Kyle L. Janek, M.D., Executive Commissioner
Request for Proposals (RFP)
for
Community Diabetes Education Programs (CDEP)
RFP No. 537-16-14030
Date of Release: March 6, 2015
CPA Class/Item Codes: 948-33
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Community Diabetes Education Programs RFP# 537-16-140303
TABLE OF CONTENTS
PROPOSAL INFORMATION ..........................................................................................4
I.
INTRODUCTION AND DEFINITIONS ............................................................... 4
A.
Eligible Respondents ............................................................................... 12
B.
Term of Contract .................................................................................... 13
C.
Use of Funds ........................................................................................... 14
D.
Schedule of Events .................................................................................. 15
II.
PROGRAM INFORMATION............................................................................. 15
A.
General Purpose and Program Goals – Scope of Work ............................. 15
B.
Program Background .............................................................................. 17
C.
Legal Authority....................................................................................... 17
D.
Community Diabetes Education Programs' Goals and Implementation ..... 17
E.
Program Requirements ........................................................................... 19
F.
Funding Opportunities ............................................................................ 20
III.
PROCUREMENT REQUIREMENTS ................................................................ 22
A.
RFP Point of Contact .............................................................................. 22
B.
Proposal Conference ............................................................................... 23
C.
Proposal Due Date................................................................................... 23
D.
Submission ............................................................................................. 24
IV.
PROPOSAL SCREENING AND EVALUATION ................................................ 24
A.
Screening Process.................................................................................... 24
B.
Evaluation Process .................................................................................. 25
C.
Evaluation Criteria ................................................................................. 26
D.
Selection, Negotiation, and Award ........................................................... 26
V.
DSHS ADMINISTRATIVE INFORMATION ..................................................... 28
A.
Rejection of Proposals ............................................................................. 28
B.
Right to Amend or Withdraw RFP .......................................................... 28
C.
Authority to Bind DSHS .......................................................................... 28
D.
Financial and Administrative Requirements ............................................ 28
E.
Contracting with Subcontractors ............................................................. 30
F.
DSHS Historically Utilized Business Participation .................................... 30
G.
Contract Information .............................................................................. 35
H.
Contract Award Protest Procedures ........................................................ 35
CONTENT AND PREPARATION .................................................................................36
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VI.
PROPOSAL CONTENT ..................................................................................... 36
A.
Instructions for Preparation .................................................................... 36
B.
Confidential Information......................................................................... 36
C.
Table of Contents .................................................................................... 37
VII.
BLANK FORMS AND INSTRUCTIONS ............................................................ 38
FORM A: FACE PAGE ...................................................................................... 39
FORM A: FACE PAGE INSTRUCTIONS .......................................................... 40
FORM B: PROPOSAL TABLE OF CONTENTS AND CHECKLIST .................. 42
FORM C: CONTACT PERSON INFORMATION .............................................. 43
FORM D: ADMINISTRATIVE INFORMATION ............................................... 44
FORM D-1: GOVERNMENTAL ENTITY .......................................................... 48
Community Diabetes Education Programs RFP# 537-16-140303
FORM D-2: NONPROFIT OR FOR-PROFIT ENTITY....................................... 49
FORM E: EXCEPTIONS FORM........................................................................ 50
FORM F: RESPONDENT BACKGROUND........................................................ 52
FORM G: ASSESSMENT NARRATIVE ............................................................ 53
FORM H: PERFORMANCE MEASURES GUIDELINES (Tier 1) ...................... 57
FORM H: PERFORMANCE MEASURES GUIDELINES (Tier 2 only) ............... 61
FORM I: WORK PLAN GUIDELINES NARRATIVE (Part A)........................... 67
FORM I: WORK PLAN TEMPLATE (Part B) ................................................... 77
FORM J: CHILD SUPPORT CERTIFICATION ................................................ 79
FORM K: FINANCIAL MANAGEMENT AND ADMINISTRATION ................ 80
QUESTIONNAIRE ............................................................................................ 80
APPENDICES ................................................................................................................84
APPENDIX A: Budget Section ........................................................................... 84
APPENDIX B: DSHS Assurances and Certifications ............................................ 85
APPENDIX C: HUB Requirements .................................................................... 91
APPENDIX D: Work Plan Template (Part B) .................................................... 101
APPENDIX E: URL References and Resources ................................................. 116
APPENDIX F: FY16 Tier 1 and 2 Requirements of ............................................ 120
Community Diabetes Education Programs (CDEP) ........................................... 120
APPENDIX G: ................................................................................................. 124
Map of 2014 ADA-recognized and 2014 AADE-accredited sites and ................... 124
2012 Adult Diabetes Prevalence by Health Service Region in Texas .................... 124
APPENDIX H: DSHS Menu of Evidence-Based Curricula Descriptions ............. 125
APPENDIX I:................................................................................................... 130
Sample Participant Health Outcome Form and Intervention Worksheet ............. 130
APPENDIX J: Class Implementation Plan......................................................... 134
APPENDIX K: Letters of Commitment ............................................................. 135
APPENDIX L: Letters of Commitment ............................................................. 136
APPENDIX M: Letters of Commitment ............................................................ 137
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Community Diabetes Education Programs RFP# 537-16-140303
PROPOSAL INFORMATION
I.
INTRODUCTION AND DEFINITIONS
The Health and Human Services Commission (HHSC) on behalf of the Department of State
Health Services (DSHS or Department) Texas Diabetes Prevention and Control Program
(TDPCP) announces the expected availability of fiscal year 2016 State funds to implement
Community Diabetes Education Programs (CDEP) for up to fourteen (14) contracts. There are
two distinct funding opportunities in the RFP. The first opportunity is a Tier 1 CDEP and the
second opportunity is a Tier 2 CDEP. This Request for Proposal (RFP) is not limited to this
source of funding if other sources become available for this project.
The purpose of funding a Tier 1 CDEP is to provide community-based diabetes prevention and
self-management interventions. The purpose of funding a Tier 2 CDEP is to create or expand
American Diabetes Association (ADA)-recognized and/or American Association of Diabetes
Educators (AADE)-accredited diabetes self-management education (DSME) programs for the
provision of community-based diabetes prevention and self-management interventions. The
National Standards for Diabetes Self-Management Education and Support can be found in
Appendix D. The differences and requirements of Tier 1 and Tier 2 are listed in the table found
in Appendix E. This Request for Proposal (RFP) will not be limited to State general revenue
funding if other sources become available.
Tier 1 and Tier 2 CDEPs will design, implement, and evaluate evidence-based diabetes
prevention and self-management education interventions and strategies at the community level.
CDEPs will collaborate with health systems, developing an effective community-clinic linkage,
to coordinate and increase access to health care delivery and community-based activities
promoting healthy behavior.
CDEPs will increase public and healthcare provider knowledge of the symptoms and risk factors
of type 2 diabetes, pre-diabetes, and gestational diabetes. CDEPs will also increase public and
healthcare provider knowledge of the importance of lifestyle in preventing, delaying and/or
managing diabetes and its potential complications, CDEPs will collaborate with health care
systems to establish and maintain a bi-directional referral mechanism and increase use of the
Texas Diabetes Council’s (TDC) toolkit, including the Minimum Standards for Diabetes Care in
Texas flow sheet and treatment algorithms.
CDEPs will increase opportunities for positive behavior changes for people who are at risk for
developing Type 2 diabetes.
This RFP contains the requirements that all respondents must meet to be considered for
contracts under this RFP. Failure to comply with these requirements will result in
disqualification of the respondent without further consideration. Each respondent is solely
responsible for the preparation and submission of a proposal in accordance with instructions
contained in this RFP.
Before completing the proposal, refer to the relevant program standards provided in SECTION
II. PROGRAM INFORMATION. Other sections within the RFP may contain additional
instructions pertaining to unique program requirements set forth in legislation or regulations, etc.
If web links in this document do not open, copy and paste them into your internet browser
window.
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Community Diabetes Education Programs RFP# 537-16-140303
PLEASE READ ALL MATERIALS BEFORE PREPARING THE PROPOSAL.
Definitions
Appendix – Additional information and/or forms that are available at the end of this solicitation
document.
Budget – A financial schedule documented in the contract that describes how funds will be used
and/or describes the basis for reimbursement for the provision of contracted services. Types of
budget may include categorical (line item), fee for service, or lump sum. The Budget Section is
required and is posted with this RFP as a separate package on the ESBD.
Budget Period – The duration of the budget (stated in the number of months the contract will
reflect from begin date to end date of the term of the contract). Each contract renewal will have
its own budget period.
Contract – A written document referring to promises or agreements for which the law
establishes enforceable duties and remedies between a minimum of two parties. A DSHS
contract is assembled using a core contract (base), one or more program attachments, and other
required exhibits (general provisions, etc.).
Contractor – An individual, organization, or entity that contracts with DSHS to provide services
and/or goods. This includes (but is not limited to) vendors, sub-recipients, and grantees.
Contract Term – The period of time during which the contract or program attachment will be
effective from begin date to end, or renewal date. The contract term may or may not be the
same as the budget period.
Cost Reimbursement – A payment mechanism by which contractors are reimbursed for
allowable costs incurred up to the total award amount specified in the contract. Costs must be
incurred in carrying out approved activities, and must be based on an approved eight -category
line-item (categorical) budget. Amounts expended in support of providing services and goods, if
any, in accordance with the contract terms and conditions must be billed on a monthly basis for
reimbursement unless otherwise specified in the contract. Reimbursement is based on actual
allowable costs incurred that comply with the cost principles applicable to the grant and
subgrants.
Debarment – An exclusion from contracting or subcontracting with state agencies on the basis
of cause set forth in Title 34, Texas Administrative Code Chapter 20, Subchapter C, §20.105 et
seq.
Deliverables – Goods or services contracted for delivery or performance.
Due Date – Established deadline for submission of a document or deliverable.
Effective Date – The date the contract term begins.
Fully Executed – When a contract is signed by each of the parties to form a legal binding
contractual relationship. No costs chargeable to the proposed contract will be reimbursed before
the contract is fully executed.
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Community Diabetes Education Programs RFP# 537-16-140303
General Provisions – Basic provisions that are essential in administering the contract, which
include assurances required by law, compliance requirements, applicable federal and state
statutes and circulars, financial management standards, records and reporting requirements,
funding contingency, sanctions, and terms and conditions of payment.
Indirect Costs – Costs incurred for a common or joint purpose benefiting more than one project
or cost objective of respondent’s organization and not readily identified with a particular project
or cost objective. Typical examples of indirect costs may include general administration and
general expenses such as salaries and expenses of executive officers, personnel administration
and accounting; depreciation or use allowances on buildings and equipment; and costs of
operating and maintaining facilities.
Procurement and Contracting Services Division (PCS) - Central contracting unit within
HHSC that is responsible for statewide procurements and their certifications. PCS oversees,
coordinates, and assists the Divisions with procurement needs, issues competitive procurements,
finalizes development, and executes contracts. PCS maintains the official contract file from
procurement to contract closeout.
Program – Depending upon the context, either a coordinated group of activities carried out by
DSHS, as authorized by state or federal law, for a specific purpose (“program”) or DSHS staff
located in a program, region, or hospital that identify and request procurement needs
(“Program”) The Program partners with CSCU on procurements.
Program Attachment – An attachment to the contract that provides details for a particular
statement of work to be performed under the contract such as services to be delivered,
performance measures or deliverables, funding, and reporting requirements. There may be
multiple program attachments associated with a core contract. A program attachment is
typically for a one-year term, with a contracting cycle made up of several one-year program
attachment renewals.
Project – All work to be performed as a result of a contract or solicitation.
Project Period – The anticipated duration of the entire project stated in total number of budget
periods.
Respondent – A person or entity that submits a response to a solicitation. For purposes of this
document, “respondent” is intended to include such phrases as “offeror”, “applicant”, “bidder”,
“responder”, or other similar terminology employed by DSHS (or HHSC) to describe the person
or entity that responds to a solicitation.
Scope of Work – A description of the services and/or goods, if any, for each service type, to be
obtained as a result of a solicitation for a project period. The scope of work is a document
written in the early stages of procurement to explain what DSHS plans to purchase.
Solicitation – The process of notifying prospective contractors of an opportunity to provide
goods or services to the state (e.g., this RFP).
Special Provisions – Modifications and additions to the General Provisions for a funded
program activity; which are usually customized for the Program’s requirements and contain
provisions specific to the program attachment.
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Community Diabetes Education Programs RFP# 537-16-140303
Statement of Work – The part of the contract that describes the services and/or goods to be
delivered by the DSHS contractor specifying the type, level and quality of service, that directly
relate to program objectives.
Subcontract – A written agreement between the DSHS contractor and a third party to provide
all or a specified part of the services, goods, work, and materials required in the original
contract. The contractor remains entirely responsible to DSHS for performance of all
requirements of the contract with DSHS. The contractor must closely monitor the
subcontractor’s performance. Subcontracting can be done only when expressly allowed in the
program attachment.
Subrecipient – A type of contractor or subcontractor to which a subaward is made in the form
of money, or property in lieu of money, to carry out all or part of the DSHS Program and that is
accountable to DSHS for the use of the funds and property provided. This type of contractor
may also be referred to as a subgrantee. Reimbursement is based on actual allowable costs
incurred that comply with cost principles applicable to the grants and subgrants.
A subrecipient contractor will have most of the following characteristics: a) determines who is
eligible to receive what assistance, according to specified criteria; b) has performance measured
against federal or state program objectives, as described in the program attachment; c) has
responsibility for programmatic decision-making, and d) carries out duties to implement all or
part of a program, as specified.
Supplant (verb) - To replace or substitute one source of funding for another source of funding.
A recipient of contract funds under this RFP must not use the funds to pay any costs that the
recipient is already obligated to pay. If a contractor, prior to responding to an RFP, had
committed to provide funding for activities defined in the contract’s statement of work (i.e., as
represented in the RFP Budget Summary), then the contractor must provide the amount of
funding previously committed in addition to the amount requested under this RFP.
Vendor – A type of contractor or subcontractor that provides services, and goods, if any, that
assist in, but are not the primary means of, carrying out the DSHS-funded Program. Under a
vendor contract, the vendor will have few if any administrative requirements. (For example, a
vendor might be required only to submit a summary report of services delivered and an invoice.)
A vendor generally will deliver services to DSHS-funded clients in the same manner the vendor
would deliver those services to its non-DSHS-funded clients.
A vendor contractor generally has most of the following characteristics: a) provides goods and
services within normal business operations, b) provides similar goods and services to many
different purchasers, c) operates in a competitive environment, d) is not subject to compliance
requirements of the federal or state program, e) provides goods and services that are ancillary to
the operation of the program. Note: Characteristics a, b, c, and d do not apply to vendor
contractors that are universities.
Vendor Identification Number (Vendor ID No.) – Fourteen-digit number needed for any
entity, whether vendor or subrecipient, to contract with the State of Texas and which must be
established with the State Comptroller’s Office. It consists of a ten-digit identification number
(IRS number, state agency number, or social security number) +check digit + 3 digit mail code.
The Vendor ID No. includes all the numbers in the TINs (defined above), including a three digit
mail code for a total of 14-digits.
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Work Plan - A plan that describes how services will be delivered to the eligible population and
includes specifics such as what types of clients will be served, who will be responsible for the
work, timelines for completion of activities, and how services will be evaluated when complete.
To be an enforceable part of the contract, details from the work plan must be approved by DSHS
and incorporated in the contract.
Texas Diabetes Prevention and Control Program Definitions
2-1-1 Texas—A program of the Texas Health and Human Services Commission that is
committed to helping Texas citizens connect with the services they need. Whether by phone or
internet, their goal is to present accurate, well-organized and easy-to-find information from state
and local health and human services programs. No matter where one lives in Texas, dial 2-1-1 to
find information about resources in the local community. https://www.211texas.org/cms/
Activities—A function of duties done to accomplish an objective. Activities do not have to be
measurable, but are tasks that have to be completed.
Advisory Board—External stakeholders and experts to promote program quality.
American Association of Diabetes Educators (AADE)-accredited and American Diabetes
Association-recognized Programs—AADE-accreditation and ADA-recognition ensures that a
program is comprehensive and meets the National Standards for DSME. It is also a requirement
for Medicare reimbursement.
Bi-directional Referral System—A process of a community program and the physician/ health
system sharing patient information to effectively manage and treat a patient’s condition. This
information is documented in the patient’s medical record. The bi-directional system can
provide baseline reports on the number of referrals, services received, and outcomes. If
integrated with an Electronic Health Record, health systems can evaluate the impact of the
community programs on population health.
Burden of Diabetes—Includes the prevalence, mortality, complications, costs, and risk factors
for adults with diabetes.
Coalition—An organization of diverse interest groups that combine human and material
resources to effect a specific change the members are unable to bring about independently.
(Butterfoss, Goodman, and Wandersman, 1993)
Community—A group of people with a common characteristic being located in a geographical
area. Neighborhoods, cities, or groups of towns are examples. Community can also be defined as
a group of people with common interests. These include religious groups, social groups, and
people who identify with one another because of language, race, ethnicity, or physical ability.
Demographic boundaries are socioeconomic, status, gender, age, and family structure.
Community-based Intervention—Key activities and associated materials that are conducted
within and by members of a particular community (e.g. grassroots efforts, efforts by a local civic
group). Community-based interventions can be done in conjunction with an outside group (e.g.
nonprofit organization, research group).
Community-Clinical Linkages—Intervention strategies ensuring that communities support and
clinics refer patients to programs to prevent, delay onset, or manage chronic conditions. Such
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Community Diabetes Education Programs RFP# 537-16-140303
interventions ensure those with or at high risk for chronic diseases have access to quality
community resources to best manage their conditions or disease risk. These supports include
interventions such as clinician referral, community delivery and third-party payment for
effective programs that increase the likelihood people with heart disease, diabetes or prediabetes, and arthritis will be able to "follow the doctor’s orders” and take charge of their health.
In turn, improving their quality of life, averting or delaying onset or progression of disease,
avoiding complications (including during pregnancy), and reducing the need for additional
health care.
Cultural Competence—Comprises behaviors, attitudes, and policies that can come together on
a continuum that will ensure that a system, agency, program, or individual can function
effectively and appropriately in diverse cultural interaction and settings.
Diabetes Self- Management Education—The process of teaching people the skills needed to
manage their diabetes on a daily bases. The Task Force on Community Preventive Services
supported by the Centers for Disease Control and Prevention (CDC) recommendations can be
found at http://www.thecommunityguide.org/diabetes/index.html
Diabetes self-management education/training (DSME/T)—A collaborative process through
which people with diabetes gain the knowledge and skills needed to modify their behavior and
successfully self-manage the disease and its related conditions. This process incorporates the
needs, goals, and life experiences of the person with diabetes and is guided by evidence-based
standards.
Evidence-Based Interventions—Interventions that have a clearly defined target audience, have
clearly defined intent and immediate outcomes, are based on sound behavioral science theory,
are focused on improving behaviors and provide opportunities to practice.
Feedback Loop – 1. The return of the output (results) of a process or system to the input that
was used to produce the output. The results should demonstrate that the actions taken made an
impact. The feedback loop is the path that leads from output resulting from the intervention back
to the input. 2. The section of a control system that allows for feedback and self-correction and
that adjusts its operation according to differences between the actual and the desired or optimal
output.
Geographic Disparities—Access to health care is a significant issue for some geographic areas
of Texas. Geographic barriers may affect a person’s access to primary care as well as hospitals.
Health Disparities—Refers to difference in the incidence, prevalence, mortality, and burden of
diseases and other adverse health conditions that exist among specific population groups in the
United States, arising as a consequence of health inequities that are systematic, avoidable,
unfair, and unjust. These health inequities include associated differences in health status and
mortality rates and in the distribution of disease and illness across population groups that are
sustained over time and generations, and are beyond the control of individuals. Examples of
interventions that impact health disparities include targeting limited resources toward
communities with the greatest disease burden or risk, and using culturally relevant
materials/approaches to design appropriate interventions in those communities.
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Health Service Region (HSR) - Texas:
1.
2.
3.
4.
5.
6.
7.
8.
Texas Panhandle-Health Service Region 1
North Texas-Health Service Region 2/3
East Texas-Health Service Region 4/5 North
South East Texas-Health Service Region 6/5 South
Central Texas-Health Service Region 7
Southwest Texas-Health Service Region 8
West Texas-Health Service Region 9/10
South Texas-Health Service Region 11
(See http://www.dshs.state.tx.us/regions/state.shtm for regional information and map.)
Impact Objectives—Reflects changes in factors such as risk factors or preventive care services
(e.g., eye exams) associated with health status. (Note: The performance measurement of these
objectives is the actual impact or benefit of an entity’s actions.)
Impaired Glucose Tolerance (IGT) and Impaired Fasting Glucose (IFG) —Terms associated
with pre-diabetes based on the type of test used to diagnose pre-diabetes. A person with IFG has
pre-diabetes based on a fasting plasma glucose test, while a person with IGT has pre-diabetes
based on an oral glucose tolerance test
Intervention—Specific set of activities and associated materials used to address the problem.
Medicare Reimbursement for DSME/T—In 1997, the federal Balanced Budget Act passed,
permitting the U.S. Health Care Finance Administration (HCFA)— now called the Centers for
Medicare and Medicaid Services (CMS)— to provide expanded coverage for DSME/T.
National Standards for DSME/T—These standards are reviewed and revised approximately
every five years by a task force of the American Diabetes Association (ADA), and published in
Diabetes Care as “National Standards for Diabetes Self-Management Education.” They are
published online on the ADA’s “Diabetes Pro” website under “Clinical Practice
Recommendations.” http://professional.diabetes.org/CPR_Search.aspx
National Diabetes Prevention Program—The National DPP is led by the CDC and was
founded on the science of the Diabetes Prevention Program research study which showed that
making modest behavior changes helped participants lose 5% to 7% of their body weight and
reduced the risk of developing type 2 diabetes by 58% in people with pre-diabetes. The CDC
Diabetes Prevention Recognition Program assures the quality of CDC-recognized programs and
provides standardized reporting and performance.
http://www.cdc.gov/diabetes/prevention/index.htm
Objective—A statement of an accomplishment that contributes to attaining the goal. Objectives
are standards to determine how your project has accomplished what it set out to do, and are
defined by who will do what, by when, where, and how many. Objectives are measurable,
achievable, realistic, and time phased. This project will only address short-term, impact, and
process objectives.
Outcome Evaluation—A method of evaluation which uses techniques that will provide
evidence as to whether or not the program or intervention accomplished the intended efforts.
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Population-based Interventions—Interventions that are targeted toward populations to
promote the overall health status of the community by preventing disease, injury, disability, and
premature death. A population-based health intervention should include the following:
assessment, health promotion, disease prevention, monitoring of services, and evaluation. Some
methods to accomplish these goals include public education programs, community projects, and
media interventions.
Pre-diabetes—Pre-diabetes is a condition in which individuals have blood glucose levels higher
than normal but not high enough to be classified as diabetes. People with pre-diabetes have an
increased risk of developing type 2 diabetes, heart disease, and stroke.
Process Objectives—Indicators of implementation of those activities that accomplish the
impact objectives. Each process objective should be related to an impact objective and should
describe what the respondent wants to accomplish or complete. Like all other objectives, process
objectives also must be measurable and time phased. (Note: The performance measurement of
these objectives should count the actions/changes achieved or the goods/services provided.)
Program Goal—A broad, general statement that describes what a program hopes to accomplish
in the long term.
Rural Area—A county that had a population in the most recent decennial census of 150,000 or
less, or that portion of a county with a population of greater than 150,000 that is not delineated
as urbanized, by the United States Census Bureau.
Series—A number of classes and/or events arranged in order and connected by being alike in
some way. For example, a diabetes self-management series will include a minimum of four
group classes. These classes will meet at least once per week for a minimum of four weeks.
Socioeconomic Status—Includes data related to per capita income, poverty levels,
unemployment, educational attainment, and health insurance status. As a guideline, eligibility
for Primary Health Care in Texas is family income at or below 150% of federal poverty level
(FPL).
Strategy—Approach used to address the problem.
Sustainable—Public health collaborations, efforts, and activities that have an adequate,
consistent financial base along with sufficient staff, resources and commitment to support
operation.
Systems—The dynamic interrelationship of components designed to enact a vision. Systems
operate at the level of the workgroup, organization, and community. A systems change would
make this interrelationship different.
Texas Diabetes Council (TDC)—The Texas Diabetes Council (TDC) addresses issues
affecting people with diabetes in Texas and advises the Texas Legislature on legislation that is
needed to develop and maintain a statewide system of quality education services for all people
with diabetes and health care professionals who offer diabetes treatment and education.
Texas Diabetes Prevention and Control Program (TDPCP)—The Texas Department of State
Health Services administers grant-funded initiatives and contracted services, while Council
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members serve on numerous committees and work groups addressing current issues affecting
people with diabetes and those at risk.
Unduplicated—
1.
A participant of a series counted only once during the fiscal year, regardless of the
number of series or activity types in which the individual participates.
2.
Participants who have had at least one visit/encounter in an intervention series (e.g.,
diabetes self-management, physical activity, or nutrition) funded by this program. They have
received at least one of the intervention services under this grant during the applicable calendar
year. The sum of unduplicated participants do not include:
a.
the same participant more than once
b.
participants attending single events (e.g. health fairs, general one-time
presentations/seminars about diabetes and/or preventive methods)
c.
persons only receiving a referral for other services (e.g., tobacco cessation)
A. Eligible Respondents
Eligible respondents include any county, municipality, public health district , or other political
subdivision, including academic institutions or hospital districts, for profit or local nonprofit
organizations in Texas (with Federal tax identification number) and must comply with the criteria
listed below.
1.Respondent must be established as an appropriate legal entity as described in the paragraph
above, under state statutes and must have the authority and be in good standing to do
business in Texas and to conduct the activities described in the RFP.
2.Respondent or their subcontractors must have a Texas business address. A post office box
may be used when the proposal is submitted, but the respondent or their subcontractors must
conduct business at a physical location in the region for which they are applying prior to the
date that the contract is awarded.
3.Respondent must be in good standing with the U.S. Internal Revenue Service.
4.Respondent is not eligible to apply for funds under this RFP if currently debarred,
suspended, or otherwise excluded or ineligible for participation in Federal or State assistance
programs.
5.Respondent may not be eligible for contract award if audit reports or financial statements
submitted with the proposal identify concerns regarding the future viability of the contractor,
material non-compliance or material weaknesses that are not satisfactorily addressed, as
determined by DSHS.
6.Respondent’s staff members, including the executive director, must not serve as voting
members on their employer’s governing board.
7. In compliance with Comptroller of Public Accounts and Texas Procurement and Support
Services rules, a name search will be conducted using the websites listed in this section prior
to the development of a contract.
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A respondent is not considered eligible to contract with DSHS, regardless of the funding
source, if a name match is found on any of the following lists:
a)
b)
c)
The General Services Administration’s (GSA) System for Award
Management (SAM) for parties excluded from receiving federal contracts,
certain subcontracts and from certain types of federal financial and nonfinancial assistance and benefits.
https://www.sam.gov/portal/public/SAM
The Office of Inspector General (OIG) List of Excluded
Individuals/Entities Search– State –
https://oig.hhsc.state.tx.us/Exclusions/search.aspx; and
Texas Comptroller of Public Accounts (CPA) Debarment List located at
http://www.window.state.tx.us/procurement/prog/vendor_performance/
debarred/. If this web link does not open, copy and paste to your internet
browser window.
8. Respondents must be listed on the following list if they are Professional Corporations,
Professional Associations, Texas Corporations, and/or Texas Limited Partnership
Companies. Secretary of State (SOS) at https://direct.sos.state.tx.us/acct/acct-login.asp.
Except as expressly provided in A.2. above, respondent is not considered eligible to apply
unless the respondent meets the eligibility conditions to the stated criteria listed above at the
time the proposal is submitted. Respondent must continue to meet these conditions
throughout the selection and funding process. DSHS expressly reserves the right to review
and analyze the documentation submitted and to request additional documentation, and
determine the respondent’s eligibility to compete for the contract award.
B. Term of Contract
It is expected that the initial contract term will begin on or about 09/01/2015, and will be made
for a 12-month period. This contract may be renewed up to three additional one year period(s),
with renewal initiated at the sole discretion of DSHS. Continued funding of the contract in
future years is contingent upon the availability of funds and the satisfactory performance of the
contractor during the prior contract period. Funding may vary and is subject to change each
renewal.
Contracts awarded under this RFP and any anticipated contract renewals are contingent upon the
continued availability of funding. DSHS reserves the right to alter, amend or withdraw this RFP
at any time prior to the execution of a contract if funds become unavailable through lack of
appropriations, budget cuts, transfer of funds between programs or agencies, amendment of the
appropriations act, health and human services agency consolidations, or any other disruption of
current appropriations. If a contract has been fully executed and these circumstances arise, the
provisions of the Termination Article in the contract General Provisions will apply.
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Community Diabetes Education Programs RFP# 537-16-140303
C. Use of Funds
In Fiscal Year 2016, approximately $2,400,000 is expected to be available to fund up to fourteen
(14) contracts. The specific dollar amount awarded to each successful respondent depends upon
the merit and scope of the proposal as well as the prevalence/mortality rates of diabetes and
availability of services in the respective communities to address this disease and is at the sole
discretion of DSHS. Additional funds may be awarded during contract negotiations.
DSHS anticipates funding programs in areas of the state with a significant burden, including
high prevalence of diabetes, risk factors for type 2 diabetes, and diabetes-related morbidity and
mortality. Priority will be given to areas with limited ADA-recognized or AADE-accredited
programs relative to the burden of diabetes, including rural or remote areas. Refer to Appendix F
for the map of 2014 American Diabetes Association-Recognized Programs, 2014 American
Association of Diabetes Educators-Accredited Programs, and 2012 Adult Diabetes Prevalence
by Health Service Region (HSR).
Funds are awarded for the purpose specifically defined in this RFP and must not be used for any
other purpose. Funds may be used for personnel, fringe benefits, staff travel, contractual
services, other direct costs, and indirect costs, as allowed in the budget.
Funding can be used to build capacity to apply for ADA-recognition or AADE-accreditation. If
currently ADA-accredited/AADE-recognized, funding can be used to expand existing programs
by adding sites in unserved or underserved areas. In addition, programs are encouraged to be
trained and apply for recognition under the CDC Diabetes Prevention Recognition Program, if
eligible. For more information, see
http://www.cdc.gov/diabetes/prevention/recognition/index.htm.
Funds must not be used to supplant other local, state, or federal funds. Funds must not be used
as a pass through to other entities. .
Funds may be used for the following project-related expenses:
1. Personnel costs related to administrative functions for program (e.g., policy
development/revision, direct supervisory functions, fiscal services, and direct reporting;
2. Curriculum licensing fees;
3. Continuing education for program coordinators and instructional staff (e.g., registered
nurse, registered dietitian, pharmacist, community health worker, etc.) as it relates to
diabetes care as well as their profession (e.g., program management, education, chronic
disease care, behavior change) (Tier 2 only);
4. Office and administrative supplies;
5. Travel related to program activities;
6. Training and educational expenses;
7. Health education materials, including food models and physical activity supplies;
8. Computer equipment, including a modem and/or software, with prior approval from
DSHS TDPCP;
9. Written prior approval from TDPCP program is required prior to the purchase of any
equipment item;
10. Contract services and other items supporting program objectives, with prior approval
from DSHS TDPCP; and
11. Below are examples of allowable items that may be used to support behavior change and
enhance retention rates. The determination of allowability is dependent upon the context
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Community Diabetes Education Programs RFP# 537-16-140303
of an item’s use and the message it conveys. No more than two percent (2%) of the
total budget can be used for participant retention items and is subject to
negotiation. Using the criteria listed above, illustrative examples of allowable purchases
are provided below.
a. Cookbooks focusing on healthy eating
b. Transportation assistance (i.e. vouchers or tokens for bus, taxi, or other modes of
transportation may be offered to assist members attend diabetes prevention or selfmanagement and/or nutrition classes)
c. Exercise tools (exercise videos, stretch bands, bicycles and bicycle helmets, jump
ropes, basketballs)
d. Pedometers (data MUST be collected, maintained, and presented at time of site visit
showing participants’ use (e.g., physical activity logs)
12. Individualized patient care or counseling services (Tier 2 only)
Funds cannot be used for:
1. Individual health services or payment for the treatment of diabetes or obesity;
2. Laboratory services;
3. Medical supplies;
4. Food except for use in education classes or demonstrations;
5. Research projects;
6. Grant writing services or administrative staff primarily responsible for writing
grants/proposals;
7. Administrative staff performing unrelated senior management functions;
8. Lobbying for or against any legislation, ordinance, or for any other political activity; and
9. Continuing education (Tier 1 only)
D. Schedule of Events
1.
2.
3.
4.
5.
6.
7.
RFP Release Date
Pre-proposal Conference
Deadline for Submitting Questions
HHSC Post Answers to Vendor Questions
Deadline for Submission of Proposals
Post Tentative Award Announcement
Anticipated Contract Begin Date
03/06/2015
03/18/2015
03/23/2015
03/27/2015
04/06/2015
05/26/2015
09/01/2015
HHSC reserves the right to change the dates shown above without notice. It is the responsibility of the
respondent to check the HHSC Business Opportunities website frequently for notice of matters affecting
the RFP. To access the website, go to http://www.hhsc.state.tx.us/about_hhsc/BusOpp/contractopportunities.asp
II.
PROGRAM INFORMATION
A. General Purpose and Program Goals – Scope of Work
The TDPCP is the diabetes prevention and control program for the State of Texas.
The vision of the TDPCP and the Texas Diabetes Council (TDC) is “A Texas Free of
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Community Diabetes Education Programs RFP# 537-16-140303
Diabetes and its Complications.” TDPCP goals address surveillance, health
communications, health systems improvements, infrastructure, community
intervention services, wellness, and health disparities. Increasing public awareness,
promoting community outreach and diabetes education are TDC priorities.
TDPCP follows the CDC National Center for Chronic Disease Prevention and Health
Promotion’s framework. The four domains of this framework are:
1. Epidemiology and surveillance: Gather, analyze, and disseminate data and
information; use results from evaluations to make decisions about prioritizing and
delivering interventions; monitor programs and population health.
2. Environmental approaches: Promote health, and support and reinforce healthful
behaviors statewide in schools, worksites, and communities.
3. Health system interventions: Increase the use and improve the effective delivery of
preventive services and clinical care. This would help prevent disease, detect diseases
sooner after onset, reduce risk factors, and control complications.
4. Strategies to improve community-clinical linkages: Ensure that communities
support programs that improve management of chronic conditions and clinics refer
patients to these programs. Specifically, this initiative is working to:
 Increase access and referrals to diabetes self-management education programs
and reimbursement for this service;
 Increase pre-diabetes awareness
 Increase referrals to, use of, and reimbursement for CDC-recognized lifestyle
change programs for the prevention of type 2 diabetes
 Increase use of health-care extenders (such as community health workers) in
the community in support of self-management.
TDPCP’s immediate outcomes for this project are:
1. Increased opportunities for physical activity and better nutrition.
2. Increased access to ADA-recognized and/or AADE-accredited diabetes selfmanagement education and support.
3.Capacity to collect and analyze data on waist circumference, BMI, tobacco
status/cessation and blood pressure and other indicators listed on the sample
participant health outcomes form in Appendix H as participants progress through
interventions.
4. Improved capacity of a Community Diabetes Education Program (CDEP)
advisory board to design, implement, and engage in program quality
improvement of diabetes interventions.
Additional project goals are to:
1. Increase public and provider knowledge of the symptoms, risk factors and
target goals of diabetes, pre-diabetes and gestational diabetes management,
and the importance of physical activity and healthy eating in preventing,
delaying, or managing diabetes and its complications.
2. Increase health care provider, payer, and patient knowledge and use of the
TDC’s Minimum Standards for Diabetes Care in Texas and treatment
algorithms (www.tdctoolkit.org).
Long-term outcomes for this project are:
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Community Diabetes Education Programs RFP# 537-16-140303
1. Reduced risk of eye disease, kidney disease, nerve damage, and
cardiovascular disease through diabetes self-management;
2. Reduced likelihood of costs associated with adverse health outcomes
resulting from diabetes;
3. Reduced risk of developing type 2 diabetes through pre-diabetic lifestyle
changes; and
4. Decreased undiagnosed cases due to better public awareness of diabetes risk
in high-prevalence areas.
These objectives and priorities are aligned with the Healthy People 2020, DSHS Commissioner
Priorities. (For websites, see URL References and Resources, Appendix D.)
B. Program Background
Recognizing that Texas includes many diverse communities with unique needs, TDPCP
supports locally tailored programs. A program that is successful for one geographical area or
ethnic group may or may not work for another area or group. The TDPCP has funded five
previous cycles of programs developed by communities that deal with diabetes and health
disparities, diabetes awareness and education, and changes in community systems,
environments, policies and practices.
These programs have demonstrated success in establishing culturally-appropriate
programming for promoting wellness, healthy nutrition, physical activity, glycemic control,
weight and blood pressure control, and tobacco cessation for persons with diabetes. Target
populations include low socio economic status, racial and ethnic minorities with
disproportionate rates of diabetes and those with limited access to health care services. In
addition, these programs have trained community health workers and have worked to
increase awareness of diabetes.
C. Legal Authority
DSHS is authorized to enter into contracts through Texas Health and Safety Code, Section
12.051.
D. Community Diabetes Education Programs' Goals and Implementation
The purpose of funding community diabetes education programs (CDEP) is to reduce the
burden of diabetes by establishing and maintaining critical partnerships to create and support
interventions targeted to populations at greatest risk of developing diabetes. CDEPs are
required to coordinate, implement and monitor quality, cost effective, culturally competent
diabetes prevention and management interventions. Programs’ interventions will target
individuals aged 18 and older and their families in high-risk populations.
Programs will use multiple communication channels, bringing programs into neighborhoods.
Community health workers and community health representatives may serve as
communicators and as role models to foster healthy attitudes and beliefs and provide social
support. The CDEP advisory board will serve to inform the design, implementation, and
promotion of quality diabetes interventions. Programs are encouraged to use the resources
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Community Diabetes Education Programs RFP# 537-16-140303
available from the TDC and CDC’s National Diabetes Education Program, the National
Public Health Initiative on Diabetes and Women’s Health, and the Native Diabetes Wellness
Program.
Programs will align any health care system components with the TDC’s Minimum Standards
for Diabetes Care in Texas. All program interventions will be consistent with the TDC’s
strategic plan. (For websites, see URL References and Resources, AppendixE.)
The goals of the CDEP interventions are:
1. Preventing type 2 diabetes in persons at high risk who do not have diabetes;
and
2. Preventing complications, disabilities, and burden associated with diabetes.
Within the limits set governing these projects, respondents will propose interventions that
will address the following community-based goals:
1. Increase public and provider knowledge of the symptoms, risk factors and
target goals of diabetes, pre-diabetes and gestational diabetes, and the
importance of physical activity, healthy eating, and tobacco cessation in
preventing, delaying, or managing diabetes and it’s complications; and
2. Increase health care provider, payer, and their patient knowledge and use of
the TDC’s Minimum Standards for Diabetes Care in Texas, treatment
algorithms (www.tdctoolkit.org), and Texas Quitline.
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Community Diabetes Education Programs RFP# 537-16-140303
Respondents will specify how activities will be measured, using Performance Measures
Guidelines (Form H). At a minimum, programs will collect data listed on Form H:
Performance Measure guidelines, which is based on funding type (Tier 1 or Tier 2). Some
indicators include waist circumference, BMI, tobacco status/cessation, blood pressure, A1c,
cholesterol, and lipids.
E. Program Requirements
Contractors are required to conduct project activities in accordance with federal and state
laws prohibiting discrimination. Guidance for adhering to non-discrimination requirements
can be found on the Health and Human Services Commission (HHSC) Civil Rights Office
website at: http://www.hhs.state.tx.us/aboutHHS/CivilRights.shtml.
Upon request, a contractor must provide the HHSC Civil Rights Office with copies of all the
contractor’s civil rights policies and procedures. Contractors must notify HHSC’s Civil
Rights Office of any civil rights complaints received relating to performance under the
contract no more than 10 calendar days after receipt of the complaint. Notice must be
directed to:
HHSC Civil Rights Office
701 W. 51st Street, Mail Code W206
Austin, TX 78751
Phone Toll Free (888) 388-6332
Phone: (512) 438-4313
TTY Toll Free (877) 432-7232
Fax: (512) 438-5885
A contractor must ensure that its policies do not have the effect of excluding or limiting the
participation of persons in the contractor’s programs, benefits or activities on the basis of
national origin, and must take reasonable steps to provide services and information, both
orally and in writing, in appropriate languages other than English, in order to ensure that
persons with limited English proficiency are effectively informed and can have meaningful
access to programs, benefits, and activities.
Contractors must comply with Executive Order 13279, and its implementing regulations at
45 CFR Part 87 or 7 CFR Part 16, which provide that any organization that participates in
programs funded by direct financial assistance from the U.S. Dept. of Agriculture or U.S.
Dept. of Health and Human Services must not, in providing services, discriminate against a
program beneficiary or prospective program beneficiary on the basis of religion or religious
belief.
Contractors are required to establish and maintain a coalition or advisory board, based on
funding type (Tier 1 or Tier 2, respectively). This coalition or advisory board must meet at
least quarterly for the duration of the contract. Input from the coalition or advisory board is
vital to maintain an effective program.
In addition, each program will:
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Community Diabetes Education Programs RFP# 537-16-140303
1. Develop and oversee implementation of specific strategies and activities to achieve goals
linked to a needs assessment. Each community will develop its own unique strategies and
activities, using evidence-based public health practices;
2. Provide community leadership for diabetes prevention and control; and
3. Develop partnerships with providers and health care systems to facilitate access to care
for uninsured people and promote patient-centered medical home models.
Programs are required to fulfill contract obligations, which include attending all trainings
and meetings, in their entirety, conducted by TDPCP or its partners.
Contractor will be required to:
1. Submit a needs assessment narrative;
2. Submit a work plan narrative and template with performance measures;
3. Submit monthly program activities via DSHS’ web-based reporting system by the 10th
day following month activities were completed;
4. Submit meeting minutes for a coalition or advisory board, including attendance rosters;
5. Submit quarterly reports, as prescribed by TDPCP, via a DSHS web-based reporting
system by the 20th day following the end of each quarter;
6. Submit an annual report, as prescribed by TDPCP, no later than one month after the end
of each fiscal year;
7. Submit participant health outcomes data to be specified by TDPCP;
8. Submit a summative report no later than one month after the 4-year project period ends;
9. Maintain documentation of activities, services, outcomes, and persons served; and
10. Attend three 3-day trainings in Austin
Respondents are also encouraged to participate in local and regional planning activities. For
information on local planning activities, respondents are encouraged to contact their local
health department or DSHS Regional Health Department.
DSHS reserves the right to modify the Statement of Work of the contract and to incorporate
Special Provisions into contracts awarded under this RFP.
F. Funding Opportunities
There are two possible opportunities in the RFP that a respondent may choose to include in
their proposal:
Page 20
1.
The first opportunity is to apply for Tier 1 funding. If the respondent is applying
for Tier 1 funding, this must be indicated by selecting the appropriate funding
type, where applicable, and submitting a work plan and budget specific to Tier 1
activities.
2.
The second opportunity is to apply for Tier 2 funding. If the respondent is
applying for Tier 2 funding, this must be indicated by selecting the appropriate
funding type, where applicable, and submitting a work plan and budget specific
to Tier 2 activities. Respondents who currently hold ADA-recognition or AADEaccreditation are considered Tier 2 applicants.
Community Diabetes Education Programs RFP# 537-16-140303
Refer to Appendix F for Tier 1 and Tier 2 Community Diabetes Education Programs (CDEP)
Requirements.
A respondent may apply for both Tier 1 and Tier 2 but will only be awarded funding for one
tier. Priority will be given to Tier 2 programs.
Tier 2 programs are funded at a higher dollar amount and require additional activities related
to delivery of accredited/recognized DSME programs. As a result, these programs are more
likely to be affected by state budget reductions. Proposing both a Tier 1 and Tier 2 program
assures that an organization has a proposal that may be implemented at a lower dollar
amount should Tier 2 funding not be available.
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Community Diabetes Education Programs RFP# 537-16-140303
III.
PROCUREMENT REQUIREMENTS
A. RFP Point of Contact
For purposes of submitting questions concerning this RFP, the only contact is Vonda White
unless otherwise delegated by the PCS Manager. All communications concerning this RFP
must be submitted by email (preferred), mail, hand-delivery, or fax to:
Mailing Address for Regular Mail:
Vonda White
Ref: RFP# 537-16-140303
Procurement and Contracting Services Division
Health and Human Services Commission
4405 North Lamar
MC 2020
Austin, Texas 78756
Physical Address for Overnight Mail or hand-delivery:
Vonda White,
Ref: RFP# 537-16-140303
Procurement and Contracting Services Division
Health and Human Services Commission
4405 North Lamar
MC 2020
Austin, Texas 78756
Phone and Fax Numbers:
512/206-4798 phone
512/206-4865 fax
PCS Email: Vonda.white@hhsc.state.tx.us
Other employees and representatives of HHSC or DSHS are not permitted to answer
questions or otherwise discuss the contents of the RFP with any respondents or potential
respondents or their representatives. Failure to observe this restriction may result in
disqualification of this or other subsequent proposals. This restriction does not preclude
discussions between affected parties for the purpose of conducting business unrelated to this
RFP.
Written inquiries or questions about this RFP must be received no later than the date
specified in Section I.D. Schedule of Events by 5:00 P.M. Central Time (CT). Questions
submitted after this date and time will not be answered. Questions will not be answered
verbally. Questions must be submitted by email (preferred), mail, hand-delivery, or fax to
the addresses or numbers above.
All questions and answers will be posted on the HHSC Business Opportunities website at:
http://www.hhsc.state.tx.us/about_hhsc/BusOpp/contract-opportunities.asp. Postings may be
made as questions are answered; however, all questions will be answered and posted no later
than 5:00 P.M. CT on the date specified in Section I D. Schedule of Events.
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Community Diabetes Education Programs RFP# 537-16-140303
HHSC is the point of contact with regard to all procurement and contractual matters relating
to the services described herein prior to the award of any contract(s) as a result of this RFP.
HHSC is the only office authorized to clarify, modify, amend, alter, or withdraw the project
requirements, terms, and conditions of this RFP.
B. Pre-Proposal Conference
HHSC will conduct a Pre-Proposal Conference on the date identified in Section I.D.
Schedule of Events from 10:00 am to 12:00 pm, CT at the HHSC, Building 2, 909 West
45th Street, Austin, TX 78756, 2nd Floor, Conference Room 240. Potential respondents
also have the option to listen-in to the Pre-Proposal Conference via teleconference. Call-in
information: 1-(877)-226-9790. To access the teleconference enter 2722551# to listen-in.
Those respondents that plan to listen-in may submit their questions prior to the Pre-Proposal
Conference via email by 2:00 P.M. (CT), 3/13/2015, to the designated RFP Point of Contact
mailbox Vonda.white@hhsc.state.tx.us. Questions will not be accepted over the phone
during the Vendor Conference.
The purpose of this conference will be to discuss the requirements of the RFP, work to be
performed under the contract, and address any other unanswered questions. The conference
is for information purposes only. Any answers furnished will not be official until verified in
writing by HHSC in the HHSC Business Opportunities website at:
http://www.hhsc.state.tx.us/about_hhsc/BusOpp/contract-opportunities.asp.
Written
questions may be submitted at the conference, and answers will be posted to HHSC website.
Refer to Section I.D. Schedule of Events for the deadline to submit questions and the
anticipated posting date of the answers on the HHSC website.
HHSC strongly recommends, but does not require, attendance at the conference. Attendees
should bring their copy of this RFP to the conference as copies will not be available for
hand-outs. Any respondent considering subcontracting will benefit from the information
regarding HUB Subcontracting Plan instructions and reporting.
C. Proposal Due Date
The proposal must be received on or before the following date and time:
2:00 P.M. CT on the date specified in Section I. D. Schedule of Events.
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Community Diabetes Education Programs RFP# 537-16-140303
D. Submission
The original proposal and five (5) additional hard copies plus one copy on electronic media
such as compact disc or flash drive must be submitted on or before the due date to the
RFP point of contact at the address specified in Section III. A. RFP Point of Contact.
DSHS will not accept proposals by fax or email.
If a proposal is sent by overnight mail or hand-delivered to the DSHS address above, the
respondent should request a receipt at the time of delivery to verify the proposal was
received on or before the proposal due date and time. Hand-delivered proposals must be
delivered to the room number identified in Section III. A. RFP Point of Contact. This is
the only official date and time stamp accepted as verification of receipt.
If a proposal is mailed, it is considered as meeting the deadline if it is delivered to the correct
address as reflected in Section III. A. RFP Point of Contact and received by HHSC on or
before the due date and time.
Respondents sending proposals by the United States Postal Service or commercial delivery
services must ensure the carrier will be able to guarantee delivery of the proposal by the due
date and time. DSHS may make exceptions only for natural disasters or catastrophes in the
affected area as determined by DSHS. The respondent must submit to the RFP contact
proper documentation that reflects the above exceptions before DSHS can consider the
proposal as having been received by the deadline. It is the respondent’s responsibility to
ensure timely delivery of the proposal as required by this RFP.
Proposals that do not meet the above criteria will not be eligible for competition.
IV.
PROPOSAL SCREENING AND EVALUATION
Proposals will be reviewed according to the criteria below. To maximize fairness for all
proposals during review, DSHS staff may only confirm receipt of a proposal and are not
permitted to discuss the proposal or its review during the review process. All proposals remain
with DSHS and will not be returned to the respondent.
A. Screening Process
Proposals are initially screened for eligibility and completeness. The preliminary screening
or eligibility criteria requirements include the following:
1. Proposal received on or before the proposal due date and time.
2. The original proposal bears an original signature of the authorized official of
the respondent organization on Form A. Face Page.
3. Historically Underutilized Business (HUB) subcontracting plan that meets
HUB requirements is included. Note to All Respondents: Texas law
provides that a proposal submitted in response to this RFP that does not
contain a HUB subcontracting plan is non-responsive, in accordance with
Texas Government Code § 2161.252.
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Community Diabetes Education Programs RFP# 537-16-140303
4. Form D: Administrative Information will be used in the initial screening
process. This information may be used to exclude a proposal from review at
the sole discretion of DSHS.
In conducting the screening process, HHSC at its sole discretion may give respondents an
opportunity to submit missing information or correct identified areas of noncompliance
within a specified period of time. In such an instance, if no new information is received by
the stated deadline, the proposal will be screened as is or may be disqualified from the
evaluation process. Information submitted after the deadline will not be part of the
evaluation.
HHSC reserves the right to waive irregularities that HHSC in its sole discretion determines
to be minor. If such irregularities are waived, similar irregularities in all proposals will be
waived.
PROPOSALS MAY BE EXCLUDED FROM REVIEW AND EVALUATION BASED
ON THE SCREENING PROCESS OR ADMINISTRATIVE INFORMATION
PROVIDED ON FORM D.
B. Evaluation Process
Proposals that successfully pass the initial screening will be evaluated by an evaluation team
consisting of DSHS employees with expertise in diabetes and chronic disease, service
delivery, and/or public health using a standardized scoring instrument. In addition, past
performance may be used as evaluation criteria if there are quantitative performance
measures available.
Respondents must set forth a proposal that is full, accurate, and complete, as required by this
RFP. Respondents should not assume that the readers of their proposals are familiar
with their specific operation. Requests for information in the RFP should be answered
fully, in order and in accordance with the specified instructions.
Review and evaluation of proposals will be conducted using a uniform scoring tool in which
each requirement and activity outlined in FORM F: Respondent Background, FORM G:
Assessment Narrative, FORM H: Performance Measures, FORM I: Work Plan, and
Appendix A: Budget.
In the event an item of non-compliance appears in a significant number of proposals,
suggesting a possible lack of clarity in the RFP, HHSC at its sole discretion, may give all
respondents an opportunity to correct the identified areas of noncompliance within a
specified period of time. In such an instance, if no new information is received by the stated
deadline, the proposal will be evaluated as is. Information submitted after the deadline will
not be part of the evaluation.
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Community Diabetes Education Programs RFP# 537-16-140303
C. Evaluation Criteria
Each funding opportunity (Tier 1 or Tier 2) included in the Respondents proposal will be
evaluated separately. DSHS will evaluate proposals based on the following best value
criteria, listed in order of precedence:
FORM I: Work Plan
FORM G: Assessment Narrative
FORM H: Performance Measures
APPENDIX A: Budget (All forms)
FORM F: Respondent Background
D. Selection, Negotiation, and Award
Funding awards will be based on evaluation scores, availability of funds, area/community
need, geographical coverage or other factors, and the best interest of the State in providing
services under this RFP. Priority will be given to Tier 2 programs; however,
area/communities of need will be considered when awarding funding.
The final funding amount and the provisions of the contract will be determined at the sole
discretion of DSHS staff. Any exceptions to the requirements in the RFP sought by the
respondent will be specifically detailed in writing by the respondent in the proposal
submitted to DSHS for consideration. DSHS will accept or reject each proposed exception
The specific dollar amount awarded to each successful respondent will depend upon the
merit and scope of the proposal and other best value considerations. Not all respondents
who are deemed eligible to receive funds are assured of receiving an award.
In making awards, DSHS priorities for funding will be given to, not in order of priority:

