Temporary Help Services Request for Services/Statement of Work
LTCH Sample Template
A.1 RFS Timetable
RFS/SOW #
for LTCH tracking purposes only
Submission Date
mmm-dd-yyyy
Vendor Response Date
mmm-dd-yyyy
B.1 Client Contact Information
Submit all documents in Word format by email to:
Requestor's Name
Phone Number eMail
LTCH Name
Client Address
alt-enter creates a new line
B.2 Invitation
Each Vendor who responds to an RFS valued at $25,000 or more may request a debriefing within 60 days of their
unsuccessful vendor notification. Vendors who provide “no bid” responses are not entitled to a debriefing.
B.3 Role Reporting
The role reports to this position, which is responsible for approving time sheets for the selected candidate. Name
Name
Phone Number eMail
LTCH Name
Client Address
alt-enter creates a new line
Service Location
Name
Phone Number eMail
LTCH Name
Client Address
alt-enter creates a new line
Contact Name
Contact Phone Number eMail
Region
choose from list
This Request for Services (“RFS”) is issued by the Long Term Care Home (Home) under the Separate Agreement per the Vendor of Record
Arrangement for Agreement # Tender 6484 and is an invitation to selected vendors (“Vendors”) to potentially provide Temporary Help
Services. Vendors are requested to make submissions for the specifics described throughout the document, respond where indicated, and
submit responses by email as indicated in section B.1.
enter "same as above" if information is the same
The Home expressly disclaims any intention to enter into a formal competitive process and expressly disclaims any obligation to any vendor or
the creation of a legal relationship prior to the execution of the Statement of Work (section D below).
This RFS and any vendor submissions do not constitute a commitment by the Home to procure the goods or services described herein or the
commitment of any vendor to supply the goods or services described herein. The Home shall not be liable for any expenses incurred, including
the expenses association with the cost of preparing responses to this RFS by any vendor.
enter "same as above" if information is the same
enter "same as above" if information is the same
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B.4 Background
B.5 Deliverable Requirements
B.5.1 Additional Requirements
Security Clearance
Y-Yes, N-No
French Language Certification
Y-Yes, N-No
B.5.2 Length of Assignment
Start Date
mmm-dd-yyyy
End Date
mmm-dd-yyyy
Number of Resources required
enter a number
B.5.3 Job Description
Please attach a copy of the job description for the position to be filled
Job Classification
Job Title
C. Vendor Response
Vendor Hourly Rate to be paid to the Temporary Help resource
Vendor please submit Candidate resume with response
C.3 RFS Submission Vendor Approval
choose vendor name
Bilingual premium (if required)
Recommended Hourly Rate to be paid to
the Temporary Help resource
Bill Rate
$ -
equals (Vendor Hourly Rate X Mark-up % ) + Bilingual premium
this area for Vendor response
C.1 Payment
Note that payment for this assignment will be made by the Homeon a per hour basis (i.e. Hourly Rate + Mark- up Percentage), provided the
performance of the Deliverables is satisfactory to the LTCH. The Home may hold back payment or set off against payment if, in the opinion of
the LTCH, the Vendor has failed to comply with any requirements of the RFS or the written agreement.
C.2 Vendor Confirmation
The Vendor confirms: - That they have provided the name, resume and references of the temporary help candidate(s); - That, to the best of its
knowledge, the information and documentation it is providing is complete and accurate; - Its submission represents an all-inclusive figure for
the cost of the Deliverables including, but not limited to, (a) all applicable taxes and duties, and (b) all delivery, travel, insurance and any other
overhead or other costs that may be incurred in the provision of the Deliverables. - The Hourly Rate is the amount that will be paid to the
Temporary Help resource, subject to statutory deductions; and - That it is not directly or indirectly demanding or charging a fee, reward or
compensation from a person seeking placement under this SOW.
mmm-dd-yyyy
Mark-Up Percentage Rate
applicable to Vendor Hourly Rate only
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D. Statement of Work
D.1 Term of Statement of Work
D.2 Deliverables, Rates and Payment Process
IN WITNESS WHEREOF the parties hereto have executed this Statement of Work effective as of the later of the two execution
dates set out below.
Long Term Care Home in section B.1 of the related Request
for Service:
Vendor Signature
Name
Title
Date
mmm-dd-yyyy
This person is authorized to sign on behalf of the Home for Temporary Help Services Y-Yes, N-No
And the Vendor referenced in Section C.2 - Vendor Confirmation, as attached to this agreement:
Client Signature
Name
Title
Date
mmm-dd-yyyy
This person is an authorized representative Y-Yes, N-No
This Statement of Work shall expire at the end of the Term as indicated in Section B.5.2. The Home shall have the option to extend this
Statement of Work for one further period of up to [**insert extension period, not to exceed six (6) months in total from date of hire without
appropriate Home Approval Level**], such extension to be upon the same terms (including Rates in effect at the time of extension), conditions
and covenants contained in this Service Level Agreement, excepting the option to renew. The option shall be exercisable by the Home upon
fifteen (15) calendar day’s prior written notice to the Vendor, setting forth the precise duration of the extension.
The Vendor agrees to provide the Deliverables to the Home in accordance with the terms and conditions of the Master Agreement and as more
particularly specified in the related Request for Service (Section B) to this Statement of Work. Subject to the Master Agreement, which
established the maximum pricing for establishing Rates under a Statement of Work, the Rates for the provision of the Deliverables shall be as
specified in the Deliverable Rate to this Statement of Work. Unless otherwise specified in the Statement of Work, the Vendor shall invoice the
Home for the Deliverables provided under this Statement of Work in accordance with the terms set out in the Separate Agreement.
The Rates for the provision of the Deliverables for this Statement of Work shall be as specified in this RFS, Section B.5.2 Length of
Assignment and Rates and Section C Vendor Response. Unless otherwise specified in B.5.2 Length of Assignment and Rates and C Vendor
Response, the Vendor shall invoice the Homefor the Deliverables provided under this Statement of Work in accordance with the terms set out
in the Separate Agreement.
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