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HomeMy WebLinkAboutA-06-274 DPH MIsc. Docs.pdf qW 4W CONTRACT STATUS FORM ti CO DATE: December 02, 2024 RECEIVED �� FR 856 DIVISION(S): Emergency Services DEC 1, 8 2024 (Lead Division listed first) DEPARTMENT OF PUBLIC HEALT CONTRACTS SECTION CONTRACTOR: Valley Children's Hospital SERVICES: EMT-P Clinical Training Experience CONTRACT TERM: 7/1/06 to 6/30/25 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-274 StateNendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2025 Extend contract through: , 20 With no changes in terms or conditions. With the following change(s): [B/Evergreen: Continue contract through: �,p , 20 zio Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Analyst: Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 ow ti CO CONTRACT STATUS FORM RECEIVED d g6 0 DATE: December 01, 2023 FxEs� FEB 21 20 DIVISION(S): Emergency Services (Lead Division listed first) DEP�pTOFuIHTNRA m CONTRACTOR: Valley Children's Hospital SERVICES: EMT-P Clinical Training Experience CONTRACT TERM: 7/1/06 to 6/30/24 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-274 StateNendor#: N/A Lead Dept: DPH Other Dept(s): Complete.the information below and return to DPH Contracts by:March 1, 2024 ❑ Extend contract through: , 20 With no changes in terms or conditions. ❑ With the following change(s): i V1Evergreen: Continue contract through: ��ip �` , 20 Z`� Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Analyst: Date: ZII yI l y Division Manager: Date: Submit to: DPH Contracts - Stop#147 - Brix Building, 6th Floor - Phone #: 600-7090 co CONTRACT STATUS FORM DATE: December 01, 2022 CE1VEpES'� RE DIVISION(S): Emergency Medical Services [gyp 2023 (Lead Division listed first) CONTRACTOR: Valley Children's Hospital pEppR v A�jsSE o �pN�RA SERVICES: EMT-P Clinical Training Experience CONTRACT TERM: 7/1/06 to 6/30/23 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2023 Extend contract through: , 20 With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: �P1 �''' , 20 -4 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: / ' Program Supervisor/Staff Analyst: y Date: 12r��Z Z Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 ftp CONTRACT STATUS FORM ��w coU�, fp O s56 O DATE: December 01, 2021 ARE`-�� DIVISION(S): Emergency Medical Services RECEIVED (Lead Division listed first) CONTRACTOR: Valley Children's Hospital DEC 0 ? Z02 DEPARTMENT OF PUBLIC HEALTH SERVICES: EMT-P Clinical Training Experience CONTRACTS SECTION CONTRACT TERM: 7/1/06 to 6/30/22 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2022 Extend contract through: 120 With no changes in terms or conditions. With the following change(s): ® Evergreen: Continue contract through: �30 , 20 2 ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. Program Supervisor/StaffA lyV:�i— Date: III 7/LI Division Manager: Date: I2/ 7 /L( Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 ti CO U� CONTRACT STATUS FORM DATE: December 01, 2020 �xESt' DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Valley Children's Hospital AN 14 2021 SERVICES: EMT-P Clinical Training Experience TNiENT OFPU6liCfo" DEPP CON1�CjS SECTION CONTRACT TERM: 7/1/06 to 6/30/21 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2021 Z"OE contract through: _, 20 With no changes in terms or conditions. With the following change(s): XEvergreen: Continue contract through: 4P �Q , 20 Z-2 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Anal Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 ti coU� OWNTRACT STATUS F02CM ti ' O� 56 O DATE: December 02, 2019 � laS� DIVISION(S): Emergency Medical Services r RECEIVED (Lead Division listed first) JUG CONTRACTOR: Valle Children's Hospital �3 2U20 Y P DEPARTMENT OF p CONTRACTS SE j_RTH SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/06 to 6/30/20 E Auto-renewal: through: (If not the marked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Evergreen Agreement-Please Review Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2020 ❑ Renew contract through: 120 With no changes in terms or conditions. ❑ With the following change(s): ❑ Evergreen: Continue contract through: 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff A lyst: Date: Division Manager: 4 Date: .3120 Zv Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 co CONTRACT STATUS FORM O� 56 O DATE: November 29, 2018 D FxES� RECEIVE DIVISION(S): Emergency Medical Services(Lead Division listed first) 0 6 2(ntV y 1s CONTRACTOR: Valley Children's Hospital DE�',AFi�n^ti`4JFS SECTION SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/06 to 6/30/2019 E Auto-renewal: O through: (if not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2019 ❑ Renew contract through: , 20 ❑ With no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: 20 ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff nal st: Date: Z �' �i �� 6 Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 ti COUP OYNTRACT STATUS FO VI �0 O 5 O DATE: December 