Human Care Agreement

HUMAN CARE AGREEMENT CONTRACTOR QUALIFICATIONS RECORD

Government of the District of Columbia

Department on Disability Services

STATUTORY AND REGULATORY AUTHORITY

The Procurement Practices Human Care Agreement Amendment Act of 2000 (D.C. Law 13-155) authorizes the District of Columbia Chief Procurement Officer, or his or her designee, to award human care agreements for the procurement of social, health, human, and education services directly to individuals in the District. The Human Care Agreement Contractor Qualifications Record (CQR) is an application package that will facilitate the process of pre-qualifying contractors for a human care agreement with the District of Columbia in accordance with D.C. Law 13-155 and Chapter 19, 27 DC Municipal Regulations.

GENERAL INSTRUCTIONS

1. Please read and complete each section of the Human Care Agreement Contractor Qualifications Record form. All information must be completed in the spaces provided, or marked “N/A.”

2. An original signature must be provided in those sections where a signature is required. Copies or a stamped signature is not acceptable.

3. Incorporated by reference in the package that will be provided to you are the “Standard Contract Provisions for Use with District of Columbia Government Supply and Services Contracts,” dated March 2007.

4. Also included in the package will be forms required by the Department of Small and Local Business Development. You must complete those forms and return them with your package to make it complete and for you to be considered for a Human Care Agreement.

5. You may use Section VIII, the “Remarks Section”, on page 6, to provide additional information or to expand on information that is provided in response to the request for information.

6. Please include and attach all information, documentation, and data as instructed and required.

7. In those instances where check boxes are provided, please check only the box or boxes which apply.

CHECKLIST

FREQUENTLY ASKED QUESTIONS

Can I fax my application for processing? No. Contractor Qualifications Records must contain original, not copied signatures.

Is this form available electronically? Yes, the Contractor Qualification Record (CQR) is available on the DDS website.

Who or what is an Individual? The term “individual” means a human person who may be licensed, certified, or otherwise authorized or qualified to perform or provide specific human care services.

Who or what is an Organization? The term “organization” means an entity other than an individual that is licensed, certified, or otherwise authorized, or qualified, to provide or perform human care services in the normal course of business.

SECTION I – GENERAL INFORMATION

SECTION II – FINANCIAL RESPONSIBILITY INFORMATION

SECTION III – DISCLOSURE INFORMATION

Please answer all questions below. If yes to any questions below, please explain fully in REMARKS SECTION, or attach a separate statement.

1. Debarred, suspended or sanctioned? YES NO

2. License currently suspended or restricted? YES NO

3. Criminal conviction in the past 10 years? YES NO

4. Judgments, civil lawsuits, or investigations? YES NO

5. Outstanding criminal fines, restitution, or overpayments? YES NO

6. Related by blood or marriage to a District government employee? YES NO

SECTION IV – ORGANIZATION HISTORY, BACKGROUND AND EXPERIENCE

1. List All Contracts With the District Government Within the Past Five (5) Years:

2. List All Contracts With Other Governments or Private Institutions Within the Past Five (5) Years:

3. If Applying As An Individual, List Your Employment/Work History for the past five (5) years:

4. List At Least Five (5) References Familiar With Service Delivery:

Are you a United States citizen? YES NO

Are you a permanent resident? YES NO

If you are not a citizen, can you provide and submit verification of your legal right to work in the United States? YES NO

SECTION V – EDUCATION, CREDENTIALS AND LICENSURE

1. Please list all colleges/universities/professional institutions attended:

2. Please list all professional certifications and licenses:

3. Please list all specialty certifications and licenses:

Have you or any member of the organization ever had any license, certification or credential revoked or suspended? YES NO

5. Please list any hospital affiliations or privileges below:

Have you or any member of the organization ever had any hospital privileges revoked, for any reason? YES NO

SECTION VI – SERVICE DATA AND INFORMATION

1. General Service Categories:

Education (EDS) Special Education (SED) Health (HTH) Human Services (HUM)

Mental Health (MEN) Psychology (PSY) Social Services (SOC) Youth/Juvenile Justice (JUV)

2. Populations:

3. Setting Codes:

4. Specific Service Categories:

5. Licensure and Certification Categories:

6. Language Skills:

SECTION VII – PERSONNEL CRITICAL TO ORGANIZATION PERFORMANCE

SECTION VIII – REMARKS SECTION

SECTION IX – CERTIFICATIONS AND INCORPORATIONS BY REFERENCE

1. Drug-Free Workplace Certification:

2. Standard Contract Provisions for Use with District of Columbia Supply and Services Contracts:

3. Information Consent:

SECTION XI – TAX CERTIFICATION AFFIDAVIT

Tax Certification: Please provide certification that you or the organization is in tax compliance in the District of Columbia.

Name of Individual/Organization:

Federal Tax Identification or Social Security No.:

DUNS No.:

Office of Tax and Revenue Registration No.:

Unemployment Insurance Account No.:

Principal Officers of Corporation:

I / We, hereby certify that:

1. I / We have complied with applicable tax filing and licensing requirements of the District of Columbia.

2. Tax compliance for the past five (5) years: use the checkboxes below for each tax type.

3. If not current, are you in compliance with a payment agreement with the Office of Tax and Revenue? YES NO

4. If no outstanding liabilities exist, attach copies of supporting forms and cancelled checks as required.

Subscribed and sworn before me on this day of , .

Notary Public:

My Commission Expires on:

SECTION XII – AFFIDAVIT AS TO ACCURATENESS AND TRUTHFULNESS

I, of being duly sworn on oath, certify that I am authorized to sign this document and that all the information contained in this Human Care Agreement Contractor Qualifications Record is complete, true and accurate.

Subscribed and sworn before me on this day of , .

Notary Public:

My Commission Expires on: