 Date Proof is in file O 49 Financial for Family Size 1 RS 13 8708 Commonwealth of Virginia Department of Rehabilitative Services Ee Vocational Rehabilitation Program 3 Client Financial Statement 4 Family Size Table Effective July 1 2008 Size of Family Living Expense Exclusion 1 21 200 2 24 800 3 28 400 4 32 000 5 35 600 6 39 200 id 42 800 8 46 400 For each additional dependent add 3 600 Source Annual Update of the HHS Poverty Guidelines Federal Register January 23 2008 Volume 73 Number 15 ER 10 n am Ea 14 LS EM LS LS 20 Ka 22 EM 24 EH ze EH wl 2 2 z a E g D H N m e Annual Disability Related Expenses L SU a Client Name Social Security 22 Annual DisabilityRelated Expenses must be specifically related to the disability an out of pocket 33 cost and not covered by comparable benefits Crou may include special nursing care attendant fees 34 extraordinary transportation costs incurred by the significantly disabled incurred medical expenses fo 25 purposes other than the ordinary maintenance of good health tutors tape recorders rehabilitation 36 technology devices hearing aid
57. ealth of Virginia which will be provided Funds may not be used for e construction of new buildings e renovation to a facility e administrative or indirect costs exceeding 10 of the amount of the total direct expenses unless justified in the budget budget narrative or e software hardware expenses D Human Research Guidelines The Contractor shall comply as applicable with all federal 45 CFR 46 and state Chapter 5 1 of the 5 IV Code of Virginia Section 32 1 162 16 et seq legislation and agency regulations 22 VAC 30 40 10 et seq and 12 VAC 5 20 10 et seq for human research PROPOSAL PREPARATION AND SUBMISSION REQUIREMENTS Offerors will be required to submit a proposal by Monday June 14 2010 at 3 00 p m Eastern Standard Time as specified in this Request For Proposals RFP Offerors may be asked to provide additional clarifying information at any time following submission of a proposal The Department of Rehabilitative Services and a review panel if used will follow the criteria published in this Request For Proposals RFP to determine those proposals which most directly and appropriately address the specific funding priorities see Section IV B 1 7 below Proposals should include A RFP Response 1 Offerors must submit a complete response to this Request For Proposals RFPs signed in blue ink by a legally authorized representative of the Offeror One original and six 6 copies of each proposal must be s
58. ed a funding mechanism for the Commonwealth Neurotrauma Initiative Fund Section 46 2 411 of the Code of Virginia authorizes Virginia Department of Motor Vehicles DMV to collect an additional fee of 30 to have an operator s license reinstated The additional fee is charged only to persons whose operator s licenses were suspended or revoked upon conviction of specified dangerous driving offenses e g DUI related offenses hit and run reckless driving failure to comply with conditions imposed upon license probation for driving offenses etc Out of the additional 30 fee 25 will go to the Commonwealth Neurotrauma Initiative Fund The balance of 5 will go to DMV however if the driving offense was DUI related the 5 will go to the Virginia Alcohol Safety Action Program VASAP Commission The purpose and parameters of the Fund established pursuant to Section 32 1 73 2 are outlined below e The Fund is to be used for the purpose of improving the treatment and care of Virginians with traumatic spinal cord or brain injuries e The Fund is to be established on the books of the Comptroller as a revolving fund and to be administered by the Department of Rehabilitative Services and the CNI Trust Fund Advisory Board e Any moneys and interest remaining in the Fund at the end of each fiscal year are not to revert to the general fund but shall remain in the Fund e The Fund is to be distributed according to the grant procedures established pursua
59. erence will be given to proposals that develop software meeting Web Accessibility Initiative WAI Priority 1 as defined by the World Wide Web Consortium W3C d A secure application to ensure each user group has absolute confidence that its data will not be viewed by other groups In addition the following security levels must be provided e DRS Security Level will be set so that the Department of Rehabilitative Services DRS Brain Injury Services Coordination Unit and the Commonwealth Neurotrauma Initiative CNI Trust Fund and other identified agency staff will have access to and rights to all data e Brain Injury Services BIS Program Security Level will be set so that each user group can identify administrator staff that will have access privileges to its program specific data and e Case Management Security Level will be set so that each Brain Injury Services BIS Program can identify individual case management staff that will have access privileges to caseload specific data at a minimum there will be eighty users at one time e A reasonable sustainable maintenance and upgrade plan for future enhancements and expansion 2 Priority will be given to proposals in which the developer demonstrates an expertise or familiarity with the following a A third normal form relational database b The standards guidelines and recommendations of the Institute of Electrical and Electronics Engineers IEEE and c An understanding
60. etc Include documentation received from other providers to verify 39 5 6 b c d e a b c d a b Do you have any food medication or other allergies If YES Textbox Do you have a seizure disorder If YES Textbox to describe nature protocol Do you currently feel that you need a primary care physician or healthcare specialists who can treat your medical health conditions or concerns not related to your brain injury Checkbox YES or NO a If YES Textbox for information explanation If YES can system automatically insert this into Trigger Sheet Form as a possible goal List any agencies with whom you are working Textbox Name of agency contact person etc Mental Behavioral Health Issues Before your brain injury did you ever receive counseling or psychological or psychiatric help for emotional or behavioral problems Checkbox YES or NO a If YES Textbox for descriptive information such as date s of services reason for services types of services inpatient outpatient providers etc Include documentation from other providers to verify e g indicate date of a neuropsychological assessment received from a provider After your brain injury did you receive counseling or psychological or psychiatric help for emotional or behavioral problems Checkbox YES or NO a If YES Textbox for descriptive information such as date s of services
61. f row or column headers i Frames shall be titled with text that facilitates frame identification and navigation j Pages shall be designed to avoid causing the screen to flicker with a frequency greater than 2 Hz and lower than 55 Hz k A text only page with equivalent information or functionality shall be provided to make a web site comply with the provisions of this part when compliance cannot be accomplished in any other way The content of the text only page shall be updated whenever the primary page changes 1 When pages utilize scripting languages to display content or to create interface elements the information provided by the script shall be identified with functional text that can be read by assistive technology m When a web page requires that an applet plug in or other application be present on the client system to interpret page content the page shall provide a link to a plug in or applet that complies with 1194 21 a through 1 n When electronic forms are designed to be completed on line the form shall allow people using assistive technology to access the information field elements and functionality required for completion and submission of the form including all directions and cues ol A method shall be provided that permits users to skip repetitive navigation links p When a timed response is required the user shall be alerted and given sufficient time to indicate more time is required Information do
62. ginia gov services html Additional information regarding certified SW AM vendors is available at www eVA state va us STATEMENT OF NEED A Commitment of Commonwealth of Virginia The Commonwealth of Virginia has allocated grant funds from the Commonwealth Neurotrauma Initiative CNI Trust Fund for the development of a Web based Case Management System to assist in the provision of case management services To more accurately track monitor and report on the case management services provided through the statewide network of providers DRS requires an Enterprise Case Management System This system must be designed so that data are secure the web interface is 4 accessible and user friendly and the system is designed to meet the needs of the individual program as well as offering an effective and efficient approach to providing services to individuals with disabilities It is imperative that this system be designed using the Commonwealth of Virginia standards for technology B Duration and Amount of Funding All grant contract funds are contingent on the availability of Commonwealth Neurotrauma Initiative CND Trust fund dollars designated for this purpose and on the demonstrated ability of the contractor to meet established contract goals and objectives as outlined in the contractor s proposal and as reviewed and accepted by the Department of Rehabilitative Services and the Commonwealth Neurotrauma Initiative Trust Fund Offer
63. h sub tier Contractor performing under the primary contract A Contractor s obligation to pay an interest charge to a subcontractor may not be construed to be an obligation of the Commonwealth 3 Each prime Contractor who wins an award in which provision of a SWAM procurement plan is a condition to the award shall deliver to the contracting Agency or institution on or before request for final payment evidence and certification of compliance subject only to insubstantial shortfalls and to shortfalls arising from subcontractor default with the SWAM procurement plan Final payment under the contract in question may be withheld until such certification is delivered and if necessary confirmed by the Agency or institution or other appropriate remedies may be assessed in lieu of withholding such payment 4 The Commonwealth of Virginia encourages contractors and subcontractors to accept electronic and credit card payments PRECEDENCE OF TERMS The following GENERAL TERMS AND CONDITIONS VENDORS MANUAL APPLICABLE LAWS AND COURTS ANTI DISCRIMINATION ETHICS IN PUBLIC CONTRACTING IMMIGRATION REFORM AND CONTROL ACT OF 1986 DEBARMENT STATUS ANTITRUST MANDATORY USE OF STATE FORM AND TERMS AND CONDITIONS CLARIFICATION OF TERMS PAYMENT shall apply in all instances If there is a conflict between any General Terms and Conditions and any Special Terms and Conditions in this solicitation the Special Terms and Conditions shall apply QUALIFICAT
