funding

Request for ProposalRevised – July 2008

Department of Public Health

RFP # 2008 - 0913

The Connecticut Department of Public Health (DPH) is pleased to announce the availability of funds to provide coordinated, culturally sensitive, developmentally appropriate, school based health center (SBHC) services that include primary care, mental health, oral health care, health promotion/risk reduction activities and outreach at ten schools in the City of Bridgeport. Services are expected to begin on or before March 1, 2009.

Funding

A total of up to $2,933,549 in total funding is expected to be available to support this project. Funding will be for a 28-month period beginning approximately March 1, 2009 through June 30, 2011, subject to the availability of funds and satisfactory performance. It is expected that the following funding will be available:

Funding Source March 1, 2009-June 30, 2009

July 1, 2009-June 30, 2010

July 1, 2010-June 30,2011

Base State Funding

$397,592 (4 mos) $1,192,777 $$1,192,777

Maternal Child Health Block Grant

$1865 (4 mos) $5,596 $5,596

Remainder of RFP allocation

137,344 (4 mos) N/A N/A

Total $536,803 (4 mos) $1,198,373 $1,198,373

Funding Restrictions

Funds are for SBHC services that may be used for personnel, fringe benefits, staff travel, contractual services, and other direct and indirect costs associated with the operations of the clinic and allowed in the budget. Other examples of allowable costs include purchase of clinic equipment or supplies.

Funds cannot be used to pay for or replace school personnel (such as school nurses, counselors, social workers), capitol improvement projects, or vehicles.

Eligibility

Applications will be accepted from public and private organizations, community-based agencies and individuals.

Applicants must have a Connecticut address and must conduct business at a physical location in Connecticut before the contract is awarded.

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Closing Date

An original and five copies of the completed proposal must be received at the DPH office no later than 3:00 p.m. on October 24, 2008.

Place Due

Department of Public HealthPublic Health Initiatives Branch410 Capitol Avenue, MS# 11MATP.O. Box 340308Hartford, CT 06134-0308Attention: Meryl Tom, Social Work Consultant, Project Manager [email protected]

Family Health Section

Further Information

Applicants who download the RFP from the DPH web site are encouraged to send written notice of their intent to apply to the DPH. This notice can be sent using either the postal address or the e-mail address provided under “place due” above.

To avoid giving one applicant advantage over others, all questions regarding the preparation of proposals in response to this RFP must be submitted in writing by October 6, 2008 to the DPH Project Manager. A copy of all written questions and responses will be provided to all applicants who request the RFP or who send a written request for such information to the contact person identified above. Responses to questions will be sent via e-mail to applicants who provide their e-mail address to the contact person listed above.

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mailto:[email protected]

TABLE OF CONTENTS

NOTE: PAGE #’s TO CHANGE

Page

I. Statement of Purpose 4

II. Background 4

III. Proposal Content Requirements 6A. Applicant InformationB. Contractor InformationC. Services to be ProvidedD. BudgetE. Work PlanF. StaffingG. Contract Compliance

IV. Application Procedures 10

V. Deliverables 11

VI. Supervision 11

VII. Review Criteria 12A. Minimum RequirementsB. Technical RequirementsC. Review Process

VIII. Regulatory Compliance 13

IX. Affirmative Action Notice 14

X. Rights Reserved to the State 14

XI. Attachments 15

A. Application FormsB. Non-Discrimination Provisions for State of Connecticut ContractsC. Preliminary Review Team Technical Review Criteria WorksheetD. Minimum Requirements ChecklistE. City of Bridgeport-School Based Health Center Information

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I. Statement of Purpose

The purpose of this funding is to provide SBHC services at the ten sites located in the following Bridgeport Schools: Bassick High School (9-12); Central High School (9-12); Harding High School (9-12); Blackham Elementary School (K-8); Columbus Elementary School (PK-6); Dunbar Elementary School (K-8); JFK Campus Elementary School (k-8); Read Elementary School (K-8); Luis Munoz Marin (PK-8); and Roosevelt Elementary School (PK-8). Medical, mental health and dental services must be provided for students during evening hours at Bassick, Central and Harding High Schools during the first four months of this contract period to receive $137,344, the remainder of the previously issued Enhanced Services RFP funding.

II. Background

School Based Health Centers

School Based Health Centers (SBHC) have served as safety net providers for medical, mental health and dental health care for Connecticut’s uninsured and underinsured students and their families dating back to the early 1980s. The Centers are located within schools or on school grounds and are present in elementary, middle, and high schools or in combination schools serving elementary and middle school students or middle and high school students in the same facility. Programs are designed to be accessible and integrated into the schools in which they operate. Education and preventive services are often offered within classrooms to become known entities to the students so that they can be comfortable seeking services at the SBHCs. The services offered to students and their families through the SBHCs are provided by a multidisciplinary team.

SBHCs operate under a variety of organizations representing community health centers, hospitals, municipalities, boards of education and regional education councils, local health departments, and community based organizations. SBHC activities are supported through a mix of funding sources including state, federal, local and private dollars.

Need for SBHC Services in Bridgeport

Bridgeport is the largest city in CT with 134,750 residents according to the 2000 census. The Bridgeport Child Advocacy Coalition (BCAC), a network of organizations, parents and community leaders committed to improving the well being of Bridgeport’s children, produces a yearly report on the State of the Child in Bridgeport.

According to the 2007 report, child poverty in Bridgeport is on the increase with a child poverty rate of nearly 30% compared to the statewide rate of 11% and rate of 18.5% nationally. More than half of Bridgeport children live below 200% of the federal poverty level, $34,340 for a family of three, the income considered necessary to meet a family’s basic costs, including food, housing, transportation and clothing.

As of June 2007, there were 21,239 Bridgeport children enrolled in the HUSKY program. Even with HUSKY, only three in five children receive preventive health checkups, fewer than three in four preschoolers are immunized, and less than one in two children sees a dentist for preventive dental care.

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The first SBHC was established in Bridgeport in 1983 and the first DPH funded center, supported by an initial grant of $50,000 was established in 1985. The SBHCs in Bridgeport currently conform to the DPH Standard Model for full time Comprehensive School Based Health Center Level V and adheres to the National Association of School Based Health Care’s (NASBHC) Principles and Goals for School Based Health Centers. (See Appendix E; Table 1 related to each of the funded sites, hours of operation, services offered and current staffing models.)

The City will no longer provide funding to support the current level of personnel for the Level V model. The City will, however, provide support by providing in-kind building support services and routine maintenance for the SBHC during days of operation including rent, utilities, water, and housekeeping services for each of the sites for the applicant who is awarded the funding for this grant. The City will also provide building insurance, as the City owns each building. The applicant awarded the contract will be responsible for negotiating an Access Agreement with the City of Bridgeport and its Board of Education. (Please see a draft Access Agreement in the Attachment section of the RFP for proposed terms required by the City of Bridgeport).

Comprehensive dental services have been previously provided to students at 7 of the 10 sites (Please refer to Appendix E; Table 1). Under these circumstances, any student enrolled in the SBHC programs from Blackham Elementary School, Harding or Central High Schools could seek dental services at any of the other sites. It is preferred that minimally, preventive dental services continue to be provided to students with the provision of dental examinations, dental screenings, dental prophylaxis, sealant placement, fluoride application, and oral health education to individual students as well as to students in-group settings. Should registered dental hygienists provide the preventive dental services, these services must be in compliance with Section 20-1261 of the General Statutes of Connecticut as it refers to scope of practice.

A Dental Director and two sub-contracted Dentists have also provided services; each ranging between 14-17 hours /week. Two full time Dental Assistants have supported the dental services provided in the SBHCs within the City of Bridgeport.

Two subcontracted child psychiatrists provide psychiatric consultation 4-7 hours/week at Central and Harding High Schools. Psychiatric consultation has been available to all enrolled SBHC students at all DPH funded sites.

SBHCs are fully integrated into each of the schools served. SBHC staff work closely with school nurses, social workers, guidance counselors, administration, teachers and other school personnel.

SBHC staff is involved with numerous community-based organizations and initiatives, including but not limited to: the Oral Health Bridgeport Initiative (ORBIT), Bridgeport Child Advocacy Coalition (BCAC), Community Resource Collaborative (CRC), Violence as it Relates to Children Task Force, and the Area Advisory Council for the Department of Children and Families (DCF).

As is the requirement for all DPH-funded SBHC contractors, the Bridgeport program has established and maintained an independent community-based SBHC advisory body that meets a minimum of twice a year for the purpose of strengthening interagency coordination, community support and program enhancement. It is expected that the contractor granted this award will maintain an Advisory Board.

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Clinical Fusion, a clinical management information system, is used to provide DPH with required data and reports. Clinical Fusion is the desired system of its kind and utilized by almost all DPH funded SBHC contractors. The license for the Clinical Fusion software will be transferable following the award of the RFP. There is an annual maintenance fee for the software at $250 per single-user copy per year. The applicant awarded the contract will be responsible for maintenance fees. The maintenance fee includes all upgrades. Provisions will be made by DPH to provide a mentor to the selected contractor if they have had no prior experience using this data management system.

Historically SBHC staff has collaborated with other non-funded DPH programs that have supported other health and well being services for students with either additional staffing or programs (i.e. Reconnecting Youth (RY), Promoting Alternative Thinking Strategies (PATHS), Families and Schools Together (FAST) and continued involvement in community-based activities and initiatives that focus on Bridgeport youth).

III. Proposal Content Requirements

Proposals must be submitted on the DPH Application Forms included in Attachment A. All requirements of this RFP must be met. Content requirements not addressed by the DPH Application Forms must be submitted in narrative form with numbered pages.

