HomeMy WebLinkAboutAccountable Communities of Health (ACH)Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
09/13/2017
Fund/Department
116 -Public Health
Contract/Grant Information
1 Agenda Date
Contract /Grant Agency: Accountable Communities of Health (ACH)
Period Begin Date: July 1, 2017
Total Grant/Contract Amount: Not to exceed $1,374.00
Grant/Contract Number:
K11 I -11-1S4 rll • 17'
Period End Date: December 31, 2017
Contract/Grant Summary:
The Agreement is entered into by and between Walla Walla County Department of Community Health,
hereinafter "County," and Kittitas County Public Health Department, hereinafter "Contractor," for
engagement and participate with Greater Columbia Accountable Community of Health, as outlined in
the attached Statement of Work. The rights and obligations of both parties are governed by the General
Terms and Conditions, and the following Exhibits attached.
Recommendation for Board of Health and Board of Health Review on
Department Head Signature: Administrator Date:
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Signature of Prosecutor's Office Date
Signature of Auditor's Office
Signature of Board of Health member
Financial Information
Date
Date
Total Amount $
State Funds $
I
Federal Funds $
Percentage County Funds
Matching Funds $
CFDA#
Grant/Contract Review Page 1
In -Kind $
Explain
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? _ Contact HR hiring — reporting requirements
Future impacts or liability to Kittitas County:
Information
Budget Amendment Needed? Yes ❑ attach budget form No ❑ why not
New Division Created?
Revenue Code
Pass Through Information
Agency to Pass Through
Auditor
Amount to Pass Through
$
Sub -Contract Approved
Date:
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes ❑ No ❑
Countv Departments Impacted
Submitted
Signature: _ Date:
Department:
ment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2
Auditor
Facilities Maintenance
Information Services
Human Resource
Prosecutor
Treasurer
Submitted
Signature: _ Date:
Department:
ment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2
Service Agreement #17-76
between
WALLA WALLA COUNTY DEPARTMENT OF COMMUNITY HEALTH
and
KITTITAS COUNTY PUBLIC HEALTH
The Agreement is entered into by and between Walla Walla County Department of Community
Health, hereinafter "County," and Kittitas County Public Health Department, hereinafter
"Contractor," for engagement and participate with Greater Columbia Accountable Community of
Health, as outlined in the attached Statement of Work. The rights and obligations of both parties
are governed by the General Terms and Conditions, and the following Exhibits, copies of which
are attached hereto and incorporated herein by this reference as fully as if set forth herein:
Exhibit A — Statement of Work
Exhibit B — Budget
Exhibit C — Expenditure Report Form
Exhibit D — Participation Report Form
Performance Period: The terms of this Agreement shall commence on July 1st, 2017 and shall,
unless terminated or renewed as provided elsewhere in the Agreement,
terminate on December 31, 2017.
Compensation: Payment to Contractor for services rendered under this Agreement shall be
as set forth in Exhibit B — Budget. The allocation of funding is currently
awarded for Calendar Year 2017. The amount of payment for the
performance period of this Agreement shall not exceed $1,374.
By their signatures below, the parties agree to the terms and conditions of this Agreement and all
documents incorporated by reference. The parties signing below certify that they are authorized
to sign this Agreement.
IN WITNESS WHEREOF, the parties hereto have signed this Agreement.
COUNTY:
Jim Duncan Date
Chair, Board of County Commissioners
Walla Walla County
314 W. Main
2"d Floor — Room 203
PO Box 1506
Walla Walla, WA 99362
Phone: (509) 524-2505 Fax: (509) 524-2512
Telephone Number / Email Address:
Mailing Address (Street address required in addition to PO Box.):
CFDA# (if applicable):
CONTRACTOR:
Authorized By
Print Name & Title of Person Signing
Social Security or Business Tax ID#:
UBI#:
State Industrial Account ID # (if applicable):
Date
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 1 of 10
GENERAL TERMS AND CONDITIONS
Definitions. For the purposes of this Agreement, including all documents incorporated by
reference, terms that are defined in Washington Administrative Code (WAC) shall have
meanings defined therein. Additionally, the words and phrases listed below, as used in
the Agreement, shall each have the following definitions:
1.1. "Agreement" means this County and Contractor Agreement regarding General
Terms and Conditions and any documents incorporated by reference.
