Request for Proposals: Evidence-Based Prevention Services

OPTUMHEALTH NEW MEXICO Request for Proposals: Evidence-Based Prevention Services State Fiscal Year 2014 (January 1, 2014 – June 30, 2014) October ...
Author: Douglas Gray
0 downloads 2 Views 232KB Size
OPTUMHEALTH NEW MEXICO

Request for Proposals:

Evidence-Based Prevention Services

State Fiscal Year 2014 (January 1, 2014 – June 30, 2014)

October 23, 2013

OHNM Prevention RFP - 1

TABLE OF CONTENTS PAGE PART I. GENERAL INSTRUCTIONS A. Intent to Submit an Application...................................................................................................................3 B. Submission of Application ......................................................................................3 C. Pre-Application Conference....................................................................................4 D. Review and Award Process....................................................................................4 E. Notification of Outcome ..........................................................................................4 F. Confidentiality of Applications..................................................................................5 G. Funding Availability.................................................................................................5 H. Term of Contract ....................................................................................................5 I. Questions ................................................................................................................6 J. Penalties .................................................................................................................6 K. Clarification and Disclosure ....................................................................................6 PART II. SUBSTANCE ABUSE PREVENTION, THE OFFICE OF SUBSTANCE ABUSE (OSAP) AND THE STATE ENTITY, AND OSAP’S PREVENTION MODEL: FREQUENTLY ASKED QUESTIONS A. What is Substance Abuse Prevention?..................................................................6 B. What are OSAP and the State Entity and What Do They Do?..............................6 C. What Does a Successful Substance Abuse Coalition Look Like?.........................6 D. How do Coalitions Organize Prevention Efforts?...................................................7 PART III. ESSENTIAL ELEMENTS A. Purpose of Procurement ........................................................................................7 B. Applicant Eligibility .................................................................................................9 C. Assurances.............................................................................................................9 PART IV. APPLICATION CONTENTS AND WEIGHTED EVALUATION FACTORS A. Coalition History and Current Community Status .................................................10 B. Cultural Competency ……………………………………………………..…………..12 C. Project Management ............................................................................................13 D. Coalition Sustainability..........................................................................................14 E. Fiscal Management & Capability...........................................................................14 Appendix A: Intent to Submit Application.................................................................16 Appendix B: Cover Sheet.........................................................................................17 Appendix C: Letter of Agreement Template.............................................................18 Appendix D: Letter of Endorsement Template.........................................................19 Appendix E: Statement of Assurances………………………………….……………..20 Appendix F: Application Checklist and Contents……………………….……………21

OHNM Prevention RFP - 2

I. GENERAL INSTRUCTIONS OptumHealth New Mexico (OHNM), acting as the State Entity, is procuring substance abuse prevention services for youth and adults through state general prevention funds. This funding is provided by the Human Services Department, Behavioral Health Services Division, Office of Substance Abuse Prevention (HSD/BHSD/OSAP.) For information on the time period of the contracts, please see “Term of Contract” on page 5. The schedule for the RFP process is as follows: Action Date 1. RFP Issued: October 23, 2013 2. Pre-Application Conference: November 1, 2013 3. Deadline to Submit Additional Questions: November 8, 2013 4. Intent to Submit an Application: November 8, 2013 5. Response to Written Questions: November 13, 2013 6. Submission of Application Deadline: November 20, 2013 7. Application Review: November 22 –December 2, 2013 8. Contract Finalizations: December 3-December 13, 2013 9. Notification of Outcome: December 16, 2013 A. INTENT TO SUBMIT AN APPLICATION Offerors are required to return by email, hand-delivery or fax the "Intent to Submit an Application" form (see Appendix A). Intent to Submit an Application shall be submitted to Karen Cheman, Prevention Manager of OSAP by one of the following methods: •

By fax # (505) 476-9272



By email to [email protected]



By mail ( or hand delivered) to Karen Cheman OSAP Prevention Manager 37 Plaza La Prensa Santa Fe, New Mexico, 87507.

