Request for Proposal Form
Site Name:
Address:
City:
State/Zip:
Physical Address of Facility (if different from above):
Address:
City:
State/Zip:
Main Phone:
Main Fax:
Jail Contact Person(s):
Title:
Phone Number(s):
Person Receiving Proposal :
Title:
Address:
City:
State/Zip:
Phone Number(s):
Number of inmates in the facility expected next year:
Men
.....
Women
Do inmates share in medical costs thru a co-pay program?
Yes
No
Is there a dental unit inside the facility?
Yes
No
Are mental health conditions/complaints handled in the facility or outside?
Facility
Outside
Is medical care currently contracted to an on-site provider?
Yes
No
Other Information:
