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SOLICITATION # DHHS91109
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EVALUATION SCORESHEET
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Score will be assigned as follows:
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Vendor:
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Pass or Fail
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Evaluator:100% Pass required
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Date:
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FormsYes/NoEvaluator Comments
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1Form #1 – Data Sheet
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2Form #2: Substitute Form W-9 This form is not required from vendors who currently hold any contract(s) with DHS.
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3Form #3: Conflict of Interest Disclosure Statement
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Documentation of Meeting Mandatory Minimum Requirements Pass/FailEvaluator Comments
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6Proof that the Vendor has an active contract with an LSAA to provide Women and Children’s Residential Substance Use Disorder Treatment services, as described in the Purpose section of the RFSQ .(A copy of the contract signature page is acceptable if it also lists the contract number.)
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7Copy of Vendor’s Residential Support and/or Residential Treatment license through the State of Utah, DHS Office of Licensing and Background Checks.
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PASS OR FAIL?
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