The form shall be signed by an authorized representative of the offeror's organization, dated and returned by close of business on or before November 8, 2013. B. SUBMISSION OF APPLICATION Each offeror shall submit: • Three separately bound applications in three-ring binders. • Original must be clearly labeled. • Applications shall be tabbed and organized to match the table of contents and according to the RFP requirements. Please organize the application so that reviewers can easily find each component. • The project narrative, excluding Section E -Fiscal Management & Capability, shall not exceed 20 pages. OHNM Prevention RFP - 3

• Each application must be typewritten in Ariel, 11 point font, on 8 ½ x 11 white paper, singlespaced, one inch margins, and numbered sequentially from beginning to end. An electronic copy with attachments must be submitted on a data storage device. Proposals are to be submitted to: Office of Substance Abuse Prevention Attn: Karen Cheman OSAP Prevention Manager 37 Plaza La Prensa Santa Fe, New Mexico, 87507 The deadline for submission of completed proposals is 5:00 pm MST on Friday, November 20, 2013. Proposals not received at the above-specified address by mail, messenger delivery services, or hand delivery on or before the specified deadline will not be considered for review. Incomplete or unresponsive proposals shall not be accepted under this Request for Applications. OSAP shall make the final determination as to a proposal's competitiveness or responsiveness. The OSAP reserves the right to waive minor technical irregularities that can be corrected without prejudice to other Applicants. C. PRE-APPLICATION CONFERENCE A Pre-Application Conference will be held on November 1, 2013 from 2:00-3:00 pm at the BHSD office located at the address listed below. Applicants are strongly encouraged to attend the pre-application conference in order to develop the best proposal possible. D. REVIEW AND AWARD PROCESS Proposals will be evaluated based upon the weighted evaluation factors described in Section III. It is the intent to award contracts based upon the response to this Request for Proposals. However, OHNM reserves the right to cancel this Request for Proposals or to reject any or all proposals in whole or in part. Proposals will be prioritized and funding allocated based upon which proposals are determined by review to be most advantageous to the needs of the OSAP in meeting the intent of this RFP. A panel will be established to evaluate all proposals and make recommendations. The recommendations of the panel will be forwarded with comments to OHNM/OSAP for Program approval or disapproval of contractor selection. All contracts resulting from this Request for Proposals must be approved by OSAP. OSAP will negotiate contracts from proposals selected under this RFP and may alter any part of a proposal in negotiating the contract. Upon completion of successful contract negotiations, a contract will be prepared by SE for the work described in the proposal. Any Applicant receiving an award shall comply with all applicable federal and state laws, rules and regulations. E. NOTIFICATION OF OUTCOME OHNM Prevention RFP - 4

OSAP will notify each offeror of the outcome of the award process in writing by December 16, 2013, or upon completion of the procurement process, whichever is sooner. This date may change due to the review and approval process within the OSAP. F. CONFIDENTIALITY OF APPLICATIONS Pursuant to Section 13-1-116, NMSA 1978 of the Procurement Code, the contents of any proposal are considered confidential and shall not be disclosed to competing offerors during the negotiation process. Proposals will become public documents exclusive of proprietary information after contracts have been executed. All information submitted will be considered non-confidential unless otherwise labeled by the Applicant. G. FUNDING AVAILABILITY Contract awards are contingent upon funds appropriated by federal and state funding agencies. OSAP reserves the right to adjust any proposed allocations to offerors based on the review of all the competitive proposals and any federal mandates included in the appropriations. Total funding available under this RFP is approximately $400,000. Four counties (San Miguel, Sierra, Socorro, and Torrance,) were selected for funding through this RFP based on data regarding underage drinking, adult drinking, alcohol-related motor vehicle deaths, rates of DWI, prescription drug abuse data, social indicators, and current OSAP county prevention funding. Funding amounts for contract awards will be approximately $100,000 per county per year, with the understanding that 20% will be set aside for evaluation. For the first year, FY 14, the funding amount will be reduced to $50,000 to reflect the fact that the contract will be for no more than six months of the fiscal year. The remaining funds will be used to provide technical assistance and training to support successful applicants as they build coalitions and develop the capacity to plan and implement substance abuse prevention efforts in their communities. Successful proposers must address at least two of the following priorities: • • • •

underage drinking, underage and adult binge drinking, driving while intoxicated, and Prescription drug abuse.