01, 2017 RECEIVED DIVISION(S): Emergency Medical Services JAN 2 3 2018 (Lead Division listed first) CONTRACTOR: Valley Children's Hospital �EPACO11R11 RTMENT OF PUBLIC HEALTH T111111ON SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/06 to 6/30/2018 E Auto-renewal: © through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2018 Renew contract through: , 20 With no changes in terms or conditions. ❑ With the following change(s): zE Evergreen: Continue contract through: 20 ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Sta A t _ Date: 1 z Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 qW lawCO U� CONTRACT STATUS FORM ti � DATE: November 28, 2016 FizES� DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Children's Hospital Central California SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/16 to 6/30/17 E Auto-renewal: W through: ENTIRE TERM: 7/1/2006 to Evergreen (If not c at he endd above,contract teflVEDrminate ORGANIZATION #(s): 56201694 DEC 0 5 2016 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: DEPARTMENT OF PUBLIC CONTRACTS SECTI Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): "Complete the information below and return to DPH Contracts by:March 1, 2017 Renew contract through: bO , 20 With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/St Anal Date: Z \ sion Manager: Date: �/ Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 ti CO U� G"NTRACT STATUS FOWM O� g6 O DATE: November 20, 2015 RF C,EV E i, S5 DIVISION(S): Emergency Medical Services 17 2015 (Lead Division listed first) TMENT OF PUBLIC HEAD.' CONTRACTOR: Children's Hospital Central California' IS SECTION SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/15 to 6/30/16 E Auto-renewal: ❑ through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:March 1, 2016 2-11'enew contract through: jk/,-K4/1 7 —, 20—. ,,Oith no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Analys . Date: �,,(�*Vision Manager: Date: L241 J7_1 c5 Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 AV i ti COUP CONTRACT STATUS FORM $' fo DATE: December 01, 2014 Est DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Children's Hospital Central California SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/14 to 6/30/15 E Auto-renewal: through: (If not the marked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 RECEIVED CONTRACT AMOUNT: $0.00 JAN 14 2015 ADDITIONAL INFO: DEPARTMENT OF PUBLIC HEALTH Contract#: A-06-274 State/Vendor#: N/A CONTRACTS SECTION Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2015 ;9,Renew contract through: (0 �� , 20_ 131WI' ith no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Appr ved by: Program Supervisor/S An Date: 'b Division Manager: Date: I Z Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 co CONTRACT STATUS FORTH 17 DATE: December, 2013 �uES DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Children's Hospital Central California SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/13 to 6/30/14 E Auto-renewal: ❑ through: (if not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): /7 Complete the information below and return to DPH Contracts by: March4'Y`20 new contract through: JUN e- 30 , 20_6_27`' RECEIVED 2 r With no changes in terms or conditions. DEC 19 1013 DEPARTMENT OF PUBLIC HEALTH ❑ With the following change(s): CONTRACTS SECTION ❑ Evergreen: Continue contract through: 20 Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): 4p roved by: Q, rogram Supervisor/Sta Anal Date: Division Manager: P0,01i If D,�4� 4 0 5ate: 4 Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 ��w cove CMTRACT STATUS F017fd DATE: December 03, 2012 FRES DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Children's Hospital Central California SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/12 to 6/30/13 E Auto-renewal: ❑ through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2013 ❑ Renew contract through: ❑ With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: o , 20 l �` Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Superviso taff Analyst: — �� -.-�� Date: �L Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 co C(TNTRACT STATUS FOM s DATE: December e, 2011 DIVISION(S): Emergency Medical Services (Lead Division listed first) a-✓ li CONTRACTOR: Children's Hospital Central California e,e c;tz,L, SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/11 to 6/30/12 E Auto-renewal: E through. (if not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete-the information below and return to DPH Contracts by: March 1, 2012 Renew contract through: 120. 