A. Applicant Information

The application must contain the official name, address and phone number of the applicant, the principal contact person for the application, and the name and signature of the person (or persons) authorized to execute the contract. The proposal narrative must be double spaced on standard 8 ½ “ x 11” paper with 1” margins and using 12-point Times New Roman or Arial font. Tables and charts may use 10-point font or larger. Each proposal shall contain the following:

1. Background Statement- (Two page limit) Provide a brief description of your organization as follows:

a. Describe how the SBHC fits into the mission of your organization. b. Describe your experience providing like services (medical, mental health

and oral health services) with similar mission to children and adolescents over the past three years.

c. Describe your experience managing and supervising staff in multiple clinical locations.

d. Describe your experience providing preventive services (e.g. nutrition, substance abuse, domestic violence, teen pregnancy prevention, etc.) to individuals and groups.

e. Describe your organization’s experience with your community and in collaborative projects in the cities/towns in which you serve. Include your plans to collaborate with other agencies and/or subcontractors to provide comprehensive services.

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B. Contractor Information

In order for the Branch to communicate effectively with the contractor, it is necessary to have accurate information about contractor staff that is responsible for certain functions.

Please provide the name, title, address, telephone and FAX number of staff persons responsible for the completion and submittal of:

1. Contract and legal documents/forms2. Program progress reports3. Financial expenditure reports

Accurate information is needed by the Branch concerning the applicant’s legal status.

Please indicate whether or not the agency is incorporated, the type of agency applying for funding, the fiscal year for the applicant agency, the agency’s federal employer ID number and/or town code number, the applicant’s Medicaid provider status and Medicaid number, if any, and if the applicant agency is registered as a Connecticut Minority Business Enterprise and/or Women Business Enterprise.

C. Services to be provided

The contractor must provide the following services and the contractor’s approach must be addressed in the proposal:

1. Service/Program Coordination (Three page limit per site)a. Types of services offered and hours of operation may vary by site. The plan for

services should address the cultural, linguistic, and ethnic needs of the targeted population. See http://www.bcacct.org/Websites/bcacct/Images/publications/SOTC_website.pdf for details related to the needs of the students in the City of Bridgeport. The applicant must describe the level of services to be offered at each and address the following areas:

1. Access: Please include hours of operation proposed for each site. The proposal should include the capacity to ensure services are available during the summer for children in need of services.

2. Proposals should include service models that include the delivery of primary care, mental health and preventive dental health services at each site. Please refer to Attachment E: Staffing Guidelines for reference.

3. Describe how you will coordinate SBHC activities with other school health programs, including other health and support services for students.

4. Describe how you will coordinate with the school nurse, school health coordinator and/or other school personnel (such as social workers, school psychologist or counselors).

5. Describe how you will conduct community outreach and include methods to be used in marketing the services to youth and families.

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http://www.bcacct.org/Websites/bcacct/Images/publications/SOTC_website.pdf

2. Implementation Plan (Three page limit per site)a. The applicant must include a reasonable and thorough implementation plan

including the following: 1. Describe your capacity to serve a similar number of students at the ten city schools. (Please refer to Table 2) 2. Obtaining licensure as outlined in the public health code for each site to meet the established timeline. 3. Complying with HIPAA regulations. 4. Describe your staffing plan including personnel and support staff to be funded at each site and identification of staff who will provide supervision, oversight, and coordination of services. Identify and describe roles of staff that will be utilized to provide services in your proposed model (Medical Director, Nurse Practitioner, Physician Assistant, Coordinator, Medical Assistant, Social Worker, Outreach worker, Dental hygienist, etc). Include a plan and timeline describing how staff will be hired and trained to meet the requirements of the program plan. Include appropriate job descriptions and resumes of key personnel. 5. Describe and state the education, expertise and experience of all staff positions.6. Describe your plan for staff training and maintaining clinical competencies.7. Describe your plan for contracting with MCO’s.8. Provide your plan for a time table from March 1, 2009 through June 30,

2011, that specifically outlines your planned services/activities for the implementation of the proposed services/activities.

3. Data/Information Management (two page limit)a. Health records: Describe policies and procedures developed to ensure confidentiality and privacy in the storage and transfer of health records (including electronic records), communicating health information related to referring students to other providers including the child’s primary care provider, or for additional services, and regular collaboration with a physician advisor.b. Describe your ability and experience with collecting and managing data that will

manage patient information data. Include a work plan for implementing the Clinical Fusion data management system in all ten sites.

4. Billing (three page limit) The selected contractor shall bill appropriate public programs and other third party insurers. The selected contractor shall operate as a not-for-profit provider.

a. Provide a description of your organization’s billing capacity, existing contracts with State health insurance serving the Bridgeport community and your plan for reinvesting reimbursements in the SBHC program.b. Include policies and procedures that minimize or eliminate co-pays.c. Any revenue received as a result of billing must be re-invested in the SBHC

program and must be identified on the end of year report.

5. Collaborations/Community Linkages (three page limit)a. Identify health care providers in the community willing to offer services to students and their families in the SBHC clinic setting and from those who agree to accept referrals from the SBHC. (The list should include providers to address acute or complex problems, as well as after-hours care needs such as for

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acute care, mental health professionals, family/social services, dental health Professionals, specialists, other.) Provide letters of commitment from each provider willing to collaborate on this project that demonstrate past collaboration and intent to provide resources.b. Describe your plan to establish and maintain cooperative working relationships with the Board of Education, school personnel, community-based providers, parents, and the community.c. Describe your plan to establish and maintain a broad -based diverse SBHC Advisory Committee to advise and assist in the development and operation of the SBHC program.

6. Quality Assurance Plan (Two page limit)

Describe your organization’s plan to measure quality, including benchmarks for participation and outreach. The plan should include, but not be limited to, addressing faculty, student and parental satisfaction, adherence to best practice standards in all clinical disciplines and reflect opportunities for improvement. The plan should also reflect actions taken to resolve identified problems and improve quality of care provided.

7. Funding

SBHC contractors are currently required to provide at least 25% matching funds to support activities to be provided. The applicant awarded this contract will be required to provide at least 25% in-kind support to operate their center(s). This must be clearly identified in the submitted budget.

D. Budget

Payments will be negotiated based on time frames and deliverables described in section V of this RFP. The proposal must contain the existing budget and the itemized budget with a detailed justification for each line item on the budget forms included in the Application in Attachment A. All costs (travel, printing, supplies, etc.) must be included in the contract price. Competitiveness of the budget will be considered as part of the proposal review process. Note: Please submit a separate budget for each site for the contract periods of 3/1/09-6/30/09, 7/1/09-6/30/10, and 7/1/10-6/30/11.

The State of Connecticut is exempt from the payment of excise, transportation and sales taxes imposed by the Federal and/or state government. Such taxes must not be included in contract prices.

The maximum amount of the bid may not be increased after the proposal is submitted. All cost estimates will be considered as “not to exceed” quotations against which time and expenses will be charged.

The proposed budget is subject to change during the contract award negotiations.

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The selected Contractor must provide DPH with four copies of the subcontract. All information required of the contractor must be applied to the subcontractor as well. *

Copies of state set aside certifications for small and/or minority business must also be provided.

Payments will be negotiated based on time frames and deliverables described in section V of this RFP.

E. Work plan (three page limit per site)

A comprehensive and realistic work plan with measurable objectives describing tasks to be performed, deliverables and timelines, including a project start date, must be provided on the Application Forms included in Attachment A. SMART objectives are objectives that are Specific, Measurable, Achievable, Realistic, and Time-bound. The work plan must be consistent with the RFP and the project’s goals and objectives. The project start date will be considered as part of the review criteria for this RFP.

F. Staffing

The proposal must describe the staff assigned to this project, including the extent to which they have the appropriate training and experience to perform assigned duties. Job descriptions, hours per week, and hourly rates must be provided for all staff assigned to this project on the form included in Attachment A. Resumes must be provided for all professional staff assigned to this project.

G. Contract Compliance

The proposal must include a completed Notification to Bidders form (return one and keep one for your records) and a Workforce Analysis Questionnaire. In addition, proposals must include a signed statement of adherence to Assurances. These forms are included in Attachment A.

IV. Application Procedures

A. Applicants must complete their proposal using the following procedures:

1. An original and five copies of the completed proposal must be addressed to the Project Manager: Meryl Tom, Social Work Consultant, Public Health Initiatives Branch, Family Health Section and must be received at DPH no later than, 3 p.m. on October 24, 2008.

2. The proposal must be completed on the Application Forms included in Attachment A and additional narrative pages as needed to meet all requirements of this RFP.

3. The proposal must be signed by an authorized official of the applicant organization.

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4. Supplemental information will not be considered after the deadline submission of proposals, unless specifically requested by DPH.

5. Notification of the outcome of proposal review will be mailed to all applicants. A contract will be mailed to the successful applicant on or about February 1, 2009, with an effective project start date on or about March 1, 2009.

V. Deliverables

In the course of providing the required services of this contract, several documents must be produced and delivered immediately upon completion to the DPH Project Manager for approval. These documents, along with the required services, will be the indicators for measuring the performance of the contractor. Development of these deliverables must be included as objectives in the project work plan described in Section III of this RFP (work plan forms are included in Attachment A). A payment schedule will be negotiated based upon the following deliverables:

A. A fully executed contract with signatures from the appropriate authorized persons from the Connecticut Department of Public Health and the contractor’s authorized official.