This funding may not be used for substance abuse treatment or law enforcement activities, although integrated community planning efforts that are inclusive of these activities as part of a continuum with prevention are encouraged, so as to better leverage these related activities and support more significant outcomes. H. TERM OF CONTRACT OHNM/OSAP has the discretion under the New Mexico Procurement Code to award contracts that are more or less than one year in length. The State will designate a State Entity to carry out contacts for the period from January 1, 2014 – June 30, 2015. . At the end of the state fiscal year, a contract amendment may be negotiated to reflect funding of services for the next year of OHNM Prevention RFP - 5

the contract. The initial term of the contract is six months, with the option to renew for three more years.

I. QUESTIONS All questions must be submitted in writing to Karen Cheman, Prevention Manager, Office of Substance Abuse Prevention, 37 Plaza La Prensa, Santa Fe, NM 87507 or via email to [email protected]. Written questions will be accepted through close of business on November 8, 2013. Responses will be emailed on to all RFP recipients who submit an “Intent to Submit an Application” form (Appendix A) on or before November 8, 2013. J. PENALTIES The Procurement Code, Sections 13-1-23 through 13-1-199, NMSA 1978, imposes civil and criminal penalties for its violation. In addition, the New Mexico criminal statutes impose felony penalties for illegal bribes, gratuities and kickbacks. K. CLARIFICATION OF PROPOSALS Proposals cannot be revised after being submitted. However, applicants may be contacted by OSAP staff for purposes of clarification only.

II. SUBSTANCE ABUSE PREVENTION, THE OFFICE OF SUBSTANCE ABUSE (OSAP) AND THE STATE ENTITY, AND OSAP’S PREVENTION MODEL: FREQUENTLY ASKED QUESTIONS A. What is Substance Abuse Prevention? Alcohol, tobacco and other drug abuse prevention is an active process that promotes the personal, physical and social well being of individuals, families and communities to reinforce positive behaviors and healthy lifestyles. The term “prevention” is reserved for interventions that occur before the initial onset of a disorder. B. What Are OSAP and the State Entity and What Do They Do? The Office of Substance Abuse Prevention (OSAP) is housed in the Behavioral Health Services Division (BHSD) within the New Mexico Human Services Department. OSAP is the lead state agency for substance abuse prevention. The State contacts with an outside organization known as the State Entity, currently OptumHealth of New Mexico, for fiscal management services. The State Entity contracts with organizations for services and provides contract support such as processing payments and contract oversight. While contracts are with individual organizations, the scope of work in the contracts cannot be successfully implemented by any one organization. Instead, the contracted party is responsible for fostering and maintaining coalitions and partnerships to create community level change. C. What Does a Successful Substance Abuse Prevention Coalition Look Like? A coalition is a diverse group of people and organizations pursuing a common goal. Experience has shown that substance abuse prevention works best and is sustainable when it OHNM Prevention RFP - 6

is done is the context of coalitions committed to preventing substance abuse in specific communities. These coalitions should include representatives from different parts of the community such as the local governments, media, law enforcement, schools, and parents, to name a few, and should represent the ethnic and economic diversity of the community. D. How do Coalitions Organize Prevention Efforts? Coalitions funded through OSAP are expected to use a public health approach to substance abuse prevention that seeks community-level change through strategies that are research based and that have been proven effective in New Mexico. In addition, coalitions are expected to use the Strategic Prevention Framework (SPF) in their work. The SPF is a cyclical process that involves assessment, capacity building, planning, implementation, and evaluation while creating sustainability and ensuring cultural competence. Proposers can learn more about the SPF process at http://captus.samhsa.gov/preventionpractice/strategic-prevention-framework. Technical assistance, training, and evaluation services are provided to all OSAP providers to assist in developing effective coalitions, implementing effective strategies, and achieving sustainable results.

