Fillable Combined-Grant-Schedules-Form PROFESSIONAL SERVICES QUESTIONNAIRE

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Combined-Grant-Schedules-Form PROFESSIONAL SERVICES QUESTIONNAIRE

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Page 1 of 3
Business Name Phone Email
Address City State Zip Federal ID #
City of Oakland Business License Number Completed by: Phone if different
Schedule C-1 – (Declaration of Compliance with the Americans with Disabilities Act)
I declare under penalty of perjury that my company will comply with the City Of Oakland American with Disabilities Act obligations.
Schedule K – (Pending Dispute Disclosure)
1. Are you or your firm involved in a pending dispute or claim Against the City of Oakland or its Agency? (Please check one) Yes No
2. If “Yes”, please list existing and pending lawsuit(s) and claim(s) with the title, contract date, brief description of the issues, officials or staff
persons involved in the matter and the City department/division administering the contract. Contract Title and Number:
Date: Official(s), Staff person(s) involved:
Administering Department/Division: Issues:
3. (check) Additional Disputes listed on Attachment
Schedule N - (Living Wage – Declaration of Compliance) Grants accumulating over $100K, Grants under $100K mark N/A
Employment Questionnaire: Please respond to the following questions:
Responses
(1) How many permanent employees are employed with your company? (If less than 5, stop here)
(2) How many of your permanent employees are paid above the Living Wage rate?
(3) How many of your permanent employees are paid below the Living Wage rate?
(4) Number of compensated days off per employee? (Refer to item “a” above)
(5) Number of trainees in your company?
(6) Number of employees under 21 years of age, employed by a nonprofit corporation for after school or summer
employment for a period not longer than 90 days.
Rev. 10/2015 dm Page 2 of 3
Schedule N-1 – (Equal Benefits – Declaration of Nondiscrimination) Grants accumulating over $25K, Grants under $25K mark N/A
Section A. Grantee Information
(1) Are you an EBO certified firm (Please check one) Yes No (if yes, please attached certificate and skip Schedule N-1)
(2) Approximate Number of Employees in the U.S. (3) Are any of your employees covered by a collective bargaining agreement or union
trust fund? (Please check one) Yes No (4) Union name(s)
Section B. Compliance
(1) Does your company provide or offer access to any benefits to employees with spouses or to spouses of employees? (Please check one) Yes No
(2) Does your company provide or offer access to any benefits to employees with domestic partners? (Please check one) Yes No
Section C. Benefits PLEASE CHECK EACH BENEFIT THAT APPLIES
Benefits
Offered to
Employees only
Offered to
Employees and their
spouses
Offered to Employees
and their Domestic
Partners
Documentation
attached
Health
Dental
Vision
Retirement (Pension, 401K, etc)
Bereavement
Family Leave
Parental Leave
Employee Assistance Program
Relocation & Travel
Company Discount, Facilities & Events
Credit Union
Child Care
Other
(1) CFAR is a City Financial Recipient. (2) Domestic Partner is defined a s a same sex couples or opposite sex couples registered as such with a state or
local government domestic partnership registry
Rev. 9/2018 dm Page 3 of 3
Schedule P – (Nuclear Free Zone - Ordinance 11474 C.M.S.)
I declare under penalty of perjury that I have read Ordinance 11478 C.M.S. titled “An Ordinance Declaring the City of Oakland a Nuclear Free
Zone and Regulating Nuclear Weapons Work and City Contracts with and Investment in Nuclear Weapons Makers”, as provided on the City’s
website, see “footnote” below I certify that my firm conforms with the conditions as defined in Ordinance 11478 C.M.S.
I declare that my company is NOT in compliance with Ordinance 11478 C.M.S., but my proposal/bid should be considered because:
Schedule V – (Affidavit of Non-Disciplinary or Investigatory Action)
I certify that the following entities: Equal Employment Opportunity Commission (EEOC), Department of Fair Employment &
Housing (DFEH) or the Office of Federal Contract Compliance Programs (OFCCP) has not taken disciplinary or investigatory action
against the Firm. If such action has been taken, attached hereto is a detailed explanation of the reason for such action, the party
instituting such action and the status or outcome of such action. Initial:
Oakland’s Minimum Wage Law – (Resolution 85423 C.M.S. - Oakland Municipal Code Section 5.92, et seq.) I certify that I have read
Oakland’s minimum wage law and I am in full compliance with all its provisions. Initial:
Affirmative Action - I certify that I/we shall not discriminate against any employee or applicant for employment because of race, color, creed, sex,
sexual orientation, national origin, age, disability, Acquired Immune Deficiency Syndrome (AIDS) AIDS related complex, or any other arbitrary
basis and shall insure compliance with all provisions of Executive Order No. 11246 (as amended by Executive Order No. 11375). I certify that I/we
shall not discriminate against any employee or applicant for employment because they are disabled veteran of the Vietnam era and shall insure
compliance with all provisions of 41CFR60-250.4 where applicable. Initial:
By signing and submitting this combined schedules form the prospective primary participant’s authorized representative
hereby obligates the proposer(s) to the stated conditions referenced in this document. I declare under penalty of perjury that
the foregoing is true and correct.
Name of Individual: Title:
Signature: Date:
PLEASE NOTE: Detailed descriptions of all policies represented in this combined form may be found at Contracts and Compliance website “Policies
and Legislation” address https://www.oaklandca.gov/documents/contracting-policies-and-legislation For an electronic copy of this combined form and
copies of standalone contract Schedules R, E, O, Q, Exit Affidavit and Schedule G please go to this web address
https://www.oaklandca.gov/documents/contracts-and-compliance-forms-and-schedules
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Combined-Grant-Schedules-Form PROFESSIONAL SERVICES QUESTIONNAIRE

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Completed 2 March 2020

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