FORM A - Organization of Application - Texas Health and ...



FORM A - Organization of ApplicationThis document serves as a guide for the organization of Application documents to be saved on each of the flash drives or compact discs. Each compact disc must be labeled as provided in Section 5.16.1 of this PEN.Create subfolders containing only the documents requested in this PEN that apply to your operation.This guide may not contain all items requested in the PEN. The Applicant is ultimately responsible to submit all required materials in the order and format requested in the PEN. File Folders must be named as indicated in the column labeled “ELECTRONIC FILE NAME.”Documents in each File Folder must be saved as individual subfolders. Subfolders must be made for each required and applicable document that may not be listed below. FILE FOLDER 1: "Application" (Section 8.3 of this PEN) Electronic File Name for SubfolderDocumentIs Document Required Yes/NoApplicationPEN Application and ContractYesFILE FOLDER 2: "Supporting Documentation" (Sections 8.3 and 8.4)Electronic File Name for SubfoldersDocumentIs Document Required Yes/No01- Contractor InfoContractor Service Information and County SelectionYes01.AProgram purpose, goals, and objectives;Yes01.BTraining requirements;Yes01.CDuration and frequency of services; Yes01.DFor Evidence-Based Programs, submit the name of the program your operation will utilize; ORYes, If applicable.01.EFor Promising Practice Program: Submit name of Evidence-Based Program(s) upon which you have based your program design; andProvide an Active Impact Evaluation Program.Yes, If applicable.02-ApplicantApplicable Work or Related Volunteer ExperienceProof of experience in managing budgets, grants, or Contracts for social services.YesSee subsection 2.6.02.A-Program Director Education Proof of Education (transcript or diploma; Professional License(s)); Yes, if applicable.See subsection 2.6.02.B-Assessment Staff Education Proof of Education (transcript or diploma; Professional License(s)); YesSee subsection 2.6.02.C-Assessment Staff Education Proof of Education (transcript or diploma, Professional License(s)); Yes, if applicable.See subsection 2.6.02.D-Direct Service Staff Education Proof of Education (transcript or diploma, Professional License(s)); YesSee subsection 2.6.02.D-Direct Service Staff Education Proof of Education (transcript or diploma, Professional License(s)); Yes, if applicable.See subsection 2.6.03-Direct Service Staff TrainingProof of Training in Home Visiting ModelYesSee subsection 2.6.03.A-Direct Service Staff TrainingProof of Training in Home Visiting ModelYes, if applicable.See subsection 2.6.04-DBAAssumed Name CertificateYes, if applicable.05-Certificate of IncorporationCertificate of IncorporationYes, if applicable.06-PartnershipCopy of Partnership Agreement. If applicable, submit a copy of the Signatory AssignmentYes, if applicable.07-Subcontract DocCopy of the subcontract or subcontract template Yes, if applicable.08-BudgetingSubmit:Monitoring reports from any Texas city, county, State Agency, or federal funding entity;All completed fiscal audits performed on the Applicant’s social service operation;Balance sheet, and/or a statement of income and expenses;Capital expenditure reports;Statement of changes in financial position or cash flows, if applicable.Yes, if applicable.See subsection 2.6.1.1.3 2.6.1.2FILE FOLDER 3: "Required Forms" (Section 8.4 of this PEN)Electronic File Name for SubfoldersDocumentIs Document Required Yes/No01-Form 2031Signature Authority DesignationOptional or equivalent contract document identifying person authorized to sign contract02-2970cRelease of Information Regarding Criminal or Abuse/Neglect HistoryApplicantYes02.A-2970cProgram DirectorYes, if applicable.02.B-2970cAssessment StaffYes02.C-2970cAssessment Staff Yes, if applicable.02.E-2970cDirect service staff and volunteersYes02.F-2970cDirect service staff and volunteersYes, if applicable.03-2971cRequest for Criminal History and DFPS History CheckApplicantYes03.A-2971cProgram DirectorYes, if applicable.03.B-2971cAssessment StaffYes03.C-2971cAssessment Staff Yes, if applicable.03.E-2971cDirect service staff and volunteersYes03.F-2971cDirect service staff and volunteersYes, if applicable.04-Form 4108xVendor Direct Deposit AuthorizationYes05-Form 4109xApplication for Texas Identification NumberYes06-Form 4732Request for Determination of Ability to ContractYesFORM B - Attachment A-3PEN APPLICATION AND CONTRACTIdentification InformationLegal Name of Applicant FORMTEXT ?????Doing Business As (DBA) NameIf different from Legal Name FORMTEXT ?????Attach a copy of Assumed Name Certificate (DBA)Vendor ID Number FORMTEXT ?????Federal ID Number – If different from Vendor ID FORMTEXT ?????Type of Applicant – Check “√” appropriate box (es). Attach documentation as indicated FORMCHECKBOX Governmental EntityDo you have taxing authority? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Individual/Sole Proprietor FORMCHECKBOX CorporationType of Corporation: FORMCHECKBOX For Profit FORMCHECKBOX Non-ProfitState of Incorporation: FORMTEXT ?????Charter Number: FORMTEXT ?????Attach a copy of Certificate of Incorporation FORMCHECKBOX PartnershipType of Partnership: FORMCHECKBOX Limited FORMCHECKBOX GeneralAttach a copy of Partnership Agreement.If applicable, also attach a copy of the Signatory AssignmentContact InformationOffice Address (Street-Suite #) FORMTEXT ?????Office Address (City, State, Zip) FORMTEXT ?????Mailing Address (P.O. Box)If different from Office Address above FORMTEXT ?????Mailing Address (City, State, Zip)If different from Office Address above FORMTEXT ?????Phone- Primary Office FORMTEXT ?????Fax- Primary Office FORMTEXT ?????Email- Primary Office FORMTEXT ?????Primary Contact PersonName-Primary Contact Person FORMTEXT ?????Title-Primary Contact Person FORMTEXT ?????Phone-Primary Contact Person FORMTEXT ?????Alternate Phone-Primary Contract Person FORMTEXT ?????Email- Primary Contract Person FORMTEXT ?????Person Authorized to Sign ContractName FORMTEXT ?????Title FORMTEXT ?????Phone Number FORMTEXT ?????Alternate Phone Number FORMTEXT ?????Email FORMTEXT ?????Person Responsible for BillingName FORMTEXT ?????Title FORMTEXT ?????Phone Number FORMTEXT ?????Alternate Phone Number FORMTEXT ?????Email FORMTEXT ?????Any notice required or permitted under this Contract by DFPS to the contractor must be in writing and sent to the primary contact information noted in this PEN Application and Contract (A-3).? At all times, Contractor will maintain and monitor at least one active electronic mail (Email) address for the receipt of Contract-related communications from DFPS. It is the Contractor's responsibility to monitor this Email address for Contract-related information.Services to Be ProvidedContractor must provide home-based assessments, home visitation services, and evidence-based parent education program services. There are no optional services under this Contract.Service Delivery Staff QualificationsContractor and each direct service provider must provide supporting documentation that clearly demonstrates that the Minimum Qualifications described in Provider Enrollment (PEN) Section 2.6 are met. SubcontractsDo you intend to use Subcontractors in the delivery of services being Contracted? FORMCHECKBOX Yes - (If yes, submit a copy of the subcontract or subcontract template to be used in the delivery of services being contracted. The Subcontract must be in compliance with procurement, monitoring and back ground check processing requirements.) FORMCHECKBOX NoService Delivery Area (SDA)Primary Region or Regions to be ServedApplicant must determine which Region(s) will be served and mark with a “√” next to the Region number. Contractor will be required to provide services in each Region selected.Region One (1)Region Seven (7)Region Two (2)Region Eight (8)Region Three (3)Region Nine (9)Region Four (4)Region Ten (10)Region Five (5)Region Eleven(11)Region Six (6)Click on the icon to see a DFPS Regional map\sCounty SelectionIn PEN Section 8.4, Attachment A-3 Contractor Service Information, click on the icon to open the Region(s) you propose to serve. Then select the counties within the primary Region(s) you propose to provide services through this Application. In Attachment A-3, Applicant may also select secondary counties if willing to provide services outside of their primary SDA.Contractor BackgroundWhat Home Visiting Program model, in which the Applicant is trained, will be utilized to meet the requirements of this PEN? ________________________________Does the Applicant have a current contract with HHSC or other State Agencies? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes: Please state the name(s) of the State Agency and the contract number(s). FORMTEXT ?????If no: Describe your organization's applicable work and relevant volunteer experience in the provision of services for at least: Three (3) years to Families with children 0-5 years of age; andThe provision of assessments and the selected Home Visiting Program in the past twelve (12) month period preceding receipt of the Application to Families and/or parents/Caregivers. Include the name(s) of the Home Visiting Program utilized during this twelve (12) month period. FORMTEXT ?????Has your organization had any non-compliance that resulted in harm to a client, child, or family in the past twenty-four months? FORMCHECKBOX Yes FORMCHECKBOX NoHas your organization had a contract suspended or terminated due to fiscal non-compliance in the past twenty-four months? FORMCHECKBOX Yes FORMCHECKBOX NoWithin the past twenty-four (24) months:Does your organization have monitoring reports from any Texas city, county, State Agency, or federal