The Strategic Planning Process (SPF)

III. ESSENTIAL ELEMENTS A. PURPOSE OF PROCUREMENT The purpose of this RFP is to address OSAP’s substance abuse prevention priorities in high need communities: 1) underage drinking among persons aged 12 to 20; and 2) DWI among youth and adults; 3) binge drinking among youth and adults; and 4) prescription drug misuse and abuse among youth and adults. Types of Programming to be funded through this Procurement:

OHNM Prevention RFP - 7

All counties will participate in and use the Strategic Prevention Framework planning model to include: needs assessment, capacity building, strategic planning, implementation, and evaluation with cultural competency and sustainability infused into each step. The FY 14 contract for the period ending June 30, 2014 will include activities listed under Phase1 Strategies and interventions will be selected after Phase 1 of this funding. Implementation of strategies and services will therefore not begin until the second year of funding. PHASE 1: (Period Ending June 30, 2014) •

Assessment of needs and resources related to the selected priority(ies). All counties must focus on at least two of the following priorities: reducing underage drinking among 12 to 20 year olds, binge drinking among youth and adults, DWI among youth and adults, and prescription drug misuse and abuse among all ages.



Capacity building and readiness around a data-driven, results-oriented, community based coalition and selected priorities.



Coalition development: Grants awarded for prevention are intended to support or establish community-based coalitions capable of effecting community-level change. For the purposes of this RFP, a coalition is defined as a community-based formal arrangement for cooperation and collaboration among groups or sectors of a community in which each group retains its identity, but all agree to work together toward a common goal of building a safe, healthy, and substance-abuse free community



Strategic Planning - Community-specific strategic plans will be developed based upon the data information gathered during the assessment and capacity phases. The strategic plan will incorporate input from stakeholders and will be focused on outcomes and evidence-based programs.

PHASE 2: (July 1, 2014 –June 30, 2015) •

Implementation of evidence-based environmental strategies. Environmental strategies incorporate prevention efforts aimed at changing or influencing community conditions, standards, institutions, structures, systems, and policies. More specifically, environmental strategies seek to: (1) limit access to substances; (2) change the culture and context within which decisions about substance use are made; and/or (3) shift the consequences associated with substance abuse.



Implementation of evidence-based direct services: Programming focusing on the direct services for youth and families for must identify hot spots or high risk populations with data.

Only those strategies that have prior evidence of effectiveness will be supported. While the nature and scope of these services are different, each is intended to further the directions of the New Mexico Human Services Department/Behavioral Health Services Division/Office of Substance Abuse Prevention and OptumHealth New Mexico (HSD/BHSD/OSAP/OHNM) in OHNM Prevention RFP - 8

terms of enhancing the quality of prevention programming and increasing the likelihood of substantial positive outcomes and impact.

B. APPLICANT ELIGIBILITY Eligible entities are only those agencies that represent the following four New Mexico counties: San Miguel, Sierra, Socorro, and Torrance, Organizations eligible to receive funds as applicants must be legally recognized domestic public or private nonprofit entities. For example, state and local governments; federally recognized tribes; state recognized tribes; urban Indian organizations (as defined in P.L. 94-437, as amended); public or private universities and colleges; professional associations, voluntary organizations, self-help groups, consumer and provider services-oriented constituency groups; community- and faith-based organizations; and tribal organizations. Applicant organizations may choose to designate another organization which meets the requirements above as its fiscal agent. C. ASSURANCES The Applicant shall assure OHNM/OSAP that it will maintain detailed records which indicate the date, time and nature of services rendered under any contract which might be negotiated pursuant to this Request for Proposals (RFP). These records shall be subject to inspection by the designated State Entity (SE), the New Mexico Department of Finance and Administration, and the State Auditor. SE shall have the right to audit billings both before and after payment and to contest any billing or portion thereof. Payment under an agreement between SE and a selected Applicant shall not forfeit the right of SE to recover excessive or illegal payments. The Applicant must assure OHNM/OSAP that any confidential information provided to or developed in the performance of the scope of work detailed in this Request for Proposals shall be kept confidential and shall not be made available to any individual or organization at any time without the prior written approval of SE. The Applicant must assure OHNM/OSAP of its commitment to abide by all Federal and State laws, rules, regulations, and executive orders of the Governor of the State of New Mexico, pertaining to equal opportunity. Pursuant to all such laws, rules, regulations, and executive orders, the Applicant assures OHNM/OSAP that no person in the State of New Mexico shall, on the grounds of race, religion, color, national origin, ancestry, sex, age, physical or mental handicap, or serious medical condition, spousal affiliation, sexual orientation or gender identity, be excluded from employment with or participation in, be denied the benefit of, or be otherwise subjected to discrimination under any program or activity performed under a contract(s) entered into pursuant to this Request for Proposals.