64. his will allow implementing the template without the use of HTML tables This method has been tested within DSA with much success For more information on CSS visit the W3C CSS page at http www w3 org Style CSS or view accessibility specific page at http www w3 org TR CSS access Web Page Certification Approval Process In addition to meeting the standards created by W3C for Web Accessibility the DSA has chosen to provide users of our web sites with links to W3C in order to facilitate further understanding of our initiative for Web Accessibility The following are listings and descriptions of the common approvals and links for and from any DSA Web Site W3C HTML 4 01 Approval This approval is specific to the actual code used to create and render the document for the end user More information can be found at http www w3 org TR html1401 W3C AA Approval http www w3 org WAI WCAGI1AA Conformance Pages bearing this logo indicate a claim of conformance by the page author or content provider to conformance level Double A of the W3C Web Content Accessibility Guidelines 1 0 including all Priority I and Priority 2 checkpoints defined in the Guidelines The Web Content Accessibility Guidelines 1 0 explain how to make Web content accessible to people with disabilities Conformance to these Guidelines will help make the Web more accessible to users with disabilities and will benefit all users COV Standard for Screen Reader JAWS C
65. ill conform to DRS info collected 24 SSN not required Textbox 24 Do you have a legal representative Checkbox YES NO or UNKNOWN If YES 31 through 44 should pop up and allow multiple entries of legal representatives If UNKNOWN skip to 34 If NO then skip to 45 25 Name Textbox 26 Relationship Textbox 27 Type of legal representatives Dropdown box Find out all types of legal representation guesstimate of 4 5 types e g medical financial estate etc DRS will research this with assistance of BIS Programs other agencies 28 Legal documentation received verified Textbox to describe 29 Mailing Address Suite Apartment Post Office Textbox 30 Number Textbox 31 Street Number Textbox 32 City or Town Textbox 33 State Default to VA but can change if needed 34 Zip Textbox 35 County of Residence Dropdown box Need to decide if each program will have write access and can list all the counties of residence within their service areas OR if the system should list ALL COUNTIES IN VA and each program can indicate which ones they want to see for their program with ability to check a county outside of their service area if necessary 36 Phone Number Textbox able to enter multiple phone numbers 37 E mail Textbox 38 Additional information Textbox 39 Do you have an Advanced Medical Directive Checkbox YES NO or UNKNOWN
66. ing NAMES OF ALL STAFF PERSONS including the name ADMINISTRATIVE as an option Programs need to have write access to that they can enter the names of all their case managers and can add delete as appropriate 49 Date date field Primary Staff Person Assigned Textbox 50 Date date field of Intake Review Board IRB Priority Status Assignment 51 Intake Review Board Priority Status 1 2 or 3 or N A Dropdown box with cursor hovering over each number and provide description We can ask for a alt or title description tags here 52 Case Status ACTIVE CLOSED PENDING INELIGIBLE WAIT LIST FOLLOW ALONG CONSULTATION Dropdown box with cursor hovering over each number and provide description We can ask for a alt or title description tags here PART II CONSUMER PROFILE NEEDS ASSESSMENT A 1 Consumer Profile Medical Information Injury Disability a Date and Description of Brain Injury Textbox to include who what when where why Need to have ability to include multiple brain injuries as risk of subsequent brain injury is high b Type of Brain Injury Dropdown Box to include Acquired NonTraumatic Brain Injury to include Anoxia Hypoxia Arteriovenous Malformation AVM Chemical Toxic Substance Exposure Infection Metabolic Disorder Other Disease Stroke Aneurysm Acquired Traumatic Brain Injury to include Acceleration Deceleration Injury Blast Concussive Blunt Force Penetrating c Mecha
67. ion must print reports through the web interface and the reports must be downloadable e The application will be used on non state sponsored computers so each group must have their own user name and password and will not be VITA supported Systems Development Methodology e This project will conform to the Council on Information Management s Model Standard for Small Scope Projects COV ITRM Guideline 91 4 e During the analysis phase of the project MS Word and MS Excel are used to document project requirements Visio is used to illustrate flow diagrams and entity relationships diagrams for the attached documentation MS Project may be used to track progress e During the analysis and discovery phase conducted by DRS the activities listed below were conducted to gain the necessary information and knowledge regarding how the application will be used to carry out business procedures e A defined Software Development Life Cycle SDLC will be used during the duration of this project Accessibility Standards The application must adhere to at least the 508 web standards It would be preferable to be at the WAI Level 1 suggested by the W3C The work will be done in accordance with a web specialist from DRS Testing for accessibility will be done by the BICMS Information Specialist throughout each phase of development Feedback will be provided to the vendor after each test is performed The next phase will not start until all issues are resolved and re
68. ity business in the performance of this contract either as part of a joint venture as a partnership as subcontractors or as suppliers Offerors are encouraged to provide additional information and expand upon the following format Firm Name Address and Type of Goods of Total Phone Number Contact Person or Services Dollar Amounts Contract 29 ATTACHMENT B Vendor Data Sheet Note The following information is required as part of the response to this solicitation Failure to complete and provide this sheet may result in finding the proposal nonresponsive 1 Qualification The vendor must have the capability and capacity in all respects to satisfy fully all of the contractual requirements 2 Vendor s Primary Contact Name Telephone Number 3 Years in Business Indicate the length of time you have been in business providing this type of good or service Years Months 4 Vendor Information FIN or FEI Number if company corporation or partnership Social Security Number if individual 5 Indicate below at least four 4 current or recent accounts commercial or governmental that the Offeror s company is servicing has serviced or has provided similar goods Include the length of service and the name address and telephone number of the point of contact A Company Name Address Contact Person Project Telephone Number Fax Number Dates of Service Value
69. ject completion according to proposed timeline and goals The specific format and content of the financial and progress reports will be determined by DRS and or the Commonwealth Neurotrauma Initiative CNI Trust Fund and as necessary and appropriate DRS and or the CNI Trust Fund may change the format or increase the frequency of reporting requirements C Prior to final payment the Contractor shall submit to DRS CNI Trust Fund a report on the actual dollars spent with small businesses and businesses owned by women and minorities during the performance of this contract At a minimum this report shall include for each firm contracted with and for each such business class i e small women owned minority owned a comparison of the total actual dollars spent on this contract with the planned involvement of the firm and business class as specified in the proposal and the actual percent of the total estimated contract value Forms for submission of this data are provided as attachments to this RFP Additional information regarding certified SWAM businesses is available at www eVA state va us GENERAL TERMS AND CONDITIONS VENDORS MANUAL This solicitation is subject to the provisions of the Commonwealth of Virginia Vendors Manual and any changes or revisions thereto which are hereby incorporated into this contract in their entirety The procedure for filing contractual claims is in section 7 19 of the Vendors Manual A copy of the manual is no
70. l to the amount of this authorization DRS will make no payment 3 There will be no charge to or acceptance of any payment from the consumer or his family for any service authorized by DRS unless the amount is previously known to and approved by DRS 4 Services will be provided in accordance with Title VI of the Civil Rights Act of 1964 Void After 180 days Payers of First Resort see condition 2 above Other Insurance Co Policy No Medicaid No Medicare No Counselor Authorized Signature required Caseload No Current Status Total Auth Amt Credit Card Yes TI Mol Cardholder Case No Client Authorization Please submit bills within 30 days In the absence of a company invoice for billing page 2 of this authorization form must be completed signed and attached to page 1 Service Provider Request For Reimbursement For Authorized Services Invoice Number optional I the undersigned have provided the services or items detailed on page 1 of this authorization on date If applicable I have billed the other payers insurance companies Medicaid Medicare etc indicated on the authorization and I am hereby billing you for the balance of the following items Service Provider Signature Date 12 Counselor Signature Date 73