1.2. "CFR" means Code of Federal Regulations. All references in this Agreement and
any Agreement to CFR chapters or sections shall include any successor, amended,
or replacement regulation. The CFR may be accessed at
htt:Ilwww. > )oLicc ess. ,,ov/cfr/index.html.
1.3. "Debarment" means an action taken by a Federal official to exclude a person or
business entity from participating in transactions involving certain federal funds.
2. Background Checks. In accordance with RCW 43.20A.710, RCW 43.43.832, RCW
74.34, and RCW 7IA. 10.020, when applicable, Contractor's staff, subcontractors or
volunteers who have unsupervised access to children or vulnerable adults are required to
have a background check, and all persons convicted of crimes listed in RCW 43.43.830
and RCW 43.43.842 are prohibited from having access to clients.
3. Billing and Payment for Contractor Services: County shall pay Contractor for
services on a reimbursement basis, pursuant to terms set forth in Exhibit B or Exhibit C —
Budget. No payment shall be made for any service that is not identified within this
Agreement.
3.1. Contractor shall submit claims for reimbursement by the tenth (10th) working day
following the end of the month in which the expenses claimed were incurred.
County agrees to make payment with County warrants, as approved by the Auditor
of County, within thirty (30) working days following receipt of Contractor's claim
for reimbursement, contingent on the availability of funds.
3.1.1. Claims for reimbursement shall be submitted in writing, in a format
approved by County. Payment shall be based upon itemized billings
supported by accompanying documentation.
3.1.2. County shall compensate Contractor no more often than monthly for
Contractor's service. No payment shall be made in the month services are
rendered unless otherwise approved by County.
3.2. In the event Contractor fails to perform any substantial obligation under this
Agreement and said failure has not been cured, County may, upon written notice,
withhold all monies due and payable to Contractor, without penalty, until such
failure to perform is cured or otherwise adjudicated.
4. Compliance with Applicable Law. At all times during the term of this Agreement,
Contractor shall comply with all applicable federal, state, and local laws, regulations, and
rules, including but not limited to, nondiscrimination laws and regulations.
5. Confidentiality. Contractor, its employees, subcontractors, and their employees shall
maintain the confidentiality of all information provided by County or acquired by
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 2 of 10
Contractor in performance of this Agreement, except upon the prior written consent of
Walla Walla County Prosecuting Attorney, or an order entered by a court after having
acquired jurisdiction over County. Contractor shall immediately give to County notice of
any judicial proceeding seeking disclosure of such information. Contractor shall
indemnify and hold harmless County, its officials, agents or employees from all loss or
expense, including, but not limited to settlements, judgments, setoffs, attorneys' fees and
costs resulting from Contractor's breach of this provision. The parties to this Agreement
shall comply with applicable Federal and State laws and regulations governing privacy,
confidentiality or security of patient information, including without limitation Chapter
70.02 RCW, Medical Records — Health Care Information Access and Disclosure; Chapter
42.17 RCW, Disclosure — Campaign Finances — Lobbying — Records; and the Health
Insurance Portability and Accountability Act, including but not limited to the "HIPAA
Privacy Rule," 45 CFR Parts 160 and 164.
6. Conflict of Interest. Contractor shall, in all matters concerning this Agreement, avoid
any actions that may constitute a conflict of interest.
7. Debarment Certification. Contractor certifies that neither it nor its principals are
presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participating in transactions by any Federal department or
agency.
8. Disputes. Except in the event of a dispute arising from County's decision to terminate
this Agreement for default, County and Contractor agree to first attempt resolution of
disputes informally, by a mutually negotiated process.