OHNM Prevention RFP - 9

IV. APPLICATION CONTENTS AND WEIGHTED EVALUATION FACTORS

ALL APPLICATIONS SHALL BE

DIVIDED INTO THREE (3) SECTIONS Please follow this order when submitting the application (preceded by a table of contents): Section I: FORMS – WEIGHT: NO POINTS) • Cover Sheet (see Appendix B) • Application Checklist and Contents (see Appendix F) Section II: WEIGHTED EVALUATION FACTORS (TOTAL WEIGHT: 100 POINTS) Narrative for Section II A-D shall not exceed 20 pages • Coalition and Community Status (30) • Cultural Competency (15) • Project Management (35) • Coalition Sustainability (15) • Fiscal Management & Capability(5) Section III: ATTACHMENTS, including but not limited to these documents (REQUIRED – WEIGHT: NO POINTS): • • • •

Letters of Agreement (LOA) for each of the 12 Sectors listed on the “Sector Member Table” and additional LOA’s from other key community partners, as appropriate. Letter of Endorsement from local governing body such as the County Commission or City Council or their designee for health related issues such as the DWI Council or County Health Council or other official entity. Statement of Assurances. Job Description for Prevention Coordinator

Section II: WEIGHTED EVALUATION FACTORS (TOTAL WEIGHT: 100 POINTS) A. Coalition and Community Status (30 points) 1. Do you currently have a functioning coalition or multi-agency group that is poised to work on alcohol abuse and prescription drug abuse? Yes No 2. The following table should be completed to demonstrate, to the best of your ability, that you have earnestly sought to involve a cross section of community stakeholders. Questions below the table ask you to demonstrate how each community sector is/will be involved in your community coalition, or how they intend to participate in the prevention project.

OHNM Prevention RFP - 10

Sector 1

Youth

2

Parent or Adult

3

Business

4

Media

5

School

6

Youth-Serving Organization

7

Law Enforcement

8

Religious/Fraternal Organization

9

Civic or Volunteer Group

Member Name

Organization and Role

Healthcare Professional 10 11

12

State, Local, or Tribal Governmental Agency with Expertise in Substance Abuse Other Organization Involved in Reducing Substance Abuse 3. Explain for each member of the 12 sectors listed in the Sector Table why he/she is the best representative to ensure successful implementation of prevention initiatives through the coalition. 4. Explain the recruitment and current engagement of other coalition members that also represent the 12 sectors and/or outside of the 12 sectors. 5. What resources are available in the community to address substance abuse and how will being awarded this grant leverage available resources and fill in where there are gaps?