funding entity? FORMCHECKBOX Yes If yes, submit a copy of the report(s) FORMCHECKBOX NoDoes your organization have completed fiscal audits performed on its social service operations? FORMCHECKBOX Yes If yes, submit a copy of completed fiscal audit(s). FORMCHECKBOX NoHas your organization had changes in financial position or cash flows? FORMCHECKBOX Yes If yes, submit statement of changes. FORMCHECKBOX NoSubmit a copy of your organization's balance sheet(s), and/or a statement of income and expenses.Submit a copy of any capital expenditure report(s). InsuranceReview the minimum insurance requirements in Section 2.9 of this PEN, Insurance Standards. Applicants must meet all requirements as outlined. Indicate in the table below, if requirement is met:For the ProviderStandard Worker's Compensation Insurance coverage; however Contractors who do not have an employee are exempt from this insurance requirement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AComprehensive Liability Insurance including Bodily Injury coverage of $100,000.00 per each occurrence and Property Damage Coverage of $25,000.00 per each occurrence FORMCHECKBOX Yes FORMCHECKBOX NoContractor will require all Subcontractors operating in Texas to carry Worker’s Compensation coverage in the amounts required by Texas law. Contractor will also require subcontractors to carry Comprehensive Liability Insurance including Bodily Injury coverage or $100,000.00 per occurrence and Property Damage Coverage of $25,000.00 per occurrence. Contractor may provide the coverage for any or all subcontractors, and, if so, the evidence of insurance submitted will so stipulate. FORMCHECKBOX Yes FORMCHECKBOX NoAttach Certificate of Insurance (COI) or equivalent (ACORD Certificate of Insurance, or a copy of the policy) for each policy currently in force and referenced within the table.For Employees and SubcontractorsFacility requires subcontractors to secure their own Comprehensive Liability Insurance including Bodily Injury coverage of $100,000.00 per occurrence and Property Damage Coverage of $25,000.00 per occurrence (See 8.1.4 of the PEN Application and Contract): FORMCHECKBOX Yes FORMCHECKBOX NoIncorporation by ReferenceThe following documents are incorporated into the Contract for all purposes:DFPS Uniform Contract Terms and Conditions, 2282UTCProvider Enrollment HHS0000069, including all addenda and attachmentsAttachment A, as completed by the Contractor, including all addenda and attachmentsEach Service Authorization Form, prepared by DFPSOrder of PrecedenceThe Contractor will provide the services and deliverables described and required by all the documents listed in this Section. In the event of conflicts or inconsistencies between documents, such conflicts or inconsistencies will be resolved by reference to the documents in the following order of precedence:This PEN Application and Contract, 2280PEN, and any amendments thereto;DFPS Uniform Contract Terms and Conditions, 2282UTC;Provider Enrollment HHS0000069 and any amendments thereto; Each Service Authorization Form prepared by DFPS; and Attachment A, as completed by the Contractor, including all addenda and attachments, and any amendments thereto.CertificationI certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this PEN. By signing this PEN, applicant certifies that if a Texas address is shown as the address of the applicant, applicant qualifies as a Texas Resident Bidder as defined in Texas Administrative Code, Title 34, Part 1, Chapter 20.I have attached Form 2031, Signature Authority Designation authorizing me to enter into contracts on behalf of this legal entity. DFPS will post all official communication regarding this PEN on the Electronic State Business Daily (ESBD). DFPS reserves the right to revise the PEN at any time. Contractors must comply with any changes, amendments, or clarifications posted to ESBD. It is the responsibility of the contractor to periodically check the ESBD for updates to the procurement. The Contractor’s failure to periodically check the ESBD will in no way release the contractor from “addenda or additional information” resulting in additional costs to meet the requirements of the PEN. The undersigned representative agrees to all the terms and conditions specified in the Contract and by signing below agree to execute the terms and conditions of the Contract upon receipt of a Service Authorization Form from the Department. Signature of Authorized RepresentativeDate FORMTEXT ?????Name of Authorized Representative (Printed) FORMTEXT ?????Title of Authorized Representative (Printed) FORMTEXT ?????Signature of Authorized DFPS RepresentativeDate FORMTEXT ?????Name of Authorized DFPS Representative (Printed) FORMTEXT ?????Title of Authorized DFPS Representative (Printed) FORMTEXT ?????Contract Information – For DFPS Use ONLYDFPS will complete the information below