71. lth of Virginia Negotiations shall be conducted with the Offeror s so selected Price shall be considered but need not be the sole determining factor After negotiations have been conducted with each Offeror so selected DRS CNI Trust Fund shall select the Offeror which in its opinion has made the best proposal and shall award the contract to that Offeror Should the Commonwealth determine in writing and at its sole discretion that only one Offeror under consideration is fully qualified a contract may be negotiated and awarded to that Offeror The award document will be a contract incorporating by reference all the requirements terms and conditions of the solicitation and the contractor s proposal as negotiated The Commonwealth may cancel this Request for Proposals RFP or reject proposals at any time prior to award and is not required to furnish reasons why a particular proposal was not deemed to be the most advantageous Code of Virginia 11 65D VI VII REPORTING AND DELIVERY INSTRUCTIONS A If required the Contractor shall include in the proposal if a security deposit or retainer is required prior to initiation of project activities including the percentage and amount of such deposit The Contractor shall submit to DRS an original signed invoice for a required security deposit prior to initiating work on the project B The Contractor shall submit monthly reports describing the financial expenditures and progress toward pro
72. ly to the payment address shown on the purchase order contract All invoices shall show the state contract number and or purchase order number social security number for individual Contractors or the federal employer identification number for proprietorships partnerships and corporations Any payment terms requiring payment in less than 30 days will be regarded as requiring payment 30 days after invoice or delivery whichever occurs last This shall not affect offers of discounts for payment in less than 30 days however All goods or services provided under this contract or purchase order that are to be paid for with public funds shall be billed by the Contractor at the contract price regardless of which public Agency is being billed The following shall be deemed to be the date of payment the date of postmark in all cases where payment is made by mail or the date of offset when offset proceedings have been instituted as authorized under the Virginia Debt Collection Act Unreasonable Charges Under certain emergency procurements and for most time and material purchases final job costs cannot be accurately determined at the time orders are placed In such cases Contractors should be put on notice that final payment in full is contingent on a determination of reasonableness with respect to all invoiced charges Charges which appear to be unreasonable will be researched challenged and that portion of the invoice held in abeyance until a
73. ments 2 The Contractor will include the provisions of 1 above in every subcontract or purchase order over 10 000 so that the provisions will be binding upon each subcontractor or vendor ETHICS IN PUBLIC CONTRACTING By submitting their proposals Offerors certify that their proposals are made without collusion or fraud and that they have not offered or received any kickbacks or inducements from any other Offeror supplier manufacturer or subcontractor in connection with their proposal and that they have not conferred on any public employee having official responsibility for this procurement transaction any payment loan subscription advance deposit of money services or anything of more than nominal value present or promised unless consideration of substantially equal or greater value was exchanged IMMIGRATION REFORM AND CONTROL ACT OF 1986 By entering into a written contract with the Commonwealth of Virginia the Contractor certifies that the Contractor does not and shall not during the performance of the contract for goods and services in the Commonwealth knowingly employ an unauthorized alien as defined in the federal Immigration Reform and Control Act of 1986 DEBARMENT STATUS By submitting their proposals Offerors certify that they are not currently debarred by the Commonwealth of Virginia from submitting bids or proposals on contracts for the type of goods and or services covered by this solicitation nor are they an agent of an
74. n any patent copyright trade secret or any other property rights of another person or organization X WARRANTY AGAINST SHUTDOWN DEVICES The contractor warrants that the equipment and software provided under the contract shall not contain any lock counter CPU reference virus worm or other device capable of halting operations or erasing or altering data or programs Contractor further warrants that neither it nor its agents employees or subcontractors shall insert any shutdown device following delivery of the equipment and software Y WARRANTY OF SOFTWARE The contractor warrants the operation of all software products for a period of 12 months from the date of acceptance During the warranty period the contractor shall provide free all patches fixes revisions updates upgrades and minor releases to both the software and it s supporting documentation Z NONVISUAL ACCESS TO TECHNOLOGY All information technology which pursuant to this 20 IX agreement is purchased or upgraded by or for the use of any State agency or institution or political subdivision of the Commonwealth the Technology shall comply with the following nonvisual access standards from the date of purchase or upgrade until the expiration of this agreement i effective interactive control and use of the Technology shall be readily achievable by nonvisual means ii the Technology equipped for nonvisual access shall be compatible with information te
75. n the eVA Internet e procurement solution either through the eVA Basic Vendor Registration Service or eVA Premium Vendor Registration Service All Offerors must register in eVA failure to register will result in the bid proposal being rejected a eVA Basic Vendor Registration Service 25 Annual Registration Fee plus the appropriate order Transaction Fee specified below eVA Basic Vendor Registration Service includes electronic order receipt vendor catalog posting on line registration electronic bidding and the ability to research historical procurement data available in the eVA purchase transaction data warehouse b eVA Premium Vendor Registration Service 25 Annual Registration Fee plus the appropriate order Transaction Fee specified below eVA Premium Vendor Registration Service includes all benefits of the eVA Basic Vendor Registration Service plus automatic email or fax notification of solicitations and amendments c For orders issued prior to August 16 2006 the Vendor Transaction Fee is 1 capped at a maximum of 500 per order d For orders issued August 16 2006 and after the Vendor Transaction Fee is i DMBE certified Small Businesses 1 capped at 500 per order ii Businesses that are not DMBE certified Small Businesses 1 capped at 1 500 per order V AVAILABILITY OF FUNDS It is understood and agreed between the parties herein that the agency shall be bound hereunder only to the extent of the funds available or
76. nagers etc these are defined later in detail The system must be able to accommodate growth as programs are added 2 Functional Requirements Types of but not limited to Interface and Input data specific fields provided later on an appendix Demographics name age ethnicity date of injury type of injury cause of injury Emergency Contact Information Emergency Information allergies seizure disorder etc Date of Initial Contact with Agency Referral Date Who Referred Date of Intake Person Conducting Intake Case Manager Assigned to Case Intake Review Board Status priority level Current Status Active Inactive Closed Pending Individual Service Plan goals objectives date to achieve The goals here should reflect the SCORECARD Residential Setting Independent Living Productive Activity Case Notes Progress Notes reflecting contact every 30 days at minimum History Education Medical Rehabilitation Therapy Employment Substance Abuse Mental Health Justice System Other Service Providers name address phone e mail Support Team Members There also needs to be a fourth SCORECARD area called Community Impact that reflects the organizational goals of education outreach awareness etc 3 Functional Requirements Interface Design Fields Enter Consumer Consumer Profile Demographics Contact Information Select Consumer Consumer Profile Demographics Contact Information Authorizations amp Expense
77. ncial condition or family size My counselor and must look for comparable benefits medical insurance student financial aid etc for certain 28 services My share ofthe annual cost after deducting available comparable benefits of fee based 39 services received is the percent shown in Line 12 above but no more than the dollar armount In Line 11 above _ 40 Parent guardian must sign below if the client is a minor ward or is on the parent s guardian s tax return s Client Name Social Security 42 Clientparent Signature Date 43 Counselor Signature Case load Date EA Proof of income is attached check the Do 46 Note 1 Line 6a Cash Assets includes checking savings money market accounts CDs and bonds maturing within 6 months stocks life insurance net cash value mutual funds and other liquid assets Do not include KEOGH SEP 48 and Individual Retirement Accounts 50 Note 2 When not required to file a tax return proof of income may include I R S Form 1099 G for unemployment s compensation or copy of monthly benefit check VW 2 form or copy of a pay stub from employer copy of direct Client Financial Statement 48 LI l Lommonwealth of virginia Vepanment of Renabilitative services ee Le RS 13 8 08 Commonwealth of Virginia Department of Rehabilitative Services l Vocational Rehabilitation Program Kei Client Financial Statement ES el Important Information U se this form before th
78. nism of Injury Dropdown Box to include Assault Moving Vehicle Accident Near Drowning Electrical Shock Fall Gunshot Heart Attack Infection Medical Surgical Procedure Pedestrian Accident Shaken Baby Syndrome Sport Recreation Accident Stroke AVM Aneurysm Suicide Attempt Workplace Accident Other with a box stating if other explain d Loss of Consciousness Length of Coma Textbox 38 2 3 4 a b c d e a b c d e a Medications Medication Management What prescription or over the counter medications do you currently take Textbox to list detailed information about prescriptions and over the counter medications date of prescriptions dosage etc Do you feel that you need help to manage your prescription medications Checkbox YES or NO If YES Textbox for information explanation If YES can system automatically insert this into Trigger Sheet Form as a possible goal Do you need assistance with paying for your prescriptions Checkbox YES or NO If YES Textbox for information explanation If YES can system automatically insert this into Trigger Sheet Form as a possible goal List any agencies with whom you are working Textbox Name of agency contact person etc Hospitalizations Rehabilitation Other Treatment Were you hospitalized or did you receive any rehabilitation or other treatment for problems related to y