OHNM Prevention RFP - 11

6. Describe resources -human, social, fiscal and other types of capital (i.e., volunteers, community organizations/agencies, existing prevention programs/efforts, match dollars, in-kind donations) - available in your community available to address substance abuse. 7. What other community systems and structures are impacted by or have an impact on substance abuse? B. Cultural Competency (15 points)

1. The National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS), issued by the U.S. Department of Health and Human Services’ (HHS) Office of Minority Health (OMH), ensure all people entering the health care system receive equitable and effective treatment in a culturally and linguistically appropriate manner. How will the coalition ensure cultural competence in its substance abuse prevention efforts? (CLAS Standards should be considered when answering this question, and can be found at: http://nmdohcc.org/files/DR-CLAS%20instrument%20final%20818-09.pdf) 2. Health Disparities are defined as differences in health status among distinct populations, such as racial and ethnic groups, rural vs. urban, different income groups, and populations of specific geographic areas. Health disparities generally refer to differences in health that are closely linked with social or economic disadvantage. Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health. These obstacles stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, or geographic location. Other characteristics include cognitive, sensory, or physical disability. (Adapted from Healthy People 2020, U.S. Dept. of Health and human Services) What do you recognize as some of your community’s biggest disparities? 3. If awarded the prevention funding, how will these additional resources help you address disparities in your community? 4. Describe the degree to which the coalition reflects the diversity of the community. 5. Describe the coalition’s efforts to recruit members that represent unique populations within the community. 6. Describe coalition efforts to ensure that there will be a diversity of perspectives heard from and addressed in coalition operations.

OHNM Prevention RFP - 12

C. Project Management (35 total points) 1. How will you structure your coalition / partnership so that key staff (paid/unpaid) and volunteer leadership ensure the implementation of the activities in the prevention project through shared work efforts? •

Describe the roles of coalition members, key staff, and grantee/legal applicant (if applicable) in monitoring the grant activities.



OSAP encourages the use of a Core Team to manage coalition/community based processes. A Core Team should consist of 3-6 people from different agencies (including the project coordinator, local evaluator, and other key people involved with program implementation). Core Team members are expected to participate in trainings in year 1 and support the coordinator in subsequent years of planning, implementation, project management, and evaluation. What might your Core Team look like? Who might be core team members and why?

2. Describe known barriers and challenges to developing and maintaining a successful coalition and the process to be used to address them. 3. Describe plans for keeping the community, including community leaders and other stakeholders, informed of progress toward implementation, adjustments and actions related to the prevention project. 4. Discuss the capability and experience of the applicant organization and other participating organizations, including experience in providing culturally appropriate/competent services. 5. Provide a complete list of staff positions for the project, including the Project Director, Prevention Coordinator, and other key personnel, explaining the role of each and their level of effort and qualifications. Please note that successful applicants must designate at least one staff member who will pursue certification as a Certified Prevention Specialist through the New Mexico Credentialing Board for Behavioral Health Professionals. Information on the certification process can be found at http://www.nmcbbhp.org. 6. Discuss how key staff have demonstrated experience and are familiar with culture(s) and language(s) of populations in the communities that may be funded.

7. Have you ever evaluated whether your prevention efforts have been effective? If yes, can you describe how you approached the evaluation process? Describe any previous work you have done with someone who was specifically trained in evaluation. (If you have no experience with evaluation of prevention describe what other experience you have with evaluation of other kinds of programming)

OHNM Prevention RFP - 13

8. Relationships are key to prevention evaluation. Much of the data needed to evaluate this project will be local, and will require strong working relationships with multiple partners. To what extent do you have the ability to form strong working relationships with the schools, law enforcement, and other institutions serving your community? What have been the challenges to developing those relationships?

D. Coalition Sustainability (15 points) This funding seeks to sustain outcomes. Please answer the following questions: 1.

What outcomes do you hope to achieve in your community? How will your community be different in three years as a result of activities led by the coalition?

2. What resources in your community will you enlist to sustain the outcomes you plan to achieve? Please explain how these resources will be used to sustain outcomes.

E. Fiscal Management & Capability (5 points) Due to the nature of this RFP, you are not required to submit a formal budget for the proposed project. We do, however, ask for information regarding the applicant’s financial capacity. Please answer the following questions. Note: If the applicant is designating an external fiscal agent for purposes of Prevention Funding, please list that organization and its contact information and then complete the information below as appropriate for the fiscal agent.