B. All required reporting documents: quarterly progress and expenditure reports, budget revisions, and annual reports.

C. A letter of assurance or subcontract with a community-based provider stating their agreement to provide patient coverage and back up when the SBHC is not in operation. (Written agreements for provision of after-hours care and care during the summer and other vacation periods must be submitted annually.)

D. Timely reporting of all contractual reporting documents.

E. Evidence of meeting all contractual agreements under this contract.

F. Evidence of a fully executed Access Agreement negotiated between the selected applicant(s) and the City of Bridgeport and Board of Education. (Please see draft Agreement in the Attachment section of the RFP.)

VI. Supervision

The DPH Project Manager within the Public Health Initiatives Branch, Family Health Section, will provide supervision.

VII. Review Criteria

Proposals submitted in response to this notice will be reviewed in two steps; first, to determine whether the minimum requirements have been met (see Attachment D, Minimum Requirements Checklist). Second, to determine the technical merit of the proposals and the extent to which they meet the goals and intent of the RFP.

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A. Minimum Requirements

Proposals will be screened for completeness and compliance with the requirements specified in the RFP (see Attachment D, Minimum Requirements Checklist). Applicants who fail to follow instructions or to include all required elements may be deemed incomplete and removed from further review. In addition, applicants with long-standing, significant outstanding unresolved issues on current and prior year contracts with the Department may be removed from consideration for additional funding.

B. Technical Requirements (Note: You are encouraged to revise this section toaddress the specific needs of your RFP)

Complete proposals will be review for technical merit based on the following criteria:

1. The extent to which the applicant has demonstrated successful experience providing similar services. Preference will be given to applicants who have experience providing primary care, mental health services and oral health in a SBHC setting.

2. The extent to which references provided support to the applicant’s success in providing similar services.

3. The extent to which services to be provided are described clearly and cover all requirements outlined in the RFP.

4. The extent to which adequate time is allocated to manage and coordinate the services to be provided.

5. The extent to which the profile of staff that will be working on this project is clear and adequate to manage the services to be provided. (Applicants are asked to consider hiring existing SBHC staff to help promote continuity of care with enrolled students and their families).

6. The extent to which a thorough work plan is presented, with measurable (SMART) objectives, appropriate timelines, and measurable outcomes.

7. The extent to which a cost effective budget is presented which follows budget instructions in Appendix A. Preference will be given to applicants who demonstrate commitment to this project and offer more than a 25% match in service delivery.

8. The extent to which the applicant provides evidence that it will utilize small and minority businesses, whenever feasible and appropriate, in the purchase of supplies and services funded through this contract.

9. The FISCAL COMPETEVENESS OF THE PROPOSAL. Preference will be given to applicants whose plan provides medical, mental health and oral health services and includes health promotion and prevention activities.

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C. Review Process

A panel of appropriate staff and outside experts will review proposals, which meet the minimum requirements. This panel will make recommendations concerning the selection of a proposal for funding. Recommendations to the Commissioner will be submitted in rank order based on Team Scores for each proposal. The final selection is at the discretion of the DPH Commissioner.

Following the final selection, a Personal Service or Human Services Agreement will be developed between the applicant and the Department that details services to be provided, budget and reporting requirements. No financial obligation by the State can be incurred until a contract is fully executed.

VIII. Regulatory Compliance

The applicant is required to be in compliance with any applicable provisions of the Regulations of Connecticut State Agencies, if a current recipient of funding from DPH and with State Non-discrimination and Affirmative Action laws, rules and regulations. Moreover, in accordance with Section 4a-60 of the Connecticut General Statutes, as amended by Public Act 07-142, Section 9, the awardee shall agree and warrant that in the performance of this award, he/she will not discriminate or permit discrimination against any person or group of persons on the grounds of race, color, religious creed, age, marital status (including civil unions, per Public Act 07-245, Section 2), national origin, ancestry, sex, mental retardation, mental or physical disability, but not limited to, blindness unless it is shown by the awardee that such disability prevents performance of the work involved, in any manner prohibited by the laws of the United States or the State of Connecticut. Also, in accordance with Section 4a-60a of the Connecticut General Statutes, as amended by Public Act 07-142, Section 10, the awardee shall agree and warrant that in performance of this award, he/she will not discriminate or permit discrimination against any person or group of persons on the grounds of sexual orientation, in any manner prohibited by the laws of the United States or the State of Connecticut, and that employees are treated when employed without regard to their sexual orientation. Also, in accordance with Section 46a-81c(1) of the Connecticut General Statutes, as amended by Public Act 07-245, Section 3, the awardee shall agree and warrant that in performance of this award, he/she by him/herself or her/his agent, except in the case of a bona fide occupational qualification or need, will not refuse to hire or employ or bar or discharge from employment any individual or discriminate against such person in compensation or in terms, conditions, or privileges of employment, because of the person's sexual orientation or civil union status. The awardee shall further agree to provide the Commission on Human Rights and Opportunities with such information requested by the Commission concerning the employment practices and procedures of the awardee as they relate to the provisions of Section 4a-60 and Regulations of Connecticut State Agencies, Sections 46a-68J-2 to 46a-68K-8.

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Further, in accordance with the Contract Compliance Regulations of Connecticut State Agencies, the applicant will be required to complete the Notification To Bidders form and the Workforce Analysis Questionnaire as part of the application process (included in Attachment A).

IX. Affirmative Action Notice

DPH strongly supports the concept and implementation of affirmative action to overcome the present effects of past discrimination. DPH urges its bidders, suppliers, contractors and awardees to implement affirmative action plans and programs of their own, and hereby notifies all DPH bidders, suppliers, contractors and awardees that DPH will not knowingly do business with, or make awards to, any individual or organization excluded from participation in any federal or state contract program, or found to be in violation of any state or federal anti-discrimination law.

X. Rights Reserved to the State

The State reserves the right to reject any and all proposals, in whole or in part, to waive technical defects, irregularities and omissions if, in its judgment, the best interest of the State will be served.

[2008RFPTEMPLATE.doc]

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XI. ATTACHMENTS

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ATTACHMENT A Page 1 of 16APPLICATION FORMS

REQUEST FOR PROPOSALRFP # 2008-0913

(School Based Health Center Program-City of Bridgeport)

DEPARTMENT OF PUBLIC HEALTHPUBLIC HEALTH INITIATIVES BRANCH

A. Applicant Information

Applicant Agency: __________________________________________________________________________Legal Name

_________________________________________________________________________________________Address

_________________________________________________________________________________________City/Town State Zip Code

__________________ _________________________ _________________________ Telephone No. FAX No. E-Mail Address

Contact Person: __________________________________ Title: ___________________________

Telephone No: ___________________________

TOTAL PROGRAM COST: $__________________

I certify that to the best of my knowledge and belief, the information contained in this application is true and correct. The application has been duly authorized by the governing body of the applicant, the applicant has the legal authority to apply for this funding, the applicant will comply with applicable state and federal laws and regulations, and that I am a duly authorized signatory for the applicant.

_________________________________________ _________________Signature of Authorizing Official: Date

_____________________________________________________Typed Name and Title

-----------------------------------------------------------------------------------------------------------------------------------------------

The applicant agency is the agency or organization, which is legally and financially responsible and accountable for the use and disposition of any awarded funds. Please provide the following information:

Full legal name of the organization or corporation as it appears on the corporate seal and as registered with theSecretary of State

Mailing address Main telephone number Fax number, if any Principal contact person for the application (person responsible for developing application) Total program cost

The funding application and all required submittals must include the signature of an officer of the applicant agency who has the legal authority to bind the organization. The signature, typed name and position of the authorized official of the applicant agency must be included as well as the date on which the application is signed.

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APPLICATION FORMS Page 2 of 16

B. CONTRACTOR INFORMATION

PLEASE LIST THE AGENCY CONTACT PERSONS RESPONSIBLE FOR COMPLETION AND SUBMITTAL OF:

Contract and Legal Documents/Forms:

Name Title Tel. No.

Street Town Zip Code

Email Fax No.

Program Progress Reports:

Name Title Tel. No.


Email Fax No.

Financial Expenditure Reporting Forms:

Name Title Tel. No.


Email Fax No,

Incorporated: YES NO Agency Fiscal Year:

Type of Agency: Public Private Other, Explain:

Profit Non-Profit

Federal Employer I.D. Number: Town Code No:

Medicaid Provider Status: YES NO Medicaid Number:

Minority Business Enterprise (MBE): YES NO

Women Business Enterprise (MBE): YES NO

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C. Services to be Provided

1. Describe your experience providing the kinds of services described in the “Services to be Provided” section of the RFP.

2. Provide at least two references (with their telephone numbers) that may be contacted to support your description of your experience in providing these services.

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3. Briefly describe the approach to the services you will provide as outlined in the “Services to be Provided” section of the RFP. Use the Workplan form to elaborate (see Section E of this application).

4. Briefly state the hours of operation of your organization and indicate the suitability of these hours to the Services and Deliverables required in this proposal. Include agreements/plans for backup coverage for medical and mental health care when the SBHCs are not in operation.

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A. Instructions Budget Summary 1

I. Personnel (lines #1 - #5) each person funded:

a) Name of person & Title

a) Hourly rate, # hours working per week, and # of weeks. (Calculate)

b) Fringe benefit rate. (Calculate)

Example:

1. Name & Position: John Smith, CoordinatorCalculation: $25.00 hr X 35hrs X 45wks $39,375Fringe Benefit: 26% $10,238

II. Line #11 Contractual (Subcontracts) provide the total of all subcontracts and complete Subcontractor Schedule.

III. Lines #6 - #13 complete categories as appropriate,

IV. Line # 14: Other Expenses are any other types of expense that do not fit into the categories listed.

For example: Equipment (purchasing a computer at a cost of $1,500). Please note that the state’s definition of equipment is tangible personal property with a normal useful life of at least one year and a value of at least $2,500 or more.

V.***Audit Costs, the cost of audits made in accordance with OMB Circular A133 (Federal Single Audit) are allowable charges to Federal awards. The cost of State Single Audits (CGS 4-23 to 4-236) is allowable charges to State awards. Audit costs are allowable to the extent that they represent a pro-rata share of the cost of such audit. Audit costs charged to Department of Public Health contracts must be budgeted, reported and justified as an audit cost line item within the Administrative and General Cost category.

VI. Line Item #15 Administrative and General Costs, these are defined as those costs that have been incurred for the overall executive and administrative offices of the organization or other expenses of a general nature that do not relate solely to any major cost objective of the overall organization. Examples of A&G costs include salaries of executive directors, administrative & financial personnel, accounting, auditing, management information systems, proportional office costs such as building occupancy, telephone, equipment, and office supplies. Please review the OPM website on Cost Standards for more information at: http://www.ct.gov/opm/cwp/view.asp?a=2981&q=382994.

VII. Administrative and General Costs must be itemized on the Budget Justification Schedule. Costs that have a separate line item in the Budget Summary may not be duplicated as an Administrative and General Cost. For example, if the Budget Summary includes an amount for telephone costs, this cannot also be included as an Administrative and General Cost.

VIII. Other Income list any other program income such as in-kind contributions, fees collected, or other funding sources and include brief explanation on Budget Justification.

IX. 2 Year Contracts : 2 sets of budget forms have been provided. Please do a full budget for each year of the contract, clearly indicating the year on each form. Assume level funding for the second year.

Note: If space allowed is not sufficient for large or complex subcontract budgets, the Budget Summary format may be copied and used instead.

20

http://www.ct.gov/opm/cwp/view.asp?a=2981&q=382994

http://www.ct.gov/opm/cwp/view.asp?a=2981&q=382994


B. Budget Justification Schedule B

I. Please provide a brief explanation for each line item listed on the Budget Summary. This must include a detailed breakdown of the components that make up the line item and any calculation used to compute the amount.

***Please note: If Laboratory Services is a line item or subcontractor, please supply a justification as to why a private laboratory is being used as opposed to the Connecticut State Laboratory.

II. For contractors who have subcontracts, a brief description of the purpose of each subcontract must be provided. Use additional sheets as necessary.

Example:Line Item (Description) Amount Justification - Breakdown of CostsTravel $730 1,659 miles @ .44 = $730.00 outreach

workers going to meetings and site visits.

C. Subcontractor Schedule A--Detail

I. All subcontractors used by each program must be included, if it is not known who the subcontractor will be, an estimated amount and whatever budget detail is anticipated should be provided. (Submit the actual detail when it is available). A separate subcontractor schedule must be completed for each program included in the contract. For example: The contract is providing both a Needle Exchange program and an AIDS Prevention Education Program and Subcontractor “A” is providing services to both program there must be a separate budget for Subcontractor “A” for each.

II. Detail of Each Subcontractor:Choose a category below for each subcontract using the basis by which it is paid:

A. Budget Basis B. Fee for Service C. Hourly Rate.

Provide the detail for each subcontract referencing the corresponding program of the contract. Detail must be provided for each subcontractor listed in the Summary.

Example A. Budget BasisOutreach Educator $20/hr x 20hrs/wk x 50wks $20,000Travel 590 miles @ .44 cents/mile 260Supplies 500

Total $20,760Example B. Fee for Service:

Develop and Produce 500 Videos @ $10 each $5,000

Total Example C. Hourly Rate:

Quality Assurance Review of 200 Patient Charts by Nurse Clinician 200 hours @ $25/hour $5,000

Total $5,000

***Please note: If Laboratory Services is a line item or subcontractor, please supply a justification as to why a private laboratory is being used as opposed to the Connecticut State Laboratory.

21


Category Amount

Personnel:1) Name & Position: ,

Calculation: Fringe Benefit: %

2) Name & Position: , Calculation: Fringe Benefit: %



5) Name & Position: , :Calculation: Fringe Benefit: %

6) Travel per mile X miles 7) Training 8) Educational Materials 9) Office Supplies 10) Medical Materials 11) Contractual (Subcontracts)*** 12) Telephone 13) Advertising 14) Other Expenses (List Below)

a) b) c) d) e) f)

15)Administrative and General Costs Total DPH Grant

Other Program Income: *** Complete Subcontractor Schedule A


Budget Justification Schedule B

Line Item (Description)

Amount Justification including Breakdown of Costs


Subcontractor Schedule A-Detail#1

Program:

Subcontractor Name: Address: Telephone: ( ) ( - )Select One: A Budget Basis B Fee-for-Service C Hourly RateIndicate One: MBE WBE Neither

Line Item Amount

Total Subcontract Amount:

#2Subcontractor Name: Address: Telephone: ( ) ( - )Select One: A Budget Basis B Fee-for-Service C Hourly RateIndicate One: MBE WBE Neither

Line Item Amount


#3Subcontractor Name: Address: Telephone: ( ) ( - )Select One: A Budget Basis B Fee-for-Service C Hourly RateIndicate One: MBE WBE Neither

Line Item Amount



E. Workplan (make as many blank pages as needed)

Services to be Provided Activities Staff Position(s) Responsible

Expected Outcomes and Measures of Success

Timetable


F. Staffing

Profile of Staff Providing Services (see Section E of this RFP). Please provide the information requested below.

Professional Staff* Name Title Hourly Rate

Assigned to Project:# Hrs/wk

Position 1

Position 2

Position 3

Position 4

Clerical/Support Staff:

Position 1

Position 2

*Attach Resumes for all Professional Staff


G. Assurances

Any prospective contractor must agree to adhere to the following conditions and must positively state such in the proposal. Please read, sign, date and return this statement with your proposal.

A. Conformance with Statutes - Any contract awarded as a result of this RFP must be in full conformance with statutory requirements of the State of Connecticut and the Federal Government.

B. Ownership of Proposals - All proposals in response to this RFP are to be the sole property of the State, and subject to the provisions of Sections 1-19 of the Connecticut General Statutes (Re: Freedom of Information).

C. Reports and Information - The contractor shall agree to supply any information required by DPH: including evaluation and billing information in the time, manner and format directed by DPH.

The contractor shall permit access by properly authorized DPH staff to the contractor’s premises, staff and participant and financial records, at any reasonable time.

The right to publish, distribute or disseminate any and all information or reports, or any part thereof, shall accrue to DPH without recourse. The contractor shall maintain written records to substantiate costs incurred under the contract.

D. Timing and Sequence - Timing and sequence of events resulting from this RFP will ultimately be determined by the State.

E. Stability of Proposed Prices - Any price offerings from applicants must be valid for a period of 120 days from the due date of applicant proposals.

F. Oral Agreements - Any alleged oral agreement or arrangement made by an applicant with any agency or employee will be superseded by the written agreement.

G. Amending or Canceling Requests - The State reserves the right to amend or cancel this RFP at its discretion, prior to the due date and time, and/or at any point to the issuance of the written agreement, if it is in the best interests of the agency and the State.

H. Rejection for Default or Misrepresentation - The State reserves the right to reject the proposal of any applicant which is in default of any prior contract or for misrepresentation.


I. State’s Clerical Errors in Awards - The State reserves the right to correct inaccurate awards resulting from its clerical errors.

J. Rejection of Proposals - Proposals are subject to rejection in whole or in part if they limit or modify any of the terms and conditions and/or specifications of the RFP.

K. Applicant Presentation of Supporting Evidence - An applicant, if requested, must be prepared to present evidence of experience, ability, service facilities, and financial standing necessary to satisfactorily meet the requirements set forth or implied in the RFP.

L. Changes to Proposals - No additions or changes to the original proposal will be allowed after submittal, unless specifically requested by DPH.

M. Collusion - By responding, the applicant implicitly states that the proposal is not made in connection with any competing applicant submitting a separate response to the RFP, and is in all respects fair and without collusion or fraud. It is further implied that the applicant did not participate in the RFP development process, had no knowledge of the specific contents of the RFP prior to its issuance, and that no employee of the agency participated directly or indirectly in the applicant’s proposal preparation.

N. Subcontracting - In a multi-contractor situation, DPH requires a single point of responsibility and accountability.

The undersigned acknowledges receiving and reading the aforementioned assurances and agrees to these terms and conditions as set forth by the Department of Public Health.

____________________________________________ ________________________________Signature Date

On behalf of:

____________________________________________________________________________


NOTIFICATION TO BIDDERS

The contract to be awarded is subject to contract compliance requirements mandated by Sections 4a-60 and 4a-60a of the Connecticut General Statutes; and, when the awarding agency is the State, Sections 46a-71 (d) and 46a-81i (d) of the Connecticut General Statutes. There are Contract Compliance Regulations codified at Section 46a-68j-21 through 46a-68j-43 of the Regulations of Connecticut State agencies, which establish a procedure for the awarding of all contracts covered by Sections 4a-60 and 46a-71 (d) of the Connecticut General Statutes.