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
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Programs demonstrating administrative capacity to implement a diabetes
prevention and control program;
Programs demonstrating an effective, realistic plan to integrate their proposed
services into the existing network of health systems and community services;
Programs collaborating with health systems;
Programs that have membership in a diabetes or chronic disease-related coalition
or advisory board (e.g., alliance, committee, council);
Programs demonstrating coordination with a Community Health Center (CHC),
Federally Qualified Health Center (FQHC), or another type of healthcare system;
Programs using Community Health Workers;
Programs targeting adults 18 years or older and their families;
Programs targeting the uninsured and/or underinsured;
Programs targeting low socioeconomic populations;
Programs targeting geographic areas with populations with high prevalence and
burdens of diabetes, including morbidity and mortality;
Programs serving the largest possible number of persons with diabetes and/or
people at high risk for developing diabetes;
Programs implemented in a variety of settings (e.g., urban and rural);
Community Diabetes Education Programs RFP# 537-16-140303



Programs implemented in areas where DSME program gaps have been identified
using telehealth;
Programs currently applying for or have received ADA recognition or AADE
accreditation (Tier 2 only); and
Programs planning to apply for the CDC Diabetes Prevention Recognition
Program, if eligible
The negotiation phase will involve direct contact between the potential contractor, HHSC
and DSHS representatives via phone. During negotiations, potential contractors may expect:


An in-depth discussion of the submitted proposal and budget; and
Requests from DSHS for clarification or additional detail regarding submitted
proposal.
The final funding amount and the provisions of the contract will be determined at the sole
discretion of DSHS staff.
Any exceptions to the requirements, terms, conditions, or certifications in the RFP or
attachments, addendums, or revisions to the RFP or General Provisions, sought by the
respondent must be specifically detailed in writing by the respondent on Form E:
Exception Form in this proposal and submitted to DSHS for consideration. DSHS will
accept or reject each proposed exception. DSHS will not consider exceptions submitted
separately from the respondent’s proposal or at a later date.
HHSC will post to the HHSC Business Opportunities Website a list of respondents whose
proposals are selected for tentative award. This posting does not constitute DSHS’s
agreement with all the terms of any respondent’s proposal and does not bind DSHS to enter
into a contract with any respondent whose tentative award is posted.
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Community Diabetes Education Programs RFP# 537-16-140303
V.
DSHS ADMINISTRATIVE INFORMATION
A. Rejection of Proposals
1. PCS reserves the right to reject any or all proposals and is not liable for any
costs incurred by the respondent in the development or submission of the
proposal.
2. Any attempt by an employee, officer, or agent of the respondent to influence
the outcome of PCS’s review through contact with any Commissioner or staff
member of PCS or other Texas Health and Human Services agency will result
in rejection of the proposal.
3. Any material misrepresentation in a proposal submitted to PCS will result in
rejection of the proposal.
4. Form D: Administrative Information. Information supplied on this form will
be used in the screening, evaluation, and/or rejection of any proposal.
5. Proposals may be rejected for failure to meet screening criteria or respondent
eligibility criteria.
B. Right to Amend or Withdraw RFP
PCS reserves the rights to alter, amend, or modify any provisions of this RFP or to withdraw
this RFP at any time prior to the execution of a contract if it is in the best interest of DSHS
and the State of Texas. The decision of PCS is administratively final. Amendment or notice
of withdrawal of the RFP will be posted to the ESBD. It is the sole responsibility of the
respondent to check the ESBD throughout the RFP process for changes and/or updates to
this RFP.
C. Authority to Bind DSHS
For the purposes of this RFP, the only individuals who may legally commit DSHS to the
expenditure of public funds under the contract are the Commissioner of DSHS, Assistant
Commissioner, Chief Financial Officer or Chief Operating Officer, or the employee
designated to act in place of one of those employees through commissioner’s directive
relating to line of authority, CD-2005.02. No costs chargeable to the proposed contract will
be reimbursed before the contract is fully executed.
D. Financial and Administrative Requirements
General Provisions
1. All contractors under this RFP must comply with the DSHS General Provisions posted
on the HHSC Business Opportunities website with this RFP. The General Provisions are
also located at: http://www.dshs.state.tx.us/grants/gen-prov.shtm.
Respondent is not required to return the General Provisions or DSHS Assurances and
Certifications with its proposal. By signing the Form A: Face Page, respondent is agreeing
to abide by the referenced General Provisions and DSHS Assurances and Certifications.
2. All contractors under this solicitation must comply with applicable cost principles, audit
requirements, and administrative requirements. Form K. Financial Management and
Administrative Questionnaire is required.
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Community Diabetes Education Programs RFP# 537-16-140303
By accepting an award from the Department of State Health Services (DSHS) your
organization and the Board of Directors or other oversight authority accept responsibility
for complying with the management and administration of programmatic, financial and
reporting requirements of the award. Communication and coordination between the
organization’s program implementation and financial staff is essential for the success of the
project being funded by the award. It is critical that staff responsible for the programmatic
and accounting functions is aware of the financial and administrative requirements
applicable to grants and subgrants. Key personnel within the organization should be
identified and assigned responsibilities for the programmatic, financial and administrative
requirements applicable to the DSHS award.
All DSHS contractors are required to maintain a financial management system that meets
federal and state standards for expending and accounting for funds received under an award.
Documents and records must be maintained that identify the receipt and expenditure of
funds separately for each DSHS contract and/or program attachment and will record
expenditures by the budget cost categories in the approved budget for a cost reimbursement
program attachment. This requires establishing within the chart of accounts and general
ledger, a separate set of accounts for each program attachment. All financial reports should
be prepared with information that comes directly from the organization’s accounting
system. There should be a reconciliation of the information that is reported to amounts
recorded in the accounting system.
Additional requirements on basic accounting and financial management systems are found
in DSHS General Provisions, Allowable Costs and Audit Requirements and the DSHS
Contractor Financial Procedures Manual. Copies of the procedures manual are available
online at http://www.dshs.state.tx.us/contracts/cfpm.shtm. OMB Circulars may be found at
http//www.whitehouse.gov/omb/circulars. Internet links to laws and regulations applicable
to the financial and administrative requirements of grants and sub grants are provided
below.
Circulars (CFRs):http://www.whitehouse.gov/omb/grants/grants_circulars.html
Federal agency common rules: http://www.whitehouse.gov/omb/grants/chart.html
Code of Federal Regulations: http://www.access.gpo.gov/nara/cfr/cfr-table-search.html
Uniform Grant Management Standards:
http://governor.state.tx.us/files/state-grants/UGMS062004.doc
Federal Department of Health and Human Services, Grants Policy Statement:
http://www.hhs.gov/grantsnet/adminis/gpd/
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Community Diabetes Education Programs RFP# 537-16-140303
E. Contracting with Subcontractors
The selected contractor may enter into contracts with subrecipient subcontractors unless
restricted or otherwise prohibited in a specific Program Attachment(s). Prior to entering into
an agreement equaling or exceeding $100,000, Contractor shall obtain written approval from
DSHS. The contractor is responsible to DSHS for the performance of any subcontractor or
sub-grantee.
If the selected respondent enters into contracts with vendor or subrecipient subcontractors,
the documents must be in writing and must comply with the requirements specified in
articles of the General Provisions posted in conjunction with this RFP
F. DSHS Historically Utilized Business Participation
In accordance with Texas Government Code Chapter 2161, Subchapter F, §2161.252 (b) a proposal
that does not contain a HUB Subcontracting Plan (HSP) is non-responsive and will be rejected without
further evaluation. In addition, if HHSC determines that the HSP was not developed in good faith,
it will reject the proposal for failing to comply with material RFP specifications.
1. Introduction
HHSC is committed to promoting full and equal business opportunities for businesses in state
contracting in accordance with the goals specified in the State of Texas Disparity Study. HHSC
encourages the use of Historically Underutilized Businesses (HUBs) through race, ethnic and genderneutral means. HHSC has adopted administrative rules relating to HUBs and a Policy on the Utilization
of HUBs which is located on HHSC’s website.
Pursuant to Texas Government Code §2161.181 and §2161.182 and HHSC’s HUB policy and rules,
HHSC is required to make a good faith effort to increase HUB participation in its contracts. HHSC may
accomplish the goal of increased HUB participation by contracting directly with HUBs or indirectly
through subcontracting opportunities.
2. HHSC’s Administrative Rules
HHSC has adopted the CPA’s HUB rules as its own. HHSC’s rules are located in the Texas
Administrative Code Title 1, Part 15, Chapter 392, Subchapter J and the CPA rules are located in Texas
Administrative Code Title 34, Part 1, Chapter 20, Subchapter B. If there are any discrepancies between
HHSC’s administrative rules and this RFP, the rules shall take priority.
3. Statewide Annual HUB Utilization Goal
The CPA has established statewide annual HUB utilization goals for different categories of contracts
in Texas Administrative Code Title 34, Part 1, Chapter 20, Subchapter B, §20.13 of the HUB rules. In
order to meet or exceed the statewide annual HUB utilization goals, HHSC encourages outreach to
certified HUBs. Contractors shall make a good faith effort to include certified HUBs in the procurement
process.
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Community Diabetes Education Programs RFP# 537-16-140303
This procurement is classified as an All Other Services procurement under the CPA rule and therefore
has a statewide annual HUB utilization goal of 26.0% per fiscal year.
4. Required HUB Subcontracting Plan
In accordance with Texas Government Code Chapter 2161, Subchapter F, §2161.252 each state agency
that considers entering into a contract with an expected value of $100,000 or more over the life of the
contract (including any renewals) shall, before the agency solicits bids, proposals, offers, or other
applicable expressions of interest, determine whether subcontracting opportunities are probable under
the contract.
In accordance with Texas Administrative Code Title 34, Part 1, Chapter 20, Subchapter B,
§20.14(a)(1)(C) of the HUB Rule, state agencies may determine that subcontracting is probable for only
a subset of the work expected to be performed or the funds to be expended under the contract. If an
agency determines that subcontracting is probable on only a portion of a contract, it shall document its
reasons in writing for the procurement file.
HHSC has determined that subcontracting opportunities are probable for this RFP. As a result, the
respondent must submit an HSP with its proposal. The HSP is required whether a respondent intends to
subcontract or not.
In the HSP, a respondent must indicate whether it is a Texas certified HUB. Being a certified HUB does
not exempt a respondent from completing the HSP requirement.
HHSC shall review the documentation submitted by the respondent to determine if a good faith effort
has been made in accordance with solicitation and HSP requirements. During the good faith effort
evaluation, HHSC may, at its discretion, allow revisions necessary to clarify and enhance information
submitted in the original HSP.
If HHSC determines that the respondent’s HSP was not developed in good faith, the HSP will be
considered non-responsive and will be rejected as a material failure to comply with advertised
specifications. The reasons for rejection shall be recorded in the procurement file.
5.
CPA Centralized Master Bidders List
Respondents may search for HUB subcontractors in the CPA’s Centralized Master Bidders List
(CMBL) HUB Directory, which is located on the CPA’s website at
http://www2.cpa.state.tx.us/cmbl/cmblhub.html. For this procurement, HHSC has identified the
following class and item codes for potential subcontracting opportunities:
National Institute of Governmental Purchasing (NIGP) Class/Item Code:





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Class 206 Item 28:Computer Systems
Class 208 Item 60:Medical Services
Class 924 Item 16:Course Development Services, Instructional/Training
Class 966 Item 31:Envelope Printing
Class 966 Item 36:Forms Printing
Community Diabetes Education Programs RFP# 537-16-140303
Respondents are not required to use, nor limited to using, the class and item codes identified above, and
may identify other areas for subcontracting.
HHSC does not endorse, recommend nor attest to the capabilities of any company or individual listed
on the CPA’s CMBL. The list of certified HUBs is subject to change, so respondents are encouraged to
refer to the CMBL often to find the most current listing of HUBs.
6. HUB Subcontracting Procedures – If a Respondent Intends to Subcontract
A HSP must demonstrate that the respondent made a good faith effort to comply with HHSC’s HUB
policies and procedures. The following subparts outline the items that HHSC will review in
determining whether an HSP meets the good faith effort standard. A respondent that intends to
subcontract must complete the HSP to document its good faith efforts.
For step-by-step audio/video instructions on how to complete the HSP, you may also visit the CPA’s
website at: http://www.cpa.state.tx.us/procurement/prog/hub/hub-subcontracting-plan/.
6.1
Identify Subcontracting Areas and Divide Them into Reasonable Lots
A respondent should first identify each area of the contract work it intends to subcontract. Then,
to maximize HUB participation, it should divide the contract work into reasonable lots or
portions, to the extent consistent with prudent industry practices.
6.2
Notify Potential HUB Subcontractors
The HSP must demonstrate that the respondent made a good faith effort to subcontract with
HUBs. The respondent’s good faith efforts shall be shown through utilization of all methods in
conformance with the development and submission of the HSP and by complying with the
following steps:
Divide the contract work into reasonable lots or portions to the extent consistent with prudent
industry practices. The respondent must determine which portions of work, including goods and
services, will be subcontracted.
Use the appropriate method(s) to demonstrate good faith effort. The respondent can use either
method(s) 1, 2, 3, 4 or 5:
6.3
Method 1: Respondent Intends to Subcontract with only HUBs:
The respondent must identify in the HSP the HUBs that will be utilized and submit written
documentation that confirms 100% of all available subcontracting opportunities will be
performed by one or more HUBs; or,
6.4 Method 2: Respondent Intends to Subcontract with HUB Protégé(s):
The respondent must identify in the HSP the HUB protégé’(s) that will be utilized and
should:
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Community Diabetes Education Programs RFP# 537-16-140303
 Include a fully executed copy of the Mentor Protégé Agreement, which must be
registered with the CPA prior to submission to HHSC; and
 Identify areas of the HSP that will be performed by the Protégé
HHSC will accept a Mentor Protégé Agreement that has been entered into by a respondent
(Mentor) and a certified HUB (protégé) in accordance with Texas Government Code §2161.065.
When a respondent proposes to subcontract with a protégé(s), it does not need to provide notice
to 3 HUB vendors for that subcontracted area.
Participation in the Mentor Protégé Program, along with submission of a protégé as a
subcontractor in an HSP, constitutes a good faith effort for the particular area subcontracted to
the protégé, or,
6.5
Method 3: Respondent Intends to Subcontract with HUBs and Non-HUBs
(Meet or Exceed the Goal):
The respondent must identify in the HSP and submit written documentation that one or more
HUB subcontractors will be utilized; and that the aggregate expected percentage of subcontracts
with HUBs will meet or exceed the goal specified in this solicitation. When utilizing this
method, only HUB subcontractors that has existing contracts with the respondent for five years
or less may be used to comply with the good faith effort requirements.
When the aggregate expected percentage of subcontracts with HUBs meets or exceeds the goal
specified in this solicitation, respondents may also use non-HUB subcontractors; or,
6.6
Method 4: Respondent Intends to Subcontract with HUBs and Non-HUBs
(Does Not Meet or Exceed the Goal):
The respondent must identify in the HSP and submit documentation regarding both of the
following requirements:
 Written notification to minority or women trade organizations or development
centers to assist in identifying potential HUBs of the subcontracting opportunities the
respondent intends to subcontract.
Respondents must give minority or women trade organizations or development centers at least
seven (7) working days prior to submission of the respondent's response for dissemination of
the subcontracting opportunities to their members. A list of minority and women trade
organizations is located on CPA's website under the Minority and Women Organization link.

Written notification to at least three (3) HUB businesses of the subcontracting opportunities
that the respondent intends to subcontract. The written notice must be sent to potential HUB
subcontractors prior to submitting proposals and must include:





Page 33
a description of the scope of work to be subcontracted;
information regarding the location to review project plans or specifications;
information about bonding and insurance requirements;
required qualifications and other contract requirements; and
a description of how the subcontractor can contact the respondent.
Community Diabetes Education Programs RFP# 537-16-140303

Respondents must give potential HUB subcontractors a reasonable amount of time to respond
to the notice, at least seven (7) working days prior to submission of the respondent's response
unless circumstances require a different time period, which is determined by the agency and
documented in the contract file;

Respondents must also use the CMBL, the HUB Directory, and Internet resources when
searching for HUB subcontractors. Respondents may rely on the services of contractor
groups; local, state and federal business assistance offices; and other organizations that
provide assistance in identifying qualified applicants for the HUB program.
Written Justification of the Selection Process
HHSC will make a determination if a good faith effort was made by the respondent in the
development of the required HSP. One or more of the methods identified in the previous
sections may be applicable to the respondent’s good faith efforts in developing and submission
of the HSP. HHSC may require the respondent to submit additional documentation explaining
how the respondent made a good faith effort in accordance with the solicitation.
A respondent must provide written justification of its selection process if it chooses a non-HUB
subcontractor. The justification should demonstrate that the respondent negotiated in good faith
with qualified HUB bidders, and did not reject qualified HUBs who were the best value
responsive bidders.
6.7
Method 5: Respondent Does Not Intend to Subcontract
When the respondent plans to complete all contract requirements with its own equipment,
supplies, materials and/or employees, it is still required to complete an HSP.
The respondent must complete the “Self Performance Justification” portion of the HSP, and
attest that it does not intend to subcontract for any goods or services, including the class and
item codes identified in Section 5. In addition, the respondent must identify the sections of the
proposal that describe how it will complete the Scope of Work using its own resources or
provide a statement explaining how it will complete the Scope of Work using its own resources.
The respondent must agree to comply with the following if requested by HHSC:




7.
provide evidence of sufficient respondent staffing to meet the RFP requirements;
provide monthly payroll records showing the respondent staff fully dedicated to the
contract;
allow HHSC to conduct an on site review of company headquarters or work site where
services are to be performed and,
provide documentation proving employment of qualified personnel holding the necessary
licenses and certificates required to perform the Scope of Work.
Post-award HSP Requirements
The HSP shall be reviewed and evaluated prior to contract award and, if accepted, the finalized HSP
will become part of the contract with the successful respondent(s).
After contract award, HHSC will coordinate a post-award meeting with the successful respondent to
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Community Diabetes Education Programs RFP# 537-16-140303
discuss HSP reporting requirements. The contractor must maintain business records documenting
compliance with the HSP, and must submit monthly subcontract reports to HHSC by completing the
HUB HSP Prime Contractor Progress Assessment Report. This monthly report is required as a condition
for payment to report to the PCS the identity and the amount paid to all subcontractors.
As a condition of award, the Contractor is required to send notification to all selected subcontractors as
identified in the accepted/approved HSP. In addition, a copy of the notification must be provided to the
agency’s Contract Manager and/or HUB Program Office within 10 days of the contract award.
During the term of the contract, if the parties in the contract amend the contract to include a change to
the scope of work or add additional funding, HHSC will evaluate to determine the probability of
additional subcontracting opportunities. When applicable, the Contractor must submit an HSP change
request for HHSC review. The requirements for an HSP change request will be covered in the postaward meeting.
When making a change to an HSP, the Contractor will obtain prior written approval from HHSC before
making any changes to the HSP. Proposed changes must comply with the HUB Program good faith
effort requirements relating to the development and submission of a HSP.
If the Contractor decides to subcontract any part of the contract after the award, it must follow the good
faith effort procedures outlined in Section 4.6 of this RFP (e.g., divide work into reasonable lots, notify
at least three (3) vendors per subcontracted area, provide written justification of the selection process,
and/or participate in the Mentor Protégé Program).
For this reason, HHSC encourages respondents to identify, as part of their HSP, multiple subcontractors
who are able to perform the work in each area the respondent plans to subcontract. Selecting additional
subcontractors may help the selected contractor make changes to its original HSP, when needed, and
will allow HHSC to approve any necessary changes expeditiously.
Failure to meet the HSP and post-award requirements will constitute a breach of contract and will be
subject to remedial actions. HHSC may also report noncompliance to the CPA in accordance with the
provisions of the Vendor Performance and Debarment Program.
G. Contract Information
DSHS will monitor contractors’ expenditures. A contractor’s budget may be subject to a
decrease for the remainder of the budget period if expenditure percentages are below the
amount projected and determined by DSHS. Vacant positions existing after ninety (90) days
may result in a decrease in funds. DSHS reserves the right to adjust the funding allocation to
contractors pursuant to the terms of the contract.
H. Contract Award Protest Procedures
Texas Administrative Code, Title 1, Part 15, Chapter 392, Subchapter C outlines HHSC’s respondent protest
procedures.
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Community Diabetes Education Programs RFP# 537-16-140303
CONTENT AND PREPARATION
VI.
PROPOSAL CONTENT
A. Instructions for Preparation
The proposal must be developed and submitted in accordance with the instructions outlined in
this section. The proposal should meet the following stylistic requirements:
 All pages clearly and consecutively numbered;
 Original and one additional copy unbound, but secured with binder clips or
rubber bands;
 Typed (computer or typewriter);
 No less than single-spaced;
 No less than12-point font on 8 1/2" x 11" paper with 1" margins;
 Black print on white paper;
 Blank forms provided in SECTION VII. BLANK FORMS AND
INSTRUCTIONS must be used (electronic reproduction of the forms is
acceptable; however, all forms must be identical to the original form(s)
provided); do not change the font used on forms provided.
 Signed in ink by an authorized official (copies must be signed but need not
bear an original signature);
 Envelope/package containing the proposal must clearly identify the
respondent’s legal name and mailing address as reflected on Form A: Face
Page.
 Envelope/package containing the proposal must clearly identify the name and
number of the RFP as reflected on the cover page of this RFP.
 An electronic disc or flash drive copy must be included.
Specific instructions for each required section are provided. Instructions for completing
forms are found on each form.
B. Confidential Information
The respondent must clearly designate any portion(s) of this proposal that contains
confidential information and state the reasons the information should be designated as such.
Marking the entire proposal as confidential will be neither accepted nor honored. If any
information is marked as confidential in the proposal, DSHS will determine whether the
requested information may be excepted from disclosure under the Public Information Act,
Texas Government Code, Chapter 552. If it constitutes an exception, and if a request is
made by any other entity or individual for the information marked as confidential, the
information will be forwarded to the Texas Attorney General along with a request for a
ruling on its confidentiality. Respondents are advised to consult with their legal counsel
regarding disclosure issues and to take the appropriate precautions to safeguard trade secrets
or any other confidential information. Following the award of any contract, proposals to this
RFP are subject to release as public information unless any proposal or specific parts of any
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Community Diabetes Education Programs RFP# 537-16-140303
proposal can be shown to be exempt from disclosure under the Public Information Act,
Texas Government Code, Chapter 552.
C. Table of Contents
THE PROPOSAL SHOULD INCLUDE A TABLE OF CONTENTS AND BE
ORGANIZED AND ARRANGED IN THE FOLLOWING ORDER:
Form A.
Face Page - Proposal for Financial Assistance
Form B.
Proposal Table of Contents and Checklist
Form C.
Contact Person Information
Form D.
Administrative Information – attach required information
Form E.
Exceptions Form
Form F.
Respondent Background
Form G.
Assessment Narrative
Form H.
Performance Measures
Form I.
Work Plan
Form J.
Child Support Certification [required - applies to for-profit
entities only]
Form K.
Financial Management and Administration Questionnaire
Appendix A. Budget – Budget Section forms and instructions are posted
separately on ESBD
Appendix C.
HUB Subcontracting Plan
Appendix D. Work Plan Template (Part B)
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Community Diabetes Education Programs RFP# 537-16-140303
VII.
BLANK FORMS AND INSTRUCTIONS
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Community Diabetes Education Programs RFP# 537-16-140303
Department of State Health Services
FORM A: FACE PAGE
Proposal for Financial Assistance #537-16-140303
This form requests basic information about the respondent and project, including the
signature of the authorized representative. The face page is the cover page of the proposal and must be completed in its
entirety.
RESPONDENT INFORMATION
1) LEGAL BUSINESS NAME:
2) MAILING Address Information (include mailing address, street, city, county, state and 9-digit zip code):
Check if address change
3) PAYEE Name and Mailing Address, including 9-digit zip code (if different from above):
Check if address change
4)
DUNS Number (9-digit) required if receiving federal funds:
5) Federal Tax ID No. (9-digit), State of Texas Comptroller Vendor ID Number (14-digit) or
Social Security Number (9-digit):
*The respondent acknowledges, understands and agrees that the respondent's choice to use a social security number as the vendor identification number for the
contract, may result in the social security number being made public via state open records requests.
6) TYPE OF ENTITY (check all that apply):
City
County
Other Political Subdivision
State Agency
Indian Tribe
Nonprofit Organization*
For Profit Organization*
HUB Certified
Community-Based Organization
Minority Organization
Faith Based (Nonprofit Org)
*If incorporated, provide 10-digit charter number assigned by Secretary of State:
7) PROPOSED BUDGET PERIOD:
Start Date:
Individual
Federally Qualified Health Centers
State Controlled Institution of Higher Learning
Hospital
Private
Other (specify):
[fill in date]
End Date:
[fill in date]
8) COUNTIES SERVED BY PROJECT:
9) AMOUNT OF FUNDING REQUESTED:
11) PROJECT CONTACT PERSON
10) PROJECTED EXPENDITURES
Does respondent’s projected federal expenditures exceed $500,000,
or its projected state expenditures exceed $500,000, for respondent’s
current fiscal year (excluding amount requested in line 9 above)? **
Yes
No
**Projected expenditures should include anticipated expenditures under all
federal grants including “pass through” federal funds from all state agencies,
or all anticipated expenditures under state grants, as applicable.
Name:
Phone:
Fax:
Email:
12) FINANCIAL OFFICER
Name:
Phone:
Fax:
Email:
The facts affirmed by me in this proposal are truthful and I warrant the respondent is in compliance with the assurances and certifications contained in
APPENDIX B: DSHS Assurances and Certifications. I understand the truthfulness of the facts affirmed herein and the continuing compliance with these
requirements are conditions precedent to the award of a contract. This document has been duly authorized by the governing body of the respondent and I (the
person signing below) am authorized to represent the respondent.
13) AUTHORIZED REPRESENTATIVE
Name:
Title:
Phone:
Fax:
Email:
Page 39
Check if change
14) SIGNATURE OF AUTHORIZED REPRESENTATIVE
15) DATE
Community Diabetes Education Programs RFP# 537-16-140303
FORM A: FACE PAGE INSTRUCTIONS
This form provides basic information about the respondent and the proposed project with the
Department of State Health Services (DSHS), including the signature of the authorized representative.
It is the cover page of the proposal and is required to be completed. Signature affirms the facts
contained in the respondent’s response are truthful and the respondent is in compliance with the
assurances and certifications contained in APPENDIX B: DSHS Assurances and Certifications and
acknowledges that continued compliance is a condition for the award of a contract. Please follow the
instructions below to complete the face page form and return with the respondent’s proposal.
1)
LEGAL BUSINESS NAME - Enter the legal name of the respondent.
2)
MAILING ADDRESS INFORMATION - Enter the respondent’s complete physical address and mailing address, city, county,
state, and 9-digit zip code.
3)
PAYEE NAME AND MAILING ADDRESS - Payee – Entity involved in a contractual relationship with respondent to receive
payment for services rendered by respondent and to maintain the accounting records for the contract; i.e., fiscal agent. Enter the
PAYEE’s name and mailing address, including 9-digit zip code, if PAYEE is different from the respondent. The PAYEE is the
corporation, entity or vendor who will be receiving payments.
4)
DUNS Number – 9- digit Dun and Bradstreet Data Universal Numbering System (DUNS) number. . This number is required if
receiving ANY federal funds and can be obtained at: http://fedgov.dnb.com/webform
5)
FEDERAL TAX ID or STATE OF TEXAS COMPTROLLER VENDOR ID NUMBER OR SOCIAL SECURITY NUMBER
- Enter the Federal Tax Identification Number (9-digit) or the Texas Vendor Identification Number assigned by the Texas State
Comptroller (14-digit). *The respondent acknowledges, understands and agrees the respondent's choice to use a social security
number as its vendor identification number for the contract, may result in the social security number being made public via state open
records requests.
6)
TYPE OF ENTITY - Check the type of entity as defined by the Secretary of State at
http://www.sos.state.tx.us/corp/businessstructure.shtml
and/or the Texas State Comptroller at https://fmx.cpa.state.tx.us/fmx/pubs/tins/tinsguide/2009-04/TINS_Guide_0409.pdf and check
all other boxes that describe the entity.
Historically Underutilized Business: A minority or women-owned business as defined by Texas Government Code, Title 10, Subtitle
D, Chapter 2161. (http://www.window.state.tx.us/procurement/prog/hub/)
State Agency: an agency of the State of Texas as defined in Texas Government Code §2056.001.ii
Institutions of higher education as defined by §61.003 of the Education Code.
MINORITY ORGANIZATION is defined as an organization in which the Board of Directors is made up of 50% racial or ethnic
minority members.
If a Non-Profit Corporation or For-Profit Corporation, provide the 10-digit charter number assigned by the Secretary of State.
7)
PROPOSED BUDGET PERIOD - Enter the budget period for this proposal. Budget period is defined in the RFP. [To be
completed by RFP developer]
8)
COUNTIES SERVED BY PROJECT - Enter the proposed counties served by the project. [If service area is pre-determined, to be
completed by RFP developer]
9)
AMOUNT OF FUNDING REQUESTED - Enter the amount of funding requested from DSHS for proposed project activities (not
including possible renewals). This amount must match column (1) row K from the BUDGET SUMMARY used for cost
reimbursement budgets.
10) PROJECTED EXPENDITURES - If respondent’s projected federal expenditures exceed $500,000 or its projected state
expenditures exceed $500,000 for respondent’s current fiscal year, respondent must arrange for a financial compliance audit (Single
Audit).
11) PROJECT CONTACT PERSON - Enter the name, phone, fax, and email address of the person responsible for the proposed
project.
12)
FINANCIAL OFFICER - Enter the name, phone, fax, and email address of the person responsible for the financial aspects of the
proposed project.
13)
AUTHORIZED REPRESENTATIVE - Enter the name, title, phone, fax, and email address of the person authorized to represent
the respondent. Check the “Check if change” box if the authorized representative is different from previous submission to DSHS.
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Community Diabetes Education Programs RFP# 537-16-140303
14)
15)
SIGNATURE OF AUTHORIZED REPRESENTATIVE - The person authorized to represent the respondent must sign in this
blank.
DATE - Enter the date the authorized representative signed this form.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM B: PROPOSAL TABLE OF CONTENTS AND CHECKLIST
Legal Business Name
of Respondent:
Respondent:
This form is provided as your Table of Contents and to ensure the proposal is complete, proper signatures are included, and
the required assurances, certifications, and attachments have been submitted. Be sure to indicate page number.
FORM
DESCRIPTION
Included
A
Face Page - completed, and proper signatures and date included
B
Proposal Table of Contents and Checklist - completed and included
C
Contact Person Information - completed and included
D
Administrative Information - completed and included (with supplemental
documentation attached if required)
Exceptions Form - completed and included (with supplemental documentation
attached if required)
E
F
Respondent Background - included
G
Assessment Narrative – included
H
Performance Measures - included
I
Work Plan – included
J
Child Support Form
K
APPENDIX
A
HUB Subcontracting Plan
APPENDIX
D
Work Plan Template (Part B)
APPENDIX
J
Class Implementation Plan
APPENDIX
K
Letters of Commitment (FORM G: ASSESSMENT NARRATIVE
GUIDELINES, Part B, 7.)
Letters of Commitment (optional) (FORM G: ASSESSMENT NARRATIVE
GUIDELINES, Part B, 10.)
Letters of Commitment (FORM I: WORK PLAN GUIDELINES
NARRATIVE, Part A, 6g.)
APPENDIX
M
Not
Applicable
Financial Management and Administration Questionnaire
[optional for
proposals with fee-for-service or unit rate budgets - see developer
instructions]
Budget Summary Form and Detail Pages- down load from ESBD completed
and included (with most recently approved indirect cost agreement and letters of
good standing if applicable)
APPENDIX
C
APPENDIX
L
Page #
Do not return the DSHS Assurances and Certifications.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM C: CONTACT PERSON INFORMATION
Legal Business Name
of Respondent:
This form provides information about the appropriate contacts in the respondent’s organization in addition to those on
FORM A: FACE PAGE. If any of the following information changes during the term of the contract, please send written
notification to the Contract Management Unit.
Contact
:Title:
Phone:
Fax:
Email:
Mailing Address (incl. street, city, county, state, & zip):
Ext.
Contact
:Title:
Phone:
Fax:
Email:
Mailing Address (incl. street, city, county, state, & zip):
Ext.
Contact
:Title:
Phone:
Fax:
Email:
Mailing Address (incl. street, city, county, state, & zip):
Ext.
Contact
:Title:
Phone:
Fax:
Email:
Mailing Address (incl. street, city, county, state, & zip):
Ext.
Contact
:Title:
Phone:
Fax:
Email:
Page 43
Mailing Address (incl. street, city, county, state, & zip):
Ext.
Community Diabetes Education Programs RFP# 537-16-140303
FORM D: ADMINISTRATIVE INFORMATION
This form provides information regarding identification and contract history of the respondent, executive management,
project management, governing board members, and/or principal officers. Respond to each request for information or
provide the required supplemental document behind this form. If responses require multiple pages, identify the supporting
pages/documentation with the applicable request.
NOTE: Administrative Information may be used in screening and/or evaluating proposals.
Legal Business Name
of Respondent:
Identifying
Information
ofrespondentresRespo
ndent:
1. The respondent must attach the following information:
If a Governmental Entity complete Form D-1.
 Names (last, first, middle) and addresses for the officials who are authorized to enter into a
contract on behalf of the respondent.
If a Nonprofit or For Profit Entity complete Form D-2.
 Full names (last, first, middle), addresses, telephone numbers, titles and occupation of members
of the Board of Directors or any other principal officers. Indicate the office held by each
member (e.g. chairperson, president, vice-president, treasurer, etc.).
 Full names (last, first, middle), and addresses for each partner, officer, and director as well as
the full names and addresses for each person who owns five percent (5%) or more of the stock
if respondent is a for-profit entity.
2.
Is respondent a nonprofit organization?
YES
NO
If YES, respondent must include evidence of its nonprofit status with the proposal. Any one of the
following is acceptable evidence. Check the appropriate box for the attached evidence.
(a) A copy of a currently valid IRS exemption certificate.
(b) A statement from a State taxing body, State Attorney General, or other appropriate
State official certifying that the respondent organization has a nonprofit status and
that none of the net earnings accrue to any private shareholders or individuals.
(c) A copy of the organization’s certificate of formation or similar document if it clearly
establishes the nonprofit status of the organization.
(d) Any of the above proof for a State or national parent organization, and a statement
signed by the parent organization that the respondent organization is a local nonprofit
affiliate.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM D: ADMINISTRATIVE INFORMATION continued
Conflict of Interest and Contract History
The respondent must disclose any existing or potential conflict of interest relative to the performance of
the requirements of this RFP. Examples of potential conflicts include an existing or potential business
or personal relationship between the respondent, its principal, or any affiliate or subcontractor, with
DSHS, the Health and Human Services Commission, or any other entity or person involved in any way
in any project that is the subject of this RFP. Similarly, any existing or potential personal or business
relationship between the respondent, the principals, or any affiliate or subcontractor, with any employee
of DSHS, or the Health and Human Services Commission must be disclosed. Any such relationship that
might be perceived, or represented as a conflict, must be disclosed. Failure to disclose any such
relationship may be cause for contract termination or disqualification of the proposal. If, following a
review of this information, it is determined by DSHS that a conflict of interest exists, the respondent
may be disqualified from further consideration for the award of a contract.
Pursuant to Texas Government Code Section 2155.004, a respondent is ineligible to receive an award
under this RFP if the bid includes financial participation with the respondent by a person who received
compensation from DSHS to participate in preparing the specifications or the RFP on which the bid is
based.
3.
Does anyone in the respondent organization have an existing or potential conflict of interest
relative to the performance of the requirements of this RFP?
YES
NO
If YES, detail any such relationship(s) that might be perceived or represented as a conflict. (Attach
no more than one additional page.)
4.
Will any person who received compensation from DSHS or Health and Human Services
Commission (HHSC) for participating in the preparation of the specifications or
documentation for this RFP participate financially with respondent as a result of an award
under this RFP?
YES
NO
If YES, indicate his/her name, job title, agency employed by, separation date, and reason for
separation.
5.
Will any provision of services or other performance under any contract that may result from
this RFP constitute an actual or potential conflict of interest or create the appearance of
impropriety?
YES
NO
If YES, detail any such actual or potential conflict of interest that might be perceived or
represented as a conflict. (Attach no more than one additional page.)
6.
Are any current or former employees of the respondent current or former employees of
DSHS or HHSC (within the last 24 months)?
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Community Diabetes Education Programs RFP# 537-16-140303
YES
NO
If YES, indicate his/her name, job title, agency employed by, separation date, and reason for
separation.
7.
Are any proposed personnel related to any current or former employees of DSHS or HHSC?
YES
NO
If YES, indicate his/her name, job title, agency employed by, separation date, and reason for
separation.
8.
Has any member of respondent’s executive management, project management, governing
board or principal officers been employed by DSHS or HHSC 24 months prior to the
proposal due date?
YES
9.
NO
If YES, indicate his/her name, job title, agency employed by, separation date, and reason for
separation.
If the respondent is a private nonprofit organization, does the executive director or other
staff serve as voting members on the organizations governing board?
YES
NO
10. Is respondent or any member of respondent’s executive management, project management,
board members or principal officers:
• Delinquent on any state, federal or other debt;
• Affiliated with an organization which is delinquent on any state, federal or other debt; or
• In default on an agreed repayment schedule with any funding organization?
YES
NO
If YES, please explain. (Attach no more than one additional page.)
11. Has the respondent had a contract suspended or terminated prior to expiration of contract
or not been renewed under an optional renewal by any local, state, or federal department or
agency or non-profit entity?
YES
NO
If YES, indicate the reason for such action that includes the name and contact information of the
local, state, or federal department or agency, the date of the contract and a contract reference
number, and provide copies of any and all decisions or orders related to the suspension,
termination, or non-renewal by the contracting entity.
12. Does this proposal include financial participation by a person or entity that has been
convicted of violating federal law, or been assessed a penalty in a federal civil administrative
enforcement action, in connection with a contract awarded by the federal government for
relief, recovery or reconstruction efforts as a result of Hurricanes Rita or Katrina or any
other disaster occurring after September 24, 2005, under Government Code 2261.053?
YES
NO
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Community Diabetes Education Programs RFP# 537-16-140303
If YES, please explain. (Attach no more than one additional page.)
13. Has respondent had a contract with DSHS within the past 24 months?
YES
NO
If YES, list the DSHS contract and attachment number(s):
DSHS Contract Number(s)
If NO, respondent must be able to demonstrate fiscal solvency. Submit a copy of the organization’s
most recently audited balance sheet, statement of income and expenses and accompanying financial
footnotes. If an organization does not have audited financial statements, submit a copy of the
organization’s most recent IRS Form 990 and an explanation why an audited financial statement is
not available. DSHS will review the documents that are submitted and may, at its sole discretion,
reject the proposal on the grounds of the respondent’s financial capability.
ALL ADDITIONAL PAGES REQUIRED BY RESPONSES TO FORM D, SHOULD BE
INSERTED HERE.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM D-1: GOVERNMENTAL ENTITY
Authorized Officials
Legal Business Name
of Respondent:
Include the full names (last, first, middle) and addresses for the officials who are authorized to enter into
a contract on behalf of the respondent.
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Page 48
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Community Diabetes Education Programs RFP# 537-16-140303
FORM D-2: NONPROFIT OR FOR-PROFIT ENTITY
Board of Directors and Principal Officers
Legal Business Name
of Respondent:
Include the full names (last, first, middle), addresses, telephone numbers, and titles of members of the
Board of Directors or any other principal officers. Indicate the office/title held by each member (e.g.
chairperson, president, vice-president, treasurer, etc.).In addition, if entity is a for-profit, include the full
names and addresses for each person who owns five percent (5%) or more of the stock.
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Name:
Title:
Phone:
Fax:
Email:
Page 49
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Mailing Address (incl. street, city, county, state, &
zip):
Ext.
Community Diabetes Education Programs RFP# 537-16-140303
FORM E: EXCEPTIONS FORM
FORM E: EXCEPTIONS FORM
RFP # 537-16-140303
This is the approved format for the respondent to: (1) state that no exceptions are being made to
the requirements, terms, conditions, or certifications in the RFP or attachments, addendums, or
revisions to the RFP or General Provisions, or (2) list all exceptions to any requirements, terms
conditions, certifications or deliverables in the RFP or General Provisions.
Respondent must submit this form with their response.
Instructions:
 If no exceptions are being requested to any issue of the RFP, respondent must check the ‘no
exception’ box below and leave the table blank.
 If exceptions are being requested, use the table below and fill in all columns for each exception.
 Ensure the RFP section number and page number or the number of the term or condition of the
issue is stated.
 Ensure each exception is described fully or by reference to the exact location within the proposal
and/or general provisions.
 Ensure it is stated whether the exception is part of a proposal deliverable with a clear citation to
the deliverable.
 Provide an explanation of why the exception is being proposed, and any alternatives being
proposed to the issue in the RFP.
 Add more table lines as necessary.
 If more space for explanations or alternatives is reasonably needed, list the exception on this
form and reference the attached page(s) – Ensure each attached page clearly identifies the line
item it refers to.
 Any alternatives may also be embedded in the proposal narrative as appropriate to make the
narrative clear, but in the proposal narrative the exception must be noted with the line item
number on this form.
If no exceptions are being
requested, check this box and
leave the table below blank
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Community Diabetes Education Programs RFP# 537-16-140303
FORM E: EXCEPTIONS FORM
RFP # 537-16-140303
TABLE OF EXCEPTIONS
Exception
No.
RFP Section No.
and Page No. or
no. of term or
condition in the
general
provisions to
which exception
is requested
Full description
of exception
requested or
reference to exact
location of full
description if
found elsewhere
in proposal
and/or general
provisions.
State if the
exception is part
of a proposal
deliverable with a
clear citation to
the deliverable
Explanation of
why the
exception is
being proposed
and any proposed
alternatives to the
issue
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM F: RESPONDENT BACKGROUND
Response Type: ☐ Tier 1 or ☐ Tier 2 (check only one per proposal submission)
Respondent must provide a narrative description. A maximum of two (2) additional pages, including the
organizational chart, may be attached, if needed.
Tier 1 and Tier 2
1. Provide the legal name of the respondent; any affiliations; its overall purpose or mission
statement; goals, and a brief history of its accomplishments related to diabetes prevention and
control or chronic disease prevention and control.
2. Describe the organizational structure, and include an organizational chart. Provide a list of the
respondent’s board of directors, officers, advisory council(s) or board, or list of committees or
other key stakeholders (e.g., Community Health Center, Local Parks and Recreation, Local
Health Departments, etc.).
3. Describe the respondent’s role and experience in the development of healthcare-related
coalitions or advisory boards. Describe the respondent’s participation in diabetes and/or
chronic disease activities currently.
Tier 2 only
4. Describe the respondent’s role and experience in accessing data or utilizing data from health
systems.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM G: ASSESSMENT NARRATIVE
Response Type: ☐ Tier 1
or ☐ Tier 2 (check only one per proposal submission)
Complete the table under Part A, and address each assessment activity under Part B. See
ASSESSMENT NARRATIVE GUIDELINES for instructions on Parts A and B. Both Tier 1 and Tier
2 respondents must complete all parts, unless noted otherwise. A maximum of four (4) additional pages
may be attached if needed.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM G: ASSESSMENT NARRATIVE GUIDELINES
Part A
Complete the table to show assessment sources and dates of sources used to complete Part B. Multiple
data sources and assessments exist for many communities. Respondent is encouraged to use the
following resources when completing the table in Part A:
Diabetes Prevalence: http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm
Mortality: http://soupfin.tdh.state.tx.us/death10.htm
Insurance Coverage:
http://www.texmed.org/Uninsured_in_Texas/
http://www.countyhealthrankings.org/app/texas/2013/rankings/outcomes/overall
Population: http://www.dshs.state.tx.us/chs/popdat/default.shtm
Preventable Hospitalizations:
http://www.dshs.state.tx.us/THCIC/publications/hospitals/PQIReport2011/PreventableHospitalizations2
011.shtm
Tobacco Cessation: http://www.dshs.state.tx.us/tobacco/
HMO Data: http://www.dshs.state.tx.us/thcic/publications/HMOs/HMOReports.shtm
Cost Data:
http://www.hhsc.state.tx.us/reports/2012/direct-indirect-costs-diabetes-texas.pdf
http://professional.diabetes.org/News_Display.aspx?CID=91943
National Diabetes Data and Trends:
http://www.cdc.gov/diabetes/statistics/prevalence_national.htm
AADE-accredited and AADE-recognized Programs in Texas:
http://www.diabeteseducator.org/ProfessionalResources/accred/Programs.html
http://professional.diabetes.org/erp_list.aspx
Texas HHSC Medicaid Transformation Waiver:
http://www.hhsc.state.tx.us/1115-RHP-Plans.shtml
Source of Assessment Data
Page 54
Date of Source
Community Diabetes Education Programs RFP# 537-16-140303
Part B
Address all of the assessment activities listed below:
1. Describe the proposed services area(s), defining in general the:
a. Geographic boundaries (e.g., urban or rural, physical environment, etc.);
b. General demographic data (e.g., age, gender, race, ethnicity, primary language, etc.);
c. General socioeconomic data (e.g., per capita income, poverty levels, unemployment rate,
occupational data, educational attainment, etc.);
d. General description of community-wide health status (e.g., key morbidity/mortality statistics
related to diabetes, etc.); and
e. General description of community-wide health environment (e.g., lack of environment to
foster healthy behaviors, geographic/physical barriers, etc.).
2. Describe the population(s) the respondent is currently serving, including the:
a. Characteristics (i.e., age range, uninsured, under-insured, numbers of clients served, types
and numbers of services provided); and
b. Geographic service area of populations with a high prevalence of diabetes, including
morbidity and mortality.
3. Describe the proposed target population(s) that will be served under this RFP, including the:
a. Characteristics of proposed target population(s). Include demographic and socioeconomic
data relative to the proposed target population(s). Relation to federal poverty level (FPL)
should be included, if known. As an example, eligibility for the state Primary Health Care
Program is at or below 150% of federal poverty level (FPL); and
b. Proposed target population’s health status, as well as population data related to health
indicators, behavioral data, and community opinion data.
4. Describe the resources available to improve the health status of persons with or at-risk for diabetes.
Include current ADA-recognized and/or AADE-accredited DSME programs and CDC-recognized
Diabetes Prevention Programs (DPP) in the proposed service area, if applicable.
5. Describe the potential barriers to improving the health status of persons with or at-risk for diabetes.
6. Tier 1 only
a. Describe the respondent’s capacity to implement a diabetes prevention and control
program, including the respondent’s capacity to serve and experience in serving
populations of low socio-economic backgrounds, racial and/or ethnic minority
populations with disproportionate rates of diabetes, and individuals with limited access to
health care services.
Tier 2 only
b. Describe the respondent’s capacity to implement an ADA-recognized and/or AADEaccredited DSME program. Include the respondent’s capacity to serve and experience of
serving populations of low socio-economic backgrounds, racial and/or ethnic minority
populations with disproportionate rates of diabetes, and individuals with limited access to
health care services.
7. Identify the current diabetes or chronic disease-related coalition(s), advisory board(s), and/or
community organizations/networks in which the respondent maintains membership. As potential
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Community Diabetes Education Programs RFP# 537-16-140303
partners, briefly describe the type of involvement each entity will have in this project. A signed
letter of participation/commitment is required from each partner organization and advisory board.
Letters must be submitted with the application in Appendix K: Letters of Commitment.
8. Describe the respondent’s plan to integrate activities implemented under this RFP into the existing
network of diabetes-related services in the proposed service area.
9. Describe current or previous coordination with Community Health Centers (CHC), Federally
Qualified Health Centers (FQHC), and/or other health systems in the proposed service area.
10. The proposal describes the respondent’s plan to promote the program to healthcare providers, and
develop a referral mechanism within health systems in the proposed service area. A letter of
commitment from one or more entities is recommended but not required. Submit letters in Appendix
L: Letters of Commitment, if applicable.
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Community Diabetes Education Programs RFP# 537-16-140303
FORM H: PERFORMANCE MEASURES GUIDELINES (Tier 1)
Respondent agrees the performance measures will be used to assess, in part, its capacity to
provide the services described in this RFP. The respondent must address all of the requirements
associated with the services proposed in this application.
Form H will document the number of classes to be delivered, including the total anticipated
number of participants who will complete the required series of classes. Performance measures
must include diabetes self-management education. As part of diabetes prevention activities,
performance measures must include nutrition, physical activity, and psychosocial support
groups.
Required performance measures are listed in bold with an asterisk (*):
 Coalition meetings*;
 Diabetes Self-Management Education activities*

Using an approved curriculum—e.g., University of Illinois at Chicago’s Diabetes
Education Empowerment Program (DEEP), Texas AgriLife Extension Service’s
Do Well, Be Well with Diabetes (DWBW), Texas AgriLife Extension Services’s
¡Si, Yo Puedo Controlar Mi Diabetes!, Stanford’s Diabetes Self-Management
Program or other DSHS-approved models*;
 Diabetes prevention (primary prevention) activities, including:*

Nutrition classes

Physical activity classes and

Psychosocial support groups;
 Diabetes self-management support (secondary prevention) activities, including

Nutrition classes;

Physical activity classes;

Psychosocial support groups;
 Healthcare provider education activities* (e.g., presentations to healthcare
providers regarding the TDC Toolkit, including the Minimum Standards of
Diabetes Care in Texas, treatment algorithms);

Number of healthcare providers that will be reached

Number of TDC Toolkits distributed to healthcare providers
 Referrals received from healthcare providers and/or health systems*;
 Program(s)/resources added or updated in 2-1-1 Texas*
 Public information activities such as:
 television (e.g., number of interviews, PSAs, ads at cinemas/movie theaters, etc.)
 radio (e.g., number of interviews, PSAs, etc.)
 distribution of print media (e.g., flyers/brochures, newsletter/newspaper articles,
ads in church bulletins/programs or business inserts, etc.)
 outdoor/mobile advertising (e.g., billboards, bus benches, ads inside buses, etc.)
 website activities (i.e., the number of persons accessing the respondent’s diabetes
prevention and control program-specific website, if applicable)
 Materials distributed to participants* (e.g., National Diabetes Education
Program (NDEP) and TDC/DSHS literature)

NOTE: These materials are to be counted separate from the healthcare provider
education materials distribution;
Page 57
140303
Community Diabetes Education Programs RFP# 537-16-








Percent decrease in average waist circumference from baseline*;
Percent decrease in average BMI from baseline *;
Percent decrease in average A1c from baseline;
Percent decrease in average fasting blood glucose from baseline;
Percent decrease in average blood pressure from baseline *;
Percent decrease in average cholesterol from baseline;
Percent decrease in average triglycerides from baseline;
Percentage of participants receiving recommended exams and immunizations (foot,
eye, dental); and
Clinical measures may be reported by the program’s average or a specified cohort. The program
must comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Refer to http://www.dshs.state.tx.us/hipaa/default.shtm#covered and/or
http://www.hhs.gov/ocr/privacy/ for requirements. Programs must maintain written consent
forms signed by program participants.
DSHS/TDPCP-approved reporting system, sign-in sheets, participant health outcomes forms, and
other forms to be prescribed by DSHS/TDPCP must be used for reporting the progress of
performances measures.
In addition to the performances measures on Form H, programs will be required to track,
document, and report to TDPCP the number of unduplicated participants attending
interventions and the number of referrals to tobacco cessations services.
The data entered on Form H: Performance Measures should consistent with Form I: Work
Plan Narrative (Part A), Work Plan Template (Part B), and Appendix J: Class
Implementation Plan. Compare these documents prior to submission.
The proposed measures and levels of performance will be negotiated and agreed upon by the
respondent and DSHS/TDPCP. However, DSHS program staff is responsible for making final
decisions about target levels of performance.
HOW TO ENTER ENCOUNTERS ON FORM H: PERFORMANCE MEASURES
The number of encounters should reflect an anticipated cumulative number of participants
attending each series of classes (i.e. diabetes self-management, nutrition, physical activity,
psychosocial support groups) and account for a retention rate of 65% or higher when
projecting these numbers.
The number of projected encounters for ALL series and/or classes proposed for FY 2016 will be
aggregated on Appendix J: Class Implementation Plan. Use the corresponding numbers in the
“Total Number of Encounters” column for Form H: Performance Measures.
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Community Diabetes Education Programs RFP# 537-16-
FORM H: PERFORMANCE MEASURES (Tier 1 only)
In the event a contract is awarded, respondent agrees performance measures will be used to
assess, in part, the respondent’s effectiveness in providing the services described. Respondent
must address all of the requirements (see PERFORMANCE MEASURES Guidelines) associated
with the services anticipated in this proposal.
DO NOT CHANGE ANY LANGUAGE ON THIS FORM. ONLY PROVIDE NUMBERS.
Performance Measures
Cumulative Totals
Coalition meetings
___# of meetings
Diabetes self-management classes (e.g., CDC diabetes selfmanagement program, “Do Well, Be Well” (Texas Cooperative
Extension Service), or other DSHS approved models) or similar
activities
Diabetes Prevention (primary prevention)
Physical activity + Nutrition classes (12+ weeks)
Psychosocial support groups
Diabetes Self-Management Support (secondary prevention)
Nutrition classes (3+ weeks)
___ # of classes
(not series)
___ # of encounters
___ # of classes
___ # of encounters
___ # of sessions
___ # of encounters
___ # of classes
___ # of encounters
Physical activity classes (8+ weeks)
___ # of classes
___ # of encounters
Psychosocial support groups
___ # of sessions
___ # of encounters
Provider education information activities (only TDC Toolkits,
including Minimum Standards of Care and treatment algorithms)
___ # of providers
reached
___ # of TDC materials
distributed to providers
Referrals received from healthcare providers and/or health systems
____ # referrals from
healthcare providers
and/or health systems
Resources added or updated in 2-1-1 Texas, a program of the Texas
Health and Human Services Commission
Television
___ # of resources
added/updated in 2-1-1
____ # of television
spots
____ # of radio spots
____# of print media
distributed
Radio
Print media (e.g., newspapers, church bulletins, business inserts or
newsletters)
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Outdoor/Mobile advertising (e.g., bill boards, bus benches, ads inside
buses, etc.)
Web site activities
Materials distributed to participants (e.g., brochures, posters, from
National Diabetes Education Program, TDC/DSHS and other sources)
Participant Health Outcomes
 Percent decrease in average waist circumference*
 Percent decrease in average BMI*
 Percent decrease in average A1c
 Percent decrease in average fasting blood glucose
 Percent decrease in average blood pressure*
 Percent decrease in average cholesterol
 Percent decrease in average triglycerides
 Percentage of participants receiving recommended exams
and immunizations (foot, eye, dental)
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____# of
advertisements
___ # of website hits
______ # of materials
distributed
%
%
%
%
%
%
%
%
Community Diabetes Education Programs RFP# 537-16-
FORM H: PERFORMANCE MEASURES GUIDELINES (Tier 2 only)
Respondent agrees the performance measures will be used to assess, in part, its capacity to
provide the services described in this RFP. The respondent must address all of the requirements
associated with the services proposed in this application.
Form H will document the number of classes to be delivered, including the total anticipated
number of participants who will complete the required series of classes. Performance measures
must include diabetes self-management education. As part of diabetes prevention activities,
performance measures must include nutrition, physical activity, and psychosocial support
groups.
Required performance measures are listed in bold with an asterisk (*):
 Evidence of application for ADA-recognition, AADE-accreditation, or
expansion, if currently accredited/recognized*;
 Official notice of acceptance as an ADA-recognized or AADE-accredited
program or program expansion*;
 Advisory board meetings*;
 Diabetes Self-Management Education activities*