For Local Government Applicants/Fiscal Agents: 1. Name, Contact Person, and Address of Fiscal Agent if Different than Applicant ____________________________________

2. Date of last audit submitted to New Mexico State Auditor’s Office (Month/Year) _____ 3. What was the formal opinion on the last audit? (Unqualified, qualified, adverse, etc.) Please summarize any findings contained in the audit. 4. Please describe the qualifications and experience of the person responsible for financial management of the proposed project.

OHNM Prevention RFP - 14

5. Please briefly describe financial controls that ensure the financial integrity of all organizational funds. For Non Profit Applicants/Fiscal Agents: 1. Name, Contact Person, and Address of Fiscal Agent if Different than Applicant ____________________________________ 2. If your organization is required to obtain an audit, date of last audit completed (Month/Year) _____

3. Please briefly describe financial controls that ensure the financial integrity of all organizational funds. 4. If your organization is required to obtain an audit, what was the formal opinion on the last audit? (Unqualified, qualified, adverse, etc.) Please summarize any findings contained in the audit. 5. If your organization was not required to submit an audit, please attach your organization’s profit/loss statement for past 12 months and/or balance sheet. 6. Please describe the qualifications and experience of the person responsible for financial management of the proposed project. PLEASE NOTE THAT SUCCESSFUL APPLICANTS WILL BE ASKED FOR ADDITIONAL DOCUMENTATION OF THE APPLICANT/FISCAL AGENT’S FINANCIAL CAPACITY.

OHNM Prevention RFP - 15

Appendix A

INTENT TO SUBMIT APPLICATION NAME OF OFFEROR:

ADDRESS OF OFFEROR:

CONTACT PERSON:

_______________________________ ____________________ Please Print Telephone # ________________________ ___________________________ Fax # E-mail address _______________________________ ____________________ Signature/Title Date

Please email, hand carry or fax this intent to submit form by November 8, 2013.

Office of Substance Abuse Prevention Attn: Karen Cheman OSAP Prevention Manager 37 Plaza La Prensa Santa Fe, New Mexico, 87507

OHNM Prevention RFP - 16

Appendix B Cover Sheet Office of Substance Abuse Prevention 37 Plaza La Prensa Santa Fe, New Mexico, 87507 Offeror (Agency) – PRINT Offeror’s Address:

Project Director:

Financial Officer:

Name:_______________________________

Name:____________________________

Title:________________________________

Title:_____________________________

Address:_____________________________

Address:__________________________

____________________________________

_________________________________

Telephone:___________________________

Telephone:________________________

Fax:________________________________

Fax:_____________________________

E-mail:_____________________________

E-mail:__________________________

Contact person for application, if different than Project Director: MAXIMUM SE Funding for Fiscal Year 2014 (01/01/14-06/30/14): $50,000 The offeror certifies, to the best of his/her knowledge and belief, the data in this application is true and correct. PRINT:______________________________ Name of Authorized Official (Board Chairperson or Designee)

_________________________________ Signature of Authorized Official _________________ _______________ Date Telephone

OHNM Prevention RFP - 17

Appendix C: Letter of Agreement Template (NOTE: This is a sample LOA. Coalitions may use this in its original format or adjust it to meet their needs.) Letter of Agreement (LOA) Coalition Name: Sector Name

Sector Member

Agency/Organization

This agreement between [Coalition Name] and the [Sector] Representative, [Sector Representative’s Name] shall be from [Start Date] until terminated by a mutual accord. This agreement will be reevaluated on a yearly basis. [Coalition Name] will be held responsible to: A. B. C. D. E. F.

Create and follow by-laws and policies. Formulate coalition goals and objectives. Oversee operations of activities, programs, and paid staff. Continue to increase new membership of the coalition. Create and follow a strategic action plan. Create a credible and relevant sustainability plan which includes volunteer membership and resources, both financial and material. G. Respects the rights of [Coalition Name] members to hold their own opinions and beliefs.