According to Section 46a-68j-30 (9) of the Contract Compliance Regulations, every agency awarding a contract subject to the contract compliance requirements has an obligation to “aggressively solicit the participation of legitimate minority business enterprises as bidders, contractors, subcontractors and suppliers of materials.” “Minority Business Enterprise” is defined in Section 4a-60 of the Connecticut General Statutes as a business wherein fifty-one percent or more of the capital stock, or assets belong to a person or persons: “(1) Who are active in the daily affairs of the enterprise; (2) Who have the power to direct the management and policies of the enterprise; and, (3) Who are members of a minority, as such term is defined in subsection (a) of Section 32-9n.” “Minority” groups are defined in Section 32-9n of the Connecticut General Statutes as “(1) Black Americans ... (2) Hispanic Americans ... (3) Women ... (4) Asian Pacific Americans and Pacific Islanders; or (5) American Indians.” The above definitions apply to the contract compliance requirements by virtue of Section 46a-68j-21 (11) of the Contract Compliance Regulations.

The awarding agency will consider the following factors when reviewing the bidder’s qualifications under the contract compliance requirements.

a) the bidder’s success in implementing an affirmative action plan;

b) the bidder’s success in developing an apprenticeship program complying with Sections 46a-68-1 to 46a-68-18 of the Connecticut General Statutes, inclusive;

c) the bidder’s promise to develop and implement a successful affirmative action plan;

d) the bidder’s submission of EEO-1 data indicating the composition of its workforce is at or near parity when compared to the racial and sexual composition of the workforce in the relevant labor market area; and,

e) the bidder’s promise to set aside a portion of the contract for legitimate minority business enterprises. See Section 46a-68j-30 (10) (E) of the Contract Compliance Regulations.

INSTRUCTION: Bidder must sign acknowledgment below line and return acknowledgment to Awarding Agency along with the bid proposal.

The undersigned acknowledges receiving and reading a copy of the “Notification to Bidders” form.

_______________________________________ ___________________________ Signature Date

On behalf of:________________________________________________________________________________

APPLICATION FORMS Page 16 of 16WORKFORCE ANALYSIS

Contractor Name: Total Number of CT employees:Address: Full Time: Part Time:

Complete the following Workforce Analysis for employees on Connecticut worksites who are:Job Categories

Overall Totals(sum of all cols. male & female)

White(not of Hispanic Origin)

Black(not of Hispanic Origin)

Hispanic Asian or Pacific Islander

American Indian or Alaskan Native

People withDisabilities

Male Female Male Female Male Female Male Female Male Female Male Female

Officials &Managers

Professionals

TechniciansOffice &ClericalCraft Workers(skilled)Operatives(semi-skilled)Laborers(unskilled)

Service Workers

Totals Above

Totals 1 year AgoFORMAL ON-THE-JOB TRAINEES (Enter figures for the same categories as are shown above)

Apprentices

Trainees

EMPLOYMENT FIGURES WERE OBTAINED FROM: Visual Check:Employment Records Other:

1. Have you successfully implemented an Affirmative Action Plan? YES NO Date of implementation:__________________If the answer is “No”, explain.

1. a) Do you promise to develop and implement a successful Affirmative Action? YES NO Not Applicable Explanation:

2. Have you successfully developed an apprenticeship program complying with Sec. 46a-68-1 to 46a-68-18 of the Connecticut Department of Labor Regulations, inclusive: YES NO Not Applicable Explanation:

3. According to EEO-1 data, is the composition of your work force at or near parity when compared with the racial and sexual composition of the work force in the relevant labor market area? YES NO Explanation:

4. If you plan to subcontract, will you set aside a portion of the contract for legitimate minority business enterprises? YES NO Explanation:

_______________________________________ ________________________Contractor’s Authorized Signature Date

Appendix B - Non -Discrimination Provisions for State of Connecticut Contracts*

*Note: Appendix B is provided for your information only. The forms in this Appendix do not need to becompleted for the RFP. These will be used for applicants awarded funding and requested during thecontract development process.

The Office of the Attorney General has approved the following nondiscrimination certification forms to assist executive branch agencies in complying with the State of Connecticut's contracting requirements, pursuant to the Connecticut General Statutes § 4a-60(a)(1) and § 4a-60a(a)(1), as amended by Public Act 07-245 and Sections 9 and 10 of Public Act 07-142.

By law, a contractor must provide the State with documentation in the form of a company or corporate policy adopted by resolution of the board of directors, shareholders, managers, members or other governing body of such contractor to support the nondiscrimination agreement and warranty under C.G.S. §§ 4a-60a and 46a-68h.

The first of these forms is designed to be used by corporate or other business entities; the second is to be used only by individuals who are to sign and perform contracts with the State in their individual capacity. One or the other of these certifications is required for all State contracts, regardless of type, term, cost, or value.Pursuant to C.G.S. § 46a-56(b), State agencies may apply to the Commission on Human Rights and Opportunities (CHRO) for a waiver from this requirement when entering into contracts with the entities listed below:

municipalities or other political subdivisions of the State; quasi-public State agencies; other state governments (including the District of Columbia); the federal government; U.S. territories and possessions; federally recognized Indian tribal governments; and foreign governments.

The appropriate certification must be signed by an authorized signatory of the contractor (or, in the case of an individual contractor, by the individual) and submitted to the awarding State agency at the time of contract execution.The appropriate form is required for all contracts signed on and after June 25, 2007.

Non-discrimination Regarding Sexual Orientation. Unless otherwise provided by Conn. Gen. Stat. § 46a-81p, the Contractor agrees to the following provisions required pursuant to § 4a-60a of the Connecticut General Statutes:

(a)(1) The Contractor agrees and warrants that in the performance of the Contract such Contractor will not discriminate or permit discrimination against any person or group of persons on the grounds of sexual orientation, in any manner prohibited by the laws of the United States or of the State of Connecticut, and that employees are treated when employed without regard to their sexual orientation;

(2) the Contractor agrees to provide each labor union or representatives of workers with which such Contractor has a collective bargaining agreement or other Contract or understanding and each vendor with which such Contractor has a Contract or understanding a notice to be provided by the commission on human rights and opportunities advising the labor union or workers’ representative of the Contractor's commitments under this section, and to post copies of the notice in conspicuous places available to employees and applicants for employment;

(3) the Contractor agrees to comply with each provision of this section and with each regulation or relevant order issued by said commission pursuant to § 46a-56 of the Connecticut General Statutes;

(4) the Contractor agrees to provide the commission on human rights and opportunities with such information requested by the commission, and permit access to pertinent books, records and accounts concerning the employment practices and procedures of the Contractor which relate to provisions of this section and § 46a-56 of the Connecticut General Statutes.

(b) The Contractor shall include the provisions of subsection (a) of this section in every subcontract or purchase order entered into in order to fulfill any obligation of a Contract with the state and such provisions shall be binding on a subcontractor, vendor or manufacturer unless exempted by regulations or orders of the commission. The Contractor shall take such action with respect to any such subcontract or purchase order as the commission may direct as a means of enforcing such provisions including sanctions for noncompliance in accordance with § 46a-56 of the Connecticut General Statutes provided, if such Contractor becomes involved in, or is threatened with, litigation with a subcontractor or vendor as a result of such direction by the commission, the Contractor may request the State of Connecticut to enter into any such litigation or negotiation prior thereto to protect the interests of the state and the state may so enter.

Nondiscrimination and Affirmative Action Provisions in Contracts of the State and Political Subdivisions Other Than Municipalities. The Contractor agrees to comply with provisions of § 4a-60 of the Connecticut General Statutes:

(a) Every Contract to which the state or any political subdivision of the state other that a municipality is a party shall contain the following provisions:

(1) The Contractor agrees and warrants that in the performance of the Contract such Contractor will not discriminate or permit discrimination against any person or group of persons on the grounds of race, color, religious creed, age, marital status, national origin, ancestry, sex, mental retardation or physical disability, including, but not limited to, blindness, unless it is shown by such Contractor that such disability prevents performance of the work involved, in any manner prohibited by the laws of the United States or of the state of Connecticut. The Contractor further agrees to take affirmative action to insure that applicants with job-related qualifications are employed and that employees are treated when employed without regard to their race, color, religious creed, age, marital status, national origin, ancestry, sex, mental retardation, or physical disability, including, but not limited to, blindness, unless it is shown by such Contractor that such disability prevents performance of the work involved;

(2) the Contractor agrees, in all solicitations or advertisements for employees placed by or on behalf of the Contractor, to state that is an “affirmative action-equal opportunity employer” in accordance with regulations adopted by the commission;

(3) the Contractor agrees to provide each labor union or representative of workers with which such Contractor has a collective bargaining agreement or other Contract or understanding and each vendor with which such Contractor has a Contract or understanding, a notice to be provided by the commission advising the labor union or workers’ representative of the Contractor’s commitments under this section, and to post copies of the notice in conspicuous places available to employees and applicants for employment;

(4) the Contractor agrees to comply with each provision of this section and Conn. Gen. Stat. §§ 46a-68e and 46a-68f and with each regulation or relevant order issued by said commission pursuant to Conn. Gen. Stat. §§ 46a-56, 46a-68e and 46a-68f;

(5) the Contractor agrees to provide the commission of human rights and opportunities with such information requested by the commission, and permit access to pertinent books, records and accounts, concerning the employment practices and procedures of the Contractor as relate to the provisions of this section and Conn. Gen. Stat. § 46a-56. If the Contract is a public works Contract, the Contractor agrees and warrants that he will make good faith efforts to employ minority business enterprises as subcontractors and suppliers of materials on such public works project.

