APPENDIX I: TEMPLATE FOR APPLICANTS

Pharmacy-Based HIV Testing in Priority Areas in the City of Philadelphia

This template covers items 2. Introduction/Executive Summary through 8. Proposed

Subcontractors only. Download the WORD version of this appendix from eContract
Philly and use it to complete this template using the instructions below. A completed
version of this document is a required submission.

When preparing your narrative, list all 18 numbered sections as they appear in Section III:
Proposed Format, Content, and Submission Requirements; Selection Process, beginning with 1.
Table of Contents.
 For 2. Introduction/Executive Summary through 8. Proposed Subcontractors, insert “See
Appendix H.”
 For 9. Requested Exceptions to Contract Terms through 18. Statement of Anticipated Job
Creation (optional) provide your written answers in the usual way.
2. Introduction/Executive Summary

NOTE: To be eligible for consideration, all proposed locations must have a street address in
a Priority ZIP Code or an Adjacent ZIP Code within the City of Philadelphia. See Section C:
Project Background of this RFP for a complete listing of eligible ZIP Codes.

Using 3,000 characters or less (approximately 500 words) provide an overview of the
pharmacy-based HIV testing services being proposed.
Begin by indicating the specific locations and ZIP Code(s) of the proposed HIV testing
setting(s).
Include a brief explanation of how you would implement HIV testing in the specific pharmacy
setting(s) proposed.
     

Appendix I: Template for Applicants for Pharmacy-Based HIV Testing in Philadelphia 2022 1
3. Applicant Profile
In the spaces provided, complete each item below to describe the Applicant itself.

Organization name      

Business address      
Telephone number      
Website address      
Federal employer identification number      
Primary contact name and title      
Business address      
Telephone number      
Email address      
For Profit Not for Profit
Organization type
Other Indicate type here:      
Registered to do business in Philadelphia Yes No
Registered to do business in Yes No
Pennsylvania
County of business formation      
State of business formation      
Number of years in business      
Primary mission of business      
Significant business experience      
Registered as a minority-owned business Yes No
Registered as a woman-owned business Yes No
Registered as a disabled-owned business Yes No
Registered as a disadvantaged business Yes No
If Yes, name of certifying agency      
ZIP Code(s) location(s) of proposed HIV      
testing
Street Address of locations(s) of      
proposed testing

Appendix I: Template for Applicants for Pharmacy-Based HIV Testing in Philadelphia 2022 2
4. Project Understanding
In the spaces provided, check YES or NO for questions A through D below and provide a
written answer to the question that follows.
By submitting this application, the Applicant understands and agrees to provide the services
and tangible work products necessary to achieve the objectives of the project that is the subject
of this RFP, which at a minimum, includes the following required activities:
(a) Complete CDC’s HIV Testing in Retail Pharmacies Training (6 hours in 2 components)
(b) Complete the Department’s HIV Testing and Linkage to Care Core and Tester Track Training
Curriculum (Total of 16 hours – 9.5 hours for Core Training and 6.5 hours for Tester Track
Training)
(c) Conduct HIV testing in the PDPH-approved priority ZIP Code area(s).
(d) Provide client education on U=U, condom use, PrEP, nPEP, and the PDPH AACO home
testing program.
(e) For persons testing HIV-positive, expedited linkage to HIV care, defined as a medical visit (or
telemedicine visit) within 96 hours of HIV diagnosis to assure immediate ART initiation.
(f) Distribute condoms and participate in PDPH’s home testing program.
(g) Participate in additional required PDPH-led training, learning collaboratives, health equity
efforts, and citywide EHE activities.
A. Does Applicant agree to the above? Yes No
By submitting this application, the Applicant understands and agrees to report and leverage
available program income to provide services, and services are to be billed to this RFP as payor
of last resort.
B. Does Applicant agree to the above? Yes No
By submitting this application, the Applicant understands and agrees to participate in the
public-facing EHE Dashboard.
C. Does Applicant agree to the above? Yes No
By submitting this application, the Applicant understands and agrees to prevent duplication of
effort of current or future directly funded HIV prevention resources, including awards from
CDC, HRSA, or any other funder of HIV services by (1) coordinating service delivery provided by
the Applicant and funded by the Department and external sources; (2) leveraging existing
Department resources, where possible; (3) providing to the Department on request the
Applicant’s performance and outcome data for HIV services regardless of funding source; and
(4) collaborating with the Department on request to revise the scopes of work and budgets for
HIV service awards from the Department where appropriate.
D. Does Applicant agree to the above? Yes No
E. Business Experience
In the space provided below, describe using 1,500 characters or less (approximately 250
words) how the Applicant’s business experience will benefit the project.
     

Appendix I: Template for Applicants for Pharmacy-Based HIV Testing in Philadelphia 2022 3
5. Proposed Scope of Work
For questions A through D, provide a brief response in the spaces provided using 3,000
characters or less (approximately 500 words). For question E, see the instructions below.
A. What do you propose to do to reduce barriers to HIV testing in your proposed pharmacy
setting(s)? Barriers can be at the individual, provider, community, or structural levels.
     