The [Sector] Representative, [Sector Representative’s Name] will be held responsible to: A. B. C. D. E. F. G. H. I. J. K.

Be a community leader amongst the represented sector. Ensure clear communication between the sector represented and the coalition. Act as a positive role model for youth, families, and peers. Support the coalition’s mission and goals. Attend coalition meetings which are held on a [Frequency] basis. Participate in at least one subcommittee. Attend coalition sponsored trainings, town hall meetings, and community events. Contribute to the strategic planning process. Participate in sustaining the coalition’s capacity, involvement, and successful outcomes. Prevent substance use through environmental strategies. Provide the following services to be used as match, if applicable:

Coalition Representative’s Name

Sector Representative’s Name

Coalition Representative’s Signature

Sector Representative’s Signature

Title

Date

Title

OHNM Prevention RFP - 18

Date

Appendix D: Letter of Endorsement Template

Letter of Endorsement Local Entity:

[i.e. DWI Council, County Health Council, City Council, etc.]

Representative Name: Contact Information: This letter acknowledges that [Coalition Name] is capable and willing to lead the efforts required to meet the Office of Substance Abuse, 2014 prevention goals and to address alcohol abuse and prescription drug abuse prevention in our county. [LOCAL ENTITIY] believes [Coalition Name] is the right group to take on this project, and to bring the necessary stakeholders to the table. We will support them and will communicate with them on progress and challenges on a quarterly basis throughout the three-year grant cycle.

Official Representative’s Name

Official Representative’s Signature

Title

Date

OHNM Prevention RFP - 19

Appendix E: Statement of Assurances

This form must be completed and signed by the Offeror and returned with the application. _________ will maintain detailed records which indicate the date, time and nature of services rendered under any contract which might be negotiated pursuant to this Request for Proposals (RFP). These records shall be subject to inspection by the designated State Entity (SE) , the New Mexico Department of Finance and Administration, and the State Auditor. SE shall have the right to audit billings both before and after payment and to contest any billing or portion thereof. Payment under an agreement between SE and a selected Applicant shall not forfeit the right of SE to recover excessive or illegal payments. ______shall keep confidential any and all confidential information provided to or developed in the performance of the scope of work detailed in this Request for Proposals and shall not make such information available to any individual or organization at any time without the prior written approval of SE. _______commits to abide by all Federal and State laws, rules, regulations, and executive orders of the Governor of the State of New Mexico, pertaining to equal opportunity. Pursuant to all such laws, rules, regulations, and executive orders, ___ assures SE/OSAP that no person in the State of New Mexico shall, on the grounds of race, religion, color, national origin, ancestry, sex, age, physical or mental handicap, or serious medical condition, spousal affiliation, sexual orientation or gender identity, be excluded from employment with or participation in, be denied the benefit of, or be otherwise subjected to discrimination under any program or activity performed under a contract(s) entered into pursuant to this Request for Proposals.

I certify that the information provided is true and correct, and assure compliance with regulations cited above.

Authorized Signature

Title

OHNM Prevention RFP - 20

Date

Appendix F OFFEROR: APPLICATION CHECKLIST AND CONTENTS NOTE: This form should be used as the table of contents for the application √

SECTION

WEIGHT

Organize the application in the following order: Table of Contents

No Points

Section I: Forms

No points

Intent to Submit Application (Appendix A)

Optional

Cover Sheet (Appendix B)

Required

Application Checklist and Contents (Appendix E) Section III: Weighted Evaluation Factors

Required 100 points

A. Coalition and Community Status

(30 pts)

B. Cultural Competency

(15 pts)

C. Project Management

(35 pts)

D. Coalition Sustainability

(15 pts)

E. Fiscal Management/Capability

(5 pts)

Section IV: Attachments LOAs from each of the 12 Sectors (Appendix C) Letter of Endorsement from Local Entity (Appendix D) Job Description for Prevention Coordinator

Required

Required

Required

Required Statement of Assurances (Appendix E)

OHNM Prevention RFP - 21

PAGE # OF THE APPLICATION