1-1 With no changes in terms or conditions. ❑ With the following change(s): _ Evergreen: Continue contract through: J -3 20 /3 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. Program Superviso Staff Analji Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 445-7090 low CONTRACT STATUS FORM DATE: December 01, 2010 DIVISION(S): Emergency Medical Services (Lead Division listed first) CONTRACTOR: Children's Hospital Central California SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/10 to 6/30/11 E Auto-renewal: ❑ through: (If not checkmarked above,contract wilt terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Comp'pte the information below and return to DPH Contracts by: March 1, 201 Renew contract through: , 20 With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: (o , 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervis /Staff Analyst: Date: 14 �/ a Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 445-7090 Y w w COUP r CONTRACT STATUS FOKM o �W1 56 0; DATE: November 24, 2009 DIVISION(S): Emergency Medical Services RECEIVED (Lead Division listed first) CONTRACTOR: Children's Hospital Central California JAN 2 6 2U 10 DEPARTMENT OF PUB'_iC HEALTH SERVICES: EMT-P Clinical Training Experience CONTRACTS SECTION CURRENT PERIOD: 7/1/09 to 6/30/10 E Auto-renewal: through: (If not chec marked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2010 �enew contract through: 49 /,::'> , 20 . With no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: q� Program Supervisor/Staff naly t: Date: Division Manager: Date: 7 C67 Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090 COUP Contract RenewalJTerminatiori Form O 856 O DATE: December 01, 2008 FrzES� DIVISION(S): Emergency Medical Services RECEIVED (Lead Division listed first) JAN 0 6 2009 CONTRACTOR: Children's Hospital Central California DEPARTMENT OF PUBLIC HEALTH CONTRACTS SECTION SERVICES: EMT-P Clinical Training Experience CURRENT PERIOD: 7/1/08 to 6/30/09 E Auto-renewal: ❑ through: (If not checkmarked above,contract will terminate ENTIRE TERM: 7/1/2006 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract #: A-06-274 State/Vendor#: N/A Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by: March 1, 2009 enew contract through: , 20IFZ , With no changes in terms or conditions. ""E ❑ With the following change(s): Evergreen: Continue contract through: 20 Cancel contract effective: , 20 1-1 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Ana t: kAD, Date: Division Manager: Date: \�� Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090 _ _ co Contract Renewal/Termination Form O 856 O DATE: November 21, 2007 FRESH TO: Emergency Medical Services RECEIVED CONTRACTOR: Children's Hospital Central California BAN 2 2066 SERVICES: EMT-P Clinical Training Experience DEPARTMENT RACTSSECTO�YhcALTH ON CURRENT TERM: 7/1/07 to 6/30/08 E Auto-renewal: ❑ Through: FULL TERM: 7/1/2006 to Evergreen ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 LEAD DEPT: DCH State/Vendor#: N/A ADDITIONAL INFO: Contract #: A-06-274 Please complete and return this form to DCH Contracts by: March 1, 2008 Renew contract through: , 20 With no changes in terms or conditions. Amend with the following change(s): Evergreen: Continue contract through: JoNe 3� , 20 f ❑ Cancel contract effective: , 20 1-1 Additional Information: Submitted by: Print Name: 2??! "P L Title: brd/ ARI Signature: Date: 67 Phone #: Approved by: Division Manager Initial: Staff Analyst Initial: Department Head: Date: i� 1 Submit to: DCH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 445-7090 F� CO rC Contract Renewal Termination Form 0 O 856 O DATE: December 01, 2006 TO: Emergency Medical Services RECEIVED CONTRACTOR: Children's Hospital Central California APR 05 4W DEPARTMENT OF CUMMUNITY HEALTH SERVICES: EMT-P Clinical Training Experience CONTRACTS SECTION CURRENT TERM: 7/1/06 to 6/30/07 E Auto-renewal: Through: FULL TERM: 7/1/2006 to ORGANIZATION #(s): 56201694 CONTRACT AMOUNT: $0.00 LEAD DEPT: DCH State/Vendor#: N/A ADDITIONAL INFO: Contract#: A-06-274 Please complete and return this form to DCH Contracts by: March 1, 2007 Renew contract through: 6 3oAq , 20 XrWith no changes in terms or conditions. With the following changes: ❑ Cancel contract effective: , 20 ❑ Additional Information: Approved by: Print Name: �'� �� w Division Manager Initial: Signature: Staff Analyst Initial: P Title: Date: 1 Z1z oG Phone #: Department Hea : Date: DCH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 445-7090 co Contract Renewal/Termination Form RECE1"VCD o� gs6 0 DATE: November FRESH TO: Emergency Medical Services C-71,�RTi GIITOFCUVA!�)ITY; _,Al T-I CONTRACTOR: Children's Hospital Central California SERVICES: EMT-P Clinical Training Experience Services TERM: 7/1/05 to 6/30/06 Auto-renew?: Through: ORGANIZATION #: 56201695 CONTRACT AMOUNT: $0.00 LEAD DEPT: DCH State/Vendor#: N/A ADDITIONAL INFO: Contract # A-04-184 Please complete and return this form to DCH Contracts by: March 1, 2006 Renew contract through: % )(U&)`e �C , 20 With no changes in terms or conditions. With the following changes: Oyf-Ai LVe m ipp Cancel contract effective: , 20 Additional Information: Approved by: Print Name: 1 ( �� Division Manager Initial 4& Signature: M.A 1 Staff Analyst Initial. Title: �i 1� d �— Date: 1zhA 46----phone #: q��-5307 Department Hea c Date: e DCH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 445-7090