9. Entire Agreement. This Agreement, including all documents incorporated by reference,
contains all terms and conditions agreed upon by the parties. No other understandings or
representations, oral or otherwise, regarding the subject matter of the Agreement shall be
deemed to exist or bind the parties.
10. Execution and Amendment. This Agreement shall be binding on the parties only upon
execution by authorized representatives of County and Contractor. This Agreement may
be altered only by a written amendment executed by authorized representatives of County
and Contractor.
11. Financial Certification. Within 60 days of the execution of the Contract, Contractor
shall submit to the County, Contractor Certification Documentation form including the
Contractor status as Non -Profit, Corporation, Governmental, Individual or Other Entity.
The applicable financial certification documents must also be submitted to the County
once every 12 months:
11.1. W-9 Form, Request for Taxpayer Identification
11.2. Last Audited Financial Statements, or Form 990; or Form 990T; or Form 1120 for
Corporations; or Schedule C from 1040 for individuals.
12. Indemnification and Hold Harmless. Contractor will indemnify, hold harmless and
defend the County from all claims, costs, damages or expenses including reasonable legal
expenses arising out of the negligence or wrongful acts of the Contractor, its
subcontractors, its successors or assigns, or its agents, servants, or employees. In the
case of negligence of both County and Contractor any damages allowed shall be levied in
proportion to the percentage of negligence attributable to each party. Each party to this
Agreement hereby assumes responsibility for claims and/or damages to persons and/or
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 3 of 10
property resulting from any act or omission on the part of itself, its employees, its
subconsultants, its officers, and its agents.
13. Industrial Insurance Waiver: With respect to the performance of this agreement and as
to claims against the County, its officers, agents and employees, the Contractor
expressly waives its immunity under Title 51 of the Revised Code of Washington, the
Industrial Insurance Act, for injuries to its employees and agrees that the obligations to
indemnify, defend and hold harmless provided in this agreement extend to any claim
brought by or on behalf of any employee of the Contractor. This waiver is mutually
negotiated by the parties to this agreement.
14. Independent Status/Contractor. Contractor's services shall be furnished as an
independent contractor and nothing herein contained shall be construed to create a
relationship of employer-employee or master -servant. All payments made hereunder and
all services performed shall be made and performed pursuant to this Agreement by
Contractor as an independent contractor. It is understood and agreed that County is not
responsible for payroll deductions of any kind, including but not limited to, Federal
Taxes, FICA and/or employee benefits.
15. Inspection. During the term of this Agreement and for one (1) year following
termination or expiration of this Agreement, Contractor shall provide reasonable access
to Contractor's place of business, Contractor records, and client records, to County and to
any authorized agent of the state of Washington or the federal government in order to
monitor, audit, and evaluate Contractor's performance and compliance with applicable
laws, regulations, and this Agreement. Such representatives shall be permitted to audit,
examine, and make excerpts or transcripts from such records and to make audits of all
contracts, invoices, materials, payroll, and records of matters covered by this Agreement.
16. Insurance. Contractor is a member of the Washington Counties Risk Pool. Contractor
shall notify County forty-five (45) days before cancellation or reduction in Contractor
insurance coverage.
16.1. Worker's Compensation Insurance: If applicable, Contractor shall show proof of
Worker's Compensation coverage by providing its State Industrial Account
Identification Number. Provision of this number will be Contractor's assurance
that coverage is in effect.
17. Licensure. Contractor shall obtain and maintain continuously for the duration of this
Agreement, all licenses, certifications and/or registrations required for carrying out the
contracted services.
18. Non -Discrimination. Contractor shall not unlawfully discriminate against any employee,
applicant for employment, recipient of services or programs, or applicant for services or
programs, on the basis of race, creed, color, sex, age, marital status, national origin,
Vietnam era or disable veteran status, or the presence of any sensory, mental or physical
handicap. Contractor shall comply with the Americans with Disabilities Act.