79. njury Services e Each phase will be tested and approved by the BICMS Information Specialist e Final testing approval will be provided by the BICMS Information Specialist e Final approval will be provided by the BICMS Information Specialist the Information Technology Customer Analyst and the Director of DRS Brain Injury Services Coordination Unit 59 On unsuccessful testing at any level an explanation of reason for failure will be provided to the Contractor along with any appropriate test results or scripts and or error logs A problem log entry should be entered and number assigned The Contractor will then return the unit to development On successful testing the unit will be moved into the training environment The vendor will have a defect tracking system that will provide reports by dates and will allow access to the BICMS Information Specialist Contractor Testing Prior to delivery of any partial or whole component to the DSA the Contractor shall test the product meeting or exceeding the levels as outlined in this section On delivery of module testing criteria for the product as well as results should be provided Training of Test Group Users Prior to testing of Level 2 3 or 4 the Contractor should provide training similar to the standard training for production This will ensure that the testing staff will understand the proper use of the product Employees who receive this training will not need to repeat the training for this
80. nt to Section 32 1 73 4 as amended e Moneys in the Fund are to be used solely to support grants for Virginia based organizations institutions and researchers as follows 47 5 percent shall be allocated for research on the mechanisms and treatment of neurotrauma 47 5 percent shall be allocated for rehabilitative 3 HI services and five percent shall be allocated for administration The Brain Injury Case Management Software System currently in use is separated into nine 9 different applications There are nine interfaces and nine databases Following accessibility testing by DRS the interfaces were deemed not accessible according to minimum federal and state standards The databases contain all of the same type of data and should be consolidated DRS is working with the BI Contractors to assure that all applications pass the federal Americans with Disabilities ADA 508 Standards for Accessibility at a minimum This is a necessary part of the state accessibility guidelines It is also essential that BI contractors provide information to the BI Manager using the accessible interface and accessible functionality for continued operation of the programs Itis vital that BI Contractors develop a functional web based Case Management Software System that contains data elements consistent across all of its state funded programs that can access and provide each program with the functionality it needs to operate Further each program must have the
81. oduct developer d A well defined on screen indication of the current focus shall be provided that moves among interactive interface elements as the input focus changes The focus shall be programmatically exposed so that assistive technology can track focus and focus changes e Sufficient information about a user interface element including the identity operation and state of the element shall be available to assistive technology When an image represents a program element the information conveyed by the image shall also be available in text f When bitmap images are used to identify controls status indicators or other programmatic elements the meaning assigned to those images shall be consistent throughout an application s performance g Textual information shall be provided through operating system functions for displaying text The minimum information that shall be made available is text content text input caret location and text attributes h Applications shall not override user selected contrast and color selections and other individual display attributes When animation is displayed the information shall be displayable in at least one non animated presentation mode at the option of the user i Color coding shall not be used as the only means of conveying information indicating an action prompting a response or distinguishing a visual element j When a product permits a user to adjust color and contrast settings a variety
82. ogram will have their own ID and roles for security purposes to access the application The only person that can look at all program data will be the purchasing agency You will host the database and web Interface Please add the cost of the hosting service for the database and web interface as a separate appendix item as mentioned above Maintenance and upgrade plan for three years upon completion as mentioned above VVVVV WV 61 REPORTS AND FORMS That can be produced in MS OFFCIE Applications such as Excel They also want to do in house emailing of reports and data Form 1 Substance Abuse Agreement Substance Abuse Policy and Agreement The use of alcohol drugs is dangerous for individuals with brain injuries Brain injury causes damage to the brain and nervous system often making an individual more susceptible to the effects of alcohol and other drugs In other words one glass of beer or wine could actually have the effect of three to five glasses In addition seizures may be caused by alcohol other drugs in head injured individuals There is no question that alcohol and drugs will SLOW RECOVERY from your injury This is because nerve cells in the brain are killed or damaged as a result of a traumatic brain injury alcohol and drugs affect brain cells that are a part of the brain s reserve capacity As more brain cells are killed or damaged the brain has a harder time making up for the losses If a BIS staff member contracte
83. ompatibility Assistive Technology Screen Reader All electronic display information shall be 100 readable by the Commonwealth of Virginia COV standard screen reader JAWS is the COV current standard screen reader The system shall be 100 compatible with the current COV standard assistive technology software version or greater JAWS shall be able to clearly interpret all displayed and input information Any modification of the assistive technology software or the BICMS system to reach 100 compatibility is the responsibility of the Contractor Description Overview General Information The following documents are required project deliverables The DRS Project Manager shall determine whether any such document is a deliverable as that term is defined in the Contract and shall notify Contractor of such determination Documents are deliverables used in partial completion of project phases tasks and or activities Each document or document group addresses different aspects of the project Minimum document deliverables include but are not limited to Project Plan and Project Plan updates bi weekly status reports design systems manual document program specifications implementation document data migration planning document training user manual and testing sheets 57 All documents should be available as appropriate per subject in electronic MS Word format or MS Excel current DSA standard version Adobe Project Visio as well as WEB
84. on concentration Checkbox YES or NO b Do you have problems with memory Checkbox YES or NO c Do you have problems with making decisions Checkbox YES or NO d Do you have problems with judgment Checkbox YES or NO e Do you have problems with learning new information Checkbox YES or NO f Do you have problems with initiating or starting activities Checkbox YES or NO g Do you have problems with following through with plans Checkbox YES or NO h Describe any additional areas of concern Textbox Emotional Behavioral a Do you feel anxious Checkbox YES or NO b Do you feel confused Checkbox YES or NO c Do you feel sad Checkbox YES or NO d Do you feel lonely Checkbox YES or NO a Do you feel irritable Checkbox YES or NO b Do you feel angry Checkbox YES or NO c Do you feel aggressive Checkbox YES or NO d Have you had any explosive episodes Checkbox YES or NO e Describe any additional areas of concern Textbox Independent Living 43 Do you need assistance with bathing Checkbox YES or NO Do you need assistance with dressing Checkbox YES or NO Do you need assistance with grooming hygiene Checkbox YES or NO a Oo SP Do you need assistance with eating Checkbox YES or NO e Do you need assistance with using the toilet Checkbox YES or NO f Do you need assistance with preparing meals Checkbox YES or NO g Do you need assistance with shopping Checkbox YES or NO
85. ople by the t Form 6 SAMPLE Application Intake Referral Form Note This is a Sample Application Intake Form and is not the final to be used for the case management system Vendor will receive actual data points upon award of the contract This is to provide an example of what will need to be created Note s in correspond to the item on the VRIS screen s in J are the codes Case No Applicant Name Caseload No SSN if not obtained at referral 01 Date mm dd yy 02 Date of Birth mm dd yy 03 City County code of residence 04 Race use applicant self report or staff best judgment Multiple Y may be checked White Y _ NL Black African American Y _ NL As Am Indian or Alaskan Native Y _ NL Native Hawaiian or Other Pacific Islan Ethnicity Hispanic Latino Y _ N L rv must also check at least one race category These items are optional now but must be filled in at or before status 06 or 10 05 Marital Status enter circle 1 code from list below Married 1 Widowed 2 Divorced 3 Separated 4 Never Married 5 06 Drivers License Y _ NL 07 Transportation public or private Y _ N L 08 Highest Education enter circle 1 code from list below for highest level earned None or before Grade 1 0 Grade 1 8 1 Grade 9 12 no diploma Spec Ed not H S regular diplom H S grad GED 4 Some college no degree Assoc degree VoTech certificate