Using an approved curriculum—e.g., Diabetes Education and Empowerment
(DEEP), Texas AgriLife Extension Service’s Do Well, Be Well with Diabetes
(DWBW), Texas AgriLife Extension Services’s ¡Si, Yo Puedo Controlar Mi
Diabetes!, Stanford’s Diabetes Self-Management Program or other DSHSapproved models*;
 Diabetes prevention (primary prevention) activities, including:*

Nutrition classes

Physical activity classes and

Psychosocial support groups;
 Diabetes self-management support (secondary prevention) activities, such as*

Nutrition classes

Physical activity classes

Psychosocial support groups; or

Other support activities as described in Form I: Work Plan Narrative (Part A), 11.
Ongoing Support
 Healthcare provider education activities* (e.g., presentations to healthcare
providers regarding the TDC Toolkit, including the Minimum Standards of
Diabetes Care in Texas, treatment algorithms);

Number of healthcare providers that will be reached

Number of TDC Toolkits distributed to healthcare providers
 Referrals received from healthcare providers and/or health systems*;
 Program(s)/resources added or updated in 2-1-1 Texas*
 Public information activities such as:
 television (e.g., number of interviews, PSAs, ads at cinemas/movie theaters, etc.)
 radio (e.g., number of interviews, PSAs, etc.)
 distribution of print media (e.g., flyers/brochures, newsletter/newspaper articles,
ads in church bulletins/programs or business inserts, etc.)
 outdoor/mobile advertising (e.g., billboards, bus benches, ads inside buses, etc.)
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










website activities (i.e., the number of persons accessing the respondent’s diabetes
prevention and control program-specific website, if applicable)
Materials distributed to participants* (e.g., National Diabetes Education
Program (NDEP) and TDC/DSHS literature)