(b) For the purposes of this section, “minority business enterprise” means any small Contractor or supplier of materials fifty-one per cent or more of capital stock, if any, or assets of which is owned by a person or persons:

(1) who are active in the daily affairs of the enterprise;

(2) who have the power to direct the management and policies of the enterprise; and

(3) who are members of a minority, as such term is defined in subsection (a) of Conn. Gen. Stat. § 49-60g.

(c) For the purposes of this section, “good faith” means that degree of diligence, which a reasonable person would exercise in the performance of legal duties and obligations. “Good faith efforts” shall include, but not be limited to, those reasonable initial efforts necessary to comply with statutory or regulatory requirements and additional or substituted efforts when it is determined that such initial efforts will not be sufficient to comply with such requirements. Determinations of the Contractor’s good faith efforts shall include but shall not be limited to the following factors: The Contractor’s employment and subcontracting policies, patterns and practices; affirmative action advertising; recruitment and training; technical assistance activities and such other reasonable activities or efforts as the commission may prescribe that are designed to ensure the participation of minority business enterprises in public works projects.

(d) The Contractor shall develop and maintain adequate documentation, in a manner prescribed by the commission, of its good faith efforts.

(e) Contractor shall include the provisions of subsection (a) of this section in every subcontract or purchase order entered into in order to fulfill any obligation of a Contract with the state and such provision shall be binding on a subcontractor, vendor or manufacturer unless exempted by regulations or orders of the commission. The Contractor shall take such action with respect to any such subcontract or purchase order as the commission may direct as a means of enforcing such provisions including sanctions for noncompliance in accordance with Conn. Gen. Stat. § 46a-56; provided, if such Contractor becomes involved in, or is threatened with, litigation with a subcontractor or vendor as a result of such direction by the commission, the Contractor may request the state of Connecticut to enter into such litigation or negotiation prior thereto to protect the interests of the state and the state may so enter.

NONDISCRIMINATION CERTIFICATION

(By corporate or other business entity regarding support of nondiscrimination against persons on account of their race, color, religious creed, age, marital or civil union status, national origin, ancestry, sex, mental retardation, physical disability or sexual orientation.)

I, Non-Discrimination Provisions for State of CT Contrac t signer's name , signer's title , of name of entity , an

entity lawfully organized and existing under the laws of name of state or commonwealth , do hereby certify

that the following is a true and correct copy of a resolution adopted on the day of , 20 by

the governing body of name of entity , in accordance with all of its documents of governance and

management and the laws of name of state or commonwealth , and further certify that such resolution has

not been modified, rescinded or revoked, and is, at present, in full force and effect.

RESOLVED: That name of entity hereby adopts as its policy to support the nondiscrimination

agreements and warranties required under Connecticut General Statutes § 4a-60(a)(1) and § 4a-

60a(a)(1), as amended in State of Connecticut Public Act 07-245 and sections 9(a)(1) and 10(a)(1)

of Public Act 07-142.

WHEREFORE, the undersigned has executed this certificate this day of , 20 .

__________________________________Signature

Effective June 25, 2007

NONDISCRIMINATION CERTIFICATION

(By individual contractor regarding support of nondiscrimination against persons on account of their race, color, religious creed, age, marital or civil union status, national origin, ancestry, sex, mental retardation, physical disability or sexual orientation.)

I, signer's name , of business address , am entering into a contract (or an extension or other modification of

an existing contract) with the State of Connecticut (the “State”) in my individual capacity for if available,

insert “Contract No. ___”; otherwise generally describe goods or services to be provided . I hereby certify

that I support the nondiscrimination agreements and warranties required under Connecticut General

Statutes Sections 4a-60(a)(1) and 4a-60a(a)(1), as amended in State of Connecticut Public Act 07-245 and

sections 9(a)(1) and 10(a)(1) of Public Act 07-142.

WHEREFORE, I, the undersigned, have executed this certificate this day of , 20 .

___________________________________Signature

Effective June 25, 2007

ATTACHMENT C PRELIMINARY REVIEW TEAM TECHNICAL CRITERIA WORKSHEET

_______________________________________Applicant

Criteria: Maximum Points Bidder’s Points

1. The extent to which applicant has demonstrated successful (10) ( ) experience providing similar services. Preference will be given to applicants who have experience providing primary care, mental health services and oral health in a SBHC setting.

2. The extent to which references support the applicant’s success (5) ( ) providing similar services.

3. The extent to which services to be provided are described ( 10 ) ( ) clearly and cover all requirements outlined in the RFP. .4. The extent to which adequate time is allocated to manage and ( 15 ) ( ) coordinate the services to be provided.

5. The extent to which the profile of staff who will be working on this ( 10 ) ( ) project is clear and adequate to manage the services to be provided.

6. The extent to which a thorough workplan is presented with ( 10 ) ( ) measurable (SMART) objectives, appropriate timelines and measurable outcomes.

7. The extent to which a cost effective budget is presented which ( 15 ) ( ) follows eligibility guidelines. Preference will be given to applicants who demonstrate commitment to this project and offer more than minimum 25% match for service delivery.

8. The extent to which contractor provides evidence that it will utilize ( 5 ) ( ) small and minority businesses, whenever feasible and appropriate, in the purchase of supplies and services funded through this contract.

9. The fiscal competitiveness of the proposal. ( 20 ) ( ) Preference will be given to applicants whose plan provides medical, mental health and oral health services and includes health promotion and prevention activities.

TOTAL ( 100 ) ( )

ATTACHMENT D MINIMUM REQUIREMENTS CHECKLIST *

_______________________________________Applicant

1. Resumes provided for all professional staff assigned to this project. __________

2. Completed Notification to Bidders form included in proposal. __________

3. Completed Workforce Analysis Questionnaire included in proposal. __________

4. Signed Statement of Adherence to Assurances included in proposal. __________

5. An original and 5 copies of the completed proposal must be received at DPH no later than October 24, 2008. __________

6. Proposal is completed on Application Forms included in Attachment A. __________

7. The proposal is signed by an authorized official of the ApplicantOrganization. __________

[Rev. 7/2008; 2008RFPTEMPLATE]

ATTACHMENT E:

City of Bridgeport School Based Health Centers 2006-2007

Table 1

School Name Hours of Operation

Services Offered

CurrentDPH Funded

Positions

PreviousCity Funded

Positions

# Unique Visits

Total Visits &

Collateral Contacts

Central High School* 8:00 am – 3:30 pm

Medical & Mental Health Services

1 FTE Social Worker1 FTE Subst. Abuse Spec.1 FTE Medical Asst.

1 FTE Nurse Practitioner

Clinic-2609 5508

Bassick High School 7:30 am – 3:00 pm

Medical & Mental Health ServicesOral Health Services

1FTE ORW 1 FTE Nurse Practitioner1FTE Social Worker1 FTE Medial Asst.

Clinic-3001 5074

Harding High School* 8:00 am – 3:30 pm


1 FTE Social Worker1 FTE Medical Asst.


Clinic-2609 3177

Blackham Elementary School

7:45 am –3:15 pm


1 FTE Social Worker1 FTE ORW1 FTE Medical Asst.


Clinic-2365 4993

JFK Campus Elementary School

8:00 am – 3:30 pm


1 FTE Social Worker

1 FTE Nurse Practitioner1 FTE Medial Asst.

Clinic-1115 2148

Dunbar Elementary School*

8:30 am – 3:00 pm


1 FTE ORW *contracted services with local CHC

Clinic-841 1750

Columbus Elementary School

8:00 am – 3:30 pm


1 FTE Medical Asst.

1 FTE Nurse Practitioner1 FTE Social Worker1 FTE Outreach Worker

Clinic-1097 2925

Roosevelt Elementary School

8:00 am – 3:30 pm


1 FTE Social Worker.5 FTE ORW

1 FTE Nurse Practitioner1 FTE Medial Asst.

Clinic-2929 5538


Table 1


Services Offered

CurrentDPH Funded

Positions

PreviousCity Funded

Positions

# Visits Total Visits &

Collateral Contacts

Luis Munoz Marin 8:00 am – 3:30 pm


None 1 FTE Nurse Practitioner1FTE Social Worker1 FTE Medial Asst.1FTE ORW

_________ 2,196(*Information

provided by the City for 2007-2008

school year)

Read Elementary School 8:00 am – 3:30 pm


1 FTE N.P.1 FTE Medical Asst.1 FTE ORW

1 FTE Social Worker

Clinic-1102 4029

Program Administration 1 FTE Sup. PA’s and ORW1 FTE Dental Asst..8 FTE Finance Mgr

Summer hours have varied due to construction/renovation needs of the particular school.Collateral Contacts refer to referrals, translations, calls/contact on a student’s behalf,etc.* Represents schools without on site dental health servicesORW-refers to Outreach Worker


Table 2


Users Clinic (unique)

VisitsMedicaid

InsurancePrivate None

Central High School 8:00 am – 3:30 pm

768 2609 29.3% 27.5% 43.2%

Bassick High School

7:30 am – 3:00 pm

570 3001 52.6% 15.7% 31.7%

Harding High School

8:00 am – 3:30 pm

358 1774 44.7% 10.1% 45.3%

Blackham Elementary School

7:45 am –3:15 pm

522 2365 45.4% 23.2% 31.4%

JFK Campus Elementary School

8:00 am – 3:30 pm

324 1115 32.7% 51.5% 15.7%

Dunbar Elementary School

8:00 am – 3:30 pm

169 841 59.2% 13.0% 27.8%

Columbus Elementary School

8:00 am – 3:30 pm

426 1097 50.0% 8.9% 41.1%

Roosevelt Elementary School

8:00 am – 3:30 pm

512 2929 72.7% 9.0% 18.4%

Read Elementary School

8:00 am – 3:30 pm

458 1102 45.2% 24.0% 30.8%

Luis Munoz Marin School

8:00 am – 3:30 pm

*452(Information

provided by the City for the 2007-2008

school year

*2,196(Information

provided by the City for the 2007-2008

school year)

________ ________ ________

Users having at least one visit record; n= 4105

School Based Health Center

Staffing Guidelines

A. A center coordinator/manager with training and experience in health/mental health systems management, supervision and administration.