once Application is screened, reviewed, and accepted for contract.NoticesAny notice required or permitted under this contract by the Contractor to DFPS must be in writing and submitted to the DFPS address below:DFPS Office Address (Street;-Suite #; or P.O. Box) FORMTEXT ?????Contract TermContract Number (DFPS staff will complete) FORMTEXT ?????Acceptance of Applications for this PEN is at the discretion of DFPS. The initial contract period will begin on the effective and end date stated below, with the total contract term not to exceed sixty (60) months. Effective Date of Contract FORMTEXT ?????End Date of ContractDecember 31, 2019The remainder of the page is intentionally left blank.FORM C - A-1 Performance MeasuresGoal and Performance MeasuresThe Contractor will achieve measures as stated below throughout the Contract Period.? Measures, indicators, targets, data sources, or methodologies are subject to change during the Contract Period or at Renewal.?DFPS will track Contractor performance throughout the Contract Period.?Any and all analyses can be used by DFPS to determine subsequent performance targets, new baselines, the need for Contract changes, or to adjust the nature and intensity of DFPS' Contract monitoring and quality assurance activities, and to keep stakeholders informed about the success of the contracting effort.FY 2020 Performance Measures forHelping Through Intervention and Prevention (HIP) ProgramProcurement Number: HHS0000069Goal of the Contract: To prevent or reduce child abuse and neglect by increasing protective factors in “at-risk” Families (based on the eligible client population as defined by this PEN)Output MeasureOutput #1: Pre-Service and Post-Service Protective Factors Survey Questionnaires are completed by the Primary Caregivers served.Performance Period: Contractor performance for this output is determined annually.Indicator: Percentage of eligible Primary Caregivers served in the Contractor’s HIP Program from whom completed Pre-Service Protective Factors Survey Questionnaires and matching Post-Service Protective Factor Survey Questionnaires are obtained by the ContractorTarget: 60%Purpose: To evaluate the Contractor’s effort at obtaining outcome dataData Sources: ***Self-reported by Contractor Methodology: The numerator is the number of eligible Primary Caregivers served by the Contractor during the contract period from whom completed Pre-Service Protective Factors Survey Questionnaires and matching Post-Service Protective Factor Survey Questionnaires were obtained. The denominator is the total number of eligible Primary Caregivers served by the Contractor during the contract period. Divide the numerator by the denominator, multiply by 100 and state as a percentage.Outcome MeasuresOutcome #1:? An absolute increase in the score for a minimum of one protective factor is reported by unduplicated Families served.Performance Period: Contractor performance for this outcome is determined annually.Indicator: The number of Protective Factors Survey subscales (protective factors) for which 75% of the Primary Caregivers indicate an absolute increase by comparing Pre-Service Protective Factors scores to Post-Service Protective Factors scores.Target: One protective factor for which 75% of Primary Caregivers indicate an absolute increase (The Contractor’s ability or inability to meet or exceed this target will not be the sole means for assessing their success in providing the contracted client services. DFPS reserves the right to revise the target for this outcome measure for any subsequent contract periods based on statewide Contractor performance data.)Purpose: To evaluate the Contractor’s success at increasing protective factors in Families who are served by the Contractor’s HIP ProgramData Sources: ***Self-reported by ContractorMethodology: For each eligible Primary Caregiver from whom both Pre- and Post-Service Protective Factors Survey Questionnaires are obtained by the Contractor: Calculate the scores of each protective factor in each Pre-Service Questionnaire and each Post-Service Questionnaire per instructions in the Protective Factors Survey User Manual. For each set of matching Pre- and Post-Service Questionnaires from the same Primary Caregiver, subtract the score of each protective factor in the Pre-Service Questionnaire from the corresponding score in the Post-Service Questionnaire. For each protective factor, count the number of Post-Service Questionnaires that indicate an increase in the score. For each protective factor, the numerator is the total number of Post-Service Questionnaires counted in #3 that indicate an increase in the score. The denominator is the total number of Post-Service Questionnaires for which the protective factor score was calculated. Divide the numerator by the denominator, multiply by 100 and state as a percentage. Total the number of