WorkSafeBC Part II

RFP #048-2024 Form of Proposal

PART II - FORM OF PROPOSAL

Through submission of this Proposal, I/we agree to all of the terms and conditions of this
RFP. No person, firm or corporation other than the undersigned has any interest in this
Proposal.

Respondents must complete and submit all of the Form of Proposal and supply all of the
information requested by the following Appendices:

APPENDIX DESCRIPTION

Appendix A Business Information and Requirements

Appendix B Facility and Personnel Requirements

Appendix C Privacy Protection Requirements

Proposals that do not include the information requested in the Appendices, or do not have
sufficient information to be readily understood and evaluated may be rejected without
further notice.

Note: Information provided must be responsive to the question. Please review all
questions carefully.

Certification and Authority

I wish to present this Proposal as a qualified provider of the Services and certify that the
information contained in this Proposal is accurate and true to the best of my knowledge and
I am duly authorized to sign the Proposal on behalf of the Respondent with the intent to
bind the Respondent to the RFP and the statements and representations in the Proposal.

Respondent Name:

Authorized Signature: Date:

Print Name: Title:

Note: This Form of Proposal should be executed by a director, officer or principal that is
duly authorized to execute contracts on behalf of the Respondent. Form of Proposals that do
not contain an authorized signature may be rejected.
WorkSafeBC Appendix A
RFP #048-2024 Form of Proposal - Business Information and Requirements

APPENDIX A - BUSINESS INFORMATION AND REQUIREMENTS

1.0 BUSINESS INFORMATION:

Respondent legal name:

If you carry on business under a name other than your legal name, please provide it:

If the Respondent is not an individual, please provide a contact name and title:

Name: _______________________ Title:_________________________

If not an individual, please provide the name and title of the representative(s) authorized to
execute contracts on behalf of the business:

Name: _______________________ Title:_________________________

Please submit the following documents as applicable, if not an individual:

 If your business is an incorporated company, a current copy of the BC Registry
Services search showing the corporate and, if applicable, dba registration.
 If your business is incorporated in a jurisdiction other than BC, a current copy of
the corporate search from the applicable jurisdiction and/or a current copy of the BC
Corporate Registry search (if extra-provincially registered).
 If your business is a registered partnership or sole proprietorship in BC, a
current copy of the BC Registry Services search showing the partnership registration
or business name registration, as applicable.
2.0 BUSINESS ADDRESS:

Street:

City: Province: Country: Postal Code:

Telephone: ( ) Cell Phone: ( )

Fax: ( ) Email:

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WorkSafeBC Appendix A
RFP #048-2024 Form of Proposal - Business Information and Requirements

3.0 MANDATORY BUSINESS REQUIREMENTS

3.1 WorkSafeBC Coverage: Under the Act, if you are an Yes No N/A
employer you are required to be registered with WorkSafeBC
Assessment Reg.
and in good standing. If an employer, are you registered? If
so, please provide your assessment registration (account) #______________
number.
Yes No
If you are a sole proprietor (with or without employees) who
Not Eligible
will perform services personally, you are required to have
personal optional protection coverage for yourself, if eligible.
Do you have personal optional protection?
Yes No
If no, confirm that you would obtain personal optional
protection coverage for yourself, if eligible, if awarded a
Contract.
3.2 Comprehensive General Liability Insurance: Confirm CGL Yes No
insurance in the minimum amount of $5 million dollars per
occurrence that complies with the requirements set out in the
Contract is or will be in place upon contract award.
3.3 Professional Liability Insurance: Confirm professional Yes No
liability insurance in the minimum amount of $1 million dollars
that shall cover all personnel delivering Services and that
complies with the requirements set out in the Contract is or will
be in place upon contract award.
3.4 Criminal Record Review Act (CRRA): Confirm ability to Yes No
ensure all employees and subcontractors who may have access
to vulnerable adults or children within the meaning of the CRRA
undergo and receive clear criminal record checks in accordance
with the requirements of the Contract.]
3.5 Terms and Conditions: If awarded a contract, do you agree to Yes No
execute a Contract containing the terms and conditions set out
in Part III?
4.0 INFORMATION FOR EVALUATED REQUIREMENTS

4.1 Quality Assurance:

a) Description of Consent: Describe the process that you Confirm you have
follow for obtaining and documenting consent in your attached this
medical practice. Please ensure that this response is information to your
prepared a Physician being proposed and is not altered in Proposal.
any manner. Please also provide an excerpt from a report
where the physician documents consent.
Yes No
b) Safety Processes: Outline the standard safety processes
that are followed with clients attending your Facility.
c) Assessment: List examples/reasons of when it is
appropriate to discontinue testing and/or assessment of
an Injured Worker. Note: the response should be a
maximum of a ¼ page.
d) For EACH of the following scenarios, provide an example
of an action plan that would be utilized by your Facility:

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WorkSafeBC Appendix A
RFP #048-2024 Form of Proposal - Business Information and Requirements

d.1 General complaint resolution (Injured Worker

complaint or referral source complaint);
d.2 Ongoing referral to admission timelines exceeding
contractual requirements.
d.3 Consistently service your contracted Location Code
WITHOUT requesting a change to service location or
delayed access to appointment dates
(staff/resources).
e) Provide a description of the Respondent’s internal control
process that responds to the questions below. The
Respondent’s internal control process must be designed to
measure and ensure that the quality of service delivered
meets or exceeds WorkSafeBC’s requirements as outlined
in this RFP and the Contract.

List what aspects of your Service(s) are measured to

determine if the Services are being successfully delivered.

5.0 ADDITIONAL INFORMATION

5.1 Conflict of Interest: The provision of Services must not No Conflict

represent a conflict of interest.
Yes, there is a
a) Are there any potential areas of conflict of interest that may potential conflict of
exist with the provision of these Services to WorkSafeBC? interest.
Without limiting the foregoing, please disclose if the
Respondent or any of the Respondent’s Personnel who will
deliver Services under the Contract are a current or If Yes, confirm you
previous employee of WorkSafeBC. have attached this
information to your
b) If there is a potential conflict, provide a description as an Proposal.
attachment to your Proposal. Yes No
For additional information refer to the Code of Business Ethics
and Behaviour at:
https://www.worksafebc.com/en/about-us/bid-opportunities/po
licies-guidelines

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WorkSafeBC Appendix B
RFP #048-2024 Facility and Personnel Requirements

APPENDIX B – FACILITY AND PERSONNEL REQUIREMENTS

YOU MUST COMPLETE ONE APPENDIX B FOR EACH PROPOSED FACILITY

1.0 NAME AND CONTACT INFORMATION FOR THE PROPOSED FACILITY:

Facility Name:

Street Address:

City: Province: Postal Code:

Telephone: ( ) Fax: ( )

Email: Payee#:

Identify a designated key contact person who is responsible for the day-to-day delivery of
Services for this Facility (e.g. Clinic manager):

Contact Name: Title:

Contact Telephone (direct): Contact Email:

2.0 BUSINESS:

2.1 Proposed Service Location: Provide the Service Location of the proposed Facility, which
must be fully operational as of the effective date of a Contract awarded under this RFP.
 VANCOUVER/RICHMOND  BURNABY/NEW WESTMINSTER/COQUITLAM
 SURREY/LANGLEY/ABBOTSFORD  NANAIMO/CENTRAL VANCOUVER ISLAND
 VICTORIA/SOUTH VANCOUVER ISLAND  PRINCE GEORGE
 KELOWNA/OKANAGAN  OTHER _____________

Note: Locations outside of the municipal boundaries may be considered – please indicate in
“Other” category above which municipalities or areas the proposed Facility can provide
Services.

3.0 MANDATORY FACILITY REQUIREMENTS

3.1 Confirm the proposed Facility will have all mandatory assessment Yes No
equipment listed under sections 2 to 4 of Schedule C of the Contract,
which is attached in Part III – Form of Contract of this RFP (without
exception).

3.2 Confirm the proposed Facility will have back-up equipment as described Yes No
under section 5 of Schedule C of the Contract, which is attached as Part
III – Form of Contract of this RFP.

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WorkSafeBC Appendix B
RFP #048-2024 Facility and Personnel Requirements

Note: The mandatory equipment identified under 3.1 above cannot be

considered as back-up equipment if awarded a Contract under this RFP.
3.3 Confirm that the proposed Facility is accessible to Injured Workers and Yes No
meets all occupational health and safety requirements under the Act
and the Occupational Health and Safety Regulation.

3.4 Confirm the proposed Facility has an appropriate and private Yes No
assessment and interview space for conducting the Services.

4.0 MANDATORY PERSONNEL RESOURCES

4.1 Confirm that each Physician proposed under section 5.2:

a) is a member in good standing with the College of Physicians Yes No
and Surgeons of British Columbia;
b) possesses a minimum of two years’ experience as a Physician; Yes No
and
c) has a minimum of one year of clinical experience in at least
one of the following:
i. Physiatry; Yes No
ii. Emergency medicine; Yes No
iii. Occupational medicine; Yes No
iv. Sports medicine; Yes No
v. Orthopedic surgery; or Yes No
vi. Formal training in biomechanics and human Yes No
performance.
5.0 INFORMATION FOR EVALUATED REQUIREMENTS