NOTE: These materials are to be counted separate from the healthcare provider
education materials distribution;
Percent decrease in average waist circumference from baseline*;
Percent decrease in average BMI from baseline *;
Percent decrease in average A1c from baseline*;
Percent decrease in average fasting blood glucose from baseline*;
Percent decrease in average blood pressure from baseline *;
Percent decrease in average cholesterol from baseline*;
Percent decrease in average triglycerides from baseline*;
Percentage of participants receiving recommended exams and immunizations
(foot, eye, dental)*; and
Additional measures required to address the needs of the target population or as
required by DSHS.
(Note: Capacity to receive all health outcome measures through internal capacity or
agreement with a health system is required.)
Clinical measures may be reported by the program’s average or a specified cohort. The program
must comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Refer to http://www.dshs.state.tx.us/hipaa/default.shtm#covered and/or
http://www.hhs.gov/ocr/privacy/ for requirements. Programs must maintain written consent
forms signed by program participants.
DSHS/TDPCP-approved reporting system, sign-in sheets, participant health outcomes forms, and
other forms to be prescribed by DSHS/TDPCP must be used for reporting the progress of
performances measures.
In addition to the performances measures on Form H, programs will be required to track,
document, and report to TDPCP the number of unduplicated participants attending
interventions and the number of referrals to tobacco cessations services.
The data entered on Form H: Performance Measures should consistent with Form I: Work
Plan Narrative (Part A), Work Plan Template (Part B), and Appendix J: Class
Implementation Plan. Compare these documents prior to submission.
The proposed measures and levels of performance will be negotiated and agreed upon by the
respondent and DSHS/TDPCP. However, DSHS program staff is responsible for making final
decisions about target levels of performance.
HOW TO ENTER ENCOUNTERS ON FORM H: PERFORMANCE MEASURES
The number of encounters should reflect an anticipated cumulative number of participants
attending each series of classes (i.e. diabetes self-management, nutrition, physical activity,
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psychosocial support groups) and account for a retention rate of 65% or higher when
projecting these numbers.
The number of projected encounters for ALL series and/or classes proposed for FY 2016 will be
aggregated on Appendix J: Class Implementation Plan. Use the corresponding numbers in the
“Total Number of Encounters” column for Form H: Performance Measures.
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FORM H: PERFORMANCE MEASURES (Tier 2 only)
In the event a contract is awarded, respondent agrees performance measures will be used to
assess, in part, the respondent’s effectiveness in providing the services described. Respondent
must address all of the requirements (see PERFORMANCE MEASURES Guidelines) associated
with the services anticipated in this proposal.
DO NOT CHANGE ANY LANGUAGE ON THIS FORM. ONLY PROVIDE NUMBERS.
Performance Measures
Cumulative Totals
Application for ADA recognition, AADE accreditation program, or
program expansion
Official notification as an ADA-recognized, AADE-accredited, or
expanded program
Advisory board meetings
Diabetes self-management classes (e.g., CDC diabetes selfmanagement program, “Do Well, Be Well” (Texas Cooperative
Extension Services) or other DSHS approved models) or similar
activities
Diabetes Prevention (primary prevention)
Physical activity + Nutrition classes (12+ weeks)
Psychosocial support groups
Diabetes Self-Management Support (secondary prevention)
Nutrition classes (3+ weeks)
___# notification(s)
___# of meetings
___ # of classes
(not series)
___ # of encounters
___ # of classes
___ # of encounters
___ # of sessions
___ # of encounters
___ # of classes
___ # of encounters
Physical activity classes (8+ weeks)
___ # of classes
___ # of encounters
Psychosocial support groups
___ # of sessions
___ # of encounters
Other ongoing support activities
___ # of activities
___ # of encounters
Provider education information activities (only TDC Toolkits,
including Minimum Standards of Care and treatment algorithms)
Referrals received from healthcare providers and/or health systems
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___# application(s)
___ # of providers
reached
___ # of TDC materials
distributed to providers
____ # referrals from
healthcare providers
and/or health systems
Community Diabetes Education Programs RFP# 537-16-
Resources added or updated in 2-1-1 Texas, a program of the Texas
Health and Human Services Commission
Television
Radio
Print media (e.g., newspapers, church bulletins, business inserts or
newsletters)
Outdoor/Mobile advertising (e.g., bill boards, bus benches, ads inside
buses, etc.)
Web site activities
Materials distributed to participants (e.g., brochures, posters, from
National Diabetes Education Program, TDC/DSHS and other sources)
Participant Health Outcomes
 Percent decrease in average waist circumference*
 Percent decrease in average BMI*
 Percent decrease in average A1c*
 Percent decrease in average fasting blood glucose*
 Percent decrease in average blood pressure*
 Percent decrease in average cholesterol*
 Percent decrease in average triglycerides*
 Percentage of participants receiving recommended exams
and immunizations (foot, eye, dental)*
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___ # of resources
added/updated in 2-1-1
____ # of television
spots
____ # of radio spots
____# of print media
distributed
____# of
advertisements
___ # of website hits
______ # of materials
distributed
%
%
%
%
%
%
%
%
Community Diabetes Education Programs RFP# 537-16-
FORM I: WORK PLAN GUIDELINES
Response Type: ☐ Tier 1
or ☐ Tier 2 (check only one per proposal submission)
Respondent must submit a comprehensive work plan for its first year of this 4-year project; the
work plan shall consist of two (2) parts.
The respondent must describe its plan for carrying out the proposed activities to the target
population(s) in the proposed service area(s), on Form I: WORK PLAN NARRATIVE, Part
A. Form I: WORK PLAN TEMPLATE, Part B shall detail the proposed activities,
performance measures, parties responsible for implementation, and the timeframe for assessing
progress. Both Tier 1 and Tier 2 respondents must complete all parts, unless noted otherwise.
The work plan must include clearly written responses to each section of the guidelines. Each
section should be labeled according to its heading and number. A maximum of nine (9)
additional pages may be attached for Form I: WORK PLAN NARRATIVE, Part A, if needed.
Templates for Form I: WORK PLAN TEMPLATE, Part B, 1. Plan for Year 1 are located in
Appendix C. Do not add additional templates. A maximum of two (2) additional pages may be
attached for Form I: WORK PLAN NARRATIVE, Part B, 2. (Plan for Years 2, 3, and 4), if
needed.
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FORM I: WORK PLAN GUIDELINES NARRATIVE (Part A)
The responses provided to Form I: Work Plan Narrative (Part A) should be consistent with
Work Plan Template (Part B), Form H: Performance Measures, and Appendix J: Class
Implementation Plan. Compare these documents prior to submission.
1. Education
a. Physical Activity, Nutrition, and Psychosocial Support:
i.
Diabetes Prevention (Primary Prevention)
The Community Preventive Services Task Force recommends combined nutrition and
physical activity promotion programs for people at increased risk of developing type
2 diabetes based on strong evidence of effectiveness in reducing new-onset diabetes.
Program participants may be considered at increased risk of type 2 diabetes if they
have blood glucose levels that are abnormally elevated, but not high enough to be
classified as type 2 diabetes, known as pre-diabetes. Participants may also be
identified using diabetes risk assessment tools. For more information, see
http://www.thecommunityguide.org/diabetes/combineddietandpa.html.
The respondent will conduct at least two (2) series of concurrent nutrition and
physical activity classes per fiscal year.
The respondent, its partner organizations, contractors, and/or volunteers must
conduct ongoing physical activities. Ongoing physical activities must be no less than
30 minutes, once per week, for a minimum of twelve (12) weeks. Physical activity
classes may continue beyond the 12-week period but no less than the specified
timeframe. Active participation in physical activity is required (e.g. walking group,
dance class, aerobics, yoga, etc.). Therefore, the distribution of literature about the
importance of exercise and/or discussing physical activity in a self-management class,
although important, does not meet the requirements of this proposal.
The respondent, its partner organizations, contractors, and/or volunteers must
conduct nutrition classes. Nutrition classes must be conducted for no less than 30
minutes once per week, and a minimum of twelve (12) weeks. Nutrition classes may
continue beyond the 12-week period but no less than the specified timeframe.
Discussing nutrition/food as part of a diabetes self-management class is not an
acceptable substitute.
Physical activity and nutrition classes must be held concurrently a minimum of
twelve (12) weeks and may continue beyond the 12-week period. However, activities
cannot be conducted for less than the specified timeframe.
The respondent, its partner organizations, contractors, and/or volunteers must
conduct psychosocial support groups as follow-up support for diabetes prevention
activities (i.e., concurrent/combined physical activity and nutrition). At least one
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psychosocial support group is required for following each series of diabetes
prevention. The respondent can determine the timeframe for post-intervention followup support groups. Psychosocial support groups may continue beyond one postintervention follow-up but no less than the specified requirement.
The Diabetes Prevention Program and Outcomes Study, available at
https://dppos.bsc.gwu.edu/web/dppos/dpp, can be used to guide planning diabetes
prevention interventions. CDC National Diabetes Prevention Program curriculum
associated with the aforementioned study is available at
http://www.cdc.gov/diabetes/prevention/recognition/curriculum.htm.
Examples of other primary prevention programs include, but are not limited to, DSHS
Walk Texas, National Diabetes Education Program (NDEP) Road to Health, and
NDEP Power to Prevent. See Appendix G for the more information and links to these
diabetes prevention resources.
The respondent is encouraged to apply for recognition under the CDC Diabetes
Prevention Recognition Program, if eligible. For more information, see
http://www.cdc.gov/diabetes/prevention/recognition/index.htm.
Using the guidelines above, describe how the activities will be implemented,
including the proposed settings (e.g., community center, faith-based institution, and
library). Describe the type(s) of physical activity that will be implemented and how it
will serve the target population(s) identified in Form G: Assessment Narrative, Part
B. Provide a description of the curriculum that will be used for nutrition education
classes and how it will be applicable to the target population(s) identified in Form G:
Assessment Narrative, Part B.
ii.
Diabetes Self-Management Support (Secondary Prevention)
As a supplement to diabetes self-management education classes, the respondent, its
partner organizations, contractors, and/or volunteers may conduct ongoing physical
activity classes for individuals living with diabetes and their families. Ongoing
physical activity must be no less than 30 minutes, once per week, for a minimum of
eight (8) weeks. Implementation of these activities requires active participation (e.g.
walking group, dance class, aerobics, and yoga). Therefore, the distribution of
literature about the importance of exercise and/or discussing physical activity in a
self-management class, although important, is not sufficient for active engagement in
physical activity.
As a supplement to diabetes self-management education classes, the respondent, its
partner organizations, contractors, and/or volunteers may conduct nutrition classes
for individuals living with diabetes. Implementation of these activities must be
conducted separate from diabetes self-management series, for no less than 30 minutes
once per week, and a minimum of three (3) weeks. Nutrition classes may continue
beyond the 3-week period but no less than the specified timeframe. Discussing
nutrition/food as part of a diabetes self-management class is not an acceptable
substitute.
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Physical activity and nutrition education may be combined. For example, a 30-minute
nutrition class, meeting for a minimum of 3 weeks, can precede a 30-minute physical
activity class that meets for at least 8 weeks on the same day. After the 3-week
nutrition class concludes, the physical activity sessions would need to continue for the
remaining 5 weeks. Combined physical activity and nutrition classes may continue
beyond the specified timeframe but no less than the 8-week and 3-week duration,
respectively.
If the respondent will conduct physical activity and/or nutrition classes as secondary
prevention, use the guidelines to describe how the following activities will be
implemented. Include the proposed settings (e.g., community center, faith-based
institution, and library). Describe the type(s) of physical activity that will be
implemented and how it will serve the target population(s) identified in Form G:
Assessment Narrative, Part B. Provide a description of the curriculum that will be
used for nutrition education classes and how it will be applicable to the target
population(s) identified in Form G: Assessment Narrative, Part B.
The respondent, its partner organizations, contractors, and/or volunteers may conduct
psychosocial support groups for individuals living with diabetes and their families.
Psychosocial support groups for participants with diabetes are may be implemented
as stand-alone activities, and are not required to be a follow-up to diabetes selfmanagement education.
b. Diabetes Self-Management Education:
All programs must conduct at least four (4) series of group self-management classes for
participants with diabetes and their families. Classes must be implemented using a
TDPCP-approved curriculum (e.g., University of Illinois at Chicago’s Diabetes
Education Empowerment Curriculum (DEEP), Texas AgriLife Extension Service’s Do
Well, Be Well with Diabetes (DWBW), Texas AgriLife Extension Services’s ¡Si, Yo
Puedo Controlar Mi Diabetes!, Stanford’s Diabetes Self-Management Program or other
DSHS-approved models. Self-management classes must occur at least once per week for
a minimum of four (4) weeks. Baseline and post-intervention data must be collected to
demonstrate the effectiveness of implementation.
In addition, kidney disease prevention must be incorporated into self-management
education using the National Kidney Disease Education Program, Love Kidneys
campaign, or other resources provided by TDPCP. Discussion should include risk factors
for kidney disease, how to maintain healthy kidneys, testing, and how to request those
tests. Information on kidney disease prevention resources can be found at
http://nkdep.nih.gov/resources.shtml and http://www.lovekidneys.com/.
Using the guidelines, describe how the diabetes self-management classes will be
implemented, including the proposed settings (e.g., community center, faith-based
institution, and library). Provide a description of the curricula/resources that will be used
for diabetes self-management, and include how it will be applicable to the target
population(s) identified in Form G: Assessment Narrative, Part B.
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c. Provider Education:
Programs shall educate and disseminate to healthcare providers TDC’s Toolkit, including
the Minimum Standards of Diabetes Care in Texas and treatment algorithms. Active
participation from healthcare providers is required (e.g., “lunch and learn”, CEU event,
face-to face meetings, etc.). Distribution of these materials without a presentation DO
NOT meet the requirements of this proposal.
Describe mechanisms that will be used to educate healthcare providers about the Texas
Diabetes Council’s (TDC) Toolkit, including the Minimum Standards of Diabetes Care in
Texas and treatment algorithms.
d. Referrals:
i.
Diabetes Self-Management
The respondent shall promote its program to healthcare providers and/or
healthcare systems in order to receive patient referrals to diabetes selfmanagement education. The respondent shall account for the number of
participants referred from healthcare providers and/or healthcare systems.
Documentation of these referrals must be maintained by the respondent.
Using the guidelines, describe how referrals will be implemented and
documentation maintained.
ii.
Diabetes Prevention
The respondent shall promote its program to and discuss with healthcare
providers and/or healthcare systems patient referrals to diabetes prevention
activities. The respondent shall account for the number of participants referred
from healthcare providers and/or healthcare systems. The respondent must
maintain documentation of these referrals.
Using the guidelines, describe how referrals will be implemented and
documentation maintained.
iii.
Tobacco Cessation
The respondent shall screen and account for the number of participants referred to
tobacco cessation activities for all participants who self-identify as a tobacco user.
The American Cancer Society Quitline can be used as a referral resource, in
addition to local tobacco cessation programs/activities. More information
regarding the quitline can be found at http://www.yesquit.org/. Written
documentation of these referrals must be maintained by the respondent.
Using the guidelines, identify tobacco cessation activities participants will be
referred to, and describe how referrals will be implemented and documentation
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maintained.
iv.
Bi-directional Referral System
Programs will establish a bi-directional referral system with healthcare providers,
systems, and/or clinics. Documentation of these referrals must be maintained by
the respondent.
Using the guidelines, propose how the bi-directional referral system will be
developed, implemented, and documentation maintained.
e. 211 Texas:
2-1-1 Texas, or Texas Information and Referral Network (TIRN), is a program of the
Texas Health and Human Services Commission, committed to helping Texas citizens
connect with the services they need. Whether by phone or internet, their goal is to present
accurate, well-organized and easy-to-find information from state and local health and
human services programs. Wherever one lives in Texas, 2-1-1 can be dialed to find
information about resources in the local community. More information about 2-1-1 is
available at https://www.211texas.org/cms.
The respondent shall be submit its program information to TIRN by the end of the first
fiscal year and assure it is updated, as needed.
For the purposes of this RFP, a response is not required in this section, but the proposed
number of resources added and/or updated in TIRN should be entered on Form H:
Performance Measures.
2. Organizational Capacity: This section of the proposal should identify the resources the
respondent has to conduct the program, who will deliver services, how services will be
delivered, how staff delivering services will be trained to assure competency.
Tier 1 and Tier 2
a. Describe delivery systems, workforce (attach organizational chart), policies, support
systems (i.e., training, technical assistance, information, financial and administrative
systems), and other infrastructure available to achieve service delivery.
Describe how human resources have been managed in the past five years, including
turnover in key staff positions, professional development of staff, and support of
leadership.
Describe plans for ongoing management, knowledge acquisition and transfer, and
operation of the program if there are unexpected vacancies, hiring restrictions, or
difficulty recruiting key positions. Submit job descriptions and resumes, if available,
for all staff budgeted in the application and a profile of staff longevity.
If Community Health Workers will be a part of workforce, describe their
responsibilities.
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Tier 2 only
Program coordinators and instructional staff (e.g., registered dietitian, registered nurse,
pharmacist, community health worker, etc.) must complete 15 hours of continuing education
on an annual basis as it relates to diabetes care as well as their profession (i.e., program
management, education, chronic disease care, behavior change). Refer to ADA-recognition
and/or AADE-accreditation guidelines for requirements related to certified diabetes
educators (CDE) and/or board certified advanced diabetes management (BC-ADM)
professionals.
b. Identify the credentials and experience of the program coordinator and instructional
staff. Outline how staff will accomplish the ADA and/or AADE annual professional
development requirement, including Community Health Workers.
3. Data and Reporting: TDPCP requires programs to use sign-in sheets, participant health
outcomes forms, and intervention worksheets. The participant health outcome form is a
standardized clinical evaluation form that will be provided following award, in addition
to worksheets required to document intervention activities. A sample participant health
outcome form and intervention worksheet is provided in Appendix I, respectively. For
series of diabetes prevention, baseline and post-intervention data must be collected at
weeks 1 and 12, respectively. Program activities will be reported to TDPCP via webbased reporting system.
Describe baseline and post-intervention data elements the respondent will collect and
how data will be analyzed and utilized after reporting to TDPCP. Identify who will be
responsible for data collection, reporting, and quality assurance monitoring. Describe
how often quality assurance monitoring will occur.
4. Quality Improvement: The respondent will measure the effectiveness of the education
and support and look for ways to improve any identified gaps in services or service
quality, using a systematic review of process and outcome data.
Describe how the program will monitor the effectiveness of program implementation and
work towards improving gaps in services and the health status of target population(s),
using a systematic review of process and outcome data. Describe the quality
improvement team and process. Include data that will be used and its analysis, in addition
to the methods for follow-up.
5. Evaluation Plan: The purpose of formative evaluation is to validate or ensure that the
goals of program implementation are achieved and to improve the program
implementation, if necessary. Programs will be required to submit a report to TDPCP no
later than one (1) month after the end of each fiscal year outlining formative evaluation
methods utilized for program improvement.
The summative evaluation must convey the effectiveness of the program over its history,
including its strengths and barriers/challenges. Cumulative quantitative and qualitative
data should inform the summative evaluation. Programs will be required to submit a
summative evaluation no later than one (1) month after the 4-year project period ends.
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Both formative and summative evaluations will be submitted in a template developed and
provided by TDPCP during the grant cycle.
Tier 1 and Tier 2
Describe how the respondent will conduct formative evaluation(s) to improve its program
throughout the fiscal year. Include:
a. A plan for monitoring retention rates and strategies to address poor retention rates;
b. A plan to identify and address program elements that are not working using
evaluation data;
c. A plan to demonstrate evidence of improved outcomes in the following areas, using
analysis of de-identified data:
o diabetes knowledge
o behavior change, including tobacco cessation
o waist circumference
o BMI
o blood pressure
Clinical measures such as A1c, fasting blood glucose, and cholesterol may be
reported, as well.; and
d. A description of any policy or agreement that may be established to obtain clinical
data through a partnership/referral system with a healthcare organization.
Tier 2 only
Describe how the respondent will collaborate with health systems to develop and
implement an outcome evaluation assessing the following for the duration of the
program:
e. Short and long-term diabetes-related hospitalization rates;
f. A1c levels of patients served by each health system, focusing on use of electronic
health records;
g. Blood pressure of patients served by each health system, focusing on use of
electronic health records; and
h. Amputation rates of patients served by each health system.
Note: Baseline data will be collected in year 1 of funding and reported at the end of each
grant year.
6. Coordination and Collaboration:
This project requires that the respondent either be a member of a coalition that includes
diabetes prevention and control in its mission and work plan (Tier 1), or an advisory
board to seek ongoing input from external stakeholders and experts to promote program
quality (Tier 2). The coalition or advisory board may exist or the respondent may
establish one if none exists. Coalition or advisory board membership should include
representation from persons living with or indirectly affected by diabetes and various
sectors (e.g., healthcare, faith-based, business, government, community interest groups,
etc.). Active participation in a coalition or advisory board must be maintained and the
group must meet at least quarterly for the duration of the program. The respondent must
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report its coalition’s or advisory board’s activities to TDPCP. (See Section II. Program
Information).
a. Describe coordination with any other programs and/or interventions currently
being conducted in the target service area(s) and describe how duplication of
services will be avoided and/or synergized (e.g. development of partnerships,
pooling of resources, etc.);
b. Describe the respondent’s experience of collaborating with other health and
human services providers and key organizations in the target service area(s).
Describe the respondent’s history of coalition building/advisory board
development with partners such as healthcare providers and/or organizations,
businesses, academic institutions, including academic training centers,
governmental agencies, law enforcement agencies, and faith based institutions.
i. Describe how community needs have been or will be assessed and
addressed through partnerships and coalitions or advisory board;
c. Describe how public and/or private sector partners were or will be involved in the
needs assessment and program planning;
d. If the respondent is a part of an established diabetes prevention and controlrelated coalition or advisory board, describe its history, membership/makeup, and
include a list members and their affiliation. Describe how the coalition or
advisory board is representative of the proposed target population (e.g., race
and/or ethnicity, gender, age, etc.). If the respondent must establish a coalition or
advisory board, describe the plan for coalition development, including
membership recruitment strategies and sectors represented;
e.
Describe the respondent’s
plan for incorporating the coalition or advisory board into programmatic activities
and how the coalition or advisory board is maintained, including membership
engagement;
f. Provide evidence of notification to Local Health Department(s) (LHD), DSHS
regional offices, Federally Qualified Health Centers (FQHC), and/or local
Community Health Centers (CHC) , if available, within the target service area(s)
about the proposed program; and
g. Provide letters of commitment from organizations (e.g., LHDs, DSHS regional
offices, CHCs, FQHCs, School Health Advisory Councils (SHAC), nonprofits,
businesses, etc.) that will collaborate with the respondent on the proposed
program. The letters shall either indicate the how entity and respondent is
currently or planning to collaborate in implementing the scope of this program.
These are not letters of support; instead, the letters will convey that the author of
the letter has knowledge of the program and will be an active part of program
implementation when necessary. The letters should describe specific activities and
agreements or contracts between the respondent and collaborating organization(s).
These letters should be included in Appendix M: Letters of Commitment.
7. Cultural Competency: All staff that may interact with participants will be required to
attend training during the funding cycle on cultural competency and the elimination of
disproportionality and disparities affecting individuals, children, and families.
Describe respondent’s current ability to provide services to culturally diverse populations
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(i.e., use of interpreter services, language and literature translation, compliance with the
Americans with Disabilities Act [ADA] requirements, locations and hours of services,
and other means to ensure accessibility for proposed target population(s)). Describe how
age, gender, race and/or ethnicity, and language factors be addressed.
8. Quality Assurance and Access: The respondent must outline proposed implementation
of diabetes self-management, nutrition, physical activity, and psychosocial support
groups, in accordance with Form H: Performance Measures and Form I: Work Plan
Narrative, Parts A and B. This response shall be submitted using the class
implementation plan Excel spreadsheet in Appendix M.
9. Financial Commitment: The respondent must demonstrate financial commitment
toward the activities proposed under this RFP, including direct funding or in-kind
contributions from the respondent or other entities.
a. Discuss how the respondent will draw on resources from other institutions such as
public and/or private local entities, including private donors or foundations, state
agencies, federal grantors, etc.;
b. Discuss existing personnel, equipment and facility resources and new resources
(e.g., personnel, equipment, and facility) that may need to be secured for program
implementation;
c. Discuss how and from whom the respondent may be seeking additional funding
for this program;
d. Discuss how the respondent proposes to sustain activities proposed under this
RFP once the 4-year funding cycle ends;
e. Provide a policy outlining the respondent’s contingency plan in the event of staff
vacancies exceeding 10 days to ensure continuity of the program. At a minimum,
ensure the plan includes personnel that would be assigned to perform the duties of
key staff and summarize the training and qualifications personnel have to perform
the functions required; and
f. The respondent is expected to have at least one and a half (1.5) Full-Time
Equivalent (FTE) dedicated to this program. Respondents may assign one fulltime staff person or use a combination of staff and sub-contractors to meet this
criteria. Discuss how this requirement will be fulfilled.
10. Individualization (Tier 2 only): The diabetes self-management, education and support
needs of each participant will be assessed by one or more instructor(s). The participant
and instructor(s) will then together develop an individualized education and support plan
focused on behavior change.
a. Identify the information that will be collected to assess the participant and the
process that will be used to collect this information;
b. Discuss the communication strategies that will be used for assessment and
support;
c. Discuss potential barriers and how barriers will be addressed; and
d. Discuss how assessment and education plan, intervention, and outcomes will be
documented to ensure the individualization requirement is met.
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11. Ongoing Support (Tier 2 only): The participant and instructor(s) will together develop a
personalized follow-up plan for ongoing self-management support. The participant’s
outcomes, goals, and the plan for support will be communicated to other members of the
healthcare team.
a. Discuss the ongoing diabetes self-management support (DSMS) options that will
be available to DSME participants;
b. Describe how ongoing DSMS will be documented;
c. Describe the process that will be used to communicate participants’ educational
outcomes, goals, and DSMS plan to other healthcare team members, including
healthcare providers and/or healthcare systems; and
d. Discuss the measures/indicators that will be communicated and timeframes for
communication between the healthcare team.
12. Patient Progress (Tier 2 only): The respondent will monitor whether participants are
achieving their personal diabetes self-management goals and other outcome(s) as a way
to evaluate the effectiveness of the educational intervention(s), using appropriate
measurement techniques. Address the following in this section:
a. Describe the process for follow-up to evaluate participants’ behavior change
goals, and discuss how this will be documented.
b. Describe the process for follow- up to evaluate participants’ clinical outcomes,
and discuss how this will be documented.
c. Describe how differences in behaviors, health beliefs, culture, and emotional
response to diabetes will be accounting for when collaborating with participants
on the design of personalized DSME and DSMS activities.
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FORM I: WORK PLAN TEMPLATE (Part B)
The responses provided to Form I: Work Plan Narrative (Part B) should be consistent with
Work Plan Template (Part A), Form H: Performance Measures, and Appendix J: Class
Implementation Plan. Compare these documents prior to submission.
The definitions for this RFP are in Section I. Introduction. The goals are described in Section II.
Program Information. Please read these sections first before completing Form I: Work Plan
Template (Part B).
1. Plan for Year 1
The respondent shall submit a Work Plan Template (Part B) using the templates provided in
Appendix C. These templates shall detail the activities, performance measures, parties
responsible for implementation, and the timeframe for assessing progress.
 Objectives and activities shall relate to the project’s purpose and goals (see Section II.
Program Information).
 Objectives and activities shall include performance measures outlined in
Form H: Performance Measures.
Objectives must be specific, measurable, achievable, reasonable and time-phased
(S.M.A.R.T.). Interventions associated with the objectives shall be evidence-based (i.e.,
based on research). The following table provides a guide for development of process
objectives:
Measure
Examples
Process Objectives
Process objectives support accountability by setting specific activities to be
completed by specific dates, explaining what will be done and when it will
be completed.
1. By August 2016, a minimum of 250 individuals will participate in 6
series, or 30 classes, of diabetes self-management education.
2. By August 2016, a minimum of 100 healthcare providers will
participate in six (6) provider education events where 100 TDC
Toolkits will be distributed.
Activities shall include interventions that focus on behavior change and improved clinical
outcomes consistent with application for ADA-recognition or AADE-accreditation.
Interventions shall offer opportunities for sustained behavior change(s) in individuals and/or
families through series of classes rather than short-term impacts of one-time events (e.g.,
health fairs).
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Tier 1 and Tier 2 respondents must adhere to the guidelines provided in Form I: Work Plan
Narrative (Part A), 1a-1e and Part B. Complete work plan templates for all of the following
activities, unless noted otherwise:
1. Diabetes prevention:
a. Tier 1 and Tier 2: Physical activity, nutrition, if included in Form H:
Performance Measures and Form I: Work Plan Narrative (Part A)
b. Tier 1 only: Psychosocial support groups, if included in Form H: Performance
Measures and Form I: Work Plan Narrative (Part A)
c. Tier 2 only: Diabetes self-management support (DSMS) included in Form H:
Performance Measures and defined in Form I: Work Plan Narrative (Part A), 11a.
Ongoing Support.
2. Diabetes self-management, including physical activity, nutrition, and psychosocial
support;
3. Healthcare provider education;
4. Referrals
a. Tobacco cessation services;
b. CDC-recognized National Diabetes Prevention Programs, if available and
appropriate
5. Bi-directional referral system; and
6. Application for ADA-recognition or AADE-accreditation (Tier 2 only)
2. Plan for Years 2, 3, and 4
The respondent shall submit a narrative description of proposed interventions for Years 2-4 of
this program. A maximum of two (2) additional pages may be attached, if needed.
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FORM J: CHILD SUPPORT CERTIFICATION (REQUIRED –
Applies to For-Profit Entities Only )
Department of State Health Services
Child Support Certification
The Texas Family Code, §231.006, places certain restrictions on child support obligors. Contracts with
governmental entities or nonprofit corporations are not subject to §231.006.
The contractor identified below is not a governmental entity or a nonprofit corporation and certifies to the
following:
1. The contractor is: (check one)
An individual or sole proprietor, or
A business entity (corporation, partnership, joint venture, limited liability company, association,
etc.)
2. The contractor certifies the following is a complete list of the names and social security numbers of either (A)
the individual or sole proprietor who is the contractor or (B) each partner, shareholder, or owner with an
ownership interest of at least 25% of the contractor/business entity: (attach additional sheet if necessary).
(A)
(B)
Printed Name:
Social Security Number:
Printed Name:
Social Security Number:
3. Under the Texas Family Code, §231.006, the contractor certifies that the individual or business entity named
in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and
acknowledges that this contract may be terminated and payment withheld if this certification is inaccurate. A
child support obligor who is more than 30 days delinquent in paying child support or a business entity in
which the obligor (who is more than 30 days delinquent) is the sole proprietor, partner, shareholder, or owner
with an ownership interest of at least 25% is not eligible to receive the specified grant, loan or payment. The
contractor understands that it is the contractor’s responsibility to verify whether a child support obligor who is
