zilongwang/ReadingBank huggingface dataset:
Meeting Title: NYP/Q DSRIP SNF Project Sub-Committee Projects: 2.b.v & 2.b.vii Meeting Date: September 8, 2016 Facilitator(s): Caroline Keane Meeting Time: 3:30 PM – 4:15 PM Dial in #: 1-877-594-8353 Passcode: 79706143# Meeting Purpose: Project Implementation – Milestones & Tasks # Topic Document Responsible Person 1. Welcome & Purpose - C. Keane 2. Approve Meeting Minutes – 8/4/16 C. Keane 3. Root Analysis Meeting Tomorrow, Friday September 9th 10am-11:30am -- C. 4. CAPC online courses We will pay for the two members of your facility/ agency to have assess We will do an education on how to access as needed Proof of attendance C.Keane/ S.Choudhury 5. SNF Partner Quality Measures and Baseline Hospital Transfer rates from CMS Establish taskforce to plan, implement and monitor process improvement strategies C. Keane/ S.Choudhury 6. INTERACT Contract & Training Plan Contract 2 member/facility 2-day training Implementation Tracker C. S.Choudhury 7. Project 2.b.vii- INTERACT Success story of implementing and utilizing INTERACT Silvercrest Center for Nursing and Rehabilitation M. Tretola 8. MOLST & eMOLST Implementation Status Update -- Committee Members 9. Cureatr rollout to SNF Partners S.Choudhury 10. Questions & Open Discussion -- S.Choudhury
Minimum Documentation: List of practitioners and licensure performing services at PCMH and/or APCM sites; Behavioral health practice schedules. Task Step # 7: Outline a timeline/roll-out schedule of all participating clinics that shows anticipated clinic start dates & availability. Due by DY3Q1 (June 2017) PMO is scheduled to build a roll-out timeline and will present it to the committee before the quarter ends. Task Step # 9: Train staff to ensure full understanding of operational processes, sensitivity, cultural competency, and behavioral health related medical record policies. Due by DY3Q4 (March 2018 ) Brightpoint – has completed their workflows and is in the process of getting buy-in and then will work on training. Child Center of NY, TLCC, ACC, ACQC- status? Task Step # 10: Recruit behavioral health care providers based on need of site (Physician/Social Worker/etc.) Due by DY3Q4 (March 2018 ) Task Step # 11: Create scheduling templates for new providers & patients. Due by DY3Q4 (March 2018 ) -------------------------------------------------------------------------------------------- Model 2: Milestone #5 Co-locate primary care services at behavioral health sites. Metric# 5.1: PPS has achieved NCQA 2014 Level 3 PCMH or Advanced Primary Care Model Practices by the end of DY3.Due by DY4Q4 (March 2019) Update: this Milestone is no longer a requirement for providers in 2. Minimum Documentation: List of participating NCQA-certified and/or APC-approved physicians/practitioners (APC Model requirements as determined by NY SHIP); Certification documentation. Metric# 5.2: Primary care services are co-located within behavioral Health practices and are available. Due by DY4Q4 (March 2019) Minimum Documentation: List of practitioners and licensure performing services at behavioral health site; Behavioral health practice schedules.
Metric# 8.1: Practice has adopted preventive and chronic care protocols aligned with national guidelines. Minimum Documentation: Policies and procedures related to standardized treatment protocols for chronic disease management; agreements with PPS organizations to implement consistent standardized treatment protocols. Metric# 8.2: Project are trained on policies and procedures specific to evidence-based preventive and chronic disease management. Minimum Documentation: Documentation of training program; written training materials; list of training dates along with number of staff trained. 7. DY3 Q4 Deliverable 4: Milestone# 9: Implement open access scheduling in all primary care practices. Metric# 9.1: PCMH 1A Access During Office Hours scheduling to meet NCQA standards established across all PPS primary care sites. Minimum Documentation: Scheduling standards documentation; report showing third next available appointment, which could include a 1.) New patient physical, 2.) Routine exam or 3.) Return visit exam [Institute for Healthcare Improvement measures]; response times reporting; materials communicating open access scheduling; vendor system documentation; other sources demonstrating implementation. ---------------------------------------------------------------- Metric# 9.2: PCMH 1B After Hours Access scheduling to meet NCQA standards established across all PPS primary care sites. Minimum Documentation: Scheduling standards documentation; response times reporting; materials communicating open access scheduling; vendor system documentation; other sources demonstrating implementation. M. D’Urso, RN/ S.Choudhury
Role of Regional Caucuses Regional caucuses are designed to give chapters an opportunity to share and discuss issues. These caucuses do not have a vote, nor do they sit in the House of Delegates as a separate entity PTA Caucus This caucus is made up of PTAs. It represents the interests of the PTA. It has a non-voting delegate in the House of Delegates In summary, as a NYPTA Delegate You have a seat in the APTA House of Delegates representing the New York Chapter You can speak to all motions and reports coming before the House You have a vote on all motions and candidates for national office You follow NYPTA delegation rules as determined by the Chief Delegate in consultation with the delegates Resources: APTA Bylaws NYPTA Bylaws NYPTA P&P New York Chapter Delegate Requirements Term of Office The term of office for all delegates
CLINICAL CRITERIA – DIAGNOSIS (CONTINUED) For other diagnoses: Please provide clinical rationale and laboratory test results (if applicable) for the use of anabolic steroid: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Please answer the following questions if requesting a non-preferred anabolic steroid (a listing of preferred and non-preferred can be found at ): Is a documented history of successful therapeutic control with a non-preferred agent? Yes No Has the patient experienced treatment failure or an adverse reaction with a preferred agent? Yes No Prescriber Signature (Required) I attest that this anabolic steroid is medically necessary for this patient and that all of the information on this form is accurate to the best of my knowledge. Date Fax Number: 1-800-268-2990 Prior Authorization Call Line: 1-877-309-9493 Billing Questions: 1-800-343-9000 For clinical questions or Clinical Drug Review Program questions, please visit or call 1-877-309-9493.