86. ors must provide a year to year estimated timeframe for the implementation of the web based Case Management Software System The contract shall not exceed a total of 180 000 for development testing training and implementation The contract also cannot exceed 90 000 per contract year Upon award of the grant funds are allocated for a 12 month period contingent upon the continued availability of funds Funds that are unexpended at the end of a grant year do not automatically roll over to the next year unless a formal written request for carry over of funds is received by the Commonwealth Neurotrauma Initiative CNI Trust Fund The written request must include the amount of carry over requested as well as justification for the request i e why the funds were not expended during the grant year as proposed in the submitted budget Maintenance of the system shall be provided by the vendor for a one year period following the expiration of the initial CNI Trust Fund grant project with the option to renew the maintenance for an additional two one year periods C Use of Funds Funds may be used for e staff in support of application development e supplies needed for the development of the application and e other direct and documented costs related to implementation and documentation of this application e travel upon prior approval by the Commonwealth Neurotrauma Initiative CNI Trust Fund travel will abide within the guidelines of the Commonw
87. ot required to furnish reasons why a particular proposal was not deemed to be the most advantageous Code of Virginia 2 2 4359D The award document is a contract incorporating by reference all the requirements terms and conditions of this solicitation and the Contractor s proposal as negotiated D CANCELLATION OF CONTRACT The Commonwealth Neurotrauma initiative Trust Fund reserves the right to cancel or terminate any contract in part or in whole without penalty upon sixty 60 days written notice to the Contractor If the initial contract period is for more than 12 months the contract may be terminated by either party without penalty after the initial twelve 12 month contract period upon thirty 30 days written notice to the other party Any contract cancellation notice shall not relieve the Contractor of the obligation to deliver and or perform on all outstanding orders issued prior to the effective date of cancellation E IDENTIFICATION OF PROPOSAL ENVELOPE The signed proposal should be returned in a separate envelope or package sealed and identified as follows From Name of Offeror Due Date Time Street or Box Number City State Zip 10 327 Request For Proposal Number Commonwealth Neurotrauma Initiative Trust Fund Development of a Web based Brain Injury Case Management Software System Title of Request For Proposal Name of Contract Officer James Gregory General Services Purchasing Department The envelope
88. oted herein Price changes may be negotiated at time of renewal however in no case shall the maintenance costs for a succeeding one year period exceed the prior year s contract price s increased or decreased by more than the percentage increase or decrease in the other services category of the CPI W section of the US Bureau of Labor Statistics Consumer Price Index for the latest twelve months for which statistics are available P SERVICE PERIOD ROUTINE Contractor shall provide 8 hour toll free phone support with a one hour return call response time Maintenance services shall carry a 24 hour response time following initial notification and shall be available during the normal working hours of 8 A M to 5 P M EST Monday through Friday excluding state holidays All necessary repairs or corrections shall be completed within 24 hours of the initial notification Q SERVICE REPORTS Upon completion of any maintenance call the contractor shall provide the agency with a signed service report that includes at a minimum a general statement as to the problem action taken any materials or parts furnished or used and the number of hours required to complete the repairs R EXCESSIVE DOWNTIME Equipment or software furnished under the contract shall be capable of continuous operation Should the equipment or software become inoperable for a period of more than 24 hours the contractor agrees to pro rate maintenance charges to account for each f
89. ount Textbox populates FEF FAMIS Do you have any dependents i e do you claim anyone on your state or federal income tax form Textbox Other sources of income Textbox populates FEF Are there any financial issues Checkbox YES or NO If YES can system automatically insert this into Trigger Sheet Form as a possible goal Financial Eligibility Form needed Checkbox YES or NO If YES open form automatically part of which is populated List any agencies with whom you are working Textbox Name of agency contact person etc PART I CONSUMER PROFILE NEEDS ASSESSMENT C Consumer Profile Residential Information 1 What is your current residential situation Textbox 2 Do you rent or own Dropdown 41 a Does the current living situation meet your needs and preferences Checkbox YES or NO If no can system automatically insert this into TRIGGER SHEET Form as a possible goal b Do you need assistance securing safe housing If YES can system automatically insert this into TRIGGER SHEET Form as a possible goal 3 Directions to current residence Textbox Link to mapquest of yahoo maps 4 Who lives in your household Textbox 5 How many people in your household are dependent on your income Enter number populate FEF 6 Are you dependent on someone else s income Textbox 7 Are there any needs related to your family support system Checkbox YES or NO If YES can system
90. our brain injury Checkbox YES or NO a If YES Textbox for descriptive information such as pre or postinjury date s of services reason for services types of services inpatient outpatient providers etc Include documentation received from other providers to verify At the time of your brain injury did you have any problems receiving hospital care or getting rehabilitation or other treatment for problems related to your brain injury Checkbox YES or NO a If YES Textbox to describe barriers if resolved or not etc Do you currently feel that you need any hospital rehabilitation or other treatment for problems related to your brain injury Checkbox YES or NO a If YES Textbox for information explanation If YES can system automatically insert this into Trigger Sheet Form as a possible goal Do you need a neuropsychological evaluation Checkbox YES or NO If YES can system automatically insert this into Trigger Sheet Form as a possible goal List any agencies with whom you are working Textbox Name of agency contact person etc Medical Health Issues Do you have any medical health conditions or concerns not related to your brain injury Checkbox YES or NO a If YES Textbox for descriptive information such as specific medical health issues whether pre or postinjury date s of services reason for services types of services inpatient outpatient providers
91. pand or improve services CI2 Outreach The program develops or expands support groups forms relationships and builds coalitions with community partners identifies and facilitates development of and referral to community resources develops or improves access to written and on line information CI3 Public Awareness The program develops conducts sponsors or participates in activities that increase the community s general knowledge of brain injury print broadcast activities health fairs awareness events etc CH Advocacy The program develops and provides information training and resources that assist survivors caregivers and others to become effective self and systems advocates Independent Goals IL1 Individual increases his her ability to access the community through public or other transportation IL2 Individual increases his her ability to perform instrumental activities of daily living IL3 Individual increases his her ability to successfully manage basic activities of daily living IL4 Individual manages basic activities of daily living Productive Goals DAT Individual is competitively employed in an integrated work setting earning minimum wage or higher or is self employed PA2 Individual is employed in a modified work setting earning a commensurate wage 68 PA3 Individual attends school or receives vocational training PA4 Individual engages in volunteer activities PAS Individual eng
92. planned for the indicated firm on this contract by the total Offeror estimated price of this contract 23 1 a Participation by Small Businesses A Offeror certifies that it is is not a small business concern For the purpose of this procurement a small business is a concern including its affiliates which is independently owned and operated is not dominant in the field of operation in which it is contracting and can further qualify under the criteria concerning number of employees average annual receipts or other criteria as prescribed by the United States Small Business Administration B List small businesses with which the Offeror has contracted or done business and dollar amounts spent with each of these businesses in the most recent 12 month period for which data are available Offerors are encouraged to provide additional information and expand upon the following format Period From To Total Company Firm Name Expenditures Address and Type of Goods for Goods and Phone Number Contact Person or Services Dollar Amounts Services 24 1 b Participation by Small Businesses Continued C Describe Offeror s plans to involve small businesses in the performance of this contract either as part of a joint venture as a partnership as subcontractors or as suppliers Offerors are encouraged to provide additional information and expand upon the following format
93. ployerY _ NL Private insurance OtherY _ N 70 Form 7 SAMPLE Authorizations and Expenses Form Note This is a sample authorization and expenses form and is not the final to be used for the case management system Vendor will receive actual data points upon award of the contract This is to provide an example of what will need to be created Phone Fax Case No Authorization No Date Service Provider Provide To Service Provider No Services You are hereby authorized to provide the client named above the following services not in excess of the amounts specified and under the conditions set forth Service Effective No Unit Unit Total AFC Item No Description Date Units Meas Cost Authorized Conditions 1 An invoice and proof of receipt of services or items is required for payment 2 DRS payment for services will be rendered according to the provider s contract with the consumer s insurance company When the provider has contractually agreed to accept the insurance company s payment as payment in full i e reasonable and customary payment DRS shall not be responsible for the uncovered balance Where the provider has no contractual agreement DRS shall pay the difference between DRS established fees and benefits paid 71 other sources including required consumer contributions If payment made by others is greater than or equa
94. rder changes within the general scope of the contract at any time by written notice to the Contractor Changes within the scope of the contract include but are not limited to things such as services to be performed the method of packing or shipment and the place of delivery or installation The Contractor shall comply with the notice upon receipt The Contractor shall be compensated for any additional costs incurred as the result of such order and shall give the CNI Trust Fund a credit for any savings Said compensation shall be determined by one of the following methods a b By mutual agreement between the parties in writing or By agreeing upon a unit price or using a unit price set forth in the contract if the work to be done can be expressed in units and the Contractor accounts for the number of units of work performed subject to DRS right to audit the Contractor s records and or to determine the correct number of units independently or By ordering the Contractor to proceed with the work and keep a record of all costs incurred and savings realized A markup for overhead and profit may be allowed if provided by the contract The same markup shall be used for determining a decrease in price as the result of savings realized The Contractor shall present DRS CNI Trust Fund with all vouchers and records of expenses incurred and savings realized DRS shall have the right to audit the records of the Contractor as it deems necessary to
95. reason for services types of services inpatient outpatient providers etc Include documentation from other providers to verify e g indicate date of a neuropsychological assessment received from a provider Do you currently feel that you need any counseling or psychological or psychiatric help for emotional or behavioral problems Checkbox YES or NO a If YES Textbox to describe If YES can system automatically insert this into Trigger Sheet Form as a possible goal List any agencies with whom you are working Textbox Name of agency contact person etc Substance Abuse Have you ever been hospitalized or received treatment for substance abuse problems such as drinking too much or using marijuana or any other recreational drugs Checkbox YES or NO a If YES Textbox for descriptive information such as pre or postinjury date s of services reason for services types of services inpatient outpatient providers etc Include documentation received from other providers to verify b If NO Has anyone ever told you that you might have a substance abuse problem such as drinking too much or using marijuana or any other party drugs Checkbox YES or NO At the time of your brain injury were you drinking or using marijuana or any recreational drugs Checkbox YES or NO 40 a If YES Textbox to describe alcohol drugs used circumstances of injury etc c Do you or does anyone close to you
96. result of this solicitation DRS CNI Trust Fund Advisory Board will publicly post such notice on the DGS DPS eVA web site www eva state va us for a minimum of ten 10 days S DRUG FREE WORKPLACE During the performance of this contract the Contractor agrees to i provide a drug free workplace for the Contractor s employees ii post in conspicuous places available to employees and applicants for employment a statement notifying employees that the unlawful manufacture sale distribution dispensation possession or use of a controlled substance or marijuana is prohibited in the Contractor s workplace and specifying the actions that will be taken against employees for violations of such prohibition iii state in all solicitations or advertisements for employees placed by or on behalf of the Contractor that the Contractor maintains a drug free workplace and iv include the provisions of the foregoing clauses in every subcontract or purchase order of over 10 000 so that the provisions will be binding upon each subcontractor or vendor For the purposes of this section drug free workplace means a site for the performance of work done in connection with a specific contract awarded to a Contractor the employees of whom are prohibited from engaging in the unlawful manufacture sale distribution dispensation possession or use of any controlled substance or marijuana during the performance of the contract NONDISCRIMINATION OF CONTRACT
97. rmally available for review at the purchasing office and is accessible on the Internet at www dgs state va us dps under Manuals APPLICABLE LAWS AND COURTS This solicitation and any resulting contract shall be governed in all respects by the laws of the Commonwealth of Virginia and any litigation with respect thereto shall be brought in the courts of the Commonwealth The Agency and the Contractor are encouraged to resolve any issues in controversy arising from the award of the contract or any contractual dispute using the Alternative Dispute Resolution ADR procedures described in Chapter 9 of the Vendors Manual Code of Virginia 2 2 4366 The Contractor shall comply with all applicable federal state and local laws rules and regulations ANTI DISCRIMINATION By submitting their proposals Offerors certify to the Commonwealth that they will conform to the provisions of the Federal Civil Rights Act of 1964 as amended as well as the Virginia Fair Employment Contracting Act of 1975 as amended where applicable the Virginians With Disabilities Act the Americans With Disabilities Act and 2 2 4311 of the Virginia Public Procurement Act VPPA If the award is made to a faith based organization the organization shall not discriminate against any recipient of goods services or disbursements made pursuant to the contract on the basis of the recipient s religion religious belief refusal to participate in a religious practice or on the b
98. s Priority Level Case Consultation Closure Individualized Services Plan Community Scorecard Progress Notes 32 Archive Data History Service Providers Team Members Resources Financial Eligibility I amp R Follow ups Reports amp Forms 5 Functional Requirements Users Roles 85 100 users Staff members who will participate in system development include Representatives from the Brain Injury Services BIS Programs the users of the proposed Brain Injury Case Management Software System Administrators and managers from the Department of the Rehabilitative Services DRS and the DRS Brain Injury Services Coordination Unit There will be roles based on your security that will be tracked for audit purposes 6 Functional Requirements Security and Disaster Recovery At a minimum a user ID and password must be required to access the software A master administrator must have the ability to add new users and give them initial passwords This will be administered through the DRS BI Services Administrator Each Program will have a master administrator Each program will have a user to add items to specific fields Each program will have case managers that will access their records and data The software must allow for restrictions on major functions according to each user and role Software must track use by user ID and date stamp Back up and recovery procedures need to be in place A procedure must be established to ensure that th
99. s assistive listening devices i e personal loop alerting devices telecommunication systems e TOD etc 9a Description 9d Description Cost 9g Description Cost Total enter tota on Par 2 Line 9 Total 0 00 i A DI Ka Attach receipt or other proof of payment for all items listed check box Ol 50 ATTACHMENT E Business Flow Case Manager Keys in Data SS KS Computer ER From Work Admin Screens HEALTH station to SQL COGNITIVE Serv r BEHAVIORAL EMOTIONAL EE SELF CARE MENTAL HEALTH Add Professionals doctors etc HISTORY Add data to Look Up tables RESIDENTIAL ip and Data is placed in tables in Disapproval E Start process over ig H Reports will be based e on data from the active records in the database Approved and becomes part of active data Case Managers will be able to generate reports based on keyed RS Ge 51 WorkFlow for the Case Management System Tuesday November 20 2007 Data collected amp Entered into Intake amp Referral Information is collected and entered Client Entry Intake amp Referral to the System Process involves a series of questions and Yes No Responses Client Interview Intake Refer to ree BE IRB Appropriate Eligibility uer Intake Review met Resources gii Board Priority 1 or Openings Review Board in Caseload Determination Creat
100. s specific for the external exchange This may not exist for all functional programs e Level four tests the integration between modules for all functional programs At this level complete cases are processed simultaneously for all functional programs Testing varies according to requirements of a specific functional program Testing also includes invoice payment budgets interfaces internal and external and management information Testing shall also include print functions Testing shall also include simultaneous processing from multiple remote locations For each level the Contractor shall supply at minimum a document which outlines specific requirements met by a 60 given testing level and expected results The testing shall cover normal and error conditions recovery security factors and timing requirements Training Responsibilities The Contractor shall provide all training and manual and will coordinate activities with BICMS Information Specialist BICMS Training Organization Training activities may be coordinated with the BICMS Information Specialist Each program area is represented by an Information Systems IS customer analyst and a functional program representative For each area schedules and all other training activities shall be coordinated through the BICMS Information Specialist the functional program customer analyst and the customer representative The DRS Brain Injury Case Manager has final review and approval authori