protective factors for which the percentage calculated in #4 equals 75% or more. (The Contractor must meet or exceed the target for Output #1 in order to achieve the target for this outcome.)Outcome #2: Children remain safe.Performance Period: Contractor performance for this output is determined annually. Indicator: Percentage of Families for whom a Primary Caregiver is not a designated perpetrator for an incident of child abuse or neglect occurring while registered in and receiving services from the Contractor’s HIP ProgramTarget: 100%Purpose: To evaluate the Contractor’s success in keeping children in HIP Program Families safeData Sources: IMPACT and ***Self-reported by ContractorMethodology: The numerator is the total number of unduplicated Families served in the Contractor’s HIP Program in which a Primary Caregiver in the reporting database is matched to a designated perpetrator as indicated in IMPACT, if the incident occurred during the contract period and while the Family was receiving HIP Program services. The denominator is the total number of unduplicated Families served in the Contractor’s HIP Program for the contract period. Divide the numerator by the denominator, subtract this number from one, multiply by 100 and state as a percentage *** The Contractor will report the Performance Measure data for each Performance Period in the format specified by DFPS.? (DFPS has developed an Internet-based data collection and reporting system for Contractors to self-report performance measure data in the PEIRS Data System.?.? DFPS requires the Contractor to report Performance Measure data through the PEIRS Data System.DefinitionsAbsolute Increase – A documented increase in the score for a subscale in the Post-Service Protective Factors Survey Questionnaires relative to the score for the same subscale in the Pre-Service Protective Factors Survey plete (the HIP Program) – The Contractor has determined that the Primary Caregiver has received all necessary services as defined by the developer of the evidence-based program and has indicated within the reporting database that the individual completed the pleted Protective Factors Survey Questionnaire – A Primary Caregiver responds to a minimum of 80% of the questions in parts I-IV of the questionnaire.Designated Perpetrator – As defined by 40 TAC (Texas Administrative Code) §700.512, “A person who has been determined by a preponderance of the evidence to have been responsible for abuse or neglect of a child.”Eligible (To respond to the Post-Service Protective Factors Survey Questionnaire) – The Primary Caregiver must have completed a Pre-Service Protective Factors Survey Questionnaire and: Completed the prescribed HIP Program; or Exited the HIP Program. (The “Exited” option is used in calculating results only for Output measure #1.)Eligible (To respond to the Pre-Service Protective Factors Survey Questionnaire) – A Primary Caregiver must be newly registered into the HIP Program during the current contract period.Family – A household including one or more caregiver(s) or parent(s) who is currently caring for at least one child under the age of 18 years and meets the criteria stated in the Purpose of this PEN.Post-Service Protective Factors Survey Questionnaire – A tool identical to the Pre-Service Protective Factors Survey Questionnaire administered to the Primary Caregiver following the receipt of services and designed to assess the Primary Caregiver’s level of Family functioning/resiliency, social emotional support, concrete support, child development/knowledge of parenting, and nurturing and attachment.Pre-Service Protective Factors Survey Questionnaire – A tool administered to the Primary Caregiver prior to the receipt of services and designed to assess the Primary Caregiver’s level of Family functioning/resiliency, social emotional support, concrete support, child development/knowledge of parenting, and nurturing and attachment.Protective Factors – Personal characteristics or environmental conditions that interact with risk factors to reduce the likelihood of problem behaviors.Protective Factors Survey User Manual – A guide that provides instructions for administering the Protective Factors Survey as well as computing subscale data and technical information about the Protective Factors Survey Questionnaire.Subscale – Groups of questions on the Protective Factor Survey Questionnaire indicative of one of five protective factors: Family Functioning/Resiliency, Social Emotional Support, Concrete Support, Child Development/ Knowledge of Parenting, and Nurturing and Attachment.Unduplicated Family – A Family with a unique registration ID number in which the Primary Caregiver receiving at least one service is only counted one time during the contract period. FORM D - A-2 FEE SCHEDULEHelping through Intervention and Prevention, HIP ProgramPayment is based on a