FY 2018
SERVICE PROVIDER RFP CHECKLIST
Name of Applicant:Name of Program:
Applicant Use / Reviewer Use
1 / Application Face Sheet / [ ] / [ ]
2 / Service Provider RFP Checklist / [ ] / [ ]
3 / Services Request Summary / [ ] / [ ]
Application Narrative & Attachments
4 / Section 1- Abstract / [ ] / [ ]
5 / Section 2- Agency Qualifications and Experience / [ ] / [ ]
6 / Section 3- Need for Health Services / [ ] / [ ]
7 / Section 4- Access to HIV/AIDS Care & Service Delivery Plan for FY 2018 / [ ] / [ ]
8 / Section 4A- Service Delivery Plan for FY18-Narrative / [ ] / [ ]
9 / Section 4B- Early Identification of Individuals with HIV/AIDS
Attachment #1- HIV Testing & Awareness Data / [ ] / [ ]
10 / Section 5- Quality Management & Outcomes Evaluation / [ ] / [ ]
11 / Section 5A- Logic Model
Attachment #2 - FY18 Logic Model Table / [ ] / [ ]
12 / Section 5B - FY18 Logic Model Table Narrative / [ ] / [ ]
13 / Section 6- Coordination of Services and Funding Streams / [ ] / [ ]
14 / Attachment #3- Coordination of Services & Funding Streams Table / [ ] / [ ]
15 / Attachment #4 - Schedule of Charges/Fee Scale / [ ] / [ ]
16 / Attachment #5 - Proof of Medicaid Denial/Exemption / [ ] / [ ]
17 / Attachment #6 -10 Memorandums of Agreement / [ ] / [ ]
18 / Section 7- Contingency Plan / [ ] / [ ]
19 / Section 8- Minority AIDS Initiative (MAI) Funding / [ ] / [ ]
Required Forms
20 / Budget and Budget Narrative Justification / [ ] / [ ]
21 / Allocation Table / [ ] / [ ]
22 / Unit Cost Budget / [ ] / [ ]
23 / Summary of Other Funding Sources / [ ] / [ ]
24 / Proof of Non-Profit Status / [ ] / [ ]
25 / Articles of Incorporation/ Certificate of Formation / [ ] / [ ]
26 / Hold Harmless Agreement / [ ] / [ ]
27 / Disclosure Statement / [ ] / [ ]
28 / Attachment A/ Minority Status / [ ] / [ ]
39 / Non-Collusion Affidavit / [ ] / [ ]
30 / Counterterrorism Compliance Form / [ ] / [ ]
31 / Certificate of Compliance w/ Charitable Registration / [ ] / [ ]
32 / Certificate regarding Tobacco Smoke / [ ] / [ ]
33 / 2016 Audit Report (or IRS Form 990) / [ ] / [ ]
34 / **Subcontracts (if applicable) / [ ] / [ ]
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