B. At least one masters-prepared advanced practice registered nurse (APRN) with experience serving the target population (including age and ethnicity), with appropriate clinical consultation and back-up or a certified physician assistant (PA) with appropriate physician supervision.

C. At least one clinically trained masters level social worker (MSW), licensed clinical social worker (LCSW) preferred, or Licensed Professional Counselor (LPC) with expertise in working with the target population (including age and ethnicity) with LCSW supervision/consultation and back up. A Marriage and Family Therapist (MFT) may be considered with clearly demonstrated expertise in working with the target population, with LMFT clinical supervision/ consultation and back up.

D. A Medical Director who must be a licensed physician with experience serving the target population and working with mid-level practitioners.

E. Support staff as needed, (i.e., clerical, receptionist, data entry professionals, etc.)

F. Additional health and/or allied health professionals as needed (i.e. nutritionist, substance prevention specialist, health educator, outreach worker, parent aid, medical assistant, psychologist, etc.)

G. If oral health/dental services are to be provided (optional), a licensed Dental Director and additional licensed dental providers, as needed.

V. MINIMUM PRIMARY CARE SERVICES TO BE PROVIDED: (UTILIZATION OF CENTER SERVICES REQUIRES WRITTEN PARENTAL PERMISSION).

A. Physical Health/Medical Services: Services must be provided in accordance with nationally recognized and accepted standards such as the American Academy of Pediatrics, “Guidelines for Health Supervision” or the Maternal Child and Health Bureau, (Health Resources & Services Administration (HRSA) and Health Care Financing Administration (HCFA)) “Bright Futures, Guidelines for Health Supervision of Infants, Children and Adolescents”. Other nationally recognized and accepted standards may be utilized as a framework for professional practice with prior Department approval.

1. Primary health care including:

a. Physical exams/health assessments/screenings for health problems.

b. Diagnosis and treatment of acute illness and injury

c. Diagnosis and management of chronic illness

d. Immunizations

e. Health promotion and risk reduction

f. Nutrition and weight management

g. Reproductive health care

h. Laboratory tests

i. Prescription and/or dispensing of medication for treatment

2. Referral and follow-up for specialty care that is beyond the scope of services provided in the SBHC.

B. Mental Health/Social Services: Services must be provided in accordance with nationally recognized and accepted standards such as the Child Welfare League of America or the National Association of Social Workers, Inc. Other nationally recognized and accepted standards may be utilized as a framework for professional practice with prior Department approval.

1. Services:

a) Assessment, diagnosis and treatment of psychological, social and emotional problems

b) Crisis intervention

c) Individual, family and group counseling or referral for same if indicated

d) Substance abuse and HIV/AIDS prevention

e) Risk reduction and early intervention services

f) Outreach to students at risk

g) Support and/or psycho-educational groups focusing on topics of importance to the target population

h) Advocacy and referral for such services as day care, housing, employment, job training, etc.

i) Consultation to school staff and parents regarding issues of child and adolescent growth and development

2) Referral and follow-up for care that is beyond the scope of services provided in the SBHC

C. Health Education Services: Services should be supportive of existing (Local Education Agency) health education activities:

1. Consultation to school staff regarding issues of child and adolescent growth and development

2. School staff and parent training regarding issues of importance in target population

3. Individual and group health education

4. Classroom presentations

D. Oral Health Services:

1. Preventive services may include:

a. Screenings

b. Dental prophylaxis

c. Fissure sealants

d. Fluoride application

e. Sealant placement

f. Education

2. Referral and follow-up for care that is beyond the scope of services provided in the SBHC

.

PROPERTY ACCESS AGREEMENT (DRAFT)

THIS AGREEMENT made as of XXXXXXXX XX, 2008 by and between the City of Bridgeport and the Board of Education, 45 Lyon Terrace, Bridgeport, Connecticut (“City” or “Licensor”) and ___________________________, a _______________ organized under the laws of the State of ________________, having a principal place of business at _____________________________ (“Licensee”; the term Licensee shall also include representatives, agents, employees, contractors, occupants and tenants, as applicable).

WHEREAS, the Licensor has agreed to permit the Licensee to enter upon and perform certain services at those certain City owned school properties identified in Exhibit A, attached hereto and made a part hereof (collectively the “Premises”) in order to provide to Bridgeport youths and communities with Community Healthcare Services under contract with the State of Connecticut, Department of Public Health; and

WHEREAS, the City has fee title ownership of the Premises, but the Board of Educations has the care, custody and control over the Premises for as long as they are utilized for educational purposes; and

WHEREAS, the Licensee has proceeded to submit a proposal dated _______________(“Proposal”) to a State of Connecticut issued Request for Proposals dated _____________ (“RFP”), the Licensee has completed the selection process and has been chosen as the appropriate respondent to perform the services contemplated therein and herein to provide Community Health Services at the Premises, and

WHEREAS the Licensee agrees to enter upon the Premises and perform those Community Health Services in such manner and in such scope as are set forth in the RFP and Proposal, which are attached hereto and made a part hereof as Exhibits A and B (“Scope of Activity”), respectively at its sole expense and liability, subject to the terms and conditions set forth herein;

NOW, THEREFORE, the Licensor and the Licensee mutually agree as follows:

1. Right of Entry. The Licensor hereby grants to the Licensee, its representatives, agents, consultants and contractors a license to enter upon the Premises at the Licensee’s sole risk and liability for the purposes set forth herein at the hours and times set forth in Exhibit C, attached hereto and made a part hereof.

2. Term of Access. The Premises will be available for the Scope of Activities for the days and times set forth in Exhibit C for a period of two years, commencing March 1, 2009.

3. Scope of Activity. The Licensee may enter upon the Premises for the purposes of performing the Scope of Activity. At all times of Licensee’s entry on the Premises pursuant to this agreement, it shall comply with all laws, regulations, ordinances, and Board of Education policies related to its entry upon and activities at the Premises.

4. Indemnification and Insurance. A. Indemnification. The Licensee agrees to defend, indemnify and hold harmless the City, its elected officials, officers, department heads, employees and agents from and against any and all claims, liabilities, obligations, causes of action of whatsoever kind and nature for damages, including but not limited to damage to the Premises or other property, and costs of every kind and description arising from its entry upon the Premises, or

arising from work or other activities conducted thereon, alleging but not limited to bodily injury, personal injury, property damage caused by the Licensee, except that the Licensee shall not be responsible or obligated for claims arising out of a.) the sole proximate cause of the City, its elected officials, officers, department heads, employees or agents, or its predecessors in interest in the Premises, or b.) the prior existence of environmentally contaminated conditions of the Premises.

B. Insurance requirements: The following insurance coverage is required to be produced to the City and maintained by the Licensee at its own expense. It is further understood that the Licensee shall require similar coverage, as appropriate, from every contractor and subcontractor in any tier, as the case may be, or any other person by reason of the license conferred by this agreement that may enter onto or occupy the Premises on behalf of the Licensee. All non-standard endorsements and provisions shall be disclosed in advance in writing to the City. The Licensee shall procure at a minimum, present to the City, and maintain in effect for the duration of this agreement without interruption and for one year after the Licensee’s last activity at the Premises, the insurance coverage identified below, with deductibles approved in advance by the City, from insurers licensed to conduct business in the State of Connecticut and having a Moody’s or Best’s financial rating of A + 15, or coverage otherwise acceptable to the City. The Licensee will not enter upon the Premises or commence any work or other activity until the required insurance is purchased, submitted to and approved by the City.

Comprehensive General Liability (occurrence form) naming the City as an additional insured and insuring against claims or suits brought by members of the public alleging bodily injury or personal injury or property damage and claimed to have arisen out of operations conducted under this agreement. Coverage shall be broad enough to include blanket contractual liability, premises and operations, contingent liability, contractual liability, broad form property damage and personal injury, political risk, care, custody and control, with limitations of $1,000,000 for each occurrence/aggregate with a combined single limit for bodily injury, personal injury and property damage. Exclusions for independent contractors, employees, and care, custody and control will be removed. The Licensee or its agent shall inform the City in advance of any unusual endorsements or policy provisions that may be part of the insurance contract(s).

Comprehensive Automobile Liability insuring against claims or suits brought by members of the public alleging bodily injury, personal injury or property damage, and uninsured motorist and claimed to have arisen out of the use of owned, hired or non-owned vehicles in connection with business naming the City as an additional insured. This policy will include endorsements providing coverage for mobile equipment and employer equipment not owned and hired. Coverage will be broad enough to include contractual liability, with limitations of $1,000,000 for each occurrence/aggregate with a combined single limit for bodily injury, personal injury and property damage.

Workers’ Compensation insuring in accordance with statutory requirements, including voluntary compensation, broad form all states endorsement, employer’s liability insurance and occupational disease insurance in order to meet obligations towards employees in the event of injury or death sustained directly or indirectly in the course of employment. Liability for employee suits shall not be less than $500,000 per claim.

Owner’s Protective Liability to the extent the work under the contract is sublet to others, the Licensee will purchase and maintain such insurance naming the Licensor as additional insured.