18.1. In Employ►nent. Contractor shall not discriminate against any employee or
employment because of race, color, sex, religion, national origin, creed, marital
status, age Vietnam era or disable veterans status, or the presence of any sensory,
Intellectual, or physical disability, or the use of any trained dog guide or service
animal by a person with a disability. Contractor shall take affirmative action to
ensure that employees are employed and treated during employment without
discrimination. Such action shall include, but not be limited to, the following:
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 4 of 10
employment upgrading, demotion, or transfer; or recruitment or selection for
training, including apprenticeships and volunteers.
18.2. In Services. Contractor shall not discriminate against any person eligible for
services or participation in the program because of race, color, sex, religion,
national origin, creed, marital status, age, Vietnam Era or disabled veterans, status
or the presence of any sensory, intellectual or physical disability, or the use of any
trained dog guide or service animal by a person with a disability, or the use of any
trained dog guide or service animal by a person with disabilities.
19. Notice, Venue and Choice of Law. Any notices, payments and communications
permitted or required between County and Contractor shall be given or made by personal
delivery or by mailing the same to the other party at the addresses on the first page of this
Agreement, or such address as either party may in writing hereinafter indicate. In the
event litigation should arise concerning the enforcement, construction or interpretation of
any of the terms of this Agreement, the venue of such action of litigation shall be in the
courts of the State of Washington in and for the County of Walla Walla. This Agreement
shall be governed by the laws of the State of Washington.
20. Order of Precedence. In the event of an inconsistency in this Agreement, unless
otherwise provided herein, the inconsistency shall be resolved by giving precedence, in
the following order, to:
19.1 Applicable federal and State of Washington statutes and regulations;
19.2 General Terms and Conditions contained in this Agreement;
19.3 Special Terms and Conditions contained in this Agreement;
19.4 Exhibits, if any, as indicated on page one (1) of this Agreement;
19.5 Any other material incorporated herein by reference.
21. Ownership Of Material. Material created by Contractor and paid for by County as a
part of this Agreement shall be owned by County and shall be "work made for hire" as
defined by Title 17 USCA, Section 101. This material includes, but is not limited to:
books; computer programs; documents; films; pamphlets; reports; sound reproductions;
studies; surveys; tapes; and/or training materials. Material which Contractor uses to
perform this Agreement but which is not created for or paid for by County is owned by
Contractor.
22. Records. The parties to this Agreement shall comply with all Federal and State laws and
regulations governing privacy, confidentiality or security of records, including without
limitation, the Washington Uniform Healthcare Information Act, Chapter 70.02 RCW,
Medical Records — Health Care Information Access and Disclosure; Chapter 42.56 RCW
Public Records Act; and the Health Insurance Portability and Accountability Act,
including but not limited to the "HIPAA Privacy Rule," 45 CFR Parts 160 and 164.
22.1. Financial Records. Contractor shall have a system of accounting and internal
controls in compliance with generally accepted accounting principles and
standards, and shall maintain sufficient books, records, documents, reports and
other evidence to accurately document all costs incurred in relationship to
contracted services.
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 5 of 10
22.2. Clinical/Consumer Service Records. The Contractor shall comply with all state
and federal requirements regarding the maintenance and content of records relating
to services provided to individual clients under this Agreement.
23. Right to Review and Record Retention. This Agreement may be subject to review by
any Federal or State auditor. County or its designee shall have the right to review and
monitor the financial and service components of this program by whatever means are
deemed expedient by County. Such review may occur with or without notice, and may
include, but is not limited to, on site inspection by County Agents or employees,
inspection of all records or other materials which County deems pertinent to the
Agreement and its performance, and any and all communications with or evaluations by
service recipients under this Agreement. Contractor shall preserve and maintain all
financial records and records relating to the performance of work under this Agreement
for six (6) years after Agreement termination, and shall make them available for review,
upon request, within Walla Walla County, State of Washington
24. Severability. The provisions of this Agreement are severable. If any court holds any
provision of this Agreement, including any provision of any document incorporated by
reference, invalid, that invalidity shall not affect the other provisions of the Agreement.