5.1 Facility Location: Confirm you have

a) Please list the ways in which the proposed facility is accessible for attached this
clients with varying disabilities? Please ensure that the provided information to
answer is a maximum of a half page. your Proposal.
b) Describe the operating hours of the proposed Facility;
Yes No
c) State the distance traveling by road (to the nearest kilometer)
between the Facility and the closest domestic airport;
d) Describe customer parking at the proposed Facility (provide
specifics regarding number of spaces available, how many spaces
are designated to your clinic, whether parking is free or pay
parking, and whether any spaces are wheelchair accessible).
5.2 Personnel Resources: Complete this section using the information Confirm you have
and qualifications of two Physicians proposed to deliver the Services attached this
at the Facility. information to
your Proposal.
RESPONDENT MUST COMPLETE AND SUBMIT SECTION 5.2 FOR TWO
PROPOSED PHYSICIAN. NOTE: WORKSAFEBC WILL BE EVALUATING Yes No
INDIVIDUALLY ALL RESPONSES TO THIS SECTION. WE WILL
TABULATE EACH SCORE AND GET THE AVERAGE SCORE TO
DETERMINE THE FINAL SCORE FOR THIS SECTION.
5.2.1 Name of Proposed Physician: _______________________

5.2.2 Indicate the number of years that the proposed physician has
worked in some capacity with a Canadian workers
compensation system.

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WorkSafeBC Appendix B
RFP #048-2024 Facility and Personnel Requirements

5.2.3 Provide the approximate number of independent medical

evaluations for disability and/or impairment rating
assessments (i.e., not assessments completed as a part of a
treatment plan) with a working aged population the Proposed
Physician has completed since January 1, 2019.
5.2.4 Describe an actual scenario that the proposed primary
physician has experienced with assessing a client with
behavioral management issues, preferably one who is
attached to a compensation system, and the steps they took
in order to complete the assessment. Please ensure that this
response is prepared by a Physician being proposed and is not
altered in any manner.
5.2.5 Provide a detailed description of the relevant accredited
professional development education (e.g., conferences and
courses) within the last seven (7) years including:
 Dates and Years applicable;
 Description of education and training;
Please be specific. General remarks (e.g., attended every
year between 20xx and 20xx will not obtain any marks).
5.2.6 List any formal training (e.g., musculoskeletal
injury/condition, spinal cord injury or neurological condition or
concussion etc.), as well as any associated certifications,
directly relevant to disability assessments that the proposed
physician possesses (last 5 years).
5.3 Sample Reports: Provide two sample reports of actual independent Confirm you have
disability assessments or two independent medical assessment attached this
reports that have been completed with a real client by one of your information to
proposed physicians. If both reports are available, the disability your Proposal.
assessment for the purposes of impairment rating is preferred.
Yes No
Please ensure the assessments and reports were for clients with (1)
primarily a musculoskeletal injury/condition and (2) spinal cord injury
or neurological condition or concussion. The reports should include all
raw data and measurements. Ensure that all information that
could be used to identify the clients are removed or blacked
out on the reports. Sample reports must be recent, completed
within the past 12 months.

5.4 Value Added Services: Describe the Facility’s ability to offer Confirm you have
additional value, i.e., a service or amenity at the specific Facility that attached this
would enhance the Injured Worker’s experience at your clinic. information to
your Proposal.
Yes No
6.0 ADDITIONAL INFORMATION

6.1 Training/Mentorship: Confirm if either of the two proposed Physician Yes No

are able to provide mentorship to any Physicians without experience
with providing the Services who will be providing the Services in
accordance with the requirements set out in the Contract.
Name of Physician: ________________

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WorkSafeBC Appendix B
RFP #048-2024 Facility and Personnel Requirements

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WorkSafeBC Appendix C
RFP #048-2024 Privacy Protection Requirements

APPENDIX C – PRIVACY PROTECTION REQUIREMENTS

1) In these Privacy Protection Requirements:

(a) “FIPPA” means the British Columbia Freedom of Information and Protection of
Privacy Act.
(b) “personal information” means information about an identifiable individual,
including metadata, but excluding business contact information. See Schedule
A for examples of personal information. Please note: FIPPA uses the term
“personal information” instead of “personal data”.
2) Service Provider Status under FIPPA: FIPPA deems all service providers to a public
body to be employees of the public body for the purpose of FIPPA, to the extent that
the service provider collects, accesses, uses, discloses, or stores personal information
as defined in FIPPA. This applies regardless of any of privacy law or legislation that
may be applicable to the service provider.
3) Requirement: Respondents, as service providers, must be able to comply with the
requirements of FIPPA, including any requirements of a privacy impact assessment
conducted under section 69(5.3) of FIPPA, with respect to protection of personal
information and data security to provide services to WorkSafeBC. Those requirements,
as WorkSafeBC determines are applicable in the circumstances, are mandatory and
non-negotiable contract terms.
4) Privacy Protection Schedule: The Privacy Protection Schedule attached as Schedule D
to the Contract sets out the nature of the provisions that are the minimum required.
5) Information: The Respondent must provide information regarding its own privacy
practices and the privacy practices of the email, data storage, cloud-based platform
and cloud-based software service provider(s) that it uses to provide services. The
Respondent may need to confirm information with its service providers, either by
reviewing its terms of service or by speaking to the service provider, to complete the
Privacy Protection Requirements. Respondents must be comprehensive in responding.
6) Security Risk Assessment: An additional security risk assessment may be required
based on the responses to the Privacy Protection Requirements or any other security
requirements. Based on the responses in the security risk assessment and any follow
up questions, WorkSafeBC will assess whether, in its sole discretion, the Respondent’s
overall security controls meet WorkSafeBC security standards, including those
standards necessary to protect personal information as required under FIPPA.
7) Acknowledgement: Respondent acknowledges that entry into a contract with
WorkSafeBC is dependent on the Respondent being able to meet the FIPPA
requirements determined by WorkSafeBC. If the Respondent is unable to meet the
requirements or will not enter into a contract with the terms WorkSafeBC determines in
its sole discretion as being required, then no contract will be awarded to the
Respondent.

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WorkSafeBC Appendix C
RFP #048-2024 Privacy Protection Requirements

The following are the minimum mandatory requirements for FIPPA

compliance. Please respond to the following questions and submit the
requested documents:

Privacy Policy
Please indicate whether your privacy policy includes the following provisions:

Yes No
1) All personally identifiable information is included in the definition of
personal information or personal data. See Schedule A for personally
identifiable information examples.

2) Prohibits collection, access, use, and disclosure of personal information

except for the purpose of delivery of services and only by and to those Yes No
persons necessary to deliver the services.

3) Includes administrative, technical and physical controls to protect personal

information/personal data from unauthorized collection, access, use, Yes No
disclosure, destruction and disposition.

4) Requires encryption of personal information in transit and at rest using

industry accepted standards, strong encryption techniques, and current Yes No
security protocols.

5) Requires secure destruction of any personal information/personal data or

includes an option for the return of all personal information at Yes No
WorkSafeBC’s request.

6) Requires all personally identifiable information to be removed or destroyed

from metadata generated by an electronic system that describes an
individual’s interaction with the system or prohibits any subsequent use and Yes No
disclosure of the metadata in individually identifiable form, including but not
limited to sharing the metadata with third parties.

7) Includes provisions for prompt notification to WorkSafeBC in the case of a

Yes No
security breach.

If you cannot meet the applicable requirements, you will not be

awarded a contract.

Aggregated and De-identified Personal Information

Confirm you will not sell or disclose to third parties, and agreements with
storage, platform and software service providers prohibit or will be amended
to prohibit sale or disclosure to third parties of, personal information related
Yes No
the Services provided to WorkSafeBC, including in aggregated and de-
identified form, unless such disclosure is expressly agreed by WorkSafeBC.
If you cannot meet this requirement, you will not be awarded a
contract.

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WorkSafeBC Appendix C
RFP #048-2024 Privacy Protection Requirements

Storage
If personal information is being stored as part of the Services or as a result of
email usage, please check the jurisdiction(s) where it is stored and indicate if it
is for email, Services or both. Storage for Services includes any back-up or
disaster recovery.
NOTE: No other jurisdictions will be accepted for data storage. DO NOT
RESPOND TO THIS RFP IF DATA STORAGE OR ACCESS IS IN A
JURISDICTION NOT LISTED BELOW.
Canada
Email Services Both

Access
If personal information is being accessed as part of the Services or as a result
of email usage, please tick the jurisdiction(s) from where it is accessed. Access
includes access to emails that include personal information as well as access to
any system or application containing personal information by the Respondent
or any software providers or platform providers, including for support and
maintenance purposes.
NOTE: No other jurisdictions will be accepted for data access. DO NOT
RESPOND TO THIS RFP IF DATA ACCESS IS IN A JURISDICTION NOT
LISTED BELOW.
Canada

Describe the following with respect to those who have access to the personal
Confirm you
information:
have
a) the purpose for the access attached this
b) how access to personal information is granted or restricted, including information
when personnel depart or change roles. to your
c) whether there is access by software providers or platform providers and Proposal.
the purpose of that access. Yes No

Please provide a copy of any software provider’s or platform provider’s privacy Confirm you
policy where the software provider or platform provider has access to personal have
information. attached this
information
to your
Proposal.
Yes No

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WorkSafeBC Schedule A
RFP #048-2024

SCHEDULE A

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WorkSafeBC Part III
RFP #048-2024 Form of Contract

PART III - FORM OF CONTRACT

The Part III Form of Contract Services Agreement is attached as a separate PDF document
on BC Bid.

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