101. sed application back up and off site storage secure building generators and other environmental safeguards 7 3 Budget Budget Justification and Sustainability three pages Prepare and submit a budget and all costs for the design development and implementation of the web based Case Management Software System This should include but not be limited to design testing upgrades specific to regulatory specifications training pilot and implementation Describe how you will ensure that the project will be completed under 90 000 dollars contract year Include a reasonable sustainable maintenance and upgrade plan for future enhancements and expansion Though hosting maintenance and data conversion will not be paid through this contract it may be paid through a separate fund so will need to be addressed in the proposal 4 Timetable for Deliverables three pages Please provide the phases of the project with a timetable as a matrix The phases should follow a software development lifecycle process and should include testing for each phase of the development process which includes DRS testing and sign off before moving to the next phase This application must be operational and implemented within a twelve to fifteen month time period Describe how you will ensure that the project will be completed within the specified time period 5 Adherence to Business Definition and Specified Data Elements five pages The database must be designed
102. settlement can be reached Upon determining that invoiced charges are not reasonable the Commonwealth shall promptly notify the Contractor in writing as to those charges it considers unreasonable and the basis for the determination A Contractor may not institute legal action unless a settlement cannot be reached within thirty days of notification The provisions of this section do not relieve an Agency of its prompt payment obligations with respect to those charges which are not in dispute Code of Virginia 2 2 4363 2 To Subcontractors a A Contractor awarded a contract under this solicitation is hereby obligated 1 To pay the subcontractor s within seven 7 days of the Contractor s receipt of payment from the Commonwealth for the proportionate share of the payment received for work performed by the subcontractor s under the contract or 12 2 To notify the Agency and the subcontractor s in writing of the Contractor s intention to withhold payment and the reason b The Contractor is obligated to pay the subcontractor s interest at the rate of one percent per month unless otherwise provided under the terms of the contract on all amounts owed by the Contractor that remain unpaid seven 7 days following receipt of payment from the Commonwealth except for amounts withheld as stated in 2 above The date of mailing of any payment by U S Mail is deemed to be payment to the addressee These provisions apply to eac
103. tested This will be part of the sign off process All sign offs for accessibility will be done by the Department of Rehabilitative Services Project Phases The project must be done in phases based on a Software Development Life Cycle The work will be done collaboratively with a BICMS Information Specialist who will be testing and working with the development 31 group through each phase right up to implementation B FUNCTIONAL AND INFORMATONAL REQUIREMENTS 1 Functional Requirements Systems Operation Application must use a graphical user interface GUI running in Windows XP Vista It needs to accommodate inexperienced users with basic knowledge of Windows XP Vista Application should incorporate standard GUI features as needed to make system operation easier check boxes drop lists radio buttons context sensitive help and drop down menus to name a few Print using commercially available laser printers such as a HP LaserJet Application must provide for multi users The application must provide for different browsers Dates must require or store four digit years so that the software functions properly at the turn of the century some clients may have been born before 1900 The BICMS Information Specialist will provide support based on usability and accessibility testing results Email functional should be built into system based on business logic Security Levels will be administrative BIS Contractors Programs Case Ma
104. tion contracts if any subcontractors are involved the subcontractor will have workers compensation insurance in accordance with 2 2 4332 and 65 2 800 et seq of the Code of Virginia The bidder or Offeror further certifies that the Contractor and any subcontractors will maintain these insurance coverages during the entire term of the contract and that all insurance coverage will be provided by insurance companies authorized to sell insurance in Virginia by the Virginia State Corporation Commission MINIMUM INSURANCE COVERAGES AND LIMITS REQUIRED FOR MOST CONTRACTS 14 1 Workers Compensation Statutory requirements and benefits Coverage is compulsory for employers of three or more employees to include the employer Contractors who fail to notify the Commonwealth of increases in the number of employees that change their workers compensation requirements under the Code of Virginia during the course of the contract shall be in noncompliance with the contract 2 Employer s Liability 100 000 3 Commercial General Liability 1 000 000 per occurrence Commercial General Liability is to include bodily injury and property damage personal injury and advertising injury products and completed operations coverage The Commonwealth of Virginia must be named as an additional insured and so endorsed on the policy R ANNOUNCEMENT OF AWARD Upon the award or the announcement of the decision to award a contract over 50 000 year as a
105. to reproduce any and all documentation provided such reproduction is for the sole use of the Commonwealth These rights are perpetual and 19 irrevocable in the event of any actual or alleged breach by the Commonwealth the contractor s sole remedy shall be to pursue a monetary claim in accordance with 2 2 4363 of the Code of Virginia T OWNERSHIP OF INTELLECTUAL PROPERTY All copyright and patent rights to all papers reports forms materials creations or inventions created or developed in the performance of this contract shall become the sole property of the Commonwealth On request the contractor shall promptly provide an acknowledgment or assignment in a tangible form satisfactory to the Commonwealth to evidence the Commonwealth s sole ownership of specifically identified intellectual property created or developed in the performance of the contract U SOURCE CODE In the event the contractor ceases to maintain experienced staff and the resources needed to provide required software maintenance the Commonwealth shall be entitled to have use and duplicate for its own use a copy of the source code and associated documentation for the software products covered by the contract Until such time as a complete copy of such material is provided the Commonwealth shall have exclusive right to possess all physical embodiments of such contractor owned materials The rights of the Commonwealth in this respect shall survive for a period of twenty
106. tween the Vendor and BICMS Information Specialist As necessary to gather further requirement details or similar activity the Vendor may meet directly with the one or more specific customer analysts and evaluators Final approval of contractual decisions shall be routed through to the BICMS Information Specialist Accessibility Requirements Overview The Disability Services Agencies are committed to complying to and maintaining the required additions and or modifications to electronic information provided both to the end user as well as internal personnel as defined by The Center for Information Technology Accommodation CITA under the Rehabilitation Act Section 508 Guidelines RAS508 http www webaim org standards 508 checklist This document is intended to provide information pertaining to the specifications and application of these guidelines as pertains to all technology related to applications The BICMS system shall meet or exceed each level of standards as described If the product does not pass accessibility requirements as stated by the aforementioned Section 508 this may result in nonpayment to the vendor All federal Information is cited from the Rehabilitation Action Section 508 Web site http www section508 gov index cfm FuseAction Content amp ID 12 Section 508 requires that when Federal agencies develop procure maintain or use electronic and 54 information technology Federal employees with disabilities have access
107. ty Training Guidelines Recommendations of the Vendor are requested and will be taken under advisement Training should cover all activities necessary to complete entire system workflow and configuration All business processes functional program management information ad hoc reporting obtaining help and support as well as specialized areas such as security configuration file parameter setups etc shall be included Training presentations shall be grouped by functional program specialized business processes and technical areas as well as staff role s If requested by the DRS Project Manager the Contractor will work with the DRS Brain Injury Services BIS Programs user groups as well as he Director of Brain Injury and Spinal Cord Injury Services to determine appropriate and sufficient training formats and methods Training User Manual There should be one training manual for the entire system Where programs or functions are different there should be a reference to another section in the manual Manual should be detailed to walk functional program staff through each specific business process from pre intake through post closure activities Authorization invoicing and management information functions also shall be detailed There shall be an overview of the system to all users and training will be based on a one on one informal process by the purchasing agency Security Security You must secure your Database Web Interface Each pr
108. ubmitted to DRS Failure to submit all requested information may result in DRS CNI Trust Fund Advisory Board requiring prompt submission of missing information a lower evaluation score or the rejection of the proposal In addition to the aforementioned paper copies an electronic format compatible with the agency s Microsoft Office Word 2003 must be provided Mandatory requirements are those required by law or regulation or are such that they cannot be waived and are not subject to negotiation 2 All information requested by this RFP on the ownership utilization and planned involvement of small businesses women owned businesses and minority owned businesses Attachment A must be submitted If an Offeror fails to submit this information DRS CNI Trust Fund may require prompt submission of missing information after the receipt of vendor proposals 3 The Vendor Data Sheet Attachment B must be completed signed and returned with the proposal B Proposal Requirements 1 Proposals must contain and address the following components a An accessible interface that will display data that has been predefined by the user group data elements will be provided b Web hosting and database hosting for the BIS Programs as defined by DRS Provision of security certificates is required on all used servers c An interface that will pass ADA Americans with Disabilities Act 508 Compliance and is functional and friendly for all users Pref