B. How will your proposed setting(s) promote HIV testing to existing customers and the
neighboring community to help customers know their HIV status?
     

C. Describe the extent to which the pharmacy setting(s) you propose currently meet(s) each
of the eight recommendations for establishing an ideal HIV testing environment? See
CDC’s guidance Implementing HIV Testing in Nonclinical Settings: A Guide for HIV Testing
Providers (pages 15-16)
     

D. For any of the above recommendations not currently met in your proposed settings(s),
describe what you plan to do to fully meet the recommendation, including timelines.
     

E. Describe how you will assure the confidentiality and privacy of your HIV testing
customers, including a detailed description of the physical space in which the test will be
conducted and how HIV testing results will be stored and secured.
     

Appendix I: Template for Applicants for Pharmacy-Based HIV Testing in Philadelphia 2022 4
Project Timetable: Indicate responsible parties and proposed completion dates for each of the
required tangible work products.
Proposed
1
Schedule of Required Tangible Work Products By When Responsible Parties Completion
Date
Pre-Implementation Phase
Within 45
Completion of Department-approved Pre- days of
           
Implementation Work Plan notice of
award
Completion of prerequisite training by all
           
relevant personnel
Approval by the Department of the proposed
           
HIV test setting
Documentation in the form of Memoranda of
Understanding (MOU) of external referral
sources to partner providers for immediate HIV
care and treatment for persons testing HIV Within 120            
positive and PrEP and nPEP services for persons days of
testing HIV-negative for whom PrEP or nPEP is receipt of
indicated Notice of
Laboratory services contract, if applicable Award            
Establishment of methods to collect and store
required data for program and surveillance            
reporting
Establishment of procedure to acquire no-cost
           
HIV test kits and controls from the Department
Completion of Implementation Work Plan            
Implementation Phase
Provide HIV testing in accordance with
           
Department-approved Work Plan
Submit progress and data reporting to the
No later than            
Department by the required deadlines
121 days
Submit invoices to the Department by the 10 th
after receipt
day of the following month for reimbursement            
of Notice of
of services provided
Award
Documentation of staff participation in ongoing
training and technical assistance and            
Department-led health equity and EHE activities.

1
The number of days begins on the first day of the project year contained in the notice of award.

Appendix I: Template for Applicants for Pharmacy-Based HIV Testing in Philadelphia 2022 5
Cost Proposal: In the space below, enter the total dollar amount requested and complete the
budget forms below.
Total amount of funding requested: $      
Cost Proposal

Pre-Implementation Phase January 1, 2023-March 31, 2023

For all proposed personnel necessary for this phase, provide firm estimates of the number of hours and costs
required to complete required training and other pre-implementation activities. List personnel by role,
beginning with the required Medical Director. Other eligible roles are pharmacist, pharmacy technician, data
specialist, and project administrator. For more information on roles, see Appendix H.
Hourly # of Proposed
Name & Title Role Total Cost
Rate Hours
      Medical Director                  
                             
                             
                             
                             
                             
                             
                             

Implementation Phase
For all proposed personnel necessary for this phase, provide firm estimates of the number of hours and costs to
provide 150 HIV tests over a 12-month period beginning April 1, 2023. List personnel by role, beginning with the
required Medical Director. Other eligible roles are pharmacist, pharmacy technician, data specialist, and project
administrator. For more information on roles, see Appendix H.
Hourly # of Proposed
Name & Title Role Total Cost
Rate Hours
      Medical Director                  
                             
                             
                             
                             
                             
                             
                             
6. Statement of Qualifications; Relevant Experience

Appendix I: Template for Applicants for Pharmacy-Based HIV Testing in Philadelphia 2022 6
In the spaces provided below, provide brief responses to questions A and B below using up to
1,500 characters (approximately 250 words), and indicate Yes/No for item C.

A. Describe in brief of your pharmacy’s qualifications to provide HIV testing in one or more
of the RFP’s priority ZIP Codes.
     
B. Describe your pharmacy’s capability to perform at least 150 HIV tests in 2023.
     
C. The Applicant confirms it meets the minimum qualifications for Applicant performance as
stated in this RFP.
Does Applicant confirm the above? Yes No

7. References
Provide at least three references, preferably for projects that are similar in type, scope, size,
and/or value to the work sought by this RFP. Letters of support are not required.
Reference Organization and Telephone and
Name and Title Street Address Email Address
                 
                 
                 

8. Proposed Subcontractors
For each proposed subcontractor, provide the name and address of the subcontractor, a
description of the work the Applicant proposes the subcontractor will provide, and whether
the subcontractor can assist with fulfilling goals for inclusion of minority, woman, or
disabled-owned businesses or disadvantaged businesses as stated in Appendix B. Note:
Applicants must also complete the OEO Solicitation and Commitment Form.
Subcontractor Description of Proposed Can Assist with
Name and Address Subcontractor Work OEO Goals?
            Yes No
            Yes No
            Yes No

Appendix I: Template for Applicants for Pharmacy-Based HIV Testing in Philadelphia 2022 7