Property Damage insuring against direct damage loss to buildings, structures or improvements covering the interest of the City, the Licensee, its contractors and subcontractors and parties having an interest therein. The City shall be named as loss payee as its interests may appear.

General requirements. All policies shall include the following provisions:

Cancellation notice—The City shall be entitled to receive from the insurance carriers not less than 30 days’ written notice of cancellation or non-renewal to be given to the City at: Purchasing Agent, City of Bridgeport, City Hall, 45 Lyon Terrace, Bridgeport, Connecticut 06604.

Certificates of Insurance—All policies will be evidenced by an original certificate of insurance on an ACORD-25S form authorized by and executed with the original signature or original stamp of the insurer or a properly-authorized agent or representative reflecting all coverage required and delivered to the City prior to any work or other activity commencing under this agreement.

Additional insured—The Licensee shall ensure that the Licensee and its contractors and subcontractors will arrange with their respective insurance agents or brokers to name the City, its elected officials, officers, department heads, employees and agents on all policies of primary and excess insurance coverage as additional insured parties except for any errors and omissions insurance coverage or workers’ compensation coverage, and shall name the City as loss payee with respect to any damage to property of the City, as its interests may appear. The undersigned shall submit to the City upon commencement of this agreement and periodically thereafter, but in no event less than once during each year of this agreement, evidence of the existence of such insurance coverage in the form of original Certificates of Insurance issued by reputable insurance companies licensed to do business in the State of Connecticut and having Best’s or Moody’s A + 15 financial ratings, or coverage otherwise acceptable to the City. Such certificates shall designate the City in the following form and manner:

The City of Bridgeport and its Board of Education, their elected officials, officers, department heads, employees, agents, servants, successors and assigns ATIMAAttention: Purchasing Agent45 Lyon TerraceBridgeport, Connecticut 06604

The coverage afforded to the City shall be primary insurance. If the City has other insurance that is applicable to the loss, such other insurance shall be on an excess or contingent basis. The amount of the contractor’s liability under any insurance shall not be reduced by the existence of such other insurance. The coverage afforded to the additional insured shall not apply to the sole negligence of the additional insured.

The cost of all deductibles on any policy of insurance to be purchased by the Licensee will be borne by the Licensee.

All policies, endorsements, certificates and other evidence of insurance shall be subject to the review and satisfaction of the City.

5. Remedies For Default. If, after the Licensee has entered the Premises pursuant to the license granted by this agreement, the Licensee fails for any reason to restore the Premises to the general condition it was in prior to Licensee’s entry immediately but in any event no later than thirty (30) days after written notice from the Licensor, the Licensee shall be liable for all costs and expenses, including attorneys’ fees, incurred by the Licensor in restoring the Premises.

6. Condition of Premises. The Licensee shall not direct any deterioration or waste to be committed at the Premises. The Licensee shall return the Premises to at least the same general condition in which the Premises was found when the Licensee commenced its entry pursuant to this agreement. If Licensee shall not remove itself from the Premises in accordance with this agreement, title to all installations and improvements, if any, made by the Licensee to the Premises, upon installation thereof, shall become the sole property of the Licensor unless otherwise stated herein. The Licensee shall not permit any mechanic’s lien, charge, or encumbrance to be placed upon the Premises in connection with, or during its entry of the Premises under this agreement.

7. Resolution of Disputes and Choice of Law. The parties agree that all disputes between them arising under this agreement or involving its interpretation, if they cannot be first resolved by mutual agreement, are subject to the following dispute resolution procedure:

(a) Initiation of Dispute Resolution Process. In the event that a dispute is not resolved after good faith effort to arrive at a mutual agreement, either party may send written notice to the other, in the manner specified for giving notice in this agreement, that a dispute continues to exist. The party giving such notice shall also forward a copy to the Director, [name of Department] (“Director”), In care of the [name of Department], [address], Bridgeport, Connecticut 06604. The notice shall set forth the nature of the dispute, the notifying party’s position statement, and copies of documents supporting its position regarding the dispute. Within seven (7) calendar days after the date such notice is given, the other party shall file its position statement and supporting documents to the Director. Within five (5) working days after receipt of such reply, the Director shall review the matter, issue a written determination (“Determination”), and mail a copy thereof to the parties. The Director may reach a Determination with or without a face-to-face meeting with the parties and with or without testimony of witnesses, in his/her sole and absolute discretion.

(b) Mediation. If either party objects to the Determination, such party shall commence non-binding mediation before the American Arbitration Association (“AAA”), or similar mediation organization selected by the City in the City’s sole discretion within thirty (30) days after the date of the Determination. The City shall determine whether such mediation will be conducted in accordance with AAA mediation rules then in effect or another entity’s mediation rules. Such mediation will be held in Bridgeport, Connecticut. Each party shall bear the cost of its respective counsel and one-half of the administrative costs of such mediation, including but not limited to the mediator’s fees and expenses. Failure by either party to file for mediation within such 30-day

period shall be deemed a waiver by both parties of their respective right to appeal such Determination, in which event such Determination shall be final and enforceable in any court having jurisdiction over the parties.

(c) Arbitration, or Litigation at City’s Option. If mediation does not resolve the dispute, either party may submit such dispute to the AAA, or similar alternate dispute resolution entity selected by the City in the City’s sole discretion. The City shall determine whether such arbitration will be conducted pursuant to the AAA construction rules of arbitration then in effect or by the rules of another entity. Notwithstanding the parties’ respective rights to seek arbitration of the dispute, the City shall have the independent right, exercisable within sixty (60) days after any arbitration is commenced, in its sole and absolute discretion, to seek resolution of the dispute in a court of law having jurisdiction over the parties, in which event, resolution of the dispute by arbitration shall be deemed waived by the parties, any pending arbitration shall be deemed stayed, and the decision of the court having jurisdiction over the parties to which the dispute is submitted by the City shall be final and binding upon the parties. If the City either (a) initiates arbitration or (b) does not move to stay an arbitration initiated by the other party within such 60-day period, the dispute shall be resolved by arbitration.

(d) Arbitration Process. Arbitration shall be held before a 3-member panel of arbitrators, unless the parties mutually agree to a single arbitrator, all of whom shall be residents of, or permanently employed in, the State of Connecticut. All arbitrators must have a minimum of ten (10) years’ current experience in their profession or occupation, a minimum of ten (10) years’ of relevant demonstrated experience, and a level of dispute resolution training commensurate with the nature and value of the dispute. The dispute resolution organization shall submit one or more lists containing a minimum of fifteen (15) potential panelists who are duly-qualified. If the parties cannot agree to a panel after three (3) lists have been provided, the selection of arbitrators shall be submitted to the chief administrative judge of the State Superior Court located in Bridgeport, Connecticut for resolution. The arbitration shall be held in the City of Bridgeport and any award rendered shall be final and binding upon the parties and enforceable in a court of competent jurisdiction. Upon the request of either party, the dispute may be determined by any expedited procedure of the AAA then in effect or expedited procedure of another alternate dispute resolution entity then in effect, if the nature and amount of such dispute warrants resolution by an expedited procedure under the AAA’s or such entity’s rules. The parties shall be entitled to full and fair discovery of documents and information necessary for the defense or prosecution of their respective claims, provided that such discovery is not unduly burdensome, unduly costly, prejudicial or violative of a party’s right to withhold confidential information such as attorney/client privileged communications and work product. In the conduct of the proceedings, the parties may vary the selected rules of administration by mutual agreement, but will give due consideration of the panel’s suggestions of varying the procedure in the interests of expedited resolution of the dispute. The parties shall specify the manner and breakdown of the panel’s award. The panel shall have authority, in its sole discretion, to award reasonable attorneys’ fees and costs to the prevailing party. If the award does not contain an award of attorneys’ fees and/or costs, each party shall bear the cost of its respective counsel, and one-half of the administrative costs of such arbitration, including but not limited to the arbitrators’ fees and expenses (except filing fees for demands and counterclaims, which shall be borne by the party initiating such demand or counterclaim). THIS AGREEMENT SHALL BE

DEEMED TO MODIFY THE ARBITRATION RULES OF THE ORGANIZATION SELECTED BY THE CITY, WHOSE RULES SHALL BE DEEMED SUBORDINATE TO THIS AGREEMENT, AND THE ARBITRATION OF THE DISPUTE SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE SUBSTANTIVE LAWS OF THE STATE OF CONNECTICUT. ANY AWARD THAT IS NOT RENDERED IN COMPLIANCE WITH PREVAILING CONNECTICUT LAW AT THE TIME THE AWARD IS RENDERED SHALL BE DEEMED VIOLATIVE OF PUBLIC POLICY AND MAY BE APPEALED TO A COURT OF COMPETENT JURISDICTION OVER THE PARTIES AS AN INDEPENDENT GROUND FOR APPEAL.

(e) Joinder in Other Proceedings. The City reserves the right to require the joinder and participation of the other party to this agreement in any other arbitration or litigation involving a claim by another party that relates to the subject matter set forth in this agreement and, reserves the additional right, if necessary or desirable in the City’s sole determination, to join or implead the other party to this agreement into such arbitration or litigation when doing so is deemed by the City to be in its best interests.

THIS AGREEMENT SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE SUBSTANTIVE LAWS OF THE UNITED STATES AND THE STATE OF CONNECTICUT.

LICENSOR

By:_______________________ Name: Title:

LICENSEE

By:_______________________ Name: Title:

funding

Health & Medicine

mental health

school personnel

high school students

school nurses

school grounds

dunbar elementary school

blackham elementary

health section