View Scheme - SCM2231

1. Type of business ^*

Please indicate your business type.

a registered (public or proprietary limited) Australian company;

foreign (overseas) company registered in Australia;

Individuals trading as a partnership

Business profile ^*

Please provide your business details by using the attached template. Once the template is completed, please upload the file here as part of the application process.

 

Profile Template

Business information ^*

Please attach your business's marketing material as a zipped file. This information will be made available to agencies and should include information about your services and any information about the business’s service delivery approach (e.g. business values and ethics).

 

Sales contact ^*

Please provide contact details (other than the details provided with your NSW eTendering registration) which you would like agencies (employers in Government) to use for service requests.

Small and medium sized enterprise ^*

Does your business employ more than 200 full time equivalent employees across Australia and New Zealand?

Yes

No

1) Tier One: Employment related medical assessment services (Core) ^*

a) Medical Assessments

Please describe: 

1. What systems, processes (including timeframes and triage processes) and practices are in place to manage and provide employer referrals for medical assessments. Indicate if the systems and processes are different for non-work related health conditions.
2. How your organisation will determine the most appropriate medical assessor for the referral, including medical specialists, where necessary. Describe any governance arrangements to ensure fairness and objectivity.

1) Tier One: Employment related medical assessment services (Core) ^*

b) Administrative support to the Review Panel

Please describe systems, processes and mechanisms your business will apply to provide this service.

1) Tier One: Employment related medical assessment services (Core) ^*

c) Pre-employment and periodic health assessments

Please describe systems, processes (including timeframes and triage processes) and practices your business applies to an agency referral for pre-employment medical and periodic health assessment. Describe any governance arrangements to ensure fairness and objectivity. 

1) Tier One: Employment related medical assessment services (Core) ^*

d) Medical certificate validations

Please describe systems, processes and practices your business applies to providing this service. Describe any governance arrangements to ensure fairness and objectivity.

2) Tier Two: Other employment related medical services (Optional)

a) Please indicate any other capabilities/services nominated for prequalification under the Scheme:

Functional capacity assessment and advice services

Vaccinations

Drug and alcohol testing

Health and wellbeing programs

2) Tier 2: Other employment related medical services (Optional)

b) If applicable please outline your business’s experience and expertise for each nominated service. Describe any governance arrangements to ensure fairness and objectivity. Approved capabilities will be published on buy.nsw.

3) Quality assurance ^*

Please describe how your business ensures quality assurance/review processes across all services nominated for prequalification in your application. Include how your business will ensure there are no conflicts of interest and that privacy and confidentiality and professional and ethical conduct is maintained. Where applicable, please also outline any differentiation in the process between internal and sub-contracted resources.

4) Privacy & confidentiality ^*

Access to personal and sensitive information will be provided during the course of an engagement. Please describe and outline the systems and processes that will be in place to manage and ensure privacy and confidentiality of such information. Where applicable, please also outline any differentiation in the process between internal and sub-contracted resources

5) Record keeping ^*

Records relating to employee and agencies will be generated with each service engagement. Please describe systems and processes of your business in record keeping, retrieval and reporting, in both paper and electronic formats. Where applicable, please also outline any differentiation in the process between internal and sub-contracted resources.

6) Tier One : Applicant referee reports ^*

Applicants must provide at least three (3) referee reports in the specified template (Schedule 6 of the Scheme Conditions) for each ‘Tier’ of service nominated in the application. Referee reports must refer to completed engagements provided or completed in the last 18 months and within Australia.

Applicants should indicate the relevant 'Tier' they are applying for on the form before sending it onto their referees for completion. The applicant must then upload all completed referee reports in a single zip folder.

Referee reports will only be considered if they:

·relate to fee-for-service engagements;     

·have been completed in the specified template and signed by an authorised representative; and

·relate to services nominated by the applicant and are covered by this Scheme.

DFSI/PSC may contact the referee to verify or clarify aspects of a referee report as part of the prequalification process, and agencies may contact referees as part of their procurement process.

Please use the attached template to provide your three (3) Referee Reports relating to medical assessments. 

Referee report template

6) Tier Two : Applicant referee reports

If applicable, please use the attached template to provide your referee reports for Tier Two services in a single zip folder. Applicants must provide three (3) referee reports for each Tier Two service level. Example:  An applicant applying to prequalify for three (3) Tier Two Services will need to provide three (3) references for each service, totalling nine (9) references.

 

Referee report template

7) Financial solvency ^*

Please upload a recent letter/statement from an independent accountant stating the solvency of the Applicant. The letter/statement must have been prepared within the last twelve (12) months and explicitly state financial solvency of the Applicant. The letter/statement cannot be open to interpretation, so financial statements or annual reports are not acceptable.

8) Operational readiness and ongoing performance ^*

Will your business be operationally ready to provide Services when the Scheme commences and for the duration of the Scheme period?

 

Yes

No

9) Further information

If you answered ‘Yes’ to Question 8, please outline how your business will prepare for the start of the Scheme and ongoing performance, including planning, governance, risk management, resourcing, technology, marketing, legal and financial arrangements.

10) Facilities ^*

Please describe your business’s facilities for service provision under the Scheme. This may include location/s of facilities that comply with disability access and privacy requirements; technology and equipment. Where applicable, please  indicate any differentiation in facilities for sub-contracted service delivery.

a) Broad form of Public Liability Insurance ^*

Please attach a current copy of your business’s Broad Form Public Liability insurance. NOTE: The certificate of currency must indicate the period of coverage and a legal name which corresponds with the legal name in this application.

Use the calendar feature to set the expiry date of the certificate attached.

b) Professional Indemnity Insurance ^*

Please attach a current copy of your business’s Professional Indemnity insurance. NOTE:

1. The certificate of currency must indicate the period of coverage and a legal name which corresponds with the legal name in this application.
2. An Applicant, who instead of delivering the services itself, subcontracts their delivery should outline how they will ensure that subcontractors hold insurance that meets the requirement (See clause 5.1(b) in the Scheme Conditions).   
   

Use the calendar feature to set the expiry date of the certificate attached.

c) Workers Compensation Insurance ^*

Please attach a current copy of your business’s Workers Compensation insurance or exemption advice from the insurer. NOTE: The certificate of currency must indicate the period of coverage and an employer legal name which corresponds with the legal name in this application.

Use the calendar feature to set the expiry date of the certificate attached.

d) Indemnity ^*

Outline how your business will ensure that all Personnel (including sub-contractors), as defined in clause 1 of the Scheme Conditions), holds and maintains the necessary insurances for the duration of the Scheme.

1. Pending legal proceedings ^*

Are you or any of your company directors/ associates currently, or have been, over the last five (5) years, the subject of any or any legal proceedings?

Yes

No

2. Further information

If you answered ‘Yes’ in Question 1, please provide details.

3. Removal from any Government contracts or schemes ^*

Has the business been removed from any Government contract or scheme?

Yes

No

4. Further information

If you answered ‘Yes’ in Question 3, please provide details.

5. Insolvency, administrations or investigations ^*

Are you or any of your company directors/ associates currently, or have been, over the last five (5) years, the subject of insolvency, administration or investigation

Yes

No

6. Further information

If you answered ‘Yes’ in Question 5, please provide details.

7. Investigations by ICAC or any other public body ^*

Are you or any of your company directors/ associates currently, or have been, over the last five (5) years, the subject of investigation by the ICAC or any other public bodies?

Yes

No

8. Further information

If you answered ‘Yes’ in Question 7, please provide details.

9. Business ethics and code of practice for procurement ^*

Have you read and do you agree to comply with the Business Ethics (hyperlink to http://www.finance.nsw.gov.au/about-us/business-ethics) and Code of Practice for Procurement (hyperlink to https://buy.nsw.gov.au/policy-library/policies/procurement-policy-framework)? 

Yes

No

10. Work health and safety statutory obligations ^*

Do you comply with all Work health and safety obligations?

Yes

No

1. Fees ^*

Please use the attached fee schedule template for rates and fees that will apply for at least 12 months from the date of acceptance onto the Scheme.

Rate card template