more than 30 days delinquent is the sole proprietor, partner, shareholder or owner with an ownership interest
of at least 25%.
4.
Printed Name of Contractor:
Printed Name of Authorized Representative:
Signing this Certification:
Signature of Authorized Representative:
Date:
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FORM K: FINANCIAL MANAGEMENT AND ADMINISTRATION
QUESTIONNAIRE
Name of Organization: ____________________________________________
ACCOUNTING SYSTEM
The type of accounting system often depends on the size of the organization. Briefly describe your organization’s
accounting system including:
a) Is the accounting system computerized, manual or a combination of both;
b) How are different types of transactions (e.g., cash disbursements, cash receipts, revenues, journal entries)
recorded and posted to the general ledger;
c) When do you close your general ledger (e.g., monthly by the 10th of the following month);
d) How are transactions organized, maintained, and summarized in financial reports. If your accounting system is
computerized, indicate the name/type.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________________________________________
Answer each of the following questions with either a “yes” or “no” answer by checking the respective box.
1.
Is your accounting system organized to allow an auditor to trace financial report
balances through the general ledger and other summary ledgers/journals to each detail
accounting transaction and supporting source documentation?
YES
2.
NO
Does your accounting system have the capability of identifying the receipt and
expenditures of program funds and program income separately for each DSHS
contract/program attachment?
YES
NO
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3.
Does your accounting system provide for the recording of expenditures for each
program attachment by the budget cost categories shown in the proposed budget?
YES
4.
Does your accounting system provide for the segregation of direct and indirect expenses
and the allocation of indirect costs?
YES
5.
NO
Are time records (e.g., time sheets) maintained for all employees where their actual
time/effort is recorded and specifically identified to a particular cost objective?
YES
6.
NO
NO
Is the employees’ time/effort that is recorded on the time record the source/basis of the
calculation of salary/wage costs recorded in the general ledger for each cost objective?
YES
NO
GENERAL ADMINISTRATION & INTERNAL CONTROLS
1.
Is the staff who will be responsible for the financial management of the award generally
familiar with the existing regulations and guidelines containing the cost principles and
financial administrative requirements applicable to state and federal contracts/grants?
YES
2.
Does your organization have written accounting policies and procedures?
YES
3.
NO
Are procedures in place with adequate controls to ensure that receipts and
disbursements are authorized and appropriately documented?
YES
5.
NO
Are generally accepted accounting principles followed for separation of duties
regarding receipts and deposit of funds and payment of goods and services?
YES
4.
NO
NO
Are all disbursements approved prior to payment?
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YES
6.
Is there any additional review or special approval required for checks exceeding a
specific dollar amount?
YES
7
NO
Do purchase orders/requisitions require specific approvals from authorized individuals
in the requesting department?
YES
9.
NO
Are there written procedures and internal controls established for the procurement of
goods and services?
YES
8.
NO
NO
Are supporting documents (invoices, receipts, approvals, receiving reports, canceled
checks, etc.) maintained for each disbursement and on file for easy location and
retrieval?
YES
NO
10. Do supporting documents accompany checks for the check signer’s signature?
YES
NO
11. Are supporting documents marked when paid to prevent reuse or duplication of
payment?
YES
NO
12. Are invoices coded to identify allocation of payment by cost objective and subaccount?
YES
13.
NO
Does your organization stay current with payments of its accounts payable, payroll
taxes and other liabilities, loans, taxes, etc.?
YES
NO
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14.
As program income is to be used for program purposes, are there procedures and
controls to ensure proper use, accountability, and allocation?
YES
15.
Do you have written personnel policies?
YES
16.
NO
Do procedures ensure that time and attendance reports can be specifically traced to
costs recorded in the general ledger for each payroll period for each cost objective?
YES
18.
NO
Does your policy require individual daily time and attendance records for personnel
(part-time, full-time, and/or in-kind volunteers)?
YES
17.
NO
NO
Do you have written job descriptions with set salary levels for each employee?
YES
NO
19. Do you have on file authorizations covering rates of pay, withholding and deductions
for each employee?
YES
NO
The Financial Management and Administration Questionnaire must be signed by an authorized person
who has either completed or reviewed the form and can attest to the accuracy of the information provided.
Approved by:
Print Name: _________________________________________________________________
Signature: __________________________________________________________________
Title: _______________________________________________________________________
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APPENDICES
APPENDIX A: Budget Section
Detailed budget category forms, general information, and instructions are loaded as a separate
attachment.
Respondent must insert budget section here.
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APPENDIX B: DSHS Assurances and Certifications
Note: It is not required that the respondent return the DSHS Assurances and
Certifications with the proposal. Some of these Assurances and Certifications may not be
applicable to your project. If you have questions, contact the contact person named in this
RFP. These assurances and certifications will remain in effect throughout the project
period of this solicitation and the term of any contract between respondent and DSHS.
As the duly authorized representative of the respondent, my signature on FORM A: FACE
PAGE certifies that the respondent:
1.
Is a legal entity legally authorized and in good standing to do business with the State of Texas and has the
legal authority to apply for state/federal assistance, and has the institutional, managerial and financial
capability and systems (including funds sufficient to pay the non-state/federal share of project costs) to
ensure proper planning, management and completion of the project described in this proposal; possesses
legal authority to apply for funding; that a resolution, motion or similar action has been duly adopted or
passed as an official act of the respondent’s governing body, authorizing the filing of the proposal
including all understandings and assurances contained therein, and directing and authorizing the person
identified as the authorized representative of the respondent to act in connection with the proposal and to
provide such additional information as may be required;
2.
Under Government Code Section 2155.004, is not ineligible to receive the specified contract and
acknowledges that this contract may be terminated and payment withheld if this certification is incorrect.
NOTE: Under Government Code Section 2155.004, a respondent is ineligible to receive an award under
this RFP if the bid includes financial participation with the respondent by a person who received
compensation from DSHS to participate in preparing the specification of RFP on which the bid is based;
3.
Has a financial system that identifies the source and application of DSHS funds and program income in a
unique set of general ledger account numbers, permits preparation of reports required by the contract,
permits the tracing of funds expended and program income, allows for the comparison of actual
expenditures to budgeted amounts, and maintains accounting records that are supported by verifiable
source documents;
4.
Will give (and any parent, affiliate, or subsidiary organization, if such a relationship exists, will give)
DSHS, HHSC Office of Inspector General, the Texas State Auditor, the Comptroller General of the
United States, and if appropriate, the federal government, through any authorized representative, access to
and the right to examine all records, books, papers, or documents related to the award; and will establish a
proper accounting system in accordance with generally accepted accounting standards or agency
directives;
5.
Will not supplant funds (i.e. use funds from a contract awarded as a result of this RFP to replace or
substitute existing funding from other sources that also supports the activities that are the subject of the
contract), but rather will use funds from the contract to supplement any existing funds currently available
for any such activities;
6.
Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or
presents the appearance of personal or organizational conflict of interest, or personal gain;
7.
Will ensure that no officer, employee, or member of the respondent’s governing body or of the
respondent’s contractor will vote or confirm the employment of any person related within the second
degree of affinity or the third degree of consanguinity (as defined in Texas Government Code Chapter
Page 85 of 137
573) to any member of the governing body or to any other officer or employee authorized to employ or
supervise such person. This prohibition does not prohibit the continued employment of a person who has
been continuously employed for a period of two years, or such other period stipulated by local law, prior
to the election or appointment of the officer, employee, or governing body member related to such person
in the prohibited degree;
8.
Has not given, offered to give, nor intends to give, at any time hereafter any economic opportunity,
present or future employment, gift, loan, gratuity, special discount, trip, favor, or service to any employee
or official of DSHS or HHSC, in connection with this solicitation or procurement; does not have nor will
it knowingly acquire any interest that would conflict in any manner with the performance of its
obligations under any awarded contract that results from this RFP;
9.
Will honor for 90 days after the proposal due date the technical and business terms contained in the
proposal;
10.
Will initiate the work after receipt of a fully executed contract and will complete it within the contract
period;
11.
Will not require a client with limited English proficiency to provide or pay for the services of a translator
or interpreter;
12.
Will identify and document on client records the primary language/dialect of a client who has limited
English proficiency and the need for translation or interpretation services;
13.
Will make every effort to avoid use of any persons under the age of 18 or any family member or friend of
a client as an interpreter for essential communications with clients who have limited English proficiency.
However, a family member or friend may be used as an interpreter if this is requested by the client and
the use of such a person would not compromise the effectiveness of services or violates the client’s
confidentiality, and the client is advised that a free interpreter is available;
14.
Will comply with the Uniform Grant Management Act (UGMA), Texas Government Code, Chapter 783,
as amended, and the current Uniform Grant Management Standards (UGMS), issued by the Governor's
Budget and Planning Office, applicable Office of Management and Budget Federal Circulars, and if
applicable the Federal awarding agency Common Rule and U.S. Department of Health and Human
Services Grants Policy Statements, which apply as terms and conditions of any resulting contract. A copy
of the UGMS manual and federal references are available upon request;
15.
Will remain current in its payment of franchise tax or is exempt from payment of franchise taxes, if
applicable;
16.
Will comply, if applicable, with Texas Family Code, § 231.006, regarding Child Support, and certifies that
it is not ineligible to receive payment if awarded a contract, and acknowledges that any resulting contract
may be terminated and payment may be withheld if this certification is inaccurate;
17.
Will comply with the non-discriminatory requirements of Texas Labor Code, Chapter 21, which requires
that certain employers not discriminate on the basis of race, color, disability, religion, sex, national origin,
or age;
18.
Will not charge a fee or profit. A profit and/or fee are considered to be an amount in excess of actual
allowable costs that are incurred in conducting an assistance program;
19.
Will comply with all applicable requirements of all other state/federal laws, executive orders, regulations,
and policies governing this program;
Page 86 of 137
20.
As the prospective participant, and any of the prospective participant’s principals (collectively,
participants):
A.
are not presently disqualified, debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any federal department or agency; in
accordance with 2CFR Parts 376 and 180 (parts A-I), and 45 CFR Part 76 (or comparable federal
regulation);
B.
have not within a 3-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a private or public (federal, state, or local)
transaction or contract under a private or public transaction; violation of federal or state antitrust
statutes (including those proscribing price fixing between competitors, allocation of customers
between competitors and bid rigging) or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements or false claims, tax evasion,
obstruction of justice, receiving stolen property or any other offense indicating a lack of business
integrity or business honesty that seriously and directly affects the participant’s present
responsibility;
C.
are not presently indicted or otherwise criminally or civilly charged by a governmental entity
(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) of
this certification;
D.
have not within a 3-year period preceding this proposal/proposal had one or more public
transactions (federal, state, or local) terminated for cause or default; and
E.
has not (nor has its representative nor any person acting for the representative) (1) violated the
antitrust laws codified by Chapter 15, Texas Business & Commercial Code , or the federal
antitrust laws; or (2) directly or indirectly communicated the bid to a competitor or other person
engaged in the same line of business.
Should the respondent not be able to provide this certification (by signing the FACE PAGE Form), an
explanation should be placed after this form in the proposal response;
The respondent agrees by submitting this proposal that the respondent will include, without modification,
the certifications in subparagraphs A through E of this paragraph in all lower tier covered transactions
(i.e., transactions with subgrantees and/or contractors) and in all solicitations for lower tier covered
transactions;
21.
Will comply with Title 31, USC §1352, entitled “Limitation on use of appropriated funds to influence
certain federal contracting and financial transactions,” which generally prohibits recipients of federal
grants and cooperative agreements from using federal (appropriated) funds for lobbying the executive or
legislative branches of the federal government in connection with a SPECIFIC grant or cooperative
agreement. Section 1352 also requires that each person who requests or receives a federal grant or
cooperative agreement must disclose lobbying undertaken with non-federal (non-appropriated) funds.
These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45
CFR Part 93):
A.
No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or employee of any agency, a
member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any federal contract, the making of any federal
grant, the making of any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan,
or cooperative agreement;
B.
If any funds other than federally-appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agent, a member of
Congress, an officer or employee of Congress, or an employee of a member of Congress in
connection with this federal contract, grant, loan, or cooperative agreement, the respondent must
complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,” (SF-LLL) in
Page 87 of 137
C.
accordance with its instructions. SF-LLL and continuation sheet are available upon request from
the Department of State Health Services; and
The language of this certification must be included in the award documents for all sub-awards at
all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative
agreements) and that all subrecipients must certify and disclose accordingly;
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into
this transaction imposed by 31 USC §1352. Any person who fails to file the required certification must
be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure;
22.
Is in good standing with the Internal Revenue Service on any debt owed;
23.
Affirms that no person who has an ownership or controlling interest in the organization or who is an agent
or managing employee of the organization has been placed on community supervision, received deferred
adjudication or been convicted of a criminal offense related to any financial matter, federal or state
program or felony sex crime;
24.
Is in good standing with all state and/or federal departments or agencies that have a contracting relationship
with the respondent;
25.
Will comply with all statutes and standards of general applicability. It is Respondent’s responsibility to
review and comply with all applicable statutes, rules, regulations, executive orders and policies.
Respondent will carry out the terms of this Contract in a manner that is in compliance with the provisions
set forth below. To the extent such provisions are applicable to respondent, respondent will comply with
the following:
a) The following statutes, rules, regulations and DSHS policies, and any of their subsequent amendments
that collectively prohibit discrimination on the basis of race, color, national origin, limited
English proficiency, sex, sexual orientation (where applicable), disabilities, age, substance abuse,
political belief, or religion: 1) Title VI of the Civil Rights Act of 1964, 4
-1683, and
1685-1686; 3) Section 504 of the Rehabilitation Act of 1973, 29 U.S.C.A. § 794(a); 4) the
Americans with Disabilities Act of 1990, 42 U.S.C.A. §§
-6107: 6) Comprehensive Alcohol Abuse and Alcoholism
Parts 80, 84, 86 and 91 or CFR Part 15; 8) Tex. Lab. Code, ch. 21; 9) Food Stamp Act of 1977 (7
USC §200 et seq); 10) US Department of Labor, Equal Opportunity E.O. 11246, as amended and
supplemented; 11) Executive Order 13279 and 45 CFR Part 87 or 7 CFR Part 16 (regarding equal
treatment and opportunity for religious organizations; 12) DSHS Policy AA-5018, Nondiscrimination Policies and Procedures for DSHS Programs; and13) any other nondiscrimination
provision in specific statutes under which application for federal or state assistance is being made,
which prohibits exclusion from or limitation of participation in programs, benefits, or activities,
or denial of any aid, care, service or other benefit;
b) Drug Abuse Office and Treatment Act of 1972, 21 U.S.C.A. §§ 1101 et seq., relating to drug abuse;
c)
-2, and 42 C.F.R. pt. 2,
relating to confidentiality of alcohol and drug abuse patient records;
d) Title VIII of the Civil Rights Act of 1968, 42 U.S.C.A. §§ 3601 et seq., relating to nondiscrimination
in housing;
e) Immigration Reform and Control Act of 1986, 8 U.S.C.A. § 1324a, regarding employment
verification;
f) Pro-Children Act of 1994, 20 U.S.C.A. §§ 6081-6084, regarding the non-use of all tobacco products;
g) National Resear
-1 et seq., and 6601 (P.L. 93348 and P.L. 103-43), as amended, regarding human subjects involved in research;
Page 88 of 137
h)
-26, which limits the political activity of
employees whose employment, is funded with federal funds;
i) Fair Labor Standards Act, 29 U.S.C.A. §§ 201 et seq., and the Intergovernmental Personnel Act of
1970, 42 U.S.C.A. §§ 4701 et seq., as applicable, concerning minimum wage and maximum hours;
J) Tex. Gov’t Code ch. 469 (Supp. 2004), pertaining to eliminating architectural barriers for persons
with disabilities;
k) Texas Workers’ Compensation Act, Tex. Labor Code, chs. 401-406 28 Tex. Admin. Code pt. 2,
regarding compensation for employees’ injuries;
l) The Clinical Laboratory Improvement Amendments of 1988, 42 USC § 263a, regarding the
regulation and certification of clinical laboratories;
m) The Occupational Safety and Health Administration Regulations on Blood Borne Pathogens, 29 CFR
§ 1910.1030, or Title 25 Tex. Admin Code ch. 96 regarding safety standards for handling blood borne
pathogens;
n) Laboratory Animal Welfare Act of 1966, 7 USC §§ 2131 et seq., pertaining to the treatment of
laboratory animals;
o) Environmental standards pursuant to the following: 1) Institution of environmental quality control
measures under the National Environmental Policy Act of 1969, 42 USC §§ 4321-4347 and Executive
Order 11514 (35 Fed. Reg. 4247), “Protection and Enhancement of Environmental Quality;” 2)
Notification of violating facilities pursuant to Executive Order 11738 (40 CFR Part 32), “Providing for
Administration of the Clean Air Act and the Federal Water Pollution Control Act with respect to Federal
Contracts, Grants, or Loans;” 3) Protection of wetlands pursuant to Executive Order 11990, 42 Fed. Reg.
26961; 4) Evaluation of flood hazards in floodplains in accordance with Executive Order 11988, 42 Fed.
Reg. 26951 and, if applicable, flood insurance purchase requirements of Section 102(a) of the Flood
Disaster Protection Act of 1973 (P.L. 93-234); 5) Assurance of project consistency with the approved
State Management program developed under the Coastal Zone Management Act of 1972, 16 USC §§
1451 et seq; 6) Conformity of federal actions to state clean air implementation plans under the Clean Air
Act of 1955, as amended, 42 USC §§ 7401 et seq.; 7) Protection of underground sources of drinking
water under the Safe Drinking Water Act of 1974, 42 USC §§ 300f-300j; 8) Protection of endangered
species under the Endangered Species Act of 1973, 16 USC §§ 1531 et seq.; 9) Federal Water Pollution
Control Act, 33 USC §1251 et seq.; 10) Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.)
related to protecting certain rivers system; and 11) Lead-Based Paint Poisoning Prevention Act (42 U.S.C.
§§ 4801 et seq.) prohibiting the use of lead-based paint in residential construction or rehabilitation;
p) Intergovernmental Personnel Act of 1970 (42 USC §§4278-4763 regarding personnel merit systems
for programs specified in Appendix A of the federal Office of Program Management’s Standards for a
Merit System of Personnel Administration (5 C.F.R. Part 900, Subpart F);
q) Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of
1970 (P.L. 91-646), relating to fair treatment of persons displaced or whose property is acquired as a
result of Federal or federally-assisted programs;
r) Davis-Bacon Act (40 U.S.C. §§ 276a to 276a-7), the Copeland Act (40 U.S.C. § 276c and 18 U.S.C. §
874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§ 327-333), regarding labor
standards for federally-assisted construction sub-agreements;
s) Assist DSHS in complying the National Historic Preservation Act of 1966, §106 (16 U.S.C. § 470),
Executive Order 11593, and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§
469a-1 et seq.) regarding historic property;
t) Financial and compliance audits in accordance with Single Audit Act Amendments of 1996 and
OMB Circular No. A-133, “Audits of States, Local Governments, and Non-Profit Organizations; ”and
u) Requirements of any other applicable state and federal statutes, executive orders, regulations, rules,
and policies.
If this contract is funded by a grant, additional state or federal requirements found in the Notice of Grant
Award may be imposed on respondent;
26.
Under §§2155.006 and 2261.053, Government Code, is not ineligible to receive a contract under this RFP
and acknowledges that any contract may be terminated and payment withheld if this certification is
Page 89 of 137
inaccurate. Sections 2155.006 and 2261.053 relate to violations of federal law in connection with a
contract awarded by the federal government for relief, recovery or reconstruction efforts as a result of
Hurricanes Rita or Katrina or certain other disasters;
27. Affirms that the statements in these assurances and certifications are true, accurate, and complete (to the best
of respondent’s and its authorized representative’s knowledge and belief), and agrees to comply with the
DSHS terms and conditions if an award is issued as a result of this proposal. Willful provision of false
information is a criminal offense. Any person making any false, fictitious, or fraudulent statement may, in
addition to other remedies available, be subject to civil penalties.
Page 90 of 137
APPENDIX C: HUB Requirements
HUB Subcontracting Plan (HSP) Quick Checklist
1.
If all (100%) of your subcontracting opportunities will be performed using only HUB vendors, complete:
 Section 1 – Respondent and Requisition Information
 Section 2 a. – Yes, I will be subcontracting portions of the contract
 Section 2 b. – List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB
vendors
 Section 2 c. – Yes
 Section 4 – Affirmation
 H S P GFE Method A (Attachment A) – Complete this attachment for each subcontracting opportunity
2.
If any of your subcontracting opportunities will be performed using HUB protégés, complete:
 Section 1 – Respondent and Requisition Information
 Section 2 a. – Yes, I will be subcontracting portions of the contract
 Section 2 b. – List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB protégés (Skip
Section 2 c and 2 d)
 Section 4 – Affirmation
 H S P GFE Method B (Attachment B) – Complete Section B-1, Section B-2, and B-4 only for each HUB Protégé subcontracting opportunity as applicable.
3.
If you are subcontracting with HUB vendors and Non-HUB vendors, and the aggregate percentage* of subcontracting with HUB vendors meets or
exceeds the HUB Goal the contracting agency identified in the solicitation, complete:
 Section 1 – Respondent and Requisition Information
 Section 2 a. – Yes, I will be subcontracting portions of the contract
 Section 2 b. – List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB vendors and NonHUB vendors
 Section 2 c. – No
 Section 2 d. – Yes
 Section 4 – Affirmation
 H S P GFE Method A (Attachment A) – Complete this Attachment for each subcontracting opportunity.
4.
If you are subcontracting with HUB vendors and/or Non-HUB vendors, and the aggregate percentage* of subcontracting with HUB vendors does not meet or
exceed the HUB Goal the contacting agency identified in the solicitation, complete:
 Section 1 - Respondent and Requisition Information
 Section 2 a. - Yes, I will be subcontracting portions of the contract
 Section 2 b. - List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB vendors and Non-HUB
vendors
 Section 2 c. - No
 Section 2 d. - No
 Section 4 - Affirmation
 HSP GFE Method B (Attachment B) - Complete this attachment for each subcontracting opportunity
*Aggregate percentage of the contract expected to be subcontracted to HUBs with which you have had contracts in place for five (5) years or less.
5.
If you will not be subcontracting any portion of the contract and will be fulfilling the entire contract with your own resources (i.e., equipment, supplies,
materials, and/or employees), complete:
 Section 1 – Respondent and Requisition Information
 Section 2 a. – No, I will not be subcontracting any portion of the contract, and I will be fulfilling the entire contract with my own resources
 Section 3 – Self Performing Justification
 Section 4 – Affirmation
Page 91 of 137
HUB SUBCONTRACTING PLAN (HSP)
In accordance with Texas Gov’t Code §2161.252, the contracting agency has determined that subcontracting opportunities are probable under
this contract. Therefore, all respondents, including State of Texas certified Historically Underutilized Businesses (HUBs) must complete and submit this
State of Texas HUB Subcontracting Plan (HSP) with their response to the bid requisition (solicitation).
NOTE: Responses that do not include a completed HSP shall be rejected pursuant to Texas Gov’t Code §2161.252(b).
The HUB Program promotes equal business opportunities for economically disadvantaged persons to contract with the State of Texas in accordance
with the goals specified in the 2009 State of Texas Disparity Study. The statewide HUB goals defined in 34 Texas Administrative Code (TAC) §20.13
are:
•
11.2 percent for heavy construction other than building contracts,
•
21.1 percent for all building construction, including general contractors and operative builders contracts,
•
32.9 percent for all special trade construction contracts,
•
23.7 percent for professional services contracts,
•
26.0 percent for all other services contracts, and
•
21.1 percent for commodities contracts.
- - Agency Special Instructions/Additional Requirements - -
In accordance with 34 TAC §20.14(d)(1)(D)(iii), a respondent (prime contractor) may demonstrate good faith effort to utilize Texas certified HUBs for its
subcontracting opportunities if the total value of the respondent’s subcontracts with Texas certified HUBs meets or exceeds the statewide HUB goal or
the agency specific HUB goal, whichever is higher. When a respondent uses this method to demonstrate good faith effort, the respondent must identify
the HUBs with which it will subcontract. If using existing contracts with Texas certified HUBs to satisfy this requirement, only contracts that have been in
place for five years or less shall qualify for meeting the HUB goal. This limitation is designed to encourage vendor rotation as recommended by the 2009
Texas Disparity Study.
SECTION 1 RESPONDENT AND REQUISITION INFORMATION
a.
Respondent (Company) Name:
State of Texas VID #:
Point of Contact:
Phone #:
E-mail Address:
Fax #:
b.
Is your company a State of Texas certified HUB?
c.
Requisition #:
- Yes
- No
Bid Open Date:
Page 92 of 137
Enter your company’s name here:
SECTION 2
Requisition #:
SUBCONTRACTING INTENTIONS RESPONDENT
After dividing the contract work into reasonable lots or portions to the extent consistent with prudent industry practices, and taking into consideration the scope of work to be performed under
the proposed contract, including all potential subcontracting opportunities, the respondent must determine what portions of work, including goods and services, will be subcontracted. Note: In
accordance with 34 TAC §20.11., an “Subcontractor” means a person who contracts with a prime contractor to work, to supply commodities, or to contribute toward completing work for a
governmental entity.
a.
Check the appropriate box (Yes or No) that identifies your subcontracting intentions:
- Yes, I will be subcontracting portions of the contract. (If Yes, complete Item b, of this SECTION and continue to Item c of this SECTION.)
- No, I will not be subcontracting any portion of the contract, and I will be fulfilling the entire contract with my own resources. (If No, continue to SECTION 3
and SECTION 4.)
b. List all the portions of work (subcontracting opportunities) you will subcontract. Also, based on the total value of the contract, identify the percentages of the contract you expect to
award to Texas certified HUBs, and the percentage of the contract you expect to award to vendors that are not a Texas certified HUB (i.e., Non-HUB).
Item #
HUBs
Non-HUBs
Percentage of the contract
Percentage of the contract
expected to be
expected to be subcontracted Percentage of the contract
subcontracted
to HUBs with which you have
expected to be
to HUBs with which you have
a continuous contract* in
subcontracted
a continuous contract* in
place
to non-HUBs .
place
for more than five (5) years.
for five (5) years or less.
Subcontracting Opportunity Description
1
%
%
%
2
%
%
%
3
%
%
%
4
%
%
%
5
%
%
%
6
%
%
%
7
%
%
%
8
%
%
%
9
%
%
%
10
%
%
%
11
%
%
%
12
%
%
%
13
%
%
%
14
%
%
%
%
%
%
%
%
%
15
Aggregate percentages of the contract expected to be subcontracted:
(Note: If you have more than fifteen subcontracting opportunities, a continuation sheet is available online at http://window.state.tx.us/procurement/prog/hub/hub-subcontracting-plan/)
c.
Check the appropriate box (Yes or No) that indicates whether you will be using only Texas certified HUBs to perform all of the subcontracting opportunities you listed in SECTION 2,
Item b.
- Yes (If Yes, continue to SECTION 4 and complete an “HSP Good Faith Effort - Method A (Attachment A)” for each of the subcontracting opportunities you listed.)
- No (If No, continue to Item d, of this SECTION.)
d.
Check the appropriate box (Yes or No) that indicates whether the aggregate expected percentage of the contract you will subcontract with Texas certified HUBs with which you have
a continuous contract* in place with for five (5) years or less meets or exceeds the HUB goal the contracting agency identified on page 1 in the “Agency Special
Instructions/Additional Requirements."
- Yes (If Yes, continue to SECTION 4 and complete an “HSP Good Faith Effort - Method A (Attachment A)” for each of the subcontracting opportunities you listed.)
- No (If No, continue to SECTION 4 and complete an “HSP Good Faith Effort - Method B (Attachment B)” for each of the subcontracting opportunities you listed.)
*Continuous Contract: Any existing written agreement (including any renewals that are exercised) between a prime contractor and a HUB vendor, where the HUB vendor provides the
prime contractor with goods or service under the same contract for a specified period of time. The frequency the HUB vendor is utilized or paid during the term of the contract is not
relevant to whether the contract is considered continuous. Two or more contracts that run concurrently or overlap one another for different periods of time are considered by CPA to be
individual contracts rather than renewals or extensions to the original contract. In such situations the prime contractor and HUB vendor are entering (have entered) into “new” contracts.
Page 93 of 137
Enter your company’s name here:
SECTION 2
a.
Requisition #:
SUBCONTRACTING INTENTIONS RESPONDENT (CONTINUATION SHEET)
This page can be used as a continuation sheet to the HSP Form’s page 2, Section 2, Item b. Continue listing the portions of work (subcontracting
opportunities) you will subcontract. Also, based on the total value of the contract, identify the percentages of the contract you expect to award to Texas certified
HUBs, and the percentage of the contract you expect to award to vendors that are not a Texas certified HUB (i.e., Non-HUB).
HUBs
Item #
Percentage of the contract
expected to be subcontracted
to HUBs with which you have
a continuous contract* in place
for five (5) years or less.
Subcontracting Opportunity Description
Aggregate percentages of the contract expected to be subcontracted:
Non-HUBs
Percentage of the contract
expected to be subcontracted
Percentage of the contract
to HUBs with which you have expected to be subcontracted
a continuous contract* in place
to non-HUBs .
for more than five (5) years.
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
*Continuous Contract: Any existing written agreement (including any renewals that are exercised) between a prime contractor and a HUB vendor, where the HUB vendor provides the
prime contractor with goods or service under the same contract for a specified period of time. The frequency the HUB vendor is utilized or paid during the term of the contract is not
relevant to whether the contract is considered continuous. Two or more contracts that run concurrently or overlap one another for different periods of time are considered by CPA to be
individual contracts rather than renewals or extensions to the original contract. In such situations the prime contractor and HUB vendor are entering (have entered) into “new” contracts.
Page 94 of 137
Enter your company’s name here:
SECTION 3
Requisition #:
SELF PERFORMING JUSTIFICATION (If you responded “No” to SECTION 2, Item a, you must complete this SECTION and continue to SECTION 4.)
Check the appropriate box (Yes or No) that indicates whether your response/proposal contains an explanation demonstrating how your company will fulfill the entire
contract with its own resources.
- Yes (If Yes, in the space provided below list the specific page(s)/section(s) of your proposal which explains how your company will perform the entire
contract with its own equipment, supplies, materials and/or employees.)
- No
(If No, in the space provided below explain how your company will perform the entire contract with its own equipment, supplies, materials and/or
employees.)
SECTION 4 AFFIRMATION
As evidenced by my signature below, I affirm that I am an authorized representative of the respondent listed in SECTION 1, and that the information and supporting
documentation submitted with the HSP is true and correct. Respondent understands and agrees that, if awarded any portion of the requisition:
 The respondent will provide notice as soon as practical to all the subcontractors (HUBs and Non-HUBs) of their selection as a subcontractor for the awarded
contract. The notice must specify at a minimum the contracting agency’s name and its point of contact for the contract, the contract award number, the
subcontracting opportunity they (the subcontractor) will perform, the approximate dollar value of the subcontracting opportunity and the expected percentage of the
total contract that the subcontracting opportunity represents. A copy of the notice required by this section must also be provided to the contracting agency’s point of
contact for the contract no later than ten (10) working days after the contract is awarded.
 The respondent must submit monthly compliance reports (Prime Contractor Progress Assessment Report – PAR) to the contracting agency, verifying its
compliance with the HSP, including the use of and expenditures made to its subcontractors (HUBs and Non-HUBs). (The PAR is available at
http://www.window.state.tx.us/procurement/prog/hub/hub-forms/progressassessmentrpt.xls).
 The respondent must seek approval from the contracting agency prior to making any modifications to its HSP, including the hiring of additional or different
subcontractors and the termination of a subcontractor the respondent identified in its HSP. If the HSP is modified without the contracting agency’s prior approval,
respondent may be subject to any and all enforcement remedies available under the contract or otherwise available by law, up to and including debarment from all
state contracting.
 The respondent must, upon request, allow the contracting agency to perform on-site reviews of the company’s headquarters and/or work-site where services are
being performed and must provide documentation regarding staffing and other resources.
Signature
Printed Name
Title
Date
(mm/dd/yyyy)
REMINDER: 

If you responded “Yes” to SECTION 2, Items c or d, you must complete an “HSP Good Faith Effort - Method A (Attachment A)” for each of
the subcontracting opportunities you listed in SECTION 2, Item b.
If you responded “No” SECTION 2, Items c and d, you must complete an “HSP Good Faith Effort - Method B (Attachment B)” for each of
the subcontracting opportunities you listed in SECTION 2, Item b.
Page 95 of 137
HSP Good Faith Effort - Method A (Attachment A)
Enter your company’s name here:
Rev. 10/14
Requisition #:
IMPORTANT: If you responded “Yes” to SECTION 2, Items c or d of the completed HSP form, you must submit a completed “HSP Good Faith Effort - Method A
(Attachment A)” for each of the subcontracting opportunities you listed in SECTION 2, Item b of the completed HSP form. You may photo-copy this page or download
the form at http://www.window.state.tx.us/procurement/prog/hub/hub-forms/HUBSubcontractingPlanAttachment-A.doc
SECTION A-1
SUBCONTRACTING OPPORTUNITY
Enter the item number and description of the subcontracting opportunity you listed in SECTION 2, Item b, of the completed HSP form for which you are completing this
attachment.
Item #:
SECTION A-2
Description:
SUBCONTRACTOR SELECTION
List the subcontractor(s) you selected to perform the subcontracting opportunity you listed above in SECTION A-1. Also identify whether they are a Texas certified HUB
and their VID number, the approximate dollar value of the work to be subcontracted, the expected percentage of work to be subcontracted, and indicate whether the
company is a Texas certified HUB.
Company Name
Texas
certified HUB
Approximate
Dollar Amount
VID #
(Required if Texas
certified HUB)
Expected Percentage
of Contract
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
REMINDER: As specified in SECTION 4 of the completed HSP form, if you (respondent) are awarded any portion of the requisition, you are required to provide notice as soon as
practical to all the subcontractors (HUBs and Non-HUBs) of their selection as a subcontractor. The notice must specify at a minimum the contracting agency’s name and its point of contact
for the contract, the contract award number, the subcontracting opportunity they (the subcontractor) will perform, the approximate dollar value of the subcontracting opportunity and the
expected percentage of the total contract that the subcontracting opportunity represents. A copy of the notice required by this section must also be provided to the contracting agency’s point
of contact for the contract no later than ten (10) working days after the contract is awarded.
Page 96 of 137
Rev. 10/14
HSP Good Faith Effort - Method B (Attachment B)
Enter your company’s name here:
Requisition #:
IMPORTANT: If you responded “No” to SECTION 2, Items c and d of the completed HSP form, you must submit a completed “HSP Good Faith Effort - Method B
(Attachment B)” for each of the subcontracting opportunities you listed in SECTION 2, Item b of the completed HSP form. You may photo-copy this page or download the
form at http://www.window.state.tx.us/procurement/prog/hub/hub-forms/HUBSubcontractingPlanAttachment-B.doc
SECTION B-1
SUBCONTRACTING OPPORTUNITY
Enter the item number and description of the subcontracting opportunity you listed in SECTION 2, Item b, of the completed HSP form for which you are
completing this attachment.
Item #:
SECTION B-2
Description:
MENTOR PROTÉGÉ PROGRAM
If respondent is participating as a Mentor in a State of Texas Mentor Protégé Program, submitting its Protégé (Protégé must be a State of Texas certified
HUB) as a subcontractor to perform the subcontracting opportunity listed in SECTION B-1, constitutes a good faith effort to subcontract with a Texas
certified HUB towards that specific portion of work.
Check the appropriate box (Yes or No) that indicates whether you will be subcontracting the portion of work you listed in SECTION B-1 to your Protégé.
- Yes (If Yes, to continue to SECTION B-4.)
- No / Not Applicable (If No or Not Applicable, continue to SECTION B-3 and SECTION B-4.)
SECTION B-3
NOTIFICATION OF SUBCONTRACTING OPPORTUNITY
When completing this section you MUST comply with items a, b, c and d, thereby demonstrating your Good Faith Effort of having notified Texas certified
HUBs and minority or women trade organizations or development centers about the subcontracting opportunity you listed in SECTION B-1. Your notice
should include the scope of work, information regarding the location to review plans and specifications, bonding and insurance requirements, required
qualifications, and identify a contact person. When sending notice of your subcontracting opportunity, you are encouraged to use the attached HUB
Subcontracting Opportunity Notice form, which is also available online at http://www.window.state.tx.us/procurement/prog/hub/hub-subcontractingplan/
Retain supporting documentation (i.e., certified letter, fax, e-mail) demonstrating evidence of your good faith effort to notify the Texas certified HUBs and
minority or women trade organizations or development centers. Also, be mindful that a working day is considered a normal business day of a state
agency, not including weekends, federal or state holidays, or days the agency is declared closed by its executive officer. The initial day the subcontracting
opportunity notice is sent/provided to the HUBs and to the minority or women trade organizations or development centers is considered to be “day zero”
and does not count as one of the seven (7) working days.
a. Provide written notification of the subcontracting opportunity you listed in SECTION B-1, to three (3) or more Texas certified HUBs. Unless the
contracting agency specified a different time period, you must allow the HUBs at least seven (7) working days to respond to the notice prior to your
submitting your bid response to the contracting agency. When searching for Texas certified HUBs, ensure that you use the State of Texas’
Centralized Master Bidders List (CMBL) and Historically Underutilized Business (HUB) Search directory located at
http://www.window.state.tx.us/procurement//cmbl/cmblhub.html. HUB Status code “A” signifies that the company is a Texas certified HUB.
b. List the three (3) Texas certified HUBs you notified regarding the subcontracting opportunity you listed in SECTION B-1. Include the company’s
Vendor ID (VID) number, the date you sent notice to that company, and indicate whether it was responsive or non-responsive to your subcontracting
opportunity notice.
Company Name
VID #
Date Notice Sent
(mm/dd/yyyy)
Did the HUB Respond?
- Yes
- No
- Yes
- No
- Yes
- No
c. Provide written notification of the subcontracting opportunity you listed in SECTION B-1 to two (2) or more minority or women trade organizations or
development centers in Texas to assist in identifying potential HUBs by disseminating the subcontracting opportunity to their members/participants.
Unless the contracting agency specified a different time period, you must provide your subcontracting opportunity notice to minority or women trade
organizations or development centers at least seven (7) working days prior to submitting your bid response to the contracting agency. A list of trade
organizations and development centers that have expressed an interest in receiving notices of subcontracting opportunities is available on the
Statewide HUB Program’s webpage at http://www.window.state.tx.us/procurement/prog/hub/mwb-links-1/
Page 97 of 137
d. List two (2) minority or women trade organizations or development centers you notified regarding the subcontracting opportunity you listed in
SECTION B-1. Include the date when you sent notice to it and indicate if it accepted or rejected your notice.
Trade Organizations or Development Centers
Page 98 of 137
Date Notice Sent
(mm/dd/yyyy)
Was the Notice Accepted?
- Yes
- No
- Yes
- No
HSP Good Faith Effort - Method B (Attachment B) Cont.
Enter your company’s name here:
SECTION B-4
Requisition #:
SUBCONTRACTOR SELECTION
a. Enter the item number and description of the subcontracting opportunity for which you are completing this Attachment B continuation page.
Item #:
Description:
b. List the subcontractor(s) you selected to perform the subcontracting opportunity you listed in SECTION B-1. Also identify whether they are a Texas
certified HUB and their VID number, the approximate dollar value of the work to be subcontracted, the expected percentage of work to be
subcontracted, and indicate whether the company is a Texas certified HUB.
Company Name
Texas
certified HUB
Approximate
Dollar Amount
VID #
(Required if Texas
certified HUB)
Expected Percentage
of Contract
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
- Yes
- No
$
%
c. If any of the subcontractors you have selected to perform the subcontracting opportunity you listed in SECTION B-1 is not a Texas certified HUB,
provide written justification for your selection process (attach additional page if necessary):
REMINDER: As specified in SECTION 4 of the completed HSP form, if you (respondent) are awarded any portion of the requisition, you are required
to provide notice as soon as practical to all the subcontractors (HUBs and Non-HUBs) of their selection as a subcontractor. The notice must specify at a
minimum the contracting agency’s name and its point of contact for the contract, the contract award number, the subcontracting opportunity it (the
subcontractor) will perform, the approximate dollar value of the subcontracting opportunity and the expected percentage of the total contract that the
subcontracting opportunity represents. A copy of the notice required by this section must also be provided to the contracting agency’s point of contact for
the contract no later than ten (10) working days after the contract is awarded.
Page 99 of 137
HUB Subcontracting Opportunity Notification
Form
In accordance with Texas Gov’t Code, Chapter 2161, each state agency that considers entering into a contract with an expected value of $100,000 or more
shall, before the agency solicits bids, proposals, offers, or other applicable expressions of interest, determine whether subcontracting opportunities are
probable under the contract. The state agency I have identified below in Section B has determined that subcontracting opportunities are probable under the
requisition to which my company will be responding.
34 Texas Administrative Code, §20.14 requires all respondents (prime contractors) bidding on the contract to provide notice of each of their subcontracting
opportunities to at least three (3) Texas certified HUBs (who work within the respective industry applicable to the subcontracting opportunity), and allow the
HUBs at least seven (7) working days to respond to the notice prior to the respondent submitting its bid response to the contracting agency. In addition, the
respondent must provide notice of each of its subcontracting opportunities to two (2) or more minority or women trade organizations or development centers
at least seven (7) working days prior to submitting its bid response to the contracting agency.
We respectfully request that vendors interested in bidding on the subcontracting opportunity scope of work identified in Section C, Item 2, reply no later than
the date and time identified in Section C, Item 1. Submit your response to the point-of-contact referenced in Section A.
Section A
PRIME CONTRACTOR’S INFORMATION
Company Name:
State of Texas VID #:
Point-of-Contact:
Phone #:
E-mail Address:
Fax #:
Section B
CONTRACTING STATE AGENCY AND REQUISITION INFORMATION
Agency Name:
Point-of-Contact:
Phone #:
Requisition #:
Bid Open Date:
Section C
SUBCONTRACTING OPPORTUNITY RESPONSE DUE DATE, DESCRIPTION, REQUIREMENTS AND RELATED INFORMATION
If you would like for our company to consider your company’s bid for the subcontracting opportunity identified below in Item 2,
we must receive your bid response no later than ____________________ Central Time on:
1. Potential
Subcontractor’s Bid
Response Due Date:
In accordance with 34 TAC §20.14, each notice of subcontracting opportunity shall be provided to at least three (3) Texas certified HUBs, and allow the HUBs at least seven (7)
working days to respond to the notice prior to submitting our bid response to the contracting agency. In addition, we must provide the same notice to two (2) or more minority or women
trade organizations or development centers at least seven (7) working days prior to submitting our bid response to the contracting agency.
(A working day is considered a normal business day of a state agency, not including weekends, federal or state holidays, or days the agency is declared closed by its executive officer.
The initial day the subcontracting opportunity notice is sent/provided to the HUBs and to the minority or women trade organizations or development centers is considered to be “day
zero” and does not count as one of the seven (7) working days.)
2. Subcontracting
Opportunity
Scope of Work:
3. Required
Qualifications:
- Not Applicable
4. Bonding/Insurance
Requirements:
- Not Applicable
5. Location to review
plans/specifications:
- Not Applicable
Page 100 of 137
APPENDIX D: Work Plan Template (Part B)
Tier 1 and Tier 2 respondents must adhere to the guidelines provided in Form I: Work Plan
Narrative (Part A), 1a-1e and Part B. Complete work plan templates for all of the following
activities, unless noted otherwise:
1.
2.
3.
4.
5.
6.
7.
Work Plan Example 1
Work Plan Example 2
Work Plan Example 3
Work Plan (Part B): Diabetes Prevention (Physical Activity and Nutrition)
Work Plan (Part B): Diabetes Prevention (Psychosocial Support Group(s))
Work Plan (Part B): Diabetes Self-Management Education (DSME)
Work Plan (Part B): Diabetes Self-Management Support (DSMS)
(Physical Activity—Support for Secondary Prevention)
8.
Work Plan (Part B): Diabetes Self-Management Support (DSMS)
(Nutrition—Support for Secondary Prevention)
9. Work Plan (Part B): Tier 1 ONLY—Diabetes Self-Management Support
(DSMS)
(Psychosocial Support Group(s)-Support for Secondary Prevention)
10. Work Plan (Part B): Tier 2 ONLY—Diabetes Self-Management Support
(DSMS) (Ongoing Support)
11. Work Plan (Part B): Healthcare Provider Education
12. Work Plan (Part B): Referrals (Tobacco Cessation Services)
13. Work Plan (Part B): Bi-directional Referral System
14. Work Plan (Part B): Tier 2 ONLY—Application for ADA-recognition or
AADE-accreditation
Page 101 of 137
APPENDIX D: Work Plan Example 1
SAMPLE
Program Name: Apple County Diabetes Program
Diabetes Self-Management Education (DSME)
Process Objective
By August 2016,
Apple County
Diabetes Program
will conduct 4
series, or 24 classes,
of diabetes selfmanagement for 60
persons with
diabetes and their
families.
Activities to Achieve
Objective
1. Secure implementation
sites from different
sectors (e.g., community
centers, faith-based
institutions, etc.)
2. Plan series evaluation
3. Identify and meet with a
healthcare system to
establish a referral
mechanism
4. Create and/or distribute
promotional materials for
classes
5. Recruit participants
6. Print class materials
7. Conduct series (6
classes per series)
8. Collect evaluation data
(e.g., baseline and postintervention, participant
satisfaction surveys, etc.)
9. Analyze evaluation data
Performance Measures
for Objective
1. 3 meetings or
contacts with
implementation site
staff
2. 1 participant
satisfaction survey
developed
3. 20 referrals received
from a healthcare
system
4. 200 promotional
flyers distributed
5. 24 self- management
classes completed
6. 60 persons with
diabetes and their
families trained
7. 60 evaluations
completed and
analyzed
Page 102 of 137
Team Members
Responsible
1.
2.
3.
Program
Coordinator
Program
Coordinator
Assistant
Community
Health
Workers
Contributing
Partner(s)
1. ABC Coalition
2. Community
centers
3. Faith-based
Institutions
Timeframe for
Assessing Progress
September 1, 2015August 31, 2016
APPENDIX D: Work Plan Example 2
SAMPLE
Program Name: Apple County Diabetes Program
Diabetes Prevention (Physical Activity and Nutrition)
Process Objective
By August 2016,
Apple County
Diabetes Program
conduct will
conduct 2
concurrent series, or
24 classes, of
physical activity
and nutrition classes
for 40 persons at
risk for Type 2
diabetes.
Activities to Achieve
Objective
Performance Measures
for Objective
1. Secure implementation
sites from different
sectors (e.g., community
centers, faith-based
institutions, etc.)
2. Plan series evaluation
3. Identify and meet with a
healthcare system to
establish a referral
mechanism
4. Create and/or distribute
promotional materials for
classes
5. Recruit participants
6. Print class materials
7. Conduct series (6
classes per series)
8. Collect evaluation data
(e.g., baseline and postintervention, participant
satisfaction surveys, etc.)
9. Analyze evaluation data
1. 2 meetings or
contacts with
implementation site
staff
2. 1 participant
satisfaction survey
developed
3. 10 referrals received
from a healthcare
system
4. 150 promotional
flyers distributed
5. 24 diabetes
prevention classes
completed
6. 40 persons at risk for
Type 2 diabetes
trained
7. 40 evaluations
completed and
analyzed
Page 103 of 137
Team Members
Responsible
Contributing
Partner(s)
1.
Program
Coordinator
1. ABC
Coalition
2.
Program
Coordinator
Assistant
2. Community
centers
3. Faith-based
3.
Community
Institutions
Health
Workers
Timeframe for
Assessing Progress
September 1, 2015August 31, 2016
APPENDIX D: Work Plan Example 3
SAMPLE
Program Name: Apple County Diabetes Program
Tier 2 ONLY—Application for ADA-recognition or AADE-accreditation
Process Objective
Activities to Achieve
Objective
Performance Measures
for Objective
By August 2016,
1. Completed National
1. 4 advisory board
Apple County
Standards 1-10 for DSME
meetings
Diabetes Program
Recognition/Accreditation
will submit an
, including:
application for
a. Process of
ADA-recognition or
identifying target
AADEpopulation
accreditation.
documented
b. Appropriate staff
hired (e.g.,
pharmacist,
registered nurse,
registered dietitian)
c. Advisory board
meetings held to
plan application
process
d. Education process
policy from
referral to followup developed
Page 104 of 137
Team Members
Responsible
1.
Program
Coordinator
2.
Other
administrative
staff
Contributing
Partner(s)
1. XYZ
Advisory
Board
2. Community
centers
3. Faith-based
Institutions
Timeframe for
Assessing Progress
September 1, 2015August 31, 2016
APPENDIX D: Work Plan Template (Part B)
Program Name:
Diabetes Prevention (Physical Activity and Nutrition)
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 105 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Diabetes Prevention (Psychosocial Support Group(s))
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 106 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Diabetes Self-Management Education (DSME)
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 107 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Diabetes Self-Management Support (DSMS) (Physical Activity)
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 108 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Diabetes Self-Management Support (DSMS) (Nutrition)
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 109 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Tier 1 ONLY—Diabetes Self-Management Support (DSMS) (Psychosocial Support Group(s))
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 110 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Tier 2 ONLY—Diabetes Self-Management Support (DSMS) (Ongoing Support)
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 111 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Healthcare Provider Education
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 112 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Referrals (Tobacco Cessation Services)
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 113 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Bi-directional Referral System
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 114 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX D: Work Plan Template (Part B)
Program Name:
Tier 2 ONLY—Application for ADA-recognition or AADE-accreditation
Process Objective
Activities to Achieve
Objective
Performance
Measures for
Objective
Team Members
Responsible
Page 115 of 137
Contributing
Partner(s)
Timeframe for
Assessing Progress
APPENDIX E: URL References and Resources
Centers for Disease Control and Prevention Division of Diabetes Translation
http://www.cdc.gov/diabetes/index.htm
Collaboration Defined: A Developmental Continuum of Change Strategies
http://depts.washington.edu/ccph/pdf_files/4achange.pdf
Community Tool Box
http://ctb.ku.edu/en/default.aspx
Diabetes Data Resources for Texas Counties:
HMO Data: http://www.dshs.state.tx.us/thcic/publications/HMOs/HMOReports.shtm
Mortality: http://soupfin.tdh.state.tx.us/death10.htm
Population: http://www.dshs.state.tx.us/chs/popdat/default.shtm
Prevalence: http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm
Preventable Hospitalizations:
http://www.dshs.state.tx.us/THCIC/Publications/Hospitals/PQIReport2008/PreventableHospitali
zations2008.shtm
Diabetes Empowerment Education Program (DEEP)
http://mlhrc.csw.uic.edu/
Diabetes Initiative Archive—National Program of the Robert Wood Johnson Foundation
1. http://diabetesnpo.im.wustl.edu/
2. http://www.diabetesinitiative.org/
Diabetes Prevention Program
http://www.bsc.gwu.edu/dpp/index.htmlvdoc
Diabetes Quality Improvement Project (DQIP)
http://www.ncqa.org/dprp/dqip2.htm
Diabetes Self-Management Education (DSME)
1. http://www.thecommunityguide.org/diabetes/index.html
2. http://care.diabetesjournals.org/content/25/7/1159.abstract?ijkey=a59bb961246bf5b81871fed7e2
13146f290f39c7&keytype2=tf_ipsecsha
3. http://ajph.aphapublications.org/cgi/content/full/95/9/1523
Do Well, Be Well with Diabetes (DWBW)
1. http://fcs.tamu.edu/health/type_2_diabetes/type_2_diabetes.php
2. http://www.nifa.usda.gov/nea/food/pdfs/health_texas_diabetes.pdf
Eligible Professional’s Guide to Stage 2 of the EHR Incentive Programs:
http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_Guide_EPs_9_23_13.pdf
Page 116 of 137
Guide to Community Preventive Services
http://www.thecommunityguide.org
Health Disparities
1. http://www.hhs.state.tx.us/oehd/index.shtml
2. http://www.omhrc.gov/
Healthy People 2020—Diabetes
http://www.healthypeople.gov/2020/topics-objectives/topic/diabetes
Love Kidneys
http://www.lovekidneys.com/
National Association of Chronic Disease Directors—DSME Resource
http://www.chronicdisease.org/?page=DiabetesDSMEresource
National Diabetes Education Program (NDEP)
http://www.cdc.gov/diabetes/ndep/index.htm/
National Diabetes Prevention Program
1. http://www.cdc.gov/diabetes/prevention/
2. http://www.cdc.gov/diabetes/prevention/recognition/curriculum.htm
3. http://www.cdc.gov/diabetes/prevention/recognition/spanish_curriculum.htm#hand
National Kidney Disease Education Program (NKDEP)
http://nkdep.nih.gov
National Public Health Performance Standards Program
http://www.cdc.gov/od/ocphp/nphpsp/
National Quality Forum (NQF)-Endorsed Measure for Diabetes Mellitus Lower-Extremity
Amputation Rate
http://www.qualitymeasures.ahrq.gov/content.aspx?id=38571
National Standards for Diabetes Self-Management Education and Support
http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/general/2012NationalStandards.pdf
NDEP Diabetes at Work
https://diabetesatwork.org/
Office of Disease Prevention and Health Promotion
http://health.gov/
Partnership for Prevention Action Guides
http://www.prevent.org/actionguides
Road to Health (RTH)
http://www.cdc.gov/diabetes/ndep/road-to-health.htm
¡Sí, Yo Puedo Controlar Mi Diabetes!
Page 117 of 137
1. http://fcs.tamu.edu/yopuedo/index.php
2. http://fcs.tamu.edu/fcs_programs/2014briefs/yo-puedo-2014-brief.pdf
Stanford Diabetes Self-Management Program
http://patienteducation.stanford.edu/crosstraining/index.html
Stanford Programa de Manejo Personal de la Diabetes
http://patienteducation.stanford.edu/programs_spanish/
Sustainability
Making public health programs last: conceptualizing sustainability
http://www.sciencedirect.com/science/article/pii/S0149718904000023
Sustainability—A Retrospective Assessment of Diabetes Initiative Projects
http://diabetesnpo.im.wustl.edu/lessons/documents/SustainabilityReportforweb.pdf
Sustainable Measures
http://www.sustainablemeasures.com/
Sustaining Community-based Programs for Families: Conceptualization and Measurement
http://spock.fcs.uga.edu/hdfs/fcrlweb/docs/Mancini/Mancini%20et.%20al%202004%20(sustaining).pdf
Texas Association of Community Health Center (TACHC)
http://www.tachc.org/
Texas Behavioral Risk Factor Surveillance System (BRFSS)
http://www.dshs.state.tx.us/chs/default.shtm
Texas Department of State Health Services Cardiovascular Disease and Stroke Program
http://www.dshs.state.tx.us/wellness/
Texas Department of State Health Services Diabetes Prevention and Control Program
http://www.dshs.state.tx.us/diabetes/default.shtm
Texas Department of State Health Services Tobacco Prevention and Control Program
https://www.dshs.state.tx.us/tobacco/
Texas Diabetes Council Strategic Plan
http://www.dshs.state.tx.us/diabetes/tdcplan.shtm
Texas Diabetes Council (TDC) Toolkit, including Minimum Standards for Diabetes Care in Texas
and treatment algorithms
http://www.tdctoolkit.org/
Texas Information and Referral Network (TIRN)
https://www.211texas.org/cms/
Walk Texas!
https://www.dshs.state.tx.us/diabetes/walktx.shtm.
Page 118 of 137
Wisdom, Power, Control
1. http://fcs.tamu.edu/wisdom/
2. http://fcs.tamu.edu/fcs_programs/2014briefs/wisdom-power-control-2014-brief.pdf
W.K. Kellogg Foundation Community Partnerships Toolkit
http://ww2.wkkf.org/Pubs/CustomPubs/CPtoolkit/CPToolkit/default.htm
Page 119 of 137
APPENDIX F: FY16 Tier 1 and 2 Requirements of
Community Diabetes Education Programs (CDEP)
Requirements of Community Diabetes Education Programs (CDEP)
National Accreditation or Recognition
The provider of diabetes self-management education (DSME) will apply for
American Diabetes Association (ADA) accreditation or American Association
of Diabetes Educators (AADE) recognition within first calendar year of funding.
Tier 1
Tier 2
X
Program Expansion
If ADA-accredited or AADE recognized at the time of application, the provider
of DSME will expand its program to additional sites during the first fiscal year
of funding.
X
Internal Structure
The provider of DSME will document an organizational structure, mission
statement, and goals. For those providers working within a larger organization,
that organization will recognize and support quality DSME as an integral
component of diabetes care.
X
External Input
The provider of DSME will seek ongoing input from external stakeholders and
experts to promote program quality.
An advisory board is required for accreditation or recognition (Tier 2), whereas
a coalition is required for an implementation only project (Tier 1).
Access
The provider of DSME will determine whom to serve, how best to deliver
diabetes education to that population, and what resources can provide ongoing
support for that population.
Program Coordination
A coordinator will be designated to oversee the DSME program. The
coordinator will have oversight responsibility for the planning, implementation,
and evaluation of education services.
Program Coordinator Staff
Fifteen hours of continuing education is required on an annual basis as it relates
to diabetes care as well as their profession (i.e., program management,
education, chronic disease care, behavior change). Refer to ADA-recognition
and/or AADE-accreditation guidelines for requirements related to certified
diabetes educators (CDE) and/or board certified advanced diabetes management
(BC-ADM) professionals.
Page 120 of 137
X
X
X
X
X
X
X
Requirements of Community Diabetes Education Programs (CDEP)
Instructional Staff (Licensed/Certified Healthcare Professional)
1 or more instructors will provide DSME and, when applicable, DSMS. At least
one of the instructors responsible for designing and planning DSME and DSMS
will be an RN, RD, or pharmacist with training and experience pertinent to
DSME, or another professional with certification in diabetes care and education,
such as a CDE or BC-ADM.
Fifteen hours of continuing education is required annually for all professionals
serving as DSME instructors. If instructor is a CDE they must maintain the CE
requirement of their certification. If the instructor is a BC-ADM they must
maintain the requirements to maintain certification.
Tier 1
Tier 2
X
X
Continuing education for instructional staff needs to be diabetes-specific,
diabetes-related, and/or behavior change self- management education-specific.
Instructional Staff (Community Health Worker (CHW))
1 or more instructors will provide DSME and, when applicable, DSMS.
Community health workers can contribute to DSME and provide DSMS with
appropriate training in diabetes and with supervision and support.
X
X
Curriculum
A written curriculum reflecting current evidence and practice guidelines, with
criteria for evaluating outcomes, will serve as the framework for the provision of
DSME. The needs of the individual participant will determine which parts of the
curriculum will be provided to that individual.
X
X
Individualization
The diabetes self-management, education, and support needs of each participant
will be assessed by one or more instructors. The participant and instructor(s) will
then together develop an individualized education and support plan focused on
behavior change.
X
Ongoing Support
The participant and instructor(s) will together develop a personalized follow-up
plan for ongoing self-management support. The participant’s outcomes and
goals and the plan for ongoing self-management support will be communicated
to other members of the healthcare team.
X
Patient Progress
The provider of DSME and DSMS will monitor whether participants are
achieving their personal diabetes self-management goals and other outcome(s)
as a way to evaluate the effectiveness of the educational intervention(s), using
appropriate measurement techniques.
Quality Improvement
The provider of DSME will measure the effectiveness of the education and
support and look for ways to improve any identified gaps in services or service
quality, using a systematic review of process and outcome data.
Page 121 of 137
X
X
X
Requirements of Community Diabetes Education Programs (CDEP)
Reporting
Tier 1
The National Standards for Diabetes Self-Management Education
Programs (NSDSMEP) must be maintained and programs must submit
information on an annual basis and as deemed necessary by AADE or ADA for
review.
The provider of DSME must enter monthly activities and submit quarterly and
annual reports to DSHS through the web-based Performance Management and
Tracking System (PMATS).
The provider of DSME will collect and report pre- and post-intervention clinical
outcomes, in addition to diabetes knowledge, self-efficacy, and behavior change.
X
X
X
Reimbursement for DSME
The accreditation or recognition process is essential to obtain Medicare
reimbursement for DSME. However, it is a separate process and reimbursement
criteria vary. For example, Medicare provides reimbursement for accredited
DSME programs that are considered "Certified Providers." Many private payers
require that provider agreements be in place prior to providing reimbursement.
Diabetes Self-Management Education Implementation
The provider of DSME will conduct at least four (4) series of DSME classes per
fiscal year, focusing on populations living with Type 2 diabetes, including
racial/ethnic minority groups, low-income, and uninsured/under-insured
individuals and families in areas with a significant prevalence of diabetes.
The provider of DSME will provide education to people aged 18 years or older
in settings other than the home, clinic, school, or worksite (e.g., community
centers, faith-based institutions, libraries, or private facilities such as residential
cardiovascular risk-reduction centers).
Diabetes Prevention Education Implementation
The provider of DSME will conduct at least two (2) series of concurrent
nutrition and physical activity classes per fiscal year, focusing on populations
with pre-diabetes or at high-risk for developing Type 2 diabetes, including
racial/ethnic minority groups, low-income, and uninsured/under-insured
individuals and families in areas with a significant prevalence of diabetes.
The provider of DSME will collaborate with and refer eligible participants with
pre-diabetes to Centers for Disease Control and Prevention (CDC)-recognized
National Diabetes Prevention Programs, where programs are available.
X
X
X
X
X
X
X
X
X
X
X
The provider of DSME may apply for National Diabetes Prevention Program
recognition through CDC, if eligible.
Clinical-Community Linkage
The provider of DSME and/its partner(s) will conduct healthcare provider
education presentations to increase use of the Texas Diabetes Council’s (TDC)
Page 122 of 137
Tier 2
X
X
X
Requirements of Community Diabetes Education Programs (CDEP)
toolkit, including the Minimum Standards for Diabetes Care in Texas and
treatment algorithms.
The provider of DSME will establish a bi-directional referral mechanism with
healthcare systems, clinicians, and/or clinics.
The provider of DSME will work with partner health systems to assess the
following for the duration of the project period:
 Short and long-term diabetes hospitalization rates
 A1c levels of patients served by each health system (focus on use of
electronic health records)
 Blood pressure of patients served by each health system (focus on use of
electronic health records)
 Amputation rates of patients served by each health system
Page 123 of 137
Tier 1
Tier 2
X
X
X
APPENDIX G:
Map of 2014 ADA-recognized and 2014 AADE-accredited sites and
2012 Adult Diabetes Prevalence by Health Service Region in Texas
Page 124 of 137
APPENDIX H: DSHS Menu of Evidence-Based Curricula Descriptions
NOTE: Please check with curriculum contacts for updated pricing and training information.
DIABETES SELF-MANAGEMENT EDUCATION CURRICULA
Name
Diabetes Empowerment
Education Program
(DEEP)
Do Well, Be Well with
Diabetes
(DWBW)
Description
The University of Illinois at Chicago Midwest Latino Health Research,
Training and Policy Center (MLHRC) developed the DEEP in 1997
under a REACH 2010 grant from the Centers for Disease Control and
Prevention. The DEEP's goal is to reduce diabetes complications and
hospitalizations, especially those from minority and medically
underserved communities. It specifically addresses issues of health
literacy and culturally appropriate health information.
Contact Information
Texas Department of State Health
Services
Luby Garza
1100 W. 49th Street
Austin, TX 78756-3199
Do Well, Be Well with Diabetes, developed by Texas A&M AgriLife
Extension Service, covers basic nutrition and self-care management
topics. The curriculum helps people living with diabetes learn the skills
needed to manage the condition well.
Texas A&M AgriLife Extension
Service
Family & Consumer Sciences
2251 TAMU
College Station, TX 77845-2251
Telephone: 512-776-2831
E-mail: luby.garza@dshs.state.tx.us
Telephone: 979-845-3850
Fax: 979-845-6496
E-mail: fdrm@tamu.edu
Websites:
http://fcs.tamu.edu/health/type_2_diabete
s/type_2_diabetes.php
http://www.nifa.usda.gov/nea/food/pdfs/h
ealth_texas_diabetes.pdf
Page 125 of 137
¡Sí, Yo Puedo Controlar
Mi Diabetes!
(Sí, Yo Puedo)
¡Sí, Yo Puedo Controlar Mí Diabetes!, developed by Texas A&M
AgriLife Service, is a 7-week diabetes self-management program for
Spanish-speaking adults, 18+ years of age, living with diabetes.
Classes are offered once a week in community settings such as
churches, libraries, and hospitals. Each session is 2 hours. Two trained
health professionals facilitate Sí, Yo Puedo: a registered nurse (RN)
and registered dietician (RD).
Texas A&M AgriLife Extension
Service
Family & Consumer Sciences
2251 TAMU
College Station, TX 77845-2251
Telephone: 979-845-3850
Fax: 979-845-6496
E-mail: fdrm@tamu.edu
Websites: http://fcs.tamu.edu/
http://fcs.tamu.edu/yopuedo/index.php
http://fcs.tamu.edu/fcs_programs/2014bri
efs/yo-puedo-2014-brief.pdf
Wisdom, Power, Control
Wisdom, Power, Control was designed to provide culturally-sensitive
diabetes self-management education (DSME) to best reach minority
populations, specifically Black/African-American population groups.
Developed by Texas A&M AgriLife Extension Service, Wisdom,
Power, Control is a 7-week diabetes self-management curriculum for
adults, 18+ years of age, living with diabetes. Classes are offered once a
week in community settings such as churches, libraries, and hospitals.
Each session is 2 hours. Two trained health professionals facilitate Sí,
Yo Puedo: a registered nurse (RN) and registered dietician (RD).
Texas A&M AgriLife Extension
Service
Family & Consumer Sciences
2251 TAMU
College Station, TX 77845-2251
Telephone: 979-845-3850
Fax: 979-845-6496
E-mail: fdrm@tamu.edu
Websites: http://fcs.tamu.edu/
http://fcs.tamu.edu/wisdom/
http://fcs.tamu.edu/fcs_programs/2014bri
efs/wisdom-power-control-2014-brief.pdf
Page 126 of 137
Stanford Diabetes SelfManagement Program
(SDSMP)
Stanford Programa de
Manejo Personal de la
Diabetes
The diabetes self-management workshop, developed by the Stanford
Patient Education Research Center, is given 2½ hours once a week for
six weeks, in community settings such as churches, community centers,
libraries and hospitals. People with type 2 diabetes attend the program
in groups of 12-16. Two trained leaders facilitate workshops from a
highly detailed manual, one or both of whom are peer leaders living
with diabetes.
Stanford Patient Education Research
Center
1000 Welch Road, Suite 204
Palo Alto, CA 94304
The Spanish language diabetes self-management workshop, developed
by the Stanford Patient Education Research Center, is given 2½ hours
once a week for six weeks, in community settings such as churches,
community centers, libraries and hospitals. People with type 2 diabetes
attend the program in groups of 12-16. Two trained leaders facilitate
workshops from a highly detailed manual, one or both of whom are peer
leaders living with diabetes.
Stanford Patient Education Research
Center
1000 Welch Road, Suite 204
Palo Alto, CA 94304
Page 127 of 137
Telephone: 650-723-7935
Fax: 650-725-9422
E-mail: self-management@stanford.edu
Website:
http://patienteducation.stanford.edu/cross
training/index.html
Telephone: 650-723-7935
Fax: 650-725-9422
E-mail: self-management@stanford.edu
Website:
http://patienteducation.stanford.edu/progr
ams_spanish/
TYPE 2 DIABETES PREVENTION CURRICULA/RESOURCES
Name
NDEP Power to Prevent
Description
Power to Prevent was designed to encourage African-Americans at
increased risk for type 2 diabetes to become more physically active
and to eat more healthy foods as a way to prevent or delay diabetes.
People with diabetes can also benefit from the program by learning
skills that will help them control their blood glucose (sugar) levels.
The curriculum presented in the manual is made up of multiple sessions
that can help informal groups and organizations plan, promote, start up,
conduct, and evaluate activities that help individuals and families make
good nutrition and physical activity part of their daily lives. Included in
the manual are health tips, resources, and suggestions for activities that
are simple and fun for just one person or for the whole family.
NDEP Road to Health
Toolkit
The Road to Health Toolkit was developed by the National Diabetes
Education Program (NDEP), a partnership of the National Institutes of
Health (NIH), the Centers for Disease Control and Prevention (CDC),
and more than 200 public and private organizations. Road to Health is
available in English and Spanish and provides community health
workers/“promotores de salud”, nurses, health educators and dietitians
with interactive tools that can be used to counsel and motivate those at
high risk for type 2 diabetes. These tools will help reduce their risk for
type 2 diabetes by encouraging healthy eating, increased physical
activity, and moderate weight loss for those who are overweight.
Contact Information
Centers for Disease Control and
Prevention
1600 Clifton Rd
Atlanta, GA 30333
Telephone: 1-800-CDC-INFO
(1-800-232-4636)
TTY: 1-888-232-6348
Email: Contact CDC-Info
Website:
http://www.cdc.gov/diabetes/ndep/roadto-health.htm
curriculum
http://ndep.nih.gov/media/power-toprevent-508.pdf
Centers for Disease Control and
Prevention
1600 Clifton Rd
Atlanta, GA 30333
Telephone: 1-800-CDC-INFO
(1-800-232-4636)
TTY: 1-888-232-6348
Email: Contact CDC-Info
Website:
http://www.cdc.gov/diabetes/ndep/roadto-health.htm
Page 128 of 137
National Diabetes
Prevention Program
(NDPP)
The National Diabetes Prevention Program encourages collaboration
among federal agencies, community-based organizations, employers,
insurers, health care professionals, academia, and other stakeholders to
prevent or delay the onset of type 2 diabetes among people with prediabetes in the United States.
The CDC-led National Diabetes Prevention Program is an evidencebased lifestyle change program for preventing type 2 diabetes.