combination of fee for service and cost reimbursement methods. Unit of service is based on face-to-face time with the Family or the specific time spent providing the service authorized by DFPS and provided within the terms defined in PEN HHS0000069. For detailed benefits and parameters, providers should refer in the order of precedence listed below:Details provided in PEN Section 2, Statement of Work, and PEN Section 3, Utilization and Compensation.CategoryService Unit RateParametersAttempted Initial Home VisitAn attempted initial home visit that resulted in either no one home, a refusal of services, or a scheduled home visit for the assessment to be conducted $75.00 Per Initial Home Visit An initial home visit must be attempted more than once if the first attempt results in no contact with the Family.Contractor must attempt to Contact Family through alternate means, such as phone calls, mail, postcard left at residence, and include documentation of such attempts before billing a second attempted home visit.No more than two attempted initial home visits may be billed per Family. Completed Initial Home Visit with AssessmentA completed initial home visit and a completed assessment $240.00 Per Initial Assessment VisitA capacity of one assessment visit per Family is paid at $240.00.An additional visit to complete an assessment will be paid at $155.00. Subsequent Home Visits Home Visiting Program services$155.00 Per Subsequent Home Visit One session per home visit is permitted to ensure fidelity of the Home Visiting Program.Attachment A-2FEE SCHEDULE-ContinuedProject HIP: Helping Through Intervention and PreventionCategoryService Unit RateLimitationsBasic Needs Support ServicesSee Section 2.14.3 of this PEN for basic needs support services.$200.00 Per FamilyUp to $75 may be spent on basic needs support to engage the Family.The remaining funds may be spent based on the outcome of the assessment conducted with the Family. The remaining funds may be billed during the course of Home Visiting Program services.Program OutreachSee Sections 2.14.4 and 3.15.2.1.4 of this PEN for Program Outreach$75.00 per eventOutreach events will be paid at $75 per event, maximum two events per month/24 per year.Program SuppliesSee Section 3.15.2.3.3 of this PEN for Other Incidental Expenses and Program Supplies$500.00 per fiscal yearIncidental expenses the Contractor may incur to conduct this program (i.e. client engagement/welcome baskets items, printing, postage, etc.) may be reimbursed up to $500 per fiscal year by DFPS.TravelTravel will be paid to and from provider's site (for agency approved business only) based on the Texas Comptroller's Travel Rate.Paid Per Mile Based on the Texas Comptroller’s Travel Rate will be paid for travel between contractor's site and client's home for each home visit. Mileage rate is based on the Texas Comptroller's Travel Rate.The Remainder of the page is intentionally left blank.FORM E - Attachment A-3Contractor Service InformationService Delivery Staff QualificationsEach direct service provider must meet the Minimum Qualifications described in Section 2.6 of this Provider Enrollment (PEN). For the Program Director or equivalent position; assessment staff; and direct service staff:How many years has your organization or sole proprietorship been in existence? _______________Is your organization or sole proprietorship currently providing Home Visiting Program services to clients? FORMCHECKBOX Yes FORMCHECKBOX NoIf currently providing Home Visiting Program services, how many consecutive years has your organization or sole proprietorship provided these services? __________________Does the Home Visiting Program that you propose utilizing provide a training certificate? FORMCHECKBOX Yes If yes, submit a copy of the training certificate of completion. FORMCHECKBOX NoDescribe your organization's applicable work and relevant volunteer experience in the provision of services: FORMTEXT ?????Provide the name of your organization's Program Director:______________________List any degrees earned by the Program Director in a Health and Human Services Field, if applicable:_____________________________________________________Provide the name of the Health and Human Services Field in which the Program Director earned a degree, if applicable: ________________________________________Submit proof of education (a bachelor's degree or higher) in a Health and Human Service Fields and any pertinent Professional Licenses, if any (transcript or diploma, Professional License(s)).How many years of relevant work and volunteer experience in a Health and Human Services Field does the Program Director have? FORMCHECKBOX Less than three (3) years FORMCHECKBOX Three (3) or more years FORMCHECKBOX Seven (7) or more yearsDescribe the Program Director's relevant work and/or volunteer experience in a Health and Human Services