109. ull day of inoperability The vendor will notify the BI Information Technology Analyst at once as to what type of maintenance will be done and rate it as its overall importance to the system using High show stopper Medium will affect some functions Low will not affect the everyday workings of the system In the event the equipment or software remains inoperable for more than 3 consecutive calendar days the contractor shall promptly replace the equipment or software at no charge upon request of the procuring agency Such replacement shall be with new unused product s of comparable quality and must be installed and operational within 7 days following the request for replacement S LIMITATION OF USE The Commonwealth s right to use computer software developed entirely at private expense may be limited by the contractor as stipulated in this contract Notwithstanding any provision to the contrary however the Commonwealth shall have at a minimum unlimited use of the software on the equipment for which it is purchased use of the software on a secondary system for backup purposes should the primary system become unavailable malfunction or is otherwise rendered inoperable use of the software at another Commonwealth site should the system be entirely transferred to that location the right to make a backup copy for safekeeping the right to modify or combine the software with other programs or materials at the Commonwealth s risk and the right
110. which may hereafter become available for the purpose of this agreement VII SPECIAL TERMS AND CONDITIONS A AUDIT The Contractor shall retain all books documentation records and other documents relative to this contract for five 5 years after final payment or until audited by the Commonwealth of Virginia whichever is sooner The Commonwealth Neurotrauma Initiative Trust Fund Department of Rehabilitative Services its authorized agents and or state auditors shall have full access to and the right to examine any of said materials during said period B AVAILABILITY OF FUNDS It is understood and agreed between the parties herein that the Commonwealth Neurotrauma Initiative CND Trust Fund and Department of Rehabilitative Services shall be bound hereunder only to the extent of the funds available through for this purpose or which may hereafter become available for the purpose of this agreement C AWARD Selection shall be made of the Offeror s deemed to be fully qualified and best suited based on the evaluation factors included in this RFP as well as those considered to be in the best interests of the Commonwealth of Virginia Following negotiations The CNI Trust Fund Advisory Board shall select one or more Offeror s which in its opinion submitted the best proposal s and shall 16 award the contract s to such Offeror s The Commonwealth may cancel this Request for Proposals or reject proposals at any time prior to award and is n
111. x Signature in Blue Ink AMOUNT OF FUNDING REQUESTED Optional Pre Proposal Conference Thursday May 27 2010 at 8004 Franklin Farms Drive Richmond VA 23229 in Conference Room 101 1 30 to 3 30 PM See page 21 under Optional Pre Proposal Conference NOTE This public body does not discriminate against faith based organizations in accordance with the Code of Virginia 11 35 1 or against a bidder or Offeror because of race religion color sex national origin age disability or any other basis prohibited by state law relating to discrimination in employment TABLE OF CONTENTS Tee EA rA ON ase ste toi ta wes s see aaa cc das ia BAG Eege 2 il BACKGROUND AND ELIGIBLE OF FERORS yiigcsscsariastivs tevescneteitosanieseeeod iasndies rhel teas 3 Va OBE a 110 EE 3 BS Tee ele E A E A ET 4 C Small Women Owned and Minority Business PDorttcipotion 4 M STATEMENT Ee a a a o a steed a A EERE 4 A Commitment E 4 B Duration and Amount of Funding geet ee eege eier 5 EIS OO TEE 5 D Human Research Guidelines cccvsssceceessccsiinaseieicauaeiegensas sun e EE E E ENEE E EEA ER 5 IV PROPOSAL PREPARATION AND SUBMISSION REQUIREMENTS ccssscesseeeeeesseeeteeeeeeeseeeneees 6 PREP EE EEN 6 EE 6 C Proposal Development Content and Format Requirements ccssscccesseeeesceeeseceeesececsseceesueeeesueeeesaeees 7 V EVALUATION AND AWARD CRITERIA osc costasies gutsy secitngesetiaks Win etea ks ree eet Aas Se RK amp As E EE 8 B Aw
112. x Radio button for Radio button for Do you have problems with balance yes or no yes or no Textbox Radio button for Radio button for Do you have mobility problems yes or no yes or no Textbox Radio button for Radio button for Do you have visual problems yes or no yes or no Textbox Radio button for Radio button for Do you have auditory problems yes or no yes or no Textbox Radio button for Radio button for Do you have problems with taste yes or no yes or no Textbox Radio button for Radio button for Do you have problems with smell yes or no yes or no Textbox Radio button for Radio button for Do you have problems with speech yes or no yes or no Textbox Radio button for Radio button for Do you have problems with swallowing yes or no yes or no Textbox Radio button for Radio button for Do you have seizures yes or no yes or no Textbox Radio button for Radio button for If yes describe your seizures yes or no yes or no Textbox Describe your seizure protocols Textbox Textbox Textbox Radio button for Radio button for Do you have problems sleeping yes or no yes or no Textbox Radio button for Radio button for Do you have problems with pain yes or no yes or no Textbox If yes describe physical needs Textbox Textbox Textbox Describe any yes answers above in more detail Textbox Textbox Textbox Can you provide all of your own self Radio button for Radio button for care yes or no yes or no Textbox Descri
113. xchanged only for the following purpose s check all that apply Service Coordination and Treatment Planning Eligibility Determination Job Placement release of information to employers x Coordination with Vendors Providers x Other write in as needed by the DRS Brain Injury Direct Services BIDS Fund to solicit and coordinate specialized treatment and rehabilitation services 9 I want to share additional information received and or included in my records after this consent is signed check one Yes Nol 10 I want to place the following restrictions on information to be shared specify 11 This consent is good until date no later than one year from the date of signature I can withdraw this consent at any time by notifying my DRS counselor My DRS counselor will notify the listed agencies that my consent has been withdrawn which will stop the agencies from sharing information I have the right to know what information about me has been shared and why when and with whom it was shared Unless prohibited by law or regulation each agency will show me this information if I ask to see it I would like all of the listed agencies individuals to accept a copy of this form as a valid consent to share information If I do not sign this form information will not be shared and I will have to contact each agency individually to give them the information they need or complete a separate consent form for each information request
114. y Financial Support check one Self O Parent O Spouse O Guardian 2 People Dependent on Family Income CH family filed tax return use from tax return 3 3b Exclusion for Annual Taxes Health Insurance and Retirement Savings if Line 3a is under 10 000 multipiy Line 3a by 15 if Line 3a is 10 000 to 14 999 multiply Line 3a by 20 if Line 3a is 15 000 to 24 999 muitipiy Line 3a by 25 if Line 3a is 25 000 to 34 999 muitipiy Line 3a by 30 if Line 3a is 35 000 and Over muitipiy Line 3a by 35 Line 3a times exclusion 3b 3c Adjusted Annual Taxable Income Line 3a Line 36 4 Non taxable Income Workers Comp Veterans Disability Chiid Support etc 5 Total Adjusted Annual Income Line 3c Line 4 0 00 E E 6b_ 5000 Exclusion for Cash Assets 6b 5 000 00 8 Annual Living Expenses Exclusion Based on Family Size a 11 Client Resources Line 7 Line 10 if Line 7 is jess than Line 10 enter 0 12 Client Percentage enter from Percent Contribution Table on Page 4 y 32 All of the information on this form is true and complete to the best of my knowledge agree to give proof ofthis _ 34 information Proof may include a copy of my most recent tax return or other satisfactory proof see Note 2 If _ 35 don t give proof when asked or give false information may lose DRS assistance DRS and will review my 36 financial condition annually or sooner if notify DRS of a change in my fina
115. y person or entity that is currently so debarred ANTITRUST By entering into a contract the Contractor conveys sells assigns and transfers to the Commonwealth of Virginia all rights title and interest in and to all causes of action it may now have or hereafter acquire under the antitrust laws of the United States and the Commonwealth of Virginia relating to the particular goods or services purchased or acquired by the Commonwealth of Virginia under said contract MANDATORY USE OF STATE FORM AND TERMS AND CONDITIONS 1 For Request For Proposals Failure to submit a proposal on the official state form s provided for that purpose may be a cause for rejection of the proposal Modification of or additions to the General Terms 11 J and Conditions of the solicitation may be cause for rejection of the proposal however the Commonwealth reserves the right to decide on a case by case basis in its sole discretion whether to reject such a proposal CLARIFICATION OF TERMS If any prospective Offeror has questions about the specifications or other solicitation documents the prospective Offeror should contact the buyer whose name appears on the face of the solicitation no later than five working days before the due date Any revisions to the solicitation will be made only by addendum issued by the buyer PAYMENT 1 To Prime Contractor a Invoices for items ordered delivered and accepted shall be submitted by the Contractor direct

RFP#: 10-327 Commonwealth Neurotrauma Initiative Trust Fund

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