KS1-2 codes * Code Stands for… KS1 TA KS1 Test KS2 TA KS2 Test A Absent     AS Achieved the Standard     B Working Below the level of the test     BLW Below the standard of the pre-key stage To be reported with P-scales or NOTSEN as appropriate     CA Ability to represent their actual ability in the test Affected     CN Ability to represent their actual ability in the test Not affected     D Disapplied (Or U is possible for KS1 science only)     EXS Working at the EXpected Standard     F Pupil will take test in the Future     GDS Working at Greater within the expected Standard     H Pupil cheating     HNM Has Not Met the expected standard     L Left     M Missing     NS Not Achieved the Standard     P Pupil has taken test in the Past     PKE Pre-Key stage Early development     PKF Foundations for the Expected Standard (Pre-Key Stage Foundation)     PKG Pre-Key Growing development     Q     T Unable to access Test     U Dissapplied (KS1science only. D preferred, if possible)    
READINESS Please indicate which of the following scales/assessment tools was used to evaluate the readiness of the patient (only one is required): SAMHSA-HRSA – & – SAMSHA-HRSA C (PREP-C) – CONTINUATION THERAPY REQUESTS **This portion is not required for initial therapy requests 4 (±2 HCV RNA 12 HCV RNA Has documentation confirming HCV RNA levels at the appropriate week been submitted? Yes No Has the patient completed all HCV evaluation appointments and procedures and demonstrated compliance to their treatment regimen? Yes No CURRENT TREATMENT REGIMEN Please indicate the Sovaldi combination treatment regimen that is being prescribed: *For patients with HCV/HIV-1 co-infection, follow the dosage recommendations ^Recommended treatment regimen and duration for pediatric patients who are ≥ 12 years of age or weigh ≥ 35kg. **Consider screening for the presence of NS5A polymorphisms at amino acid positions M28, Q30, L31, and Y93 in patients with cirrhosis who are infected with HCV genotype 1a prior to the initiation of treatment with Daklinza and Sovaldi with or without RBV. ¥Consider screening for the presence of NS 3Q80K polymorphism in patients who are infected with HCV genotype 1a prior to initiation of treatment with Olysio and Sovaldi. Please provide dosing information for the treatment regimen selected above:
New York State Medicaid Preferred Drug Program Fax Number: (800) 268-2990 Zepatier™ Prior Authorization Worksheet Enrollee Information (2 5 1 Female Male Prescriber Information ( ) - ( ) - (HCV) AND 10 HCV 12 10 CME 12 Clinical Criteria MEDICAL STATUS C TREATMENT OF TREATMENT WITH
Board Meeting 12/21/17 Agenda Welcome & Introductions: Trevor Calvey Adoption of Minutes: Steven Orff Treasurers Report: Mark Johnson Fundraising Report: Nicole/Charity Updates: Safety – Mike Plumb BVGSL Update – Kathleen / Sean Nicholson Twin Valley (Summer) – Kris Patrick Uniforms – John Gemmel Concessions – Kerrie Julian League Schedule – Ricky Adams Fall Ball – John DiAnni Web Site – Pat Klupa Equipment – Chuck Julian Field Maintenance- Bill Casey VP Update – Stephanie DeBaggis Winter Clinics Update – Stephanie DeBaggis Presidents Update – Trevor Calvey New Business: Flanagan Donation Adjourn
Board Meeting 11/16/17 Agenda Welcome & Introductions: Trevor Calvey Adoption of Minutes: Steven Orff Treasurers Report: Mark Johnson (Budget Review/vote 2018) Fundraising Report: Nicole/Charity Updates: Safety – Mike Plumb BVGSL Update – Kathleen / Sean Nicholson Twin Valley (Summer) – Kris Patrick Uniforms – John Gemmel Concessions – Kerrie Julian League Schedule – Ricky Adams Fall Ball – John DiAnni Web Site – Pat Klupa Equipment – Chuck Julian Field Maintenance- Bill Casey VP Update – Stephanie DeBaggis Winter Clinics Update – Stephanie DeBaggis Presidents Update – Trevor Calvey New Business: Adjourn
Board Meeting 4/19/18 Agenda Welcome & Introductions: Trevor Calvey Adoption of Minutes: Steven Orff Treasurers Report: Mark Johnson Fundraising Report: Nicole/Charity Updates: Safety – Mike Plumb BVGSL Update – Kathleen / Sean Nicholson Twin Valley (Summer) – Kris Patrick Uniforms – John Gemmel Concessions – Kerrie Julian League Schedule – Ricky Adams Fall Ball – John DiAnni Web Site – Pat Klupa Equipment – Chuck Julian Field Maintenance- Bill Casey VP Update – Stephanie DeBaggis Winter Clinics Update – Stephanie DeBaggis Buddy Program Update- Amy Kindl Presidents Update/Draft/Opening Day – Trevor Calvey New Business: Adjourn
Board Meeting 3/15/18 Agenda Welcome & Introductions: Trevor Calvey Adoption of Minutes: Steven Orff Treasurers Report: Mark Johnson Fundraising Report: Nicole/Charity Updates: Safety – Mike Plumb BVGSL Update – Kathleen / Sean Nicholson Twin Valley (Summer) – Kris Patrick Uniforms – John Gemmel Concessions – Kerrie Julian League Schedule – Ricky Adams Fall Ball – John DiAnni Web Site – Pat Klupa Equipment – Chuck Julian Field Maintenance- Bill Casey VP Update – Stephanie DeBaggis Winter Clinics Update – Stephanie DeBaggis Buddy Program Update- Amy Kindl Presidents Update/Draft/Opening Day – Trevor Calvey New Business: Adjourn
Supporting Question 1 Featured Source Source A: Digital History, explanation of the United States global expansion in the 19th century, “The United States Becomes a Power,” 2014 By 1890, the United States had by far the world's most productive economy. American industry produced twice as much as its closest competitor—Britain. But the United States was not a great military or diplomatic power. Its army numbered less than 30,000 troops, and its navy had only about 10,000 seamen. Britain's army was five times the size of its American counterpart, and its navy was ten times bigger. The United States' military was small because the country was situated between two large oceans and was surrounded by weak or friendly nations. It faced no serious military threats and had little interest in asserting military power overseas. From the Civil War until the 1890s, most Americans had little interest in territorial expansion. William Seward, the secretary of state under presidents Lincoln and Johnson, did envision American expansion into Alaska, Canada, Mexico, Central America, the Caribbean, Iceland, Greenland, Hawaii, and other Pacific islands. But he realized only two small parts of this vision. In 1867, the United States purchased Alaska from Russia for $72 million and occupied the Midway Islands in the Pacific. Americans resisted expansion for two reasons. One was that imperial rule seemed inconsistent with America's republican principles. The other was that the United States was uninterested in acquiring people with different cultures, languages, and religions. But where an older generation of moralists thought that ruling a people without their consent violated a core principle of republicanism, a younger generation believed that the United States had a duty to uplift backward societies.
4 The screen looks funny – images aren’t showing up / things seem out of place, etc. Your computer network may be preventing important from loading because it doesn’t recognize DLM as a “friendly” organization. You may be trying to deliver the test on a screen that is too small. YES Make sure you are using a computer or tablet that meets the technology requirements. That information can be found at . Your technical support person may need to whitelist items on your district's firewall. That information can be found at . 5 My student is supposed to have specific accommodations and they aren’t showing up. Accommodations may not have been entered into Educator Portal. Accommodations may have been entered incorrectly into Educator Portal. YES Go back into Educator Portal and check to make sure the proper accommodations are selected in the student’s PNP. If they are correct in Educator Portal, contact the DLM help desk at or 6 My student is supposed to be able to respond assistive technology (alternate keyboard, switch, etc.) OR is supposed to be able to hear the text read aloud and it is not working. The assistive device or speakers may not be installed properly. The software to run the assistive device may need to be updated. KITE may not support the device. YES Contact local technical support to ensure your computer recognizes the devices and the drivers are updated. If everything is working properly, contact the DLM help desk at 1-844-261-6481 or .
Households Households with At Least One Adult and One Child Adult Households without Children Households with Only Children Total # with Head of Household 25 years old & older # with Head of Household under 25 # with Head of Household 25 years old & older # with Head of Household under 25 Total Number of Households B. Population to be Served in the Project (Annually – over the course of a year) (Not applicable for PSH - Applies to RRH and Joint TH-RRH only) Households Households with At Least One Adult and One Child Adult Households without Children Households with Only Children Total # with Head of Household 25 years old & older # with Head of Household under 25 # with Head of Household 25 old & older # with Head of Household under 25 Number of Households Cost Per Household - considering the information reported in #9, #12 and #13 above, please calculate the annual cost per household for each household type. Please use Annual Capacity for RRH and Joint RH-RRH and Point-in-time (PIT) Capacity for PSH, when calculating. Projects serving more than one household type will need to estimate costs differentiated by household type to complete this table. NOTE: See Priorities section for information about bonus points related to annual cost per household. EXAMPLES: A PSH project has a total annual Supportive Services budget of $100,000 and proposes to serve at a PIT 5 families with children with Heads of Household 25years+, and 5 Adult Households under 25: Annual cost per family household 25 years+ @$13,200 and an annual cost per Adult household <25 of $6,800. Total budget supportive services budget= $100,000 ($66,000 for families and $34,000 for singles ) A RRH project has a total annual Supportive Services budget of $300,000 and proposes to serve annually 10 families with children with Heads of Household under 25 years, and 10 Adult Households under 25 years: Annual cost per family household under 25 @$19,800 and
an annual cost of Adult household <25 of $10,200. Total supportive services budget= $300,000 ($198,000 for families and $102,000 for singles). Households Households with At One Adult and One Child Adult Households without Children Households with Only Children Head of Household 25 years old & older Head of Household under 25 years old 25 years old & older under 25 years old Annual Supportive Services Cost/Household Annual Rental Assistance Cost/Household Annual Leasing Cost/Household Annual Operating Cost/Household I. Organizational Experience and Capacity of Applicant & Sub-Recipients PLEASE NOTE: maximum combined page is 15 pages using a 12 point font with one inch margin for Sections I (Organizational Experience and Capacity), II (Project Description, and III (Supportive Services for Participants).
Vets Disabled Adults over age 24 Non-disabled Adults over age 24 Disabled Adults ages Non-disabled Adults ages Total Persons Households with Only Children Chron. Homlss or Vets Chron. Homlss Or Vets Chronic Subs. Abuse Persons with HIV/ AIDS Severely Mentally Ill Victims of Dom. Viol. Phys. Disab Dvlpmt Disab Not Other-wise Represented Disabled Children >18 Disabled Children >18 Disabled Children >18
Please indicate what are the most challenging aspects of the setting you selected: (please choose the top 2.) % responses by those who cited a specific setting Answer Choices Responses Rural (40) Urban (11) Suburban* Transportation 74% 45 98% 39 36% 4 67% 2 Availability of needed services 34% 21 35% 14 36% 4 33% 1 Distance of travel to access services 20% 12 25% 10 9% 1 33% 1 Availability of employment 41% 25 55% 22 18% 2 0% 0 Employer support 0% 0 0% 0 0 0 0% 0 Housing 15% 9 2.5% 1 54% 6 33% 1 N/A 8% 5 0% 0 0% 0 0% 0 Other (please specify) 52% 3 2.5% 1 18% 2 0% 0 Answered 61 The three “other” responses included: VRCs in rural areas working out of home offices impedes client access to face to face visits Living in impoverished conditions with few or no natural supports Parental involvement Please list below the communities/consumer groups, if any, that you consider to be unserved or underserved in your region. Please indicate what the challenges are in reaching or serving them. All 62 participants responded to this question. indicated that no one is underserved/NA. These responses were from counselors serving primarily urban and suburban consumers. The full list identified includes the following underserved groups: Rural consumers (17) Many cited specific rural regions, counties or the rural sections of counties Minority and/or immigrant communities (9) – specifically cited: Asian, Hispanic, Middle Eastern, Native American, and African-American Non-English speakers (9) – specifically cited: South East Asian, Spanish speakers, Deaf-blind (5) Elderly, especially rural (3)
TRAFFIC MANAGEMENT CONTRACTORS A sample of traffic management companies are available Other companies are available and may be used. AA Signs Lister Point Tel: 0800 731 7003 Website: Traffic Management Services/ RAC Signs Retford Nottinghamshire DN22 7EE Tel: 01777 705053 Fax: 01777 709878 Email: Website: Green Light Traffic Management Unit Riverbank Centre Dewsbury WF13 3RQ Tel: 01924 463223 Fax: 01924 485202 Email: Direct Traffic Management Ltd Unit 26 Frontier Works, King Edward Road Thorne South Yorkshire DN8 4HU Tel: 01405 817733 Fax: 01405 813007 Email: Website: Premier Traffic Management Ltd Head Office: Unit 13, Tudhoe Industrial Estate Tudhoe Co DL16 6TL Tel: 01388 815661 Fax: 01484 420993 Email: Website: Bob Cowell HG2 0BN Tel: 01423 508277 07702 936513 Email: rfmcowell@sky.com Hatton Traffic Management Ltd Unit 10b, Industrial Estate Newcastle Upon Tyne and Wear NE13 7BA Tel: 0191 2368060 Fax: 01388 710880 E-mail: Website: Road Blaydon Tyne & Wear NE21 5NJ Tel: 0191 4615057 Fax: 0191 4990118 Castleford West WF10 4PF Tel: 558445 Fax: 01977 557278 Services Station Yard, Ripley HG3 3BA Tel: 01423 771006 Fax: 01423 771464 Website:
Team Leader/Clinical Supervisor - Print Name/Credentials (if needed): Team Leader/Clinical Supervisor Signature (if needed): Date: For programs using this as a billable note, fill out Billing Strip below. Date of Service Staff Identifier Loc. Code Service Code Mod 1 Mod 2 Mod 3 Mod 4 Start Time Stop Time Duration in Minutes
Organization Name: Program Name: Date: Individual’s Name MI Last): Record #: DOB: Reason for Update: Update of New Information Re-Admission Annual Update – Date of Admission: Date of Most Recent Comprehensive Assessment: Comprehensive Assessment Sections for Update Check the box(es) next to the section(s) of the assessment (including addendums), which you are updating. Be sure to label all additional/updated information in your narrative with the number of the section of the Assessment or Addendum being updated. Reason for Referral and Chief Complaint/Presenting Problem Trauma History Psychiatric Illness/Substance Use/Addictive Behavior History Social/Leisure Mental Health and Addiction Service Treatment History Physical Health History Social and Developmental Status Mental Status, Suicide, Violence Sexual History Life Goals, Strengths, Abilities and Barriers Vocation/Education/Employment Diagnosis (Case Management Only) Military Service Prioritized Assessed Legal Other: Living Situation Other: Family History and Relationships Update Narrative: List each assessment section being updated with narrative explanation below it. SCREENING TOOLS Was any evidence-based screening tool(s), for either mental health or substance use, utilized?: No Yes If Yes, specify: Diagnosis: No Change Change in Diagnoses Listed below DSM Codes ICD Codes Check Primary Axis Code Narrative Description Axis I Axis II Axis III Axis IV No Yes Problems with primary support group: If yes, describe:
List all medications individual in care is taking including medications prescribed by this provider, medications prescribed by outside prescribers as well as herbal remedies, vitamins, nutraceuticals, or over-the-counter drugs. Date Medication Dosage / Route / Frequency Supply: Amount / Refills Status Purpose Rationale for Change Name of Prescriber Source of Knowledge New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report New/Adj. Continue Discont. Prescriber Outside Prescriber Pharmacy Individual Self-Report
No Yes Problems related to the social environment: If yes, describe: No Yes Educational problems: If yes, describe: No Yes Occupational problems: If yes, describe: No Yes Housing problems: If yes, describe: No Yes Economic problems: If yes, describe: No Yes Problems with access to health care services: If yes, describe: No Yes Problems with interaction with the legal system/crime: If yes, describe: No Yes Other psychosocial and environmental problems: If yes, describe: Axis V Current GAF: Highest GAF in Past Year (if known): Individual Served /Family/Guardian Expression of Service Preferences Service Preferences: Treatment Recommendations / Assessed Needs: No Additional Recommendations Clinically Indicated A-Active, ID-Individual Declined, D-Deferred, R-Referred Out (If declined/deferred/referred out, please provide rationale) A ID* D* R* 1. 2. 3. 4. *Individual Declined/Deferred/Referred Rationale(s) (Explain why Individual Declined to work on Need Area; List rationale(s) for why Need Area(s) is Deferred or Referred Out below). None 1. 2. 3. Further Evaluations Needed: None Indicated Psychiatric Visual Psychological Auditory Neurological Nutritional Medical Educational AOD Assessment Vocational Other: of Care/ Indicated Services Recommendation: No change Individual Served/Guardian/Family Response to Recommendations:
Treatment Planning Updates Change In IAP Required: No Yes (If Yes, complete the IAP Revision/Review Form to record needed changes in Goal(s),Objective(s), Interventions, Services, Frequency, and/or Provider type) Individual Signature (Optional): Date: Guardian Signature (Optional): Date: Completed By - Print Name/Credentials: Staff Signature: Date: Clinical Supervisor/ Professional Staff/ QHP/Team Leader - Print Name/Credentials (if needed): Clinical Supervisor/ Professional Staff/ QHP/Team Leader - Print Name/Credentials (if needed): Date: Other - Print Name/Credentials (if needed): Other Signature (if needed): Date: Psychiatrist-Print Name/Credentials (if needed): Psychiatrist Signature (if needed): Date
Organization Name: Program Name: Date: Individual’s Name (First MI Last): Record #: DOB: Provider Number: Program Number: Sex: Male Female Date Last Treated: Education at Discharge (if education at admission was entered incorrectly, it must be updated in “Client Management” online) Highest Grade Completed No formal education 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th High School Diploma General Equivalency Diploma Vocational Cert w/o Diploma/GED Vocational Cert w/ Diploma/GED Some College – No degree Associates Degree Bachelors Degree Graduate Degree Employment Employment Status Employed FullTime-35+ hrs/wk Employed Part Time-<35 hrs/wk Employed in Sheltered Workshop Unemployed, In Treatment Unemployed, Looking for Work Not in Labor Force, Child Care Not in Labor Force, Disabled Not in Labor Force, In Training Not in Force, Inmate Not in Labor Force, Retired Not in Labor Force, Student Not in Labor Force, Other Soc Srvcs Work Exp Program Soc Srvcs Determined, Not Employed/Able to Work Soc Srvcs Determined, Unable to Work, Mandated Treatment Length of Employment at Discharge: 0-30 Days 31- 60 Days 61-90 Days 91-120 Days 121 + Days Individual’s of Residence Type of Residence Private Residence Homeless, Shelter Homeless, No Shelter Single Resident Occupancy CD Community Residence CD Supportive Living MH/OPWDD Community Residence Other Group Residential Setting Institution, Other (Jail/Hospital) Other Living Arrangements: Living Alone Living w/ Non-Related Persons Living with Spouse/Relatives Primary Payment Source (Select One) None Self-Pay Medicaid Medicaid Managed Care Medicaid Pending Medicare DSS Congregate Care Department of Veterans Affairs Private Insurance – Fee for Service Private Insurance – Managed Care Other: Mental Health Co-existing Psychiatric disorder Yes No Ever Treated for a mental illness problem Yes No Ever Hospitalized for mental illness Yes No Ever Hospitalized for 30 or more days for mental illness Yes No
Criteria A: For residents without indwelling catheter: Criteria B: For residents with indwelling catheter: Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostate OR (defined above) or leukocytosis (14,000 μL) and at least one of the following (new or increased): costovertebral (CVA) pain or tenderness Suprapubic pain hematuria Urinary incontinence Urgency Frequency OR No fever and least two of the following symptoms (new or increased): Urgency Frequency Suprapubic pain Gross hematuria Urinary incontinence At least one of the symptoms listed below: Fever, rigors or new-onset hypotension, with no alternate site of infection Acute change in mental status or acute functional decline, with no alternate diagnosis AND leukocytosis New-onset suprapubic pain or CVA pain or tenderness Purulent discharge from around the catheter or acute pain, swelling or tenderness of the testes, epididymis, or prostate Specimen collected from clean catch voided urine and positive culture with no more than 2 species of microorganisms, at least 1 of which is a bacterium of ≥105 CFU/m OR Specimen collected from in/out straight catheter and positive culture with any number of micro-organism, at least 1 of which is a bacterium of ≥102 CFU/m OR Specimen collected from an indwelling catheter* and positive culture with ≥105 CFU/mL of any microorganism. *If catheter has been in place for >2 weeks, change catheter before obtaining urine sample
Male Female African-American or Black Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Races Disabled Veteran White African-American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Races Disabled Veteran Level Officials and Managers Officials and Managers Technicians Sales Workers Support Workers Craft Workers Operatives Laborers and Helpers Service Workers TOTAL BY DATE: NAME AND TITLE OF
Comments: Organizational Background (50 points) The proposal provides an overview and brief description of the applicant district, demonstration school, and administrative structure Excellent Good Fair Poor N/F 4 3 2 1 0 The proposal identifies the process that was used by the applicant to secure institutions of higher education (IHE); and community based programs (CBP) as partners in identifying school models 2 1.5 1 .5 0 Applicant will describe model to replicate their success with their identified partner school. 6 4.5 3 1.5 0 In the proposal, the applicant provides a brief history, accomplishments, qualifications, and educational experience in serving the needs of at risk populations. 8 6 4 2 0 The proposal demonstrates that at least one school in the eligible district can demonstrate that it has produced improved academic performance for boys and young men of color, for at least two consecutive years. Percentages are for the >50% students proficient on ELA 40-49% students proficient on ELA 35-39% students proficient on ELA 30-34% students proficient on ELA <29% students proficient on ELA 6 4.5 3 1.5 0 >50% students proficient on math 40-49% students proficient on math 35-39% students proficient on math 30-34% students proficient on math <29% students proficient on math 6 4.5 3 1.5 0
of at risk populations. The proposal demonstrates that at least one school in the eligible district can demonstrate that it has produced improved academic performance for boys and young men of color, for at least two consecutive years. Percentages are for the lowest performing subgroup of boys and young men of color. >64% students pass ELA Regents 58-63% students pass ELA Regents 54-57% students pass ELA Regents 50-53% students pass ELA Regents <49% students pass ELA Regents 3 2.25 1.5 .75 0 >64% students pass Algebra Regents 58-63% students pass Algebra Regents 54-57% students pass Algebra Regents 50-53% students pass Algebra Regents <49% students pass Algebra Regents 3 2.25 1.5 .75 0 The proposal demonstrates that at least one school in the eligible district can demonstrate that it has produced a reduction in the academic achievement gap for boys and young men of color, for at least two consecutive years. Percentages are for the lowest performing subgroup of boys and young men of color. Achievement Gap ELA Regents <3% Achievement Gap ELA Regents 4-6% Achievement Gap ELA Regents 7-10% Achievement Gap ELA Regents 11-14% Achievement Gap ELA Regents >15% 3 2.25 1.5 .75 0 Achievement Gap Algebra Regents <3% Achievement Gap Algebra Regents 4-6% Achievement Gap Algebra Regents Achievement Gap Algebra Regents Achievement Gap Algebra Regents >15% 3 2.25 1.5 .75 0 Achievement Gap Graduation <5% Achievement Gap Graduation 6-10% Achievement Gap Graduation 11-16% Achievement Gap Graduation 17-24% Achievement Gap Graduation >25% 6 4.5 3 1.5 0
Male Female White African-American or Black Native Hawaiian\ or Other Pacific Islander Asian American Indian or Alaska Native Two or More Races Disabled Veteran White African-American Native Hawaiian or Pacific Islander Asian American Indian or Alaska Native Two or More Races Disabled Veteran Level Officials and Managers Officials and Managers Technicians Workers Support Workers Workers Operatives Laborers and Helpers Service Workers TOTAL BY DATE: NAME AND TITLE OF
b. Student Assistants c. Other 3 Purchased Services 40 4 Supplies & Materials 45 a. Instructional b. Other 5 Travel Expenses 46 a. Student/Programmatic b. Staff/Administrative 6 Employee Benefits 80 a. Professional % b. Clerical/Secretarial % c. Student Assistants % d. % 7 SUBTOTAL of 1-6 8 Indirect Cost* 90 XXXXXXXXX 9 Equipment 20 XXXXXXXXX 10 GRAND TOTAL (Lines 7 - 9) CENTS TO THE NEAREST DOLLAR. Attachment V. Application Checklist Listed below are the required documents for a complete application package, in the order that they should be submitted. Use this checklist to ensure that your application submission is complete and in compliance with application instructions. Required Documents Checked-Applicant Checked –SED Application Checklist (Attachment V) Application Cover Page with Original Signature of Chief Executive/Administrative Officer (Attachment I) Statement of Assurances with Original Signature of Chief Executive/Administrative Officer (Attachment III) Proposed Budget (Attachment IV) Payee Information Form (if applicable)
Contract is renewed or extended. Contractor also agrees that any proposed Assignee of this Contract will be required to certify that it is not on the Prohibited Entities List before the contract assignment will be approved by the State. During the term of the Contract, should the state agency receive information that a person (as defined in State Finance Law is in violation of the above-referenced certifications, the state agency will review such information and offer the person an opportunity to respond. If the person fails to demonstrate that it has ceased its engagement in the investment activity which is in violation of the Act within 90 days after the determination of such violation, then the state agency shall take such action as may be appropriate and provided for by law, rule, or contract, including, but not limited to, imposing sanctions, seeking compliance, recovering damages, or declaring the Contractor in default. The state agency reserves the right to reject any bid, request for assignment, renewal or extension for an entity that appears on the Prohibited Entities List prior to the award, assignment, renewal or extension of a contract, and to pursue a responsibility review with respect to any entity that is awarded a contract and appears on the Prohibited Entities list after contract award. (January 2014)
EMPLOYMENT OPPORTUNITY - STAFFING PLAN Instructions on Page 2 Bidder Name: Telephone: Address: Federal ID No.: City, State, ZIP: RFP No: Report includes: Reporting Entity: Work force to be utilized on this contract Contractor Contractor/Subcontractor's work force Subcontractor - Name: Enter the total number of employees in each classification in each of the EEO-Job Categories identified. EEO - Job Categories Total Work Force Race/Ethnicity - report employees in only one category Hispanic or Latino Not-Hispanic or Latino Male Female Male Female African-American or Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Disabled Veteran White African-American Native Hawaiian or Pacific Islander Asian American Indian or Alaska Native Two or More Races Disabled Veteran Executive/Senior Level Officials and Managers First/Mid-Level Officials and Managers Professionals Technicians Sales Workers Administrative Support Workers Craft Workers Operatives Laborers and Helpers Service Workers TOTAL PREPARED BY (Signature): NAME AND OF PREPARER: TELEPHONE/EMAIL: (print or type)
negotiate a final best price. The contents of this RFP, any subsequent correspondence during the proposal evaluation period, and such other stipulations as agreed upon may be made a part of the final contract prepared by NYSED. Successful bidders may be subject to audit and should ensure that adequate controls are in place to document the allowable activities and expenditure of State funds. Debriefing Procedures All unsuccessful bidders may request a debriefing within fifteen (15) calendar days of receiving notice from NYSED. Bidders may request a debriefing letter on the selection process regarding this RFP by submitting a written request to the Fiscal Contact person at: NYS Education Department Contract Administration Unit 89 Washington Avenue Room 501W EB Albany, NY 12234 The Fiscal Contact person will make arrangements with program staff to provide a written summary of the proposal’s strengths and weaknesses, as well as recommendations for improvement. Within ten (10) business days, the program staff will issue a written debriefing letter to the bidder. Contract Protest Procedures Bidders who receive a notice of may protest the NYSED award decision subject to the following: 1. The protest must be in writing and must contain specific factual and/or legal allegations setting forth the basis on which the protesting party challenges the contract award by NYSED. 2. The protest must be filed within ten (10) business days of receipt of a debriefing letter. The protest letter must be filed with: NYS Education Department Contract Administration Unit 89 Washington Avenue Room 501W EB Albany, NY 12234 3. The NYSED Contract Administration Unit (CAU) will convene a review team that will include at least one staff member from each of NYSED’s Office of Counsel, CAU, and the Program Office. The review team will review and consider the merits of the protest and will decide whether the protest is approved or denied. Counsel’s Office will provide the bidder with written notification of the review team’s decision within seven (7) business days of the receipt of the protest. The original protest and decision will be filed with OSC when the contract procurement record is submitted for approval and CAU will advise OSC that a protest was filed.
6. M/WBE 105 Contractor’s Good Faith Efforts No Participation-Request for Complete Waiver Signature Required 1. M/WBE Cover Letter 2. M/WBE 101 Request for Waiver 3. M/WBE 105 Contractor’s Good Faith Efforts
EQUAL EMPLOYMENT OPPORTUNITY - STAFFING PLAN Instructions on Page 2 Bidder Name: Telephone: Address: Federal ID No.: City, State, ZIP: RFP No: Report includes: Reporting Entity: Work force to be utilized on this contract Contractor Contractor/Subcontractor's work force Subcontractor - Name: the total number of employees in each classification in each of the EEO-Job Categories identified. EEO - Job Categories Total Work Force Race/Ethnicity - report employees in only one category Hispanic or Latino Not-Hispanic or Latino Male Female Male Female White African-American or Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Two or More Races Disabled Veteran White African-American Native Hawaiian or Pacific Islander Asian American Indian or Alaska Native Two or More Races Disabled Veteran Executive/Senior Officials and Managers Officials and Managers Professionals Technicians Sales Workers Administrative Support Workers Workers Operatives Laborers and Helpers Service Workers TOTAL PREPARED BY (Signature): NAME AND TITLE OF PREPARER: TELEPHONE/EMAIL: (print or type) EEO 100
Name of Vendor Type of Services or Supplies Year 1 Cost Cost (including Year 1) Total MBE Costs Total Budget Total MBE Costs divided by Total Budget (%) Table 2-- Women-Owned Business Enterprise (WBE) Name of Vendor Type of Services or Supplies Year 1 Cost Cost (including Year 1) Total WBE Costs Total Budget WBE Costs divided by Total Budget (%)
EQUAL EMPLOYMENT OPPORTUNITY - STAFFING PLAN Instructions on Page 2 Bidder Name: Telephone: Address: Federal ID No.: City, State, ZIP: RFP No: Report includes: Reporting Entity: Work force to be utilized on this contract Contractor Contractor/Subcontractor's total work force Subcontractor - Name: Enter the total number of employees in each classification in each of the EEO-Job Categories identified. EEO - Job Categories Total Work Force Race/Ethnicity - report employees in only one category Hispanic or Latino Not-Hispanic or Latino Male Female Male Female White African-American or Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Disabled Veteran White African-American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Races Disabled Veteran Executive/Senior Level Officials and Managers Officials and Managers Professionals Technicians Sales Workers Administrative Support Workers Craft Workers Operatives Laborers and Helpers Service Workers PREPARED BY (Signature): NAME AND TITLE OF PREPARER: TELEPHONE/EMAIL: (print or type) EEO 100
1) comply with the participation goals specified in the RFP; OR 2) partially comply with the participation goals specified in the RFP, and include a request for partial waiver, and document its good faith efforts to fully comply with the percentage goals specified in the RFP; OR 3) do not include certified M/WBE subcontractors or suppliers, and include a request for a complete waiver, and document its good faith efforts to fully comply with the participation goals specified in the RFP. All M/WBE firms are required to be certified by Empire State Development (ESD) or must be in the process of obtaining certification from ESD. Online Certification can be found at the website. Failure to comply with the requirements of Article 15-A as set forth under this procurement and in conjunction with the corresponding contract, will result in the withholding of associated funds and other enforcement proceedings set forth under Article 15-A.
Fax: Fax: Email: Email: Please indicate your applicant status: Individual Applicant Consortium Applicant Total combined number of students of lead applicant and/or partnership/ consortium: Total Funding Amount Requested: (Not to exceed $1,500,000) County of the Lead applicant: I hereby certify that I am the applicant’s chief school/administrative officer and that the information contained in this application is, to the best of my knowledge, complete and accurate. I further certify, to the best of my knowledge, that any ensuing program and activity will be conducted in accordance with all applicable Federal and State laws and regulations, application guidelines and instructions, Assurances, Certifications, and that the requested budget amounts are necessary for the implementation of this project. It is understood by the applicant that this application constitutes an offer and, if accepted by the NYS Education Department or renegotiated to acceptance, will form a binding agreement. It is also understood by the applicant that immediate written notice will be provided to the grant program office if at any time the applicant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. Authorized Signature Title (Chief School/ Administrative Officer) Name: Date: Phone number: Email address: Attachment II: Mandatory Requirements Certification By signing this form, the undersigned certifies it can provide and/or meet the mandatory requirements listed below and outlined in the RFP. Certification for (Insert Applicant Name) Mandatory Requirement Explanation Included in application? Application Cover Page: Attachment I Signed Attachment I Yes Mandatory Requirements Certification: Attachment II Signed to certify that the application meets all mandatory requirements. Yes Memorandum(s) of Understanding (MOU): Attachment IV For consortium applicants only: An MOU between the lead applicant and each consortium member must be completed, signed and submitted. Yes Assurance of Funding: Attachment V Signed Attachment V, certifying that STLE-D grant funding is supplemental to, and does not supplant, other funding sources. Yes
APPENDICES Appendix A STANDARD CLAUSES FOR NYS CONTRACTS The parties to the attached contract, license, lease, amendment or other agreement of any kind (hereinafter, "the contract" or "this contract") agree to be bound by the following clauses which are hereby made a part of the contract (the word "Contractor" herein refers to any party other than the State, whether a contractor, licenser, licensee, lessor, lessee or any other party): 1. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the State shall have no liability under this contract to the Contractor or to anyone else beyond funds appropriated and available for this contract.
BUDGET TOTAL COST Total cost per Geometry module multiplied by 3 modules Total cost per Algebra II module (there is 1 Algebra II module) Total cost per Pre-calculus module multiplied by 4 modules Total cost per weekly one-hour phone call multiplied by the maximum of 30 calls Total cost per hour of consultation multiplied by the maximum of 30 hours TOTAL BUDGET Vendor Name: ________________________________________________________________________ Vendor Representative Printed Name: _________________________________________________________ Title: _________________________________________________________ Date: ________________________ Subcontracting Form New York State Education Department MATHEMATICS CURRICULUM REVIEWER FOR GEOMETRY, ALGEBRA II AND PRE-CALCULUS (GRADES 10-12) Bidder Name: ________________________________________________ RFP #: SA-13 (whole dollar figures only) Name of Subcontractor M/WBE Entity Type Work Description & Estimated Projected Cost MBE WBE For Profit Not –For-Profit MBE WBE For Profit Not –For-Profit
EQUAL EMPLOYMENT OPPORTUNITY - STAFFING PLAN (Instructions on Page 2) Applicant Name: Telephone: Address: Federal ID No.: City, State, ZIP: Project No: Report includes: Work force to be utilized on this contract OR Applicant’s total work force Enter the total number of employees in each classification in each of the EEO-Job Categories identified. EEO - Job Categories Total Work Force Race/Ethnicity - report employees in only one category Hispanic or Latino Not-Hispanic or Latino Male Female Male Female African-American or Black Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Disabled Veteran White African-American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Disabled Veteran Executive/Senior Level Officials and Managers First/Mid-Level Officials and Managers Professionals Technicians Sales Workers Administrative Support Workers Craft Workers Operatives Laborers and Helpers Service Workers TOTAL