25. Subcontracting
25.1. Contractor may, without prior notice to County, subcontract with agencies
specifically identified in the Statement of Work. For subcontracts with an agency,
person, partnership, corporation or governmental entity not identified in the
Statement of Work, Contractor shall obtain written approval from County at least
forty (40) days prior to the proposed effective date of a new or amended
subcontract.
25.1.1. Contractor shall be responsible for the acts and omissions of its
subcontractors.
25.1.2. For the purpose of this Agreement, vendors used regularly by Contractor
are not subcontractors.
25.1.3. A personal services contract between Contractor and an individual does not
require prior approval by County.
25.2. All subcontracts entered into by Contractor for performance of services defined
herein shall be in writing and shall contain language substantially as provided in
the following sections of this agreement:
■ Accounting
• Background Checks
• Compliance with Applicable Law
■ Confidentiality
• Conflict of Interest
• Definitions
• Debarment Certification
• Indemnification and Hold Harmless
■ Independent Audit
• Inspection
• Insurance
• Licensure and Bonding
• Non-discrimination in Client
Services
• Records
■ Record Maintenance and Retention
• Reporting
• Treatment of Property
• Subcontracting
• Subrecipient
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 6 of 10
25.3. County reserves the right to inspect and approve any subcontract document. In the
event of subcontract inspection by County, approval will be assumed unless
County informs Contractor that the subcontract is disapproved within forty (40)
calendar days of receipt of the subcontract document by County.
26. Subrecipients
26.1. General. If Contractor is a subrecipient of federal awards as defined by Office of
Management and Budget (OMB) Circular A-133 and this Agreement, Contractor
shall:
26.1.1. Maintain records that identify, in its accounts, all federal awards received
and expended and the federal programs under which they were received, by
Catalog of Federal Domestic Assistance (CFDA) title and number, award
number and year, name of the federal agency, and name of the pass-
through entity;
26.1.2. Maintain internal controls that provide reasonable assurance that the
Contractor is managing federal awards in compliance with laws,
regulations, and provisions of contracts or grant agreements that could have
a material effect on each of its federal programs;
26.1.3. Prepare appropriate financial statements, including a schedule of
expenditures of federal awards;
26.1.4. Incorporate OMB Circular A-133 audit requirements into all agreements
between the Contractor and its subcontractors who are subrecipients;
26.1.5. Comply with any future amendments to OMB Circular A-133 and any
successor or replacement Circular or regulation;
26.1.6. Comply with the applicable requirements of OMB Circular A-87 and any
future amendments to OMB Circular A-87, and any successor or
replacement Circular or regulation; and
26.1.7. Comply with the Omnibus Crime Control and Safe Streets Act of 1968,
Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation
Act of 1973, Title II of the Americans with Disabilities Act of 1990, Title
IX of the Education Amendments of 1972, The Age Discrimination Act of
1975, and The Department of Justice Non -Discrimination Regulations, 28
C.F.R. Part 42, Subparts C.D.E, and G, and 28 C.F.R. Part 35 and Part 39.
(See www.ojp.usdollgoy/ocr for additional information and access to the
aforementioned Federal laws and regulations.)
26.2. Single Audit Act Compliance. If Contractor is a subrecipient and expends
$500,000 or more in federal awards from any and/or all sources in any fiscal year,
Contractor shall procure and pay for a single audit or a program -specific audit for
that fiscal year. Upon completion of each audit, Contractor shall:
26.2.1. Submit to County the data collection form and reporting package specified
in OMB Circular A-133, reports required by the program -specific audit
guide (if applicable), and a copy of any management letters issued by the
auditor;
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 7 of 10
26.2.2. Follow-up and develop corrective action for all audit findings; in
accordance with OMB Circular A-133, and prepare a "Summary Schedule
of Prior Audit Findings."
26.3. Overpayments. If it is determined by County, or during the course of the required
audit, that Contractor has been paid unallowable costs under this Agreement,
County may require Contractor to reimburse County in accordance with OMB
Circular A-87.
27. Survivability. The terms and conditions contained in the Agreement that, by their sense
and context, are intended to survive the expiration of the Agreement shall so survive.
Surviving terms include, but are not limited to: Confidentiality, Disputes,
Indemnification and Hold Harmless, Inspection, Records, Right to Review and Record
Retention, Ownership of Material, Termination for Default, Termination Procedure.
28. Termination. The terms and conditions of this Agreement shall remain in full force and
effect during the specified Agreement period unless specifically terminated, or modified
by mutual assent of the parties hereto, regardless of the termination or modification of
any contract or subcontract of which this Agreement is a part. Termination of this
Agreement by either party in accord with the terms herein shall not constitute a breach of
contract.
28.1. Termination for Convenience. Either County or Contractor may terminate this
Agreement for convenience, in whole or in part, whenever either determines such
termination to be in its best interest. Such termination shall require notice of thirty
(30) calendar days. When the Agreement is terminated in accordance with this
paragraph, Contractor shall be entitled to payment for actual work performed at
unit contract prices for completed items of work.
28.2. Termination Due to Change in Funding. If the funds County relied upon to
establish this Agreement are withdrawn, reduced, or limited, or if additional or
modified conditions are placed on such funding, County may terminate this
Agreement by providing written notice to Contractor. Termination shall be
effective on the date specified in the notice of termination.
28.3. Termination for Default. County may terminate this Agreement for default, in
whole or in part, by written notice to Contractor, if County has a reasonable basis
to believe that Contractor has:
• Failed to meet or maintain any requirement for contracting with County;
• Failed to perform under any provision of this Agreement;
■ Violated any law, regulation, rule, or ordinance applicable to the services provided
under this Agreement;
• Become insolvent or declared bankrupt, committed any act of bankruptcy or
insolvency, or made an assignment for the benefit of creditors, and/or
■ Otherwise breached any provision or condition of this Agreement.
28.3.1. Before County may terminate this Agreement for default, County shall
provide Contractor with written notice of Contractor's noncompliance with
this Agreement and provide Contractor a reasonable opportunity to correct
said noncompliance. If Contractor has not corrected its noncompliance
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 8 of 10
within the period of time specified in the written notice of noncompliance,
County may then terminate this Agreement.
28.3.2. County may terminate this Agreement for default without written notice
and without opportunity for correction if County has a reasonable basis to
believe that Contractor has failed to ensure the health or safety of any client
for whom services are being provided under this Agreement, or that
Contractor has violated any law, regulation, rule or ordinance applicable to
the services provided under this Agreement.
28.3.3. If the Agreement is terminated for default, Contractor shall not be entitled
to receive any further payments under the Agreement until all work called
for has been fully performed. Any extra cost or damage to County
resulting from such default shall be deducted from any money due or
coming due to Contractor. Contractor shall be liable for actual, incidental
and consequential damages, including the reasonable cost of procuring
similar services actually procured by the County from another source to
fully execute the Contractor's duties under this Agreement.
29. Termination Procedure. The following provisions apply in the event this Agreement is
terminated:
29.1. Contractor shall cease to perform any services required by the Agreement as of the
effective date of termination and shall comply with all reasonable instructions
contained in the notice of termination which are related to the transfer of clients,
distribution of property, and termination of services
29.2. County shall be liable for and shall pay for only those services authorized and
provided through the date of termination. County may pay an amount agreed to by
the parties for partially completed work and services, if work products are useful
to or usable by County.
29.3. If this Agreement is terminated for default, County may withhold a sum from the
final payment