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ClearWay MinnesotaSM Request for Qualifications

August 17, 2015 Cessation Policy Consultant

August 17, 2015 RFQ released September 4, 2015 Intent to Apply Due

September 15, 2015 Proposals due by 4:30 p.m. CDT October 1 – 9, 2015 Review process and possible interviews (10/7-10/9)

November 18, 2015 Notification January 1, 2016 Contract begins

About ClearWay MinnesotaSM Founded in 1998, ClearWay Minnesota is an independent nonprofit organization whose mission is to enhance life in Minnesota by reducing tobacco use and exposure to secondhand smoke through research, action and collaboration. We have helped reduce smoking in Minnesota from 22 to 14.4 percent, served more than 100,000 with our quit-smoking services, advanced health policies including smoke-free policies and tobacco price increases, increased access to barrier-free tobacco cessation services, broken ground in research, partnered with diverse communities to reduce tobacco’s burden and created many innovative programs. ClearWay Minnesota was created with 3 percent of the settlement paid to Minnesota by tobacco companies and given a 25-year lifespan. Because of its unique position as a life-limited organization, ClearWay Minnesota has established three Legacy Goals to guide our work:

1. Reduce adult smoking prevalence to less than 9 percent by 2023; 2. Reduce adult secondhand smoke exposure to less than 5 percent by 2023; and 3. Ensure that all Minnesota smokers have access to comprehensive tobacco dependence

treatment by 2023. Given that the organization will sunset in eight years, our work is strategically prioritized and focused on activities that will have the most long-term impact. This strategic decision making is especially necessary when planning and prioritizing activities aimed at achieving our third Legacy Goal. In 2011, ClearWay Minnesota identified three strategic areas of work in order to achieve our third Legacy Goal. These areas are: Health Insurance Benefit Design, Health Care Quality and Performance Measurement and Health System Integration. Since 2011, ClearWay Minnesota has used various policy approaches to achieve our goals in each of these three strategic areas of work (see page 4).

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Purpose ClearWay Minnesota is currently seeking applications for a public policy consultant to work collaboratively with staff in continuing efforts to ensure access to comprehensive tobacco dependence treatment for all Minnesotans. This includes providing support and consultation in areas of health insurance benefit design, health care quality and performance measurement and health system integration, with special strategic attention paid to ClearWay Minnesota’s unique position as a life-limited organization.

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Scope of Work The cessation policy consultant is responsible for working collaboratively with ClearWay Minnesota staff on the following duties as they relate to ensuring access to comprehensive tobacco dependence treatment for all Minnesotans:

Identifying and communicating emerging health care reform trends and relevant policy issues, including identifying opportunities to capitalize on environmental changes;

Facilitating ongoing planning processes including providing expertise and consultation as ClearWay Minnesota defines our role in this area of work;

Identifying key stakeholders and facilitating relationship building with entities such as health plans, state agencies, legislators, other decision makers, community stakeholders and independent organizations;

Providing support, consultation and strategic direction around administrative and legislative meetings related to this work;

Providing technical assistance to ClearWay Minnesota staff on issues related to Minnesota’s health care provider organizations, quality and performance measurement systems and health insurance coverage;

Providing support and consultation for efforts to include a comprehensive tobacco cessation benefit within all public and private insurance products available to Minnesotans;

Providing support and consultation for efforts to strengthen how documenting tobacco use and treatment delivery is equitably integrated within quality and performance measurement systems;

Providing support and consultation for policy-focused efforts to integrate tobacco dependence treatment into routine health care;

Providing support and consultation on evaluation activities, as needed; and

Performing other related duties as requested.

Qualifications Applicants should have:

Experience in providing high-quality public policy consulting services in areas of health care policy and public health, including regulatory, legislative and voluntary policy change;

In-depth knowledge of state and federal health care reform trends and related implementation activities in Minnesota;

Understanding of and experience working with key stakeholders and decision makers within: o Relevant state agencies in Minnesota o Minnesota’s health care system, including hospital systems, individual clinics, safety net

clinics and other health care provider organizations; o Innovative health care delivery models such as Health Care Homes, Accountable Care

Organizations, Accountable Communities for Health and Integrated Health Partnerships; o Minnesota’s health insurance market, including MNsure, Minnesota Health Care

Programs, State Employees Group Insurance Program and private plans (individual, small and large group, and self-funded);

o Quality and performance measurement systems, including Minnesota’s Statewide Quality Reporting and Measurement System and other quality measurement or

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performance incentive systems for providers or health plans (e.g. Meaningful Use, National Quality Forum endorsed measures);

Knowledge of best practices in increasing access to tobacco cessation services;

Commitment to improving health in Minnesota by reducing tobacco use, reducing secondhand smoke exposure and increasing access to tobacco cessation services;

An ability to work collaboratively as part of a diverse team;

An ability to be proactive, flexible and responsive;

The financial and administrative capacity to manage the contract;

The technical expertise to successfully implement the full range of duties outlined in this RFQ; and

An in-state office.

Strategic Areas of Work and Progress to Date

ClearWay Minnesota’s third Legacy Goal is: 100 percent of Minnesotans will have access to comprehensive tobacco dependence treatment by 2023. In order to achieve this goal, three strategic areas of work have been undertaken: Health Insurance Benefit Design, Health Care Quality and Performance Measurement and Health System Integration. Health Insurance Benefit Design The goal of this strategic area is to ensure all health insurance products include comprehensive tobacco cessation benefits. ClearWay Minnesota defines a comprehensive benefit as barrier-free coverage for all types of counseling (individual, group and phone) and all seven FDA-approved cessation medications. The U.S. Centers for Disease Control and Prevention (CDC) names expanding tobacco cessation insurance coverage as a best practice for comprehensive tobacco control programs. Expanding such coverage increases the number of smokers who attempt to quit, use evidence-based cessation treatments and successfully quit. 1 Removing barriers to tobacco dependence treatment increases use of cessation pharmacotherapy, quit attempts and sustained abstinence rates. 2,3 Since 2010, the Patient Protection and Affordable Care Act (ACA) has required new private health insurance to cover – with no cost sharing, prior authorization or lifetime limits – preventive services graded “A” or “B” by the U.S. Preventive Services Task Force (USPSTF). The USPSTF included “tobacco cessation interventions” in its list of recommended services and assigned them an “A” grade. However, the “A” recommendation itself did not specify which services it refers to, or that all treatments should be covered. To help address this ambiguity, the U.S. Departments of Health and Human Services, Labor and Treasury recently issued guidance, in the form of Frequently Asked Questions (FAQ), on insurance coverage of tobacco cessation as a preventive service. ClearWay Minnesota’s work in this area aims to address coverage through Minnesota Health Care Programs, MNsure, the State Employee Group Insurance Program and private insurance products.

1 U.S. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs — 2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 2 Curry SJ, Keller PA, Orleans CT, Fiore MC. The Role of Health Care Systems in Increased Tobacco Cessation. Annual Review of Public Health. April 2008;29:411-428 3 Reda AA, Kotz D, Evers SMAA, Schayck CPv. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database Systematic Review. April 15, 2009(3).

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Insurance coverage for tobacco cessation services still varies across health plans and products. ClearWay Minnesota has been using the Affordable Care Act and state-based health care reform policy changes as leverage points for achieving this goal. To date, we have worked closely with relevant state agencies in using the Affordable Care Act requirements and the corresponding federal FAQ within their annual review process of health insurance products sold in Minnesota. This work has helped close some gaps in coverage within Minnesota Health Care Programs, products sold on MNsure, and other individual and group products sold outside of the exchange. Gaps in coverage still remain, particularly within the State Employees Group Insurance Program, and among some large group insurance products and products in the self-insured market. The Cessation Policy Consultant will play a key role in facilitating planning processes and defining strategic direction for these areas of work, as well as others, to help close these gaps. This will include facilitating strategic meetings and relationship building with key decision makers, stakeholders and partners. Health Care Quality and Performance Measurement This area of work aims to strengthen and integrate population-wide tobacco dependence treatment measures and performance incentives into health care delivery systems. Strengthening tobacco-related quality and performance measures will help ensure that health care professionals and providers address tobacco use consistently and effectively. Minnesota’s 2008 health reform law established mandatory standards for measuring quality of services offered by health care providers. Since then, physician clinics, hospitals and ambulatory surgical centers are required to report on these measures, which are collectively called the Statewide Quality Reporting and Measurement System (SQRMS). Individual health plans, other payers and health care provider organizations have their own quality and performance measurement and incentive systems that may or may not include tobacco use and treatment components. Work to date in this strategic area has included an environmental scan of existing tobacco use and treatment quality measures, including analyzing existing data about tobacco use among Minnesotans with diabetes or vascular disease (reports can be found here and here). Currently, within SQRMS, tobacco use is only measured within other chronic disease measures rather than across the entire patient population. Opportunities exist to strengthen measurement of tobacco use and treatment within SQRMS by developing a population-wide measure (e.g. engaging with the Minnesota Department of Health in implementation of the Adult Healthy Lifestyle/Risk Reduction measure). There is also wide variation in how health plans and health systems are using performance incentive systems to improve delivery of best practices in tobacco dependence treatment. Opportunities also exist to leverage or strengthen other quality measurement or performance incentive systems for providers or health plans to improve tobacco treatment delivery (e.g. Meaningful Use, National Quality Forum-endorsed measures, individual measures used in contracting processes). ClearWay Minnesota has also engaged in efforts to strengthen data collection related to the social determinants of health (e.g. race, ethnicity, preferred language) to help interpret health care quality measures. Because tobacco use is not distributed evenly across the entire population, collecting additional data and integrating it with quality measures related to tobacco has the potential to assist health care provider organizations in better understanding where gaps in tobacco treatment delivery exist and identify strategies to help close those gaps. This collaborative approach with other key stakeholders will help lead to more consistent delivery of best practice tobacco dependence treatment to all patients.

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The Cessation Policy Consultant will play a critical role in identifying opportunities to advance this work moving forward, including both continued implementation of the above activities in addition to beginning new components of this work, with the goal of ensuring that tobacco use and treatment delivery are equitably measured at the population level. Health Systems Integration The goal of this strategic area is to ensure that tobacco dependence treatment is integrated into routine health care. By normalizing the treatment of tobacco dependence within health care, we anticipate that not only will patients’ health be improved but that health care systems will have the potential to realize cost savings. ClearWay Minnesota is working with health care provider organizations to ensure that care processes for tobacco dependence are fully implemented into all aspects of health care delivery. Our main focus has been on the primary care setting, but we are open to continuing to engage strategically in other health care settings as well. Our health systems integration work has three components: a granting initiative, capacity-building efforts and policy strategies. Our granting initiative provided an opportunity for health systems to make the delivery of tobacco treatment a standard practice of care through health systems change, resulting in changes that can be sustained over time. We have five grantees - Hennepin County Medical Center, CentraCare Health, Mille Lacs Band of Ojibwe, Essentia Health and Apple Tree Dental. Information about other health systems change work ClearWay Minnesota has supported can be found here. We are also beginning new work to help build capacity for tobacco treatment delivery within health care provider organizations in Minnesota. Through this work, we are seeking to improve health care provider organizations’ abilities to systematically assess and address their patients’ tobacco use. To achieve this goal we aim to elevate addressing tobacco use as a priority among these organizations by providing information and resources and incorporating other strategies to support changes in assessing and addressing tobacco use. ClearWay Minnesota’s currently open RFQ titled “Health Systems Change Capacity Building Contract for Assessing and Addressing Tobacco Use” is focused on activities to build capacity within these organizations. The Cessation Policy Consultant being sought under this RFQ will focus on policy strategies that complement capacity-building activities and support integration of tobacco dependence treatment into routine health care. The policy-focused work to integrate tobacco dependence treatment into health care delivery models (e.g., Health Care Homes, Accountable Care Organizations, Accountable Communities for Health and Integrated Health Partnerships) is newer work for ClearWay Minnesota. The Cessation Policy Consultant will assist us in defining the strategic direction of this work and subsequent implementation activities. ClearWay Minnesota staff will closely coordinate all of our health systems integration work to both capitalize on opportunities to collaborate and to avoid duplication.

Selection Schedule and Contract Details

August 17, 2015 RFQ released

September 4, 2015 Intent to Apply Due

September 15, 2015 Proposals due by 4:30 p.m. CDT

October 1 – 9, 2015 Review process and possible interviews (10/7-10/9)

November 18, 2015 Notification

January 1, 2016 Start of contract

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Initial contract term and available budget The initial contract awarded as a result of this RFQ will be for a six-month term, January 1, 2016 – June 30, 2016. The budget for this six-month period is not to exceed $60,000. After the initial contract period, we anticipate annual, 12-month renewal contracts for a maximum of five years total, based on satisfactory performance.

Application Process and Instructions There are two steps in the proposal process:

1. Applicants email Intent to Apply to ajansen@clearwaymn.org. 2. Applicants use online submission system to submit a full proposal.

Instructions for Submitting an Intent to Apply

Applicants interested in submitting a full proposal under this RFQ must email ClearWay Minnesota Senior Cessation Manager Amanda Jansen at ajansen@clearwaymn.org by 4:30 p.m. CDT on September 4, 2015. This email must include the following information about the applicant:

Name of Organization

Name of Contact Person

Physical Mailing Address of Minnesota Office

Email Address

Phone Number

Statement that you/your organization intend(s) to submit a full application specifically in response to “The Cessation Policy Consultant RFQ”

Interested applicants will then be provided instructions on the online application submission process.

Instructions for Completing Full Application

Use the provided instructions to submit a Full Application. All application materials must be received by ClearWay Minnesota by 4:30 p.m. CDT on September 15, 2015. Application materials will be submitted online and directions for this process will be given to applicants when their Intent to Apply is received. Late applications will not be accepted. Any questions regarding the application process should be sent to Amanda Jansen, ClearWay Minnesota Senior Cessation Manager, at ajansen@clearwaymn.org or call 952-767-1429. ClearWay Minnesota staff and external experts will review proposals using a variety of criteria and will recommend a contractor to our Board of Directors for approval. The review process will focus on applicant capabilities, relevant past experience, competitive fees and the strategic approach to help ClearWay Minnesota achieve its goals related to ensuring access to comprehensive tobacco dependence treatment for all Minnesotans.

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Advisory warning to applicants submitting materials containing proprietary information ClearWay Minnesota complies with the Minnesota Government Data Practices Act, Minn. Stat. Ch. 13, and the Open Meeting Law, Minn. Stat. Ch. 13D. Under these laws, any information submitted to ClearWay Minnesota is a “public record” unless it is the kind of information that falls into a specific statutory exception. All contracts under this RFQ will be discussed and awarded at a ClearWay Minnesota Board Meeting, which will be open to the public. All applications are non-public until recommended for funding by the ClearWay Minnesota Board, at which time the submissions will be public except to the extent they contain classified information under the Data Practices Act.

Format

The narrative and support documents should be provided in no less than 11-point font. All page margins must be at least one inch in width. Label and number all sections and provide page numbers. The page limit is nine pages (excluding permissible supporting documents). Follow the order listed below.

Applicants submitting proposals should include the following:

I. Cover Letter (one-page maximum). Provide a cover letter that identifies the applicant’s name, address, contact person, phone/fax numbers and email address. An officer must sign the letter confirming that you meet the qualifications, specifically stating you have:

a. The financial and administrative capacity to manage the contract; b. The technical expertise to successfully implement the full range of duties outlined in this

RFQ; c. An in-state office; and d. You acknowledge that an authorizing official has read the Contractor (Vendor)

Acknowledgement of Terms and Conditions (Form 2) and has verified that your organization can comply with all of the requirements.

II. Contractor Profile (four-page maximum). Provide a narrative addressing each of the following components.

a. Current description of your organization, including: - Number of years in business; - Areas of expertise; - Philosophy on client service; and - Approach to public policy consulting work.

b. Relevant experience in health care policy work, including any tobacco control experience. c. Personnel. Provide a description of staff who will be assigned to the ClearWay Minnesota

account, including the following information: - Name and title; - Description of relevant expertise, capabilities and credentials; - Current clients assigned, length of time assigned and a description of duties - Indicate percentage of staff members’ time to be devoted to ClearWay Minnesota and

their proposed responsibilities to the ClearWay Minnesota account. - You may include a one-page resume for each staff member as an attachment. Resumes

will not count toward the page limit. d. Proposed payment structure, including billing rates of applicable personnel.

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e. Client References. Provide the names, affiliations and telephone numbers of three (3) client references from accounts active any time during the period of January 1, 2012 through the present. (This may be included as a separate attachment that will not count toward the page limit.)

f. Client List. Provide a complete list of clients for the past three years. Indicate where ClearWay Minnesota would rank on the list according to size of account. (This may be included as a separate attachment that will not count toward the page limit.)

III. Strategic Assignment (four-page maximum).

From your own understanding of the health care environment in Minnesota and related state and federal reforms, and with the information provided in this RFQ, propose an approach to work collaboratively with ClearWay Minnesota over the next three years to make progress towards achieving the goals outlined within each of the following areas of work: health insurance benefit design, health care quality and performance measurement and health system integration. This should include identifying strategic opportunities, relevant stakeholders and key activities to make progress towards our goals.

IV. Completed Applicable Forms (not included in the 9 page limit):

a. Full Application Form (Form 1) b. Contractor Acknowledgement of Terms and Conditions (Form 2) c. Contractor Applicant Financial Questionnaire with required attachments (Form 3)

Right to amend ClearWay Minnesota reserves the right to amend or supplement this RFQ without liability. Right of rejection This RFQ does not obligate ClearWay Minnesota to complete the proposed project. ClearWay Minnesota may cancel the solicitation if it is not considered to be in its best interest. ClearWay Minnesota expressly reserves the right to reject all proposals or portions thereof without reason, cause or explanation. Funding not guaranteed No person or organization has a right to or expectation of such funding, except as provided in a fully approved and executed contract agreement. Approved funding may be withdrawn (or project approval may be rescinded) if the parties fail to reach agreement during the contract negotiation process.

FORM 1 – Cessation Policy Consultant RFQ

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Full Application Form This form will be available in the online submission system for those applicants approved to submit a full proposal. The full application packet is due by 4:30 p.m. CDT on September 15, 2015. Date (month/day/year): / / General Information Legal Name of Organization: Address: County: Telephone: Fax: Project Information Name of Project Director: Title: Email: Telephone: Fax: Address: Name of Financial Officer: Title: Email: Telephone: Fax: Address:

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Is your organization/agency a: IRS 501(c)(3) (nonprofit organization) IRS 501(c)(6) (professional or trade organization) Local unit of government Tribal Government For Profit Other:

Federal Tax ID number: State Tax ID number:

Checks to be made payable to: Name: Address: City: State: Zip

FORM 2 – Cessation Policy Consultant RFQ

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ClearWay MinnesotaSM

Contractor (Vendor) Acknowledgement of Application Terms and Conditions

Contractor must read, complete and acknowledge the following items by signing and dating this form on Page 16. As the undersigned, you represent, on behalf of an organization applying for a contract from ClearWay MinnesotaSM, that you have the authority to execute this and related contract agreements on behalf of the applicant organization. You further acknowledge and agree to the following in applying for a contract with ClearWay Minnesota: The Application Process

Applicant represents and warrants in submitting a proposal that it has complied with and/or shall comply with all applicable federal, state and local laws, rules and regulations for businesses in their industry.

No application for funding will be considered unless it is complete and fully complies with criteria set forth in the applicable Request for Proposals/Applications/Qualifications.

No application for funding will be considered unless and until this Acknowledgment of Application Terms and Conditions is signed and returned to ClearWay Minnesota’s authorized representative.

This Request for Proposals/Applications/Qualifications) may be withdrawn or modified by ClearWay Minnesota at any time during the application process.

The Review Process Applicant acknowledges that:

Proposals submitted become public information, subject to the Minnesota Government Data Practices Act, at the time they are presented to the ClearWay Minnesota Board of Directors. Pricing and service agreements of proposals are considered public information, unless Applicant can demonstrate that the information is a “trade secret” or “non-public business data” as defined by the Act

Any attempt to contact a review panel member to discuss the application under review during the review process will disqualify an Applicant from receiving funding.

ClearWay Minnesota has the sole right and discretion to select or reject proposals for any reason.

No person or organization has a right to or expectation of such funding, except as provided in a fully approved and executed contract agreement. Funding may be withdrawn (or project approval may be rescinded) if the parties fail to reach agreement during the contract negotiation process.

If Applicant is an existing or prior ClearWay Minnesota contractor, ClearWay Minnesota may provide the review panel information about previous experience with Applicant.

Conditions for Funding Applicant acknowledges and will comply with the following ClearWay Minnesota policies and directives if awarded a contract:

Smoke-Free Workplaces Organizations receiving funding from ClearWay Minnesota must provide smoke-free worksites, unless they are specifically exempt from an applicable smoke-free policy.

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As the undersigned, you represent that you have reviewed ClearWay Minnesota’s Smoke-Free Workplaces Policy and that the organization is (please check one):

Smoke-free.

Specifically exempt from an applicable smoke-free policy.

Contractor Interaction With Tobacco Companies ClearWay Minnesota will not contract with a tobacco company, or with its parent or subsidiaries.

ClearWay Minnesota will actively seek to contract with organizations that have no present or anticipated relationships with tobacco companies, their parents or subsidiaries. ClearWay Minnesota generally will not contract with an organization that currently receives funding, has received funding in the previous 12 months or would accept funding during the ClearWay Minnesota contract’s lifetime from a tobacco company or its parents or subsidiaries.

ClearWay Minnesota may choose to contract with a Project Lead with an organization that currently receives funding from a tobacco company, or from its parent or subsidiaries if the Project Lead working on the ClearWay Minnesota project is clearly and demonstrably free of any current or anticipated involvement with tobacco-related funding, and if the quality of service is deemed significantly better than that provided by competitors. Because the tobacco industry has targeted, manipulated or sought to exploit certain populations, ClearWay Minnesota may choose to contract with an organization that has received funding from a tobacco company, or from its parent or subsidiaries, if the ClearWay Minnesota funding is clearly and demonstrably used for work unrelated to that done with the tobacco funding and if the organization is deemed uniquely better qualified than its competitors to use the ClearWay Minnesota funding.

For the purposes of this Policy, tobacco is defined as commercially manufactured products containing tobacco and does not include sacred and traditional tobacco use by American Indians and other cultures.

As the undersigned, you represent that you have reviewed ClearWay Minnesota’s Policy on Contractor Interaction With Tobacco Companies and that the organization (check all that apply):

Will comply with ClearWay Minnesota’s policies and directives concerning relations with tobacco companies and related businesses, if awarded funding.

Will disclose any relationship of which it is aware by Applicant and its proposed subcontractors with any tobacco company, affiliate or subsidiary of any tobacco company.

Has no present or anticipated relationships with tobacco companies, their parents or

subsidiaries or that the individuals working on the ClearWay Minnesota project have

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not worked directly with such entities in the last 12 months, and agree that they will not work directly with such entities while working with ClearWay Minnesota.

Contractor Compliance with Minnesota Government Data Practices Act Applicant acknowledges that proposals submitted become public information, subject to the Minnesota Government Data Practices Act, at the time they are approved.

If ClearWay Minnesota contracts with a private sector person or entity to “perform any of its functions,” the contract must require the contractor to agree to be subject to the Minnesota Government Data Practices Act (Minn. Stat. § 13) with respect to any data “created, collected, received, stored, used, maintained or disseminated” by the private contractor.

Contractor agrees to comply with the Act with respect to the agreement data as if Contractor were a government entity (as defined in the Act). Agreement data is considered public information under the Act, unless it can be demonstrated that there is reason any given agreement data should not be treated as public information, including but not limited to that such agreement data is a “trade secret” pursuant to Minn. Stat. §13.37, subd. 1, or “non-public business data” pursuant to Minn. Stat. §13.591, subd. 1. Contractor understands that pursuant to Minn. Stat. §13.05, subd. 11, the remedies provided in §13.08 of the Act apply to Contractor.

Pricing and service agreements of proposals are considered public information, unless Applicant can demonstrate that the information is a “trade secret” or “non-public business data” as defined by the Act. If an individual or organization believes that a document it submits to ClearWay Minnesota contains trade secret information, the individual or organization must do the following:

1) Clearly mark the information with the words “trade secret”; and 2) Explain in writing how the information meets each of the three requirements in the

definition of trade secret information.

“Proprietary” information is not defined or classified under the DPA. Therefore, proprietary information will be public data and available to anyone upon request. This is important because if Contractor marks something as “proprietary,” it is not the same as marking it “trade secret.”

In the event that Contractor receives a request for agreement data under the Act, Contractor agrees to notify ClearWay Minnesota promptly upon such request. In the event that Contractor reasonably desires that certain agreement data requested not be disclosed, Contractor shall give ClearWay Minnesota notice requesting that ClearWay Minnesota withhold specific agreement data from being disclosed. Such notice shall identify the specific agreement data that Contractor desires be withheld, and the statutory basis for claiming that such agreement data is not public information.

ClearWay Minnesota will not reimburse Contractor for any of Contractor’s attorneys’ fees or costs, or for any other expenses incurred in responding to Act requests or requests for information from any government agency.

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As the undersigned, you represent that you have reviewed ClearWay Minnesota’s requirement for contractor compliance with the Minnesota Government Data Practices Act and the organization is:

Willing to comply with this requirement. Contractor Compliance with ClearWay Minnesota’s Conflict of Interest Policy Applicant warrants that no member of its staff or board of directors is, or during the term of any agreement will be, a member of the staff or Board of Directors of ClearWay Minnesota. ClearWay Minnesota will not enter into contracts with a ClearWay Minnesota Board Member or a ClearWay Minnesota employee or the family members of either while the person is serving ClearWay Minnesota and for one year after the person ceases to be a Board Member or employee of ClearWay Minnesota.

If a family member or relative of a ClearWay Minnesota Board Member is (or becomes) affiliated with an organization that has a grant or contract with ClearWay Minnesota, that organization must:

a) Certify in writing to ClearWay Minnesota that the family member or relative will not solicit, supervise, manage, administer or have a financial interest in the ClearWay Minnesota grant or contract for the duration of that grant or contract;

b) Submit the certification within 30 days of the disclosure of the relationship to the affiliated organization or of a written request from ClearWay Minnesota; and

c) Promptly update the certification if the status of the family member or relative changes.

“Family members” of a person are the person’s spouse or domestic partner, parents, stepparents, siblings, children, stepchildren, and spouses or domestic partners of the person’s children and stepchildren. “Relatives” of a person are the person’s aunts and uncles.

This is a link to ClearWay Minnesota’s website, which contains a list of ClearWay Minnesota Board Members and staff:

http://www.clearwaymn.org Please review the list and disclose if your organization is affiliated with either a Board or staff member of ClearWay Minnesota.

As the undersigned, you represent that you have reviewed ClearWay Minnesota’s Conflict of Interest Policy and the list of ClearWay Minnesota Board Members and staff and your organization (check one):

Has no affiliation with a ClearWay Minnesota Board Member or a ClearWay Minnesota employee.

Discloses an affiliation with a ClearWay Minnesota Board Member or a ClearWay Minnesota employee. (See attached Disclosure.)

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Contractor Liability and Insurance Requirements

Contractor shall be solely responsible for obtaining, and for any expense in obtaining, worker’s compensation, medical, dental, life, liability and all other insurance for Contractor for the Term. Contractor understands that it is not covered by the insurance policies of ClearWay Minnesota. Contractor is responsible for obtaining, at Contractor’s sole expense, licenses and permits usual and necessary for performing the Services.

During the period of time that Applicant’s proposal is under consideration for funding by ClearWay Minnesota, Applicant agrees to inform ClearWay Minnesota immediately of any material change affecting the capacity of the applicant organization to meet the requirements and responsibilities outlined in the Request for Proposal as submitted.

Proposals are subject to a financial due-diligence process. Funding will be contingent upon

the successful review of the Applicant Financial Questionnaire and related documents.

Willing to comply with this requirement. Withholding of Funds or Termination After Contract Execution ClearWay Minnesota, at our sole option, also may terminate contract agreements at any time if:

Contractor breaches the conditions set forth in the Contract agreement. At ClearWay Minnesota’s sole discretion, ClearWay Minnesota believes that Contractor

becomes unable to meet ClearWay Minnesota’s needs.

By checking this box, you represent that you have the authority to execute this and related contract agreements on behalf of the contracting organization and agree to the application terms and conditions stated above. Name (please print): Date (month/day/year): / / Title: Representing (organization’s legal name):

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ClearWay MinnesotaSM Affiliation Disclosure Form

(Only complete if applicable)

1. Legal Name of Organization:

2. Name of ClearWay Minnesota Board Member or employee affiliated with the organization:

3. Answer the following questions.

a. Does the ClearWay Minnesota Board Member or employee named above have an affiliation

with or financial interest in the organization?

Yes No

If yes, describe the circumstances.

b. Does a relative or family member of the ClearWay Minnesota Board Member or employee

named above have an affiliation with or financial interest in the organization?

Yes No

If yes, describe the circumstances.

c. Does the ClearWay Minnesota Board Member or employee named above or his or her

relative or family member have any influence in seeking grants or contracts for the

organization or any involvement in managing grants or contracts for the organization?

Yes No

If yes, describe the circumstances.

d. Are there any circumstances that could create a perception that the ClearWay Minnesota

Board Member or employee named above is not able to make a fair, objective and

independent decision regarding funding the organization?

Yes No

If yes, describe the circumstances.

Name: Date (month/day/year): / / Title: Representing (organization’s legal name):

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Definitions

ClearWay Minnesota Board Members or employees are “affiliated” with an organization (and have an “affiliation” with an organization) if they or their family members are officers of, directors of, employed by, independent contractors for, or receiving proceeds from a ClearWay Minnesota grant or contract, or have a financial interest in the organization.

A person has a “financial interest” if the person has, directly or indirectly, through governance, business or investment:

a) An existing, foreseeable or recent (within the past year) ownership interest of more than 2 percent in any entity with which ClearWay Minnesota has, or is negotiating, a grant, contract or other arrangement; or b) An existing, foreseeable or recent (within the past year) compensation arrangement with ClearWay Minnesota or with any entity or person with which ClearWay Minnesota has, or is negotiating, a grant, contract or other arrangement.

FORM 3 – Cessation Policy Consultant RFQ

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CLEARWAY MINNESOTASM

Contractor Applicant Financial Questionnaire

The purpose of this Financial Questionnaire is to verify the organization’s good financial standing and capacity to

successfully complete the ClearWay Minnesota project. Only one copy of each of these documents is required.

ClearWay Minnesota staff will treat all personal financial information as confidential and will not disclose, use, or

discuss confidential personal financial materials except to verify applicant eligibility. Personal confidential

financial material is not subject to disclosure under the Minnesota Government Data Practices Act.

Fill out the following Questionnaire as it applies to your organization and provide the materials requested.

Organization Name: ____________________________________________________________________

Name and title of person completing questionnaire: ____________________________________________

Date: _______________________

Name and title of the top financial representative of the organization: ______________________________

____________________

Please respond to each question.

1. Please provide a resume of the top financial representative of the organization. Please verify that s/he has never

been convicted nor is a charge pending for fraud, misrepresentation, or theft.

2. Are there any lawsuits, judgments, or liens pending against your organization that directly impact the ability to

administer the funds if awarded, or is it currently under investigation by any entity?

____ Yes _____No

If yes, please provide details (attach a sheet if necessary):

________________________________________________________________________

________________________________________________________________________

3. Please provide contact information for three trade references.

4. Has your organization ever been denied a surety bond, filed for bankruptcy or been insolvent?

____ Yes _____No (If yes, please attach an explanation)

5. Please provide the most recent audited financial statements for the applicant entity proposed to complete this

project. (If you don’t conduct an audit please submit the latest IRS tax filing for the applicant entity. Sole

proprietors need to send their most recent IRS Form 1040, excluding any schedules, and should redact their Social

Security number on the Form 1040.)

6. Is your organization in good standing with your Secretary of State’s Office?

____ Yes _____No ____N/A

If yes, please attach a copy of your Certificate of Good Standing. Please provide an explanation if it is not

available or is not applicable to your organization. ClearWay Minnesota must be notified if there is a change in

your good standing status.

____________________________________ ______________________

Signature of person completing questionnaire Date