Field. FORMTEXT ?????Provide the name(s) of Assessment Staff:______________________________________List the names of Assessment Staff that have a master’s degree or higher in a Health and Human Services Field:_____________________________________________List the names of Assessment Staff that have a bachelor's degree in a Health and Human Services Field:____________________________________________________Submit proof of education (a bachelor’s degree or higher in a Health and Human Services Field) and any pertinent Professional Licenses, if any (transcript or diploma, Professional License(s)).How many years of relevant direct service work and volunteer experience with At-Risk Families with children ages 0-5 years in a Health and Human Service Field does the Assessment Staff have? FORMCHECKBOX Two (2) to five (5) years; List names: __________________________________________________________________ FORMCHECKBOX Six (6) or more years; List names: __________________________________________________________________Describe the Assessment Staff's relevant work and/or volunteer experience with At-Risk Families with children ages 0-5 years in a Health and Human Services Field. FORMTEXT ?????Provide the name(s) of Direct Service Staff and volunteers who are primarily responsible for delivering the Home Visiting Program:______________________________________List the names of Direct Service Staff that have an associate’s degree or higher in a Health and Human Services Field:_______________________________________Submit proof of education in a Health and Human Services Field;ORList the names of the Direct Service Staff that have two (2) years of relevant direct service work and volunteer experience in a Health and Human Services Field:______________________________________________________________Describe each individual Direct Service Staff member's relevant work and/or volunteer experience in a Health and Human Services field. FORMTEXT ?????If the model proposed to be utilized has greater requirements than the minimum requirements cited above, are the requirements met? FORMCHECKBOX Yes FORMCHECKBOX NoIs at least one Direct Service Staff currently trained in the Home Visiting Program that will be utilized by the operation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list the name(s) of the Direct Service Staff trained in the Home Visiting Program that will be utilized by the operation: ________________________________________________Note: Refer to Organization of Application in Section 8.5, Required Forms. Service Delivery Area (SDA) DetailApplicant selected the proposed Region(s) to serve through this Application in the PEN Application and Contract, Form 2280PEN, in Section 8.3 of this PEN. DFPS Regions 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 are served on a county basis and the Applicant must next select the counties within each Region where services will be provided.How to Select Primary SDA Counties and Application RequirementTo select counties to be served follow these steps:Click on the icon below to open the Region(s) Applicant intends to serve through this Application.Applicant must choose the counties to be served from the list of available counties.Note: All counties within a Region may not be currently available for enrollment. Only counties in bold and with a “?” in front of the county name are available for enrollment.Return the SDA detail page for the service region(s) with your completed Application packet.Contractor will be required to provide services within each county selected.Region 1:ClosedRegion 7:Closed Region 2: ClosedRegion 8:Closed Region 3:ClosedRegion 9:ClosedRegion 4:ClosedRegion 10:ClosedRegion 5: ClosedRegion 11:ClosedRegion 6:ClosedHow to Select Secondary SDA Counties and Application RequirementTo select secondary counties, follow these steps:Is Applicant willing to provide services in Secondary SDA counties? FORMCHECKBOX Yes FORMCHECKBOX NoIf willing to provide services in one or more secondary counties, click on the icon(s) below to open the secondary Region(s) and choose the counties. Return the secondary SDA detail page with your completed Application packet.All counties within a Region may not be currently available for enrollment. Only counties in bold and with a “?” in front of the county name are available for enrollment.Contractor will only receive service authorizations in the area(s) selected if the SDA has not been identified as a primary SDA by another Contractor.Region 1:ClosedRegion 7:ClosedRegion 2:ClosedRegion 8:Closed Region 3:ClosedRegion 9:ClosedRegion 4:Closed Region 10:Closed Region 5: ClosedRegion 11:ClosedRegion 6:ClosedHome Visiting ProgramSelect the Home Visiting Program your operation will utilize to meet the requirements of this PEN, and list the program name in the space provided below. FORMCHECKBOX Evidence-Based Program: ________________________________________________ FORMCHECKBOX Promising Practice Program: ______________________________________________For Promising Practice Program: List the names of Evidence-Based Program(s) upon which you have based your program design. _____________________________________________Submit an Active Impact Evaluation Program with the application.Submit a plan for following the fidelity of the Home Visiting Program your operation will utilize, to include:A description of the program purpose, goals, and objectives;A description of proposed program service delivery including program duration and frequency of visits;A description of proposed training program, to include initial training requirements for selected Home Visiting Program as well as continuing education requirements for staff; andDocumentation of completed training for Direct Service Staff referenced in 3.3.3. of this document.Documentation that you are authorized to use the selected Home Visiting Program (if selected Home Visiting Program provides authorization).Will you, your staff, or subcontractors be delivering services from satellite office sites other than the location listed in Section 6 of the PEN Application and Contract, Form 2280PEN? FORMCHECKBOX Yes - (if yes, be sure to complete question 4.3 below) FORMCHECKBOX NoPrimary OfficePrimary office is designated in Section 3 of the PEN Application and Contract, Form 2280PEN (See Section 8 of this PEN). Complete the table below providing a schedule for the days and times routinely available to provide services at the primary office location. These represent only routine days and times. Applicant will be expected to adjust the schedule to accommodate the needs of DFPS referred clients.Primary Office:DAYHOURSExample: FORMCHECKBOX MondayFrom:To:From:To:7 AMNoon2 PM7 PM FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Satellite Office(s)Designate any satellite office(s) by completing the table and providing a schedule indicating days and times routinely available to provide services at each satellite office location. These represent only routine days and times. Applicant is expected to adjust schedule to accommodate the needs of DFPS referred clients. Use additional copies of this section, as necessary, to provide complete information.Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????DAYHOURSFrom:To:From:To: FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????DAYHOURSFrom:To:From:To: FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????The remainder of the page is intentionally left blank.FORM F - Attachment B Required FormsNotesForms can be accessed via the link (hold down the "Ctrl" key while clicking on the link) or icon (double click on the icon to open the attachment) provided in the column titled "Download" of the Required Forms Table. Save the form on your computer, and complete the saved form as instructed.Forms must be completed and signed.Note: Review each form in its entirety to ensure that applicable sections are completed. Forms requiring an original signature must be signed and saved in the electronic (pdf) copy.Some forms may include special instructions or clarification provided under the name of the form in the column titled "Name."If a form does not apply to you or your organization, mark the form "N/A", include your operation's name, sign, date, and return the form with response package.ATTACHMENT BRequired FormsNumberNamePurposeDownload2970CDisclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect [Respondent is required to complete and return form 2970c only on the personnel that will be responsible for initial and ongoing entry of background checks into ABCS.]Release of information regarding criminal history or DFPS abuse and neglect history.2971CRequest for Criminal History and DFPS History Check[Respondent is required to complete and return form 2970c only on the personnel that will be responsible for initial and ongoing entry of background checks into ABCS.]Application for requesting criminal history and DFPS abuse or neglect history.4108xVendor Direct Deposit Authorization[Complete Sections 1 through 4. Please review the instructions at the end of the document for completing those sections.]For vendor to receive direct deposit4109xApplication for Texas Identification Number/Additional Mailing Address[If currently a Contractor with DFPS and a Texas Identification Number (TIN/Vendor ID #) is already set up, entering the Applicant’s name and writing “Already Set Up” at the top of the form is an acceptable response.]Application for identification number\s5645VDFPS Terms and Conditions Uniform Terms and Conditions for vendor contracts\s5622VDFPS Supplemental and Special Conditions The following supplemental conditions modify the DFPS Uniform Terms and Conditions \s ................
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