It can help people cut their risk of developing type 2 diabetes in
half.
The Diabetes Prevention Program research study showed that
making modest behavior changes helped participants lose 5% to
7% of their body weight—that is 10 to 14 pounds for a 200pound person.
These lifestyle changes reduced the risk of developing type 2
diabetes by 58% in people with pre-diabetes.
Participants work with a lifestyle coach in a group setting to
receive a 1-year lifestyle change program that includes 16 core
sessions (usually 1 per week) and 6 post-core sessions (1 per
month).
Centers for Disease Control and
Prevention
1600 Clifton Rd
Atlanta, GA 30333
Telephone: 1-800-CDC-INFO
(1-800-232-4636)
TTY: 1-888-232-6348
Email: Contact CDC-Info
Websites:
http://www.cdc.gov/diabetes/prevention/i
ndex.htm
http://www.cdc.gov/diabetes/prevention/r
ecognition/curriculum.htm
curriculum in English
http://www.cdc.gov/diabetes/prevention/
pdf/curriculum.pdf
curriculum in Spanish
http://www.cdc.gov/diabetes/prevention/r
ecognition/spanish_curriculum.htm#hand
Page 129 of 137
APPENDIX I:
Sample Participant Health Outcome Form and Intervention Worksheet
Page 130 of 137
SIGN IN SHEET (DRAFT)
Circle One: one of a series OR single event
Record Number: _________
If series, provide series name: ____________________________________________________
Date of
Activity
Location and Time of
Activity
Name of Location
Type of Activity
Check One
________________________
Time of Event
 Diabetes
Selfmanagement
Education
________________________  General
Diabetes
Education
(single-event
Select the Sector:
 Business/Industry/Retail
only)
 Community
 Faith-based
 Minimum
 Government
Standard of
 Healthcare
Care/Algorit
 School/Education
hms
 Worksite Wellness
 Psychosocial
Support
Group
Language
Curriculum and
Education Materials
Used (if any)
Check One
 English
Check Curriculum(s) Used
 Spanish
 Cantonese
 Cooking Well with Diabetes
 Mandarin
 DEEP
 Portuguese  Diabetes and Cardiovascular Self Vietnamese
Management Guide (developed by
 Other
Gateway Community Health Center)
 Do Well, Be Well with Diabetes
 Kidney Health Module (sponsored by
Texas Medical Foundation)
 NDEP Road to Health
 Not applicable
 Other—Name the Curriculum
_________________________
_________________________
 Nutrition
Education
Primary
Prevention:
Circle Yes OR
No
 Physical
Activity
Primary
Prevention:
Circle Yes OR
No
Page 131 of 137
List Education
Materials Distributed
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Number of
Healthcare
Providers:
_________
Name of Participant
Male/Female
(M/F)
1
Circle One: M/F
2
Circle One: M/F
3
Circle One: M/F
4
Circle One: M/F
5
Circle One: M/F
6
Circle One: M/F
7
Circle One: M/F
8
Circle One: M/F
9
Circle One: M/F
10
Circle One: M/F
11
Circle One: M/F
12
Circle One: M/F
13
Circle One: M/F
14
Circle One: M/F
15
Circle One: M/F
16
Circle One: M/F
17
Circle One: M/F
18
Circle One: M/F
19
Circle One: M/F
20
Circle One: M/F
Age Range
(Circle One Below)
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Pre K
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Grades
K-5
Page 132 of 137
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
6-8
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
Grades
9-12
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
18-24
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
25-49
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
50+
years
1. Write a narrative to provide details about the intervention that took place (i.e. describe the selfmanagement lessons discussed, name types of physical activity conducted, etc.).
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________________________
2. What types of evaluation methods were used? Check all that apply.
 BMI
 Client Satisfaction
 Clinical Baseline
 Pre-test
 Post-test
 Other
 None
3. If participants do not return to class, provide explanation(s) below.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
4. What methods will be used to retain participants in response to feedback noted in question #3?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
5. How were the participants noted in question #3 contacted for feedback?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Page 133 of 137
APPENDIX J: Class Implementation Plan
Complete and submit the Excel spreadsheets outlining proposed class implementation for FY
2016. Instructions are provided on the first worksheet in the workbook.
Page 134 of 137
APPENDIX K: Letters of Commitment
(FORM G: ASSESSMENT NARRATIVE GUIDELINES, Part B, 7.)
Page 135 of 137
APPENDIX L: Letters of Commitment
(FORM G: ASSESSMENT NARRATIVE GUIDELINES, Part B, 10.)
Page 136 of 137
APPENDIX M: Letters of Commitment
(FORM I: WORK PLAN GUIDELINES NARRATIVE, Part A, 6g.)
Page 137 of 137