Attachment 1

Page 1
Bid Form [For business, personal or consultant services]
Name of Bidding Firm (Legal name as it will appear on the contract)

Mailing address City State Zip Code

Telephone number Fax number Email address, if applicable

( ) ( )
Name of Contact Person Telephone number: (If different from above)
( )
Amounts Bid [Modify this section to reflect how costs are billed for the service you are seeking.]
Annual Cost(s): A (Year 1) $ XX-XX-XX through XX-XX-XX
B (Year 2) $ XX-XX-XX through XX-XX-XX [Delete row, if not multi-year]
C (Year 3) $ XX-XX-XX through XX-XX-XX [Delete row, if not multi-year]
Total Costs: A + B + C = $ XX-XX-XX through XX-XX-XX [Alter row, if not multi-year]

Bidding Preferences Claimed (Check only the preferences claimed)

Certified small business or microbusiness preference (including Nonprofit Veteran Service Agencies)
Non-small business subcontractor preference (committing use of 25% or more of small business subcontracts)
DVBE Incentive (committing to use DVBE subcontracts)
TACPA preference [Delete if not applicable]
EZA preference [Delete if not applicable]

Bidder Acknowledgment / Certification

The Bidder hereby certifies that the materials submitted in response to this IFB and the price(s)/rate(s) offered on this
Bid Form are true and accurate to the best of the Bidder's knowledge.

The Bidder agrees that the price(s)/rate(s) offered herein shall remain in effect until CDPH awards the agreement and
throughout the duration of the agreement. Any cost over runs or increases in services, if allowed, shall be billed at the
price(s)/rate(s) stated for the appropriate budget period. Contract extensions, if any, shall be billed at the
price(s)/rate(s) stated for the last budget period/year if more than one budget period/year is shown.
The Bidder further understands that the above quoted rate(s) must include all of the bidders costs including operating
expenses, labor, service call charges, diagnostic fees/estimates, transportation/travel costs, mileage or per diem
expenses, equipment costs, supplies, annual inflation costs/rate adjustments, profit margin, etc. By submitting this Bid
Form the Bidder hereby claims its willingness to certify to and comply with all requirements and terms and conditions
cited in this IFB and any attachment thereto.
The Bidder understands that its bid response will become a public document and will be open to public inspection.
Bidder's signature: Date signed

Printed/typed name Title

 Attachment 1
Page 1
Bid Form
Name of Bidding Firm (Legal name as it will appear on the contract)

Mailing address City State Zip Code

Telephone number Fax number Email address, if applicable

( ) ( )
Name of Contact Person Telephone number: (If different from above)
( )
Amounts Bid: [Modify this section to reflect how costs are billed for the service you are seeking.]
A$ Regular hourly labor rate – XX-XX-XX through XX-XX-XX (Year 1)
B$ Regular hourly labor rate – XX-XX-XX through XX-XX-XX (Year 2)
C$ Regular hourly labor rate – XX-XX-XX through XX-XX-XX (Year 3)
*Cost Calculation for bidding purposes only: Add A + B + C, then divide the total by 3 as shown below:
A+B+C= $ ÷ by 3 = $ Total average regular hourly labor rate
*Note: This calculation is for bidding purposes only. The winning bidder will be reimbursed at the actual hourly labor rate quoted
for each year. Parts will be reimbursed at the rate in effect at the time any parts are ordered. [If necessary, modify this section to
add emergency or overtime service rates or other rates that apply to the services you are seeking.]

Bidding Preferences Claimed (Check only the preferences claimed)

Certified small business or microbusiness preference (including Nonprofit Veteran Service Agencies)
Non-small business subcontractor preference (committing use of 25% or more of small business subcontracts)
DVBE incentive (committing use of DVBE subcontracts)
TACPA preference [Delete if not applicable]
EZA preference [Delete if not applicable]

Bidder Acknowledgment / Certification

The Bidder hereby certifies that the materials submitted in response to this IFB and the price(s)/rate(s) offered on this
Bid Form are true and accurate to the best of the Bidder's knowledge.

The Bidder agrees that the price(s)/rate(s) offered herein shall remain in effect until CDPH awards the agreement and
throughout the duration of the agreement. Any cost over runs or increases in services, if allowed, shall be billed at the
price(s)/rate(s) stated for the appropriate budget period, except that costs for parts, if any, may be billed at the
prevailing rate in effect at the time parts are ordered. Contract extensions, if any, shall be billed at the price(s)/rate(s)
stated for the last budget period/year if more than one budget period/year is shown.

The Bidder further understands that the above quoted rate(s) must include all of the bidder’s costs including operating
expenses, labor, service call charges, diagnostic fees/estimates, transportation/travel costs, mileage or per diem
expenses, equipment costs, supplies, annual inflation costs/rate adjustments, profit margin, etc. By submitting this Bid
Form the Bidder hereby claims its willingness to certify to and comply with all requirements and terms and conditions
contained in this IFB and any attachment thereto.

The Bidder understands that its bid response will become a public document and will be open to public inspection.
Bidder's signature: Date signed

Printed/typed name Title

 Attachment 1A
Page X
Budget Detail Work Sheet
(Year 1)
(XX/XX/XX – XX/XX/XX)
[Only include this form in IFBs seeking Consultant or Professional Personal Services]
Personnel
Position Title and No of each Salary Rate/Range FTE % Annual Cost
$ % $
$ % $
$ % $
Total Personnel $

Fringe Benefits ( % of Personnel) $

Operating Expenses
Expense Description Cost
$
$
$
Total Operating $

Equipment
Equipment Description # of Units Unit Cost Total Cost
$ $
$ $
$ $
Total Equipment $

Travel $

Subcontracts [Include a Subcontractor Budget attachment if more than 2 subcontracts are expected.]
Name of Subcontractor:
Personnel Gen. Exp. Travel Subcontracts Indirect Costs Total Cost
$ $ $ $ $ $
Name of Subcontractor:
Personnel Gen. Exp. Travel Subcontracts Indirect Costs Total Cost
$ $ $ $ $ $

Name of Subcontracted Project (If Subcontractor is unknown):

$

Total Subcontracts $
Other Costs
Item Description Estimated Cost
$
$
Total Other Costs $

Indirect Costs ( % of [Enter cost basis] Costs) $

Total Costs $
Copy this format or use a similar one and use as many sheets as are necessary.
 Attachment 1B
Page X
Budget Detail Work Sheet
(Year 2)
(XX/XX/XX – XX/XX/XX)
[Only include this form in IFBs seeking Consultant or Professional Personal Services]
Personnel
Position Title and No of each Salary Rate/Range FTE % Annual Cost
$ % $
$ % $
$ % $
Total Personnel $

Fringe Benefits ( % of Personnel) $

Operating Expenses
Expense Description Cost
$
$
$
Total Operating $

Equipment
Equipment Description # of Units Unit Cost Total Cost
$ $
$ $
$ $
Total Equipment $

Travel $

Subcontracts [Include a Subcontractor Budget attachment if more than 2 subcontracts are expected.]
Name of Subcontractor:
Personnel Gen. Exp. Travel Subcontracts Indirect Costs Total Cost
$ $ $ $ $ $
Name of Subcontractor:
Personnel Gen. Exp. Travel Subcontracts Indirect Costs Total Cost
$ $ $ $ $ $

Name of Subcontracted Project (If Subcontractor is unknown):

$

Total Subcontracts $
Other Costs
Item Description Estimated Cost
$
$
Total Other Costs $

Indirect Costs ( % of [Enter cost basis] Costs) $

Total Costs $
Copy this format or use a similar one and use as many sheets as are necessary.
 Attachment 1C
Page X
Budget Detail Work Sheet
(Year 3)
(XX/XX/XX – XX/XX/XX)
[Only include this form in IFBs seeking Consultant or Professional Personal Services]
Personnel
Position Title and No of each Salary Rate/Range FTE % Annual Cost
$ % $
$ % $
$ % $
Total Personnel $

Fringe Benefits ( % of Personnel) $

Operating Expenses
Expense Description Cost
$
$
$
Total Operating $

Equipment
Equipment Description # of Units Unit Cost Total Cost
$ $
$ $
$ $
Total Equipment $

Travel $

Subcontracts [Include a Subcontractor Budget attachment if more than 2 subcontracts are expected.]
Name of Subcontractor:
Personnel Gen. Exp. Travel Subcontracts Indirect Costs Total Cost
$ $ $ $ $ $
Name of Subcontractor:
Personnel Gen. Exp. Travel Subcontracts Indirect Costs Total Cost
$ $ $ $ $ $

Name of Subcontracted Project (If Subcontractor is unknown):

$

Total Subcontracts $
Other Costs
Item Description Estimated Cost
$
$
Total Other Costs $

Indirect Costs ( % of [Enter cost basis] Costs) $

Total Costs $
Copy this format or use a similar one and use as many sheets as are necessary.
 Attachment 2
Page 1
Required Attachment / Certification Checklist
Use this sample to create the IFB Checklist. Do not re-name this form. Follow the instructions in blue type.
Confirmed
Qualification Requirements. I certify that I meet the following qualification requirements:
by CDPH
Yes My firm possesses at least three consecutive years of experience of the types listed in Item 1 of Yes
the IFB section entitled, “Qualification Requirements”. That experience occurred within the past
N/A No
five years. [Alter the Years shown only if a corresponding change is made within the IFB.]
Yes My firm has read and is willing to comply with the terms, conditions, and contract exhibits Yes
N/A addressed in the IFB section entitled, “Contract Terms and Conditions”. No
Yes (Corporations) My firm is in good standing and qualified to conduct business in California. Yes
N/A [Check “N/A” if not a Corporation.] No
Yes (Nonprofit Organizations) My firm is eligible to claim nonprofit status. Yes
N/A [Check “N/A” if not a nonprofit organization.] No
Yes My firm has a past record of sound business integrity and a history of being responsive to past Yes
N/A contractual obligations. My firm authorizes the State to confirm this claim. No
Yes My firm has certified via Attachment 7 that its bid response is not in violation of Public Yes
N/A Contract Code Section 10365.5 and has, if applicable, identified previous State consultant No
services contracts entered into that were related in any manner to the services, goods, or
supplies being acquired in this procurement.
Yes My firm has complied with the DVBE actual participation and/or good faith effort requirements as Yes
N/A instructed in the DVBE Instructions / Forms (Attachment 8). [Check N/A if the total bid price No
is under $10,000.] [Conditional – Delete this row only if CMU issues a DVBE waiver before the
IFB is released and no DVBE requirements appear in the Qualification Requirements section H.]
Yes My firm will supply before contract execution, proof of self-insurance or copies of insurance Yes
N/A certificates proving possession of appropriate liability insurance that meets the requirements No
stipulated in Item 7 of the IFB section entitled, “Qualification Requirements”. [Conditional –
Retain this row if insurance requirements appear in the Qualification Requirements section H.]
Confirmed
Bid Content. I have completed and returned the following Attachments: by CDPH
Yes Attachment 1, Bid Form Yes
N/A No
Yes Attachment 1B, 1C, 1D, Budget Detail Work Sheets [Retain this row only if CDPH is seeking Yes
N/A consultant services or highly specialized professional personal services. Delete if not needed.] No
Yes Attachment 2, Required Attachment / Certification Checklist Yes
N/A No
Yes Attachment 3, Business Information Sheet Yes
N/A No
Yes Attachment 4, Client References Yes
N/A No
Yes Attachment 5, CCC 307 – Certification [Revised 4-2-07 to reference CCC 307 instead of 1005] Yes
N/A No
Yes Attachment 6, Payee Data Record Yes
N/A Indicate “N/A” if the bidding firm has had a prior contract with CDPH. No
Yes Attachment 7, Follow-on Consultant Contract Disclosure. Disclosure attachment is present when Yes
N/A applicable. No
Yes Attachment 8a, Actual DVBE Participation, and DVBE certifications for each DVBE subcontractor Yes
N/A or supplier listed. [Indicate “N/A” if zero participation was achieved and the Bidder chose No
to complete the good faith effort form or indicate “N/A” if the total bid is under $10,000.]
[Delete this row only if CMU waives DVBE requirements before the IFB is released.]
 Attachment 2
Page 2
Required Attachment / Certification Checklist
Confirmed
Bid Content. I have completed and returned the following Attachments: (Continued) by CDPH
Yes Attachment 8b, Good Faith Effort, and applicable GFE documentation. Check “N/A” if 3% Yes
N/A DVBE participation was achieved and Attachment 8a was submitted or check “N/A” if the No
total bid is under $10,000. [Delete this row only if CMU waived the DVBE requirements for this
procurement ]
Yes Attachment 8a, DVBE Subcontractor use confirmed the DVBE incentive is being requested Yes
N/A Check “N/A” if not applying for this DVBE subcontractor Incentive. No
Yes Attachment 9a, Non-Small Business Subcontractor Preference Request and Yes
N/A Attachment 9b, Small Business Subcontractor/Supplier Acknowledgement No
Check “N/A” if not applying for this subcontractor preference.
Yes Attachment 10a DVBE Subcontractor Incentive Request and Yes
N/A Attachment 10b, DVBE Subcontractor/Supplier Acknowledgement No
Check “N/A” if not applying for this subcontractor preference.
Yes Attachment 11, Target Area Contract Preference Act Request Yes
Check “N/A” if not applying for TACPA preference. [Delete this row if you did not include the
N/A No
TACPA form in the Bid content requirements section.
Yes Attachment 12, Enterprise Zone Act (EZA) Preference Request Yes
N/A Check “N/A” if not applying for EZA preference. [Delete this row if you did not include the No
EZA form in the Bid content requirements section.
Confirmed
Required Documentation. Enclosed with the bid is the following required documentation.
by CDPH
Yes (California Businesses) Copy of a current business license issued by the government Yes
N/A jurisdiction in which the business is located, unless no license is required. Attach an No
explanation if a license copy cannot be supplied or there is reason to believe no license
is required. Check “N/A” if not a California business or no business license is required.
Yes (Corporations) Either a copy of the Certificate of Status issued by California’s Office of the Yes
N/A Secretary of State or a copy of the bidding firm’s active on-line status information downloaded No
from the California Business Portal website. Attach an explanation if the required documentation
cannot be supplied. Check “N/A” if not a Corporation.
Yes (Nonprofit Organizations) A copy of a current IRS determination letter indicating nonprofit or Yes
N/A 501 (3) (c) tax exempt status. Check “N/A” if not a nonprofit organization. No
Yes Copies of financial statements for the last year or latest 12-month period (i.e., annual income Yes
N/A statement and quarterly/annual balance sheets). [Conditional - Retain this row only if proof of No
financial stability appears in the Bid content requirements section (i.e., for consultant or highly
specialized professional personal services).]
Yes Resumes for all professional and technical staff, independent consultants and/or service Yes
N/A subcontractors. [Conditional - Retain this row only if resume submission requirement s appear in No
the Bid content requirement section and CDPH is seeking consultant services or highly
specialized professional personal services.]
Yes Brief description of your business, its date of establishment, and a description of the types of Yes
N/A services that can be provided by the bidding firm. [Conditional – Retain this row only when No
seeking consultant services or highly specialized professional personal services.]
Yes Describe the type(s) and amounts of experience possessed by the bidding firm that demonstrates Yes
N/A it meets the experience requirements stipulated in the Qualification Requirements section of the No
IFB. [Conditional – Retain this row only if seeking consultant services or highly specialized
professional personal services.]
Yes [Optional -- Add here any additional item that bidders must submit to prove they can perform the Yes
N/A work. The items added here must appear in the Bid content requirement section H of the IFB. No
Delete this row if there are no other items to add.]
Name of Bidding Firm: Signature

Printed Name/Title: Date:

 Attachment 3
Page 1
Business Information Sheet
A signature affixed hereon and dated certifies compliance with all bid requirements. The signature below authorizes the State
to verify the claims made on this form.
Name of Bidding Firm: CA Corp. No. (If applicable) Federal ID Number

Name of Principal (If not an individual): Title: Telephone Number Fax Number

Street Address / P.O. Box City State Zip Code

Type of Business Organization / Ownership (Check all that apply)

Ownership Corporation Governmental Other Type of Entity
Sole Proprietor Nonprofit City/County, California State Public or Municipal Corporation, School or Water
Partnership For Profit Agency, Federal Agency, State District, California State College, University of
Joint venture Private (other than California) California, Joint Powers Agency
Association Public Other: Auxiliary College Foundation
Other:
California Certified Small Business Status N/A Microbusiness Small business NVSA
Certified By DGS Certification No: Expiration Date:

If certified, attach a copy of certification letter. If an application is pending, date submitted to DGS:
Small Business Type (If applicable) N/A Services Non-Manufacturer Manufacturer
Contractor (Construction Type): Contractor’s License Type:

Veteran Status of Business Owner N/A (not a veteran or not certified by DGS)
Disabled Veteran Certified by DGS Certification No. Expiration Date:
If certified, attach a copy of certification letter. If an application is pending, date submitted to DGS:

Disadvantaged Business Enterprise Status: N/A Approved by the Cal Trans, Office of Civil Rights.
Certification number issued by Cal Trans: Expiration Date:
Race/Ethnicity of Primary Business Owner N/A (No single owner possess more the 50% ownership)
Owner’s Ethnicity (check one) Owner’s Race (check one) If Asian, Native Hawaiian or Pacific Islander
Asian-Indian American Indian/Alaska Native (check one):
Black Asian Asian-Indian Japanese
Hispanic Black or African American Cambodian Korean
Native American Native Hawaiian or Other Chinese Laotian
Pacific-Asian Pacific Islander Filipino Samoan
Other ______________ White Guamanian Vietnamese
Other _______________ Hawaiian Other ___________________

Gender of Primary Business Owner N/A (Not independently owned) Male Female
Indicate possession of required licenses and/or certifications (if applicable): N/A (None required)
Contractor’s State Licensing Board No. PUC License Number Required Licenses/Certifications (If applicable)
CAL-T-

Signature Date Signed

Printed/Typed Name Title

Public Records Information

The above information is required for statistical reporting purposes. Completion of this form is mandatory. This information will be
made public upon award of the contract and will be supplied to department contract staff, Department of General Services and
possibly other public agencies. To access contract related records, contact the Contract Management Unit, 1501 Capitol Avenue,
Suite 71.5178, MS 1802, P.O. Box 997377, Sacramento, CA 95899-7377 or call (916) 650-0100.
 Attachment 4
Page 1
Client References
List 3 clients served in the past 5-years for which the bidding firm provided similar services. List the most recent first.
REFERENCE 1
Name of Firm

Street address City State Zip Code

Contact Person Telephone number

( )
Dates of service Value or cost of service

Brief description of service provided

REFERENCE 2
Name of Firm

Street address City State Zip Code

Contact Person Telephone number

( )
Dates of service Value or cost of service

Brief description of service provided

REFERENCE 3
Name of Firm

Street address City State Zip Code

Contact Person Telephone number

( )
Dates of service Value or cost of service

Brief description of service provided

If three references cannot be provided, explain why:

Attachment 5
 Page 1

CCC 307 – CERTIFICATION

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective
Contractor to the clause(s) listed below. This certification is made under the laws of the State of California.

Contractor/Bidder Firm Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County of

CONTRACTOR CERTIFICATION CLAUSES

1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the nondiscrimination program
requirements. (GC 12990 (a-f) and CCR, Title 2, Section 8103) (Not applicable to public entities.)

2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the requirements of the Drug-Free Workplace
Act of 1990 and will provide a drug-free workplace by taking the following actions:

a. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a
controlled substance is prohibited and specifying actions to be taken against employees for violations.

b. Establish a Drug-Free Awareness Program to inform employees about:

1) the dangers of drug abuse in the workplace;

2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.

c. Every employee who works on the proposed Agreement will:

1) receive a copy of the company's drug-free workplace policy statement; and,

2) agree to abide by the terms of the company's statement as a condition of employment on the Agreement.

Failure to comply with these requirements may result in suspension of payments under the Agreement or termination of the
Agreement or both and Contractor may be ineligible for award of any future State agreements if the department determines
that any of the following has occurred: (1) the Contractor has made false certification, or violated the certification by failing to
carry out the requirements as noted above. (GC 8350 et seq.)

3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies that no more than one (1) final unappealable
finding of contempt of court by a Federal court has been issued against Contractor within the immediately preceding two-
year period because of Contractor's failure to comply with an order of a Federal court which orders Contractor to comply with
an order of the National Labor Relations Board. (PCC 10296) (Not applicable to public entities.)

4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO REQUIREMENT: Contractor hereby certifies that
contractor will comply with the requirements of Section 6072 of the Business and Professions Code, effective January 1,
2003.

(Continued on next page)

 Attachment 5
Page 2

CCC 307 - CERTIFICATION

Contractor agrees to make a good faith effort to provide a minimum number of hours of pro bono legal services during each
year of the contract equal to the lesser of 30 multiplied by the number of full time attorneys in the firm’s offices in the State,
with the number of hours prorated on an actual day basis for any contract period of less than a full year or 10% of its contract
with the State.

Failure to make a good faith effort may be cause for non-renewal of a state contract for legal services, and may be taken into
account when determining the award of future contracts with the State for legal services.

5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an expatriate corporation or subsidiary of an
expatriate corporation within the meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to contract
with State of California.

6. SWEATFREE CODE OF CONDUCT:

a. All Contractors contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the
procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare
under penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies
furnished to the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor,
forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children
in sweatshop labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal
sanction, abusive forms of child labor or exploitation of children in sweatshop labor. The contractor further declares
under penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the California Department of
Industrial Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108.

b. The contractor agrees to cooperate fully in providing reasonable access to the contractor’s records, documents, agents or
employees, or premises if reasonably required by authorized officials of the contracting agency, the Department of
Industrial Relations, or the Department of Justice to determine the contractor’s compliance with the requirements under
paragraph a.

7. DOMESTIC PARTNERS: For contracts over $100,000 executed or amended after January 1, 2007, the contractor certifies
that contractor is in compliance with Public Contract Code section 10295.3.

NOTE: This form represents only the certification portion of the Contractor Certification Clauses (CCC). Additional
information about contracting with the State appears in the full text of the applicable CCC. Visit this web site to view
the entire document: http://www.ols.dgs.ca.gov/Standard+Language/default.htm.
 Attachment 6

This page is a place holder for the Payee Data Record (STD 204)

Include and label as Attachment 6 a downloaded copy of the current STD 204 from this Intranet site:

http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx

The purpose of this place holder page is to merely show the order and numbering of the IFB attachments.

It is not necessary to insert the cited form here; however, the referenced form must be assembled in this place
within the final IFB package, and in the email message that transmits the full bid document to CMU for Internet
posting.
 Attachment 7
Page 1

Follow-on Consultant Contract Disclosure

Background Information:

1. PCC Section 10365.5 generally prohibits a person, firm, or subsidiary thereof that has been awarded a
consulting services contract from submitting a bid for and/or being awarded an agreement for, the provision
of services, procurement of goods or supplies, or any other related action that is required, suggested, or
otherwise deemed appropriate in the end product of a consulting services contract.
2. PCC Section 10365.5 does not apply to any person, firm, or subsidiary thereof that is awarded a
subcontract of a consulting services agreement that totals no more than 10 percent of the total monetary
value of the consulting services agreement.
3. Consultants/employees of a firm that provides consulting advice under an original consulting contract are
not prohibited from providing services as employees of another firm on a follow-on contract, unless the
persons are named contracting parties or named parties in a subcontract of the original contract.
4. PCC Section 10365.5 does not distinguish between intentional, negligent, and/or inadvertent violations. A
violation could result in disqualification from bidding, a void contract, and/or imposition of criminal penalties.

Disclosure [Mark one (1) box]:

I hereby certify that neither my firm nor any subcontractor that my firm intends to use under the
contract resulting from this procurement, is currently providing consulting services to the state under
a state contract (or as a subcontractor providing more than 10 percent of dollar value of a consulting
service contract with the state) or has provided such services within five (5) years prior to the
release of this IFB that are related in any manner to the services, goods, or supplies being acquired
pursuant to this IFB. [Sign below.] This option is likely to apply to bidding firms that do not
currently and/or never have provided consultant services to the State.

Attached is a disclosure of current and/or prior consulting services provided by my firm or a

proposed subcontractor to the state under a state contract within five (5) years prior to the release of
this IFB that may be related in some manner to the services, goods, or supplies being acquired
pursuant to this IFB. [Sign below and attach to this document a detailed disclosure.]

Name of Bidding Firm

Signature Date Signed

Printed/Typed Name Title

 Attachment 8

This page is a place holder for the DVBE Forms / Instructions

Include and label as Attachment 8 a downloaded copy of the CDPH 2349 from this Intranet site:

http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx

The purpose of this place holder page is to merely show the order and numbering of the IFB attachments.

It is not necessary to insert the cited form here; however, the referenced form must be assembled in this place
within the final IFB package, and in the email message that transmits the full bid document to CMU for Internet
posting.
 Attachment 9
Non-Small Business Subcontractor Preference Instructions

Preference Non-small business bidders will be granted up to a five percent (5%) non-small business
information subcontractor preference on a bid evaluation by an awarding department when a
responsive non-small business has submitted the lowest priced responsive bid and when
a non-small business bidder:
1. Has included in its bid a notification that it commits to subcontract at least twenty-
five percent (25%) of its total bid price with one or more small businesses; and
2. Has submitted a timely, responsive bid; and
3. Is determined to be a responsible bidder; and
4. Lists the small businesses it commits to subcontract with for a commercially useful
function in the performance of the resulting contract.

Commercially A subcontractor is deemed to perform a commercially useful function if the subcontractor

useful function does the following:
1. Is responsible for the execution of a distinct element of the contracted work; carrying
out its obligation by actually performing, managing or supervising the work involved;
and performing work that is normal for its business services and functions; and
2. Is not further subcontracting a greater portion of the work than would be expected by
normal industry practices.
3. Is responsible, with respect to materials and supplies provided on the subcontract, for
negotiating price, determining quality and quantity, ordering the material, installing
(when applicable), and paying for the material itself.
A subcontractor will not be considered as performing a commercially useful function if its
role is limited to that of an extra participant in a transaction, contract, or project through
which funds are passed in order to achieve the appearance of participation.
How to calculate Unless otherwise instructed in the solicitation document, first determine the total dollar
25% subcontract value or amount that will be bid for the entire contract term, then multiply this figure by
participation 25% to determine how much of the bid price must be committed to small business
subcontracts that will perform commercially useful functions including but not limited to
things such as labor, supplies, materials, equipment, or support services.

Use of proposed If awarded the contract, the selected contractor must faithfully use each small business
subcontractors / subcontractor proposed for use and identified in its preference request. No substitutions
substitution or alterations are allowed after a bid is submitted. Substitutions are only allowed after
contract execution if the Contractor submits a Request for Substitution to the CDPH
Program Contract Manager and that request is subsequently granted by CDPH.
Small business subcontract substitution instructions will appear in the resulting agreement
in a clause entitled “Use of Small Business Subcontractors”.
Preference If preference is claimed, indicate so on the Bid Form and complete Attachment 9a
request identifying each small business or microbusiness subcontractor that will be used. For
instructions each subcontractor identified on Attachment 9a, obtain a completed and signed Small
Business Subcontractor/Supplier Acknowledgment (Attachment 9b). Affix each
Attachment 9b to Attachment 9a for submission with the bid response. If a signed
Attachment 9b cannot be collected from each subcontractor in time for bid submission,
indicate why. Submission of a signed Attachment 9b for each subcontractor listed on
Attachment 9a is a prerequisite for contract award confirmation.
Identify only currently certified small business or microbusiness subcontractors, as active
certification is required and certification possession will be verified. The detailed budget
worksheets, if required to be submitted in a bid, must list each subcontract service
provider and its respective dollar value as identified on Attachment 9a. All proposed
subcontracted services must appear in the Scope of Work.
 Attachment 9a
Non-Small Business Subcontractor Preference Request
List each certified small business or microbusiness that will be subcontracted with. To be granted a bidding preference,
total small business or microbusiness subcontractor use must equal at least 25% of the total price or cost offered. Each
named subcontractor must be actively certified as a small business or microbusiness by the bid submission due date
and must acknowledge their participation as claimed herein via a Small Business Subcontractor/Supplier
Acknowledgement (Attachment 9b). Attach to this form an acknowledgement (Attachment 9b) signed by an
authorized representative of each named subcontractor acknowledging their proposed use as described herein.
Name of certified small business (or microbusiness) Subcontractor
Name of Subcontractor

Street address City State Zip Code

Contact Person Telephone number

( )
Small Business Certification No. Certification exp. date Participation dollar value Committed % of total bid
$ %
Brief description of the commercially useful function(s) to be performed and/or provided:

Name of certified small business (or microbusiness) Subcontractor

Name of Subcontractor

Street address City State Zip Code

Contact Person Telephone number

( )
Small Business Certification Certification exp. date Participation dollar value Committed % of total bid
$ %
Brief description of the commercially useful function(s) to be performed and/or provided:

Name of certified small business (or microbusiness) Subcontractor

Name of Subcontractor

Street address City State Zip Code

Contact Person Telephone number

( )
Small Business Certification Certification exp. date Participation dollar value Committed % of total bid
$ %
Brief description of commercially useful function(s) to be provided

If necessary or desired, this form may be photocopied or reproduced in a like form for use in a bid response. If the bidding firm
chooses to render a like copy by computer or other means, the instructions appearing on Attachment 9 may be omitted.
 Attachment 9b
Small Business Subcontractor/Supplier Acknowledgement

Name of Bidding Firm / Prime Contractor CDPH IFB or RFP Number:

Total Dollar Value of Subcontractor Use CDPH Bid Number:

This document confirms and acknowledges that the firm named below agreed to be identified by a bidding firm
as a proposed small business or microbusiness or DVBE subcontractor or supplier for a CDPH procurement.

Subcontractor acknowledgements:

A. The subcontracting firm named herein has committed to perform or provide services/labor or supplies
equal to a percentage of the total bid/cost proposal price submitted by the bidding firm named above.

B. The subcontracting firm named herein acknowledges the total dollar value of claimed participation
identified above.

C. The subcontracting firm named herein agrees to provide the following subcontracted services/labor or
supplies under the resulting contract if the bidding firm named above receives the contract award:

Below and/or continued on an attachment is a brief description of the commercially useful function(s) that
the subcontractor/supplier identified herein will provide or supply:

The subcontracting firm named herein understands it is its sole responsibility to contact the bidding firm named
above to learn if the Proposer was awarded the contract pursuant to the referenced bid number and to confirm
its subcontract agreement. If the bidding firm named above receives an award based in part on non-small
business subcontractor preference or the DVBE incentive, the bidding firm/contractor is obligated to use each
small and/or microbusiness or DVBE subcontractor or supplier identified in its proposal unless a subcontractor
substitution is requested after contract execution pursuant to Public Contract Code Section 4107 and Title 2
California Code of Regulations Section 1896.10.

The person signing below certifies the information supplied on this form is true and accurate to the best of its knowledge
and agrees to allow the State to confirm this information, if deemed necessary.

Name of Proposed Subcontractor/Supplier Date Signed

Signature of Subcontractor/Supplier Representative Telephone number Email address (if applicable)

( )
Printed/Typed Name Title
 Attachment 10
DVBE Subcontractor Incentive Instructions

Incentive Bidders will be granted from 1% up to 5% DVBE subcontractor incentive on a bid

information evaluation by an awarding department when a responsive bidder has submitted the
lowest priced responsive bid and when a bidder:
1. Has included in its bid a notification that it commits to subcontract the amount an
amount indicated in the bid documents which can range from 1 percent up to
5 percent of its total bid price with one or more DVBEs; and
2. Has submitted a timely, responsive bid; and
3. Is determined to be a responsible bidder; and
4. Lists the DVBE(s) it commits to subcontract with for a commercially useful function in
the performance of the resulting contract.

Commercially A subcontractor is deemed to perform a commercially useful function if the subcontractor

useful function does the following:
1. Is responsible for the execution of a distinct element of the contracted work; carrying
out its obligation by actually performing, managing or supervising the work involved;
and performing work that is normal for its business services and functions; and
2. Is not further subcontracting a greater portion of the work than would be expected by
normal industry practices.
3. Is responsible, with respect to materials and supplies provided on the subcontract, for
negotiating price, determining quality and quantity, ordering the material, installing
(when applicable), and paying for the material itself.
A subcontractor will not be considered as performing a commercially useful function if its
role is limited to that of an extra participant in a transaction, contract, or project through
which funds are passed in order to achieve the appearance of participation.
How to calculate Unless otherwise instructed in the solicitation document, first determine the total dollar
the incentive value or amount that will be bid for the entire contract term, then multiply this figure by the
percentage indicated in the bid documents for the specific DVBE use commitment to
determine how much of the bid price must be committed to DVBE subcontracts that will
perform commercially useful functions including but not limited to things such as labor,
supplies, materials, equipment, or support services.

Use of proposed If awarded the contract, the selected contractor must faithfully use each DVBE
subcontractors / subcontractor proposed for use and identified in its preference request. No substitutions
substitution or alterations are allowed after a bid is submitted. Substitutions are only allowed after
contract execution if the Contractor submits a Request for Substitution to the CDHS
Program Contract Manager and that request is subsequently granted by CDHS.
DVBE subcontract substitution instructions will appear in the resulting agreement in a
clause entitled “Use of DVBE Subcontractors”.
Incentive If the incentive is claimed, indicate so on the Required Attachment/Certification Checklist
request (Attachment 2) and complete Attachment 11a identifying each DVBE subcontractor that
instructions will be used. For each subcontractor identified on Attachment 11a, obtain a completed
and signed Small Business/DVBE Subcontractor/Supplier Acknowledgment (Attachment
11b). Affix each Attachment 11b to Attachment 11a for submission with the bid response.
If a signed Attachment 11b cannot be collected from each subcontractor in time for bid
submission, indicate why. Submission of a signed Attachment 11b for each subcontractor
listed on Attachment 11a is a prerequisite for contract award confirmation.
Identify only currently certified DVBE subcontractors, as active certification is required and
certification possession will be verified. The detailed budget worksheets, if required to be
submitted in a bid, must list each subcontract service provider and its respective dollar
value as identified on Attachment 11a. All proposed subcontracted services must appear
in the Scope of Work.
 Attachment 10a
DVBE Subcontractor Incentive Request
List each certified DVBE that will be subcontracted with. To be granted a bidding incentive, total DVBE subcontractor use
must equal at least 1 percent up to a total of 5 percent, unless other specifications are included elsewhere in the agreement, of
the total price or cost offered. Each named subcontractor must be actively certified as a DVBE by the bid submission due date
and must acknowledge their participation as claimed herein via a DVBE Subcontractor/Supplier Acknowledgement
(Attachment 10b). Attach to this form an acknowledgement (Attachment 10b) signed by an authorized representative
of each named subcontractor acknowledging their proposed use as described herein.
Name of certified DVBE Subcontractor
Name of Subcontractor

Street address City State Zip Code

Contact Person Telephone number

( )
DVBE Certification No. Certification exp. date Participation dollar value Committed % of total bid
$ %
Brief description of the commercially useful function(s) to be performed and/or provided:

Name of certified DVBE Subcontractor

Name of Subcontractor

Street address City State Zip Code

Contact Person Telephone number

( )
DVBE Certification No. Certification exp. date Participation dollar value Committed % of total bid
$ %
Brief description of the commercially useful function(s) to be performed and/or provided:

Name of certified DVBE Subcontractor

Name of Subcontractor

Street address City State Zip Code

Contact Person Telephone number

( )
DVBE Certification No. Certification exp. date Participation dollar value Committed % of total bid
$ %
Brief description of the commercially useful function(s) to be performed and/or provided:

If necessary or desired, this form may be photocopied or reproduced in a like form for use in a bid response.
 Attachment 10b
DVBE Subcontractor/Supplier Acknowledgement

Name of Bidding Firm / Prime Contractor CDPH IFB or RFP Number:

Total Dollar Value of Subcontractor Use CDPH Bid Number:

This document confirms and acknowledges that the firm named below agreed to be identified by a bidding firm
as a proposed DVBE subcontractor or supplier for a CDPH procurement.

Subcontractor acknowledgements:

A. The subcontracting firm named herein has committed to perform or provide services/labor or supplies
equal to a percentage of the total bid/cost proposal price submitted by the bidding firm named above.

B. The subcontracting firm named herein acknowledges the total dollar value of claimed participation
identified above.

C. The subcontracting firm named herein agrees to provide the following subcontracted services/labor or
supplies under the resulting contract if the bidding firm named above receives the contract award:

Below and/or continued on an attachment is a brief description of the commercially useful function(s) that
the subcontractor/supplier identified herein will provide or supply:

The subcontracting firm named herein understands it is its sole responsibility to contact the bidding firm named
above to learn if the Proposer was awarded the contract pursuant to the referenced bid number and to confirm
its subcontract agreement. If the bidding firm named above receives an award based in part on the DVBE
subcontractor incentive, the bidding firm/contractor is obligated to use each DVBE subcontractor or supplier
identified in its proposal unless a subcontractor substitution is requested after contract execution pursuant to
Public Contract Code Section 4107 and Title 2 California Code of Regulations Section 1896.10 and
Section 999.5(a) of the Military and Veterans Code.

The person signing below certifies the information supplied on this form is true and accurate to the best of its knowledge
and agrees to allow the State to confirm this information, if deemed necessary.

Name of Proposed Subcontractor/Supplier Date Signed

Signature of Subcontractor/Supplier Representative Telephone number Email address (if applicable)

( )
Printed/Typed Name Title
 Attachment 11

This page is a place holder for the TACPA Request form STD 830.

Include and label as Attachment 10 a downloaded copy of the STD 831 from this Intranet site:

http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx
.]

The purpose of this place holder page is to merely show the order and numbering of the IFB attachments.

It is not necessary to insert the cited form here; however, the referenced form must be assembled in this place within the final IFB package, and in the
email message that transmits the full bid document to CMU for Internet posting.
 Attachment 12

This page is a place holder for the EZA Request form STD 831.

Include and label as Attachment 11 a downloaded copy of the STD 830 from this Intranet site:

http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx

It is not necessary to insert the cited form here; however, the referenced form must be assembled in this place within the final IFB package, and in the
email message that transmits the full bid document to CMU for Internet posting.
 Contract Exhibits
[Assemble the applicable contract forms and exhibits following this page.

Many of the bid and contract forms/exhibits that are to be attached to the bid document must be downloaded
from this Intranet Forms site: http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx.]

Downloadable forms and exhibits include the Payee Data Record; DVBE forms/instructions; TACPA/EZA
preference forms, Standard Agreement; Special Terms and Conditions exhibit D(B), D(C), or D(F); Travel
Reimbursement Information, Contractor’s Release, etc.]

Remove all colored text and shaded instructions from each form/attachment before finalizing
the bid document.
 Exhibit A1

This page is a place holder for the Standard Agreement STD 213.

Include and label as Exhibit A1 a downloaded blank copy of the STD 213 from this Intranet site:

http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx

The purpose of this place holder page is to merely show the order and numbering of the Contract exhibits
attached to the IFB.

It is not necessary to insert the cited document here; however, the referenced form must be assembled in this
place within the final IFB package, and in the email transmitted to CMU for Internet posting.

Leave Item 4 of the sample STD 213 empty by removing all default text.

Forms and exhibits are periodically revised and it is essential that you use the most recent version.
 Exhibit A
Page X
Scope of Work
[You must develop this exhibit. To develop this exhibit, follow the Exhibit A instructions in the applicable CMU
contract model that matches the service type (i.e., Business, Personal, or Consultant service). Contrary to
contract model instructions, do not add a line entry in the header for a Contractor’s name or contract number.]

1. Service Overview

[Check the applicable contract model to obtain current language.] [Detailed text removed 3-07.]

2. Service Location

[Check the applicable contract model to obtain current language.] [Detailed text removed 3-07.]

3. Service Hours

[Check the applicable contract model to obtain current language.] [Detailed text removed 3-07.]

4. Project Representatives

A. The project representatives during the term of this agreement will be:

California Department of Public Health Contractor Name [TBD]

Name of Contract Manager Name of Contract Manager [TBD]
Telephone: (XXX) XXX-XXXX Telephone: [To be determined]
Fax: (XXX) XXX-XXXX Fax: [To be determined]
Email: Xxx.xxxxx@cdph.ca.gov Email: [To be determined]

B. Direct all inquiries to:

California Department of Public Health Contractor Name [TBD]

Attention: enter name, if applicable Section or Unit Name, if applicable [TBD]
Section or Unit Name: Attention: [To be determined]
Mail Station Code XXXX Street address [To be determined]
Street address, suite/room number P.O. Box Number [To be determined]
P.O. Box Number City, State Zip Code [To be determined]
City, State, Zip Code
Telephone: [To be determined]
Telephone: (XXX) XXX-XXXX Fax: [To be determined]
Fax: (XXX) XXX-XXXX Email: [To be determined]
Email: Xxx.xxxxx@cdph.ca.gov

C. Either party may make changes to the information above by giving written notice to the other party.
Said changes shall not require an amendment to this agreement.

5. Services to be Performed

[Insert a detailed description of the services to be performed. Number each paragraph and
subparagraph. Read and follow the IFB User Guide and CMU Bulletin 00-08 and applicable contract
model (i.e., Business Service, Personal, or Consultant) for tips and instructions on developing the
scope of work content.]
 Exhibit B
Page X
Budget Detail and Payment Provisions
[This exhibit must be developed by program staff. To develop this exhibit, follow the Exhibit B instructions in
the applicable CMU contract model that matches the service type (i.e., Business, Personal, or Consultant
service) with the exception of Provision 4 (included below). Contrary to contract model instructions, do not add
a line entry in the header for a Contractor’s name or contract number and do not indicate any projected annual
dollar values in Provision 4.]

1. Invoicing and Payment

[Obtain current language from the applicable contract model.]

2. Budget Contingency Clause

[Obtain current language from the applicable contract model.]

3. Prompt Payment Clause

[Obtain current language from the applicable contract model.]

4. Amounts Payable

[When developing a bid document, do not enter any dollar amounts as these amounts will be
determined after the bid award is made. You may not tell bidders how much to bid for any budget
period.]

[This numbered item may appear in the final contract with the selected bidder. If included, this
item will be completed after the bid amounts are known.]

[Obtain the most current language from Exhibit B in the applicable contract model.]
A. The amounts payable under this agreement shall not exceed:

1) $[leave blank] for the budget period of XX/XX/XX through XX/XX/XX.

2) $[leave blank] for the budget period of XX/XX/XX through XX/XX/XX.
3) $[leave blank] for the budget period of XX/XX/XX through XX/XX/XX.

B. Reimbursement shall be made for allowable expenses up to the amount annually encumbered
commensurate with the state fiscal year in which services are performed and/or goods are received.

C. The Contractor must maintain records reflecting actual expenditures for each state fiscal year
covered by the term of this agreement. [Conditionally applicable - Retain Paragraph C only if the
budget periods displayed in Paragraph A are on a cycle other than the state’s fiscal year (i.e., the
ending dates are other than June 30 for multiple years). Paragraph C added 3-07]

5. Timely Submission of Final Invoice

[Obtain current language from the applicable contract model.]

6. Budget Flexibility or Allowable Line Item Shifts

[Obtain current language from the applicable contract model.]

7. Federal Contract Funds

[Conditional Use. [Check the applicable contract model to determine when this provision is needed and
to obtain current language.]

8. [Insert provision title here or delete this numbered item.]

[Check the applicable contract model to determine the other types of provisions to add to this exhibit.]
 Exhibit C
Page X

General Terms and Conditions

This page is a place holder for Exhibit C.

The State’s General Terms and Conditions (GTC 307) can only be viewed or downloaded from the following
Internet site: http://www.ols.dgs.ca.gov/Standard+Language/default.htm.

The State’s General Terms and Conditions are modified from time to time by the California Department of
General Services to comply with changes to federal or state law and the version that applies to the resulting
agreement will be determined based on the contract start date. CDPH reserves the right to cite an alternate
version number in the resulting agreement, if applicable.

If a bidding firm does not have Internet access they are to contact the program identified in the bid cover letter
to request a hard or paper copy of the State’s General Term and Conditions.

[Insert this Place Holder page into the bid document but note that it will not appear in the final contract that is
submitted to CMU after the award is made.]
 Exhibit D(X)

This page is a place holder for Special Terms and Conditions Exhibit D(B) or D(C) or D(F), which can be
downloaded from the Intranet at the following Form Site:

http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx
.

The purpose of this place holder page is to merely show the order of the Contract exhibits attached to an IFB.

It is not necessary to insert the cited document here; however, the referenced form/exhibit must be assembled
in this place within the final IFB package, and in the email transmitted to CMU for Internet posting.

See the Exhibit D instructional document appearing in the applicable CMU contract model (i.e., Business,
Personal, or Consultant service) if assistance is needed in determining which Exhibit D version to use.
 Exhibit E
Page X

Additional Provisions
[This exhibit must be developed by program staff. To develop this exhibit, review and follow the Exhibit E
instructions appearing in the applicable CMU contract model that matches the service type being sought (i.e.,
Business, Personal, or Consultant service). At a minimum, Exhibit E must contain the Contract Amendments
clause (Provision 2 below), Cancellation/Termination clause (Provision 3 below), and Use of Small Business
Subcontractors (Provision 5 below). Other clauses appearing in the contract model that are expected to
appear in the resulting contract should also be included in this exhibit. Contrary to contract model instructions,
do not add a line entry in the header for a Contractor’s name or contract number.]

1. Additional Incorporated Exhibits

[This provision is conditionally used when needed. Check the applicable contract model to determine
when/if this provision is necessary and to obtain current language.] [Detailed text removed 3-07.]

2. Amendment Process

[This provision is required. Check the applicable contract model to obtain current language.] [Title
revised 3-07.]

3. Cancellation / Termination

[This provision is required. Check the applicable contract model to obtain the current language of the
cancellation clause that only allows CDPH to cancel with 30 days notice.] [Detailed text removed 3-07.]

4. Debarment and Suspension Certification

[This provision is conditionally applicable. Check the applicable contract model to determine when this
provision is needed and to obtain the current language.]

5. Use of Small Business Subcontractors

[This provision is conditionally applicable. Check the applicable contract model to determine when this
provision is needed and to obtain the current language.] [Detailed text removed 3-07.]

6. [Insert a provision title here or delete this numbered item.]

[Optional. Check the applicable contract model to determine the types of other provisions that may be
added to this exhibit.]
 Exhibit X

This page is a place holder for Contractor’s Release exhibit

Download the current Contractor’s Release form from the Intranet at:

http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx

The purpose of this place holder page is to merely show the order of the Contract exhibits attached to an IFB.

It is not necessary to insert the cited document here; however, the referenced form/exhibit must be assembled
in this place within the final IFB package, and in the email transmitted to CMU for Internet posting.
 Exhibit X

This page is a place holder for Travel Reimbursement Information exhibit.

Download the current Travel Reimbursement Information exhibit form from the Intranet at:
http://cdphintranet/FormsPubs/Pages/FormsIndex.aspx

Do not include the Travel Reimbursement Information exhibit if no travel costs will be reimbursed or if travel will
be billed at an hourly wage rate (i.e., for equipment maintenance services).

The purpose of this place holder page is to merely show the order of the Contract exhibits attached to an IFB.

It is not necessary to insert the cited document here; however, the referenced form/exhibit must be assembled
in this place within the final IFB package, and in the email transmitted to CMU for Internet posting.
 Exhibit X

HIPAA Business Associate Addendum (BAA)

This page is a place holder for HIPAA Addendum.

Download the current HIPAA Addendum version from the link supplied within the IFB model.

Review CMU Bulletin 07-01 regarding the applicability and use of the HIPAA Addendum.

The purpose of this place holder page is to merely show the order of the Contract exhibits attached to an IFB.

It is not necessary to insert the cited document here; however, the referenced form/exhibit must be assembled
in this place within the final IFB package, and in the email transmitted to CMU for Internet posting.

This exhibit may have been revised since you used it last. Please use the most current exhibit
appearing in the applicable Bid Model.
 Exhibit X

Information Confidentiality & Security Requirements (ICSR)

This page is a place holder for HIPAA Addendum.

If you determine this exhibit will apply to the services being obtained through this solicitation, obtain a copy of
the current HIPAA ICSR from the IFB bid model folder. Contrary to contract model instructions, do not add a
placeholder for the contractor’s name and contract number at the top of Exhibit X.

Review CMU Bulletin 07-02 regarding the applicability and use of the HIPAA Addendum.

This exhibit may have been revised since you used it last. Please use the most current exhibit
appearing in the applicable Bid Model.

Exhibit X
 SR1 CDPH-ISO Project Requirement

This page is a place holder for HIPAA Addendum.

If you determine the HIPAA BAA and/or ICSR exhibit(s) will apply to the services being obtained through this
solicitation, the SR1 CDPH-ISO Project Requirement exhibit is required. Contrary to contract model
instructions, do not add a placeholder for the contractor’s name and contract number at the top of Exhibit X.

Review the HIPAA Exhibit Guidelines and/or ICSR Exhibit Guidelines for more information.

This exhibit may have been revised since you used it last. Please use the most current exhibit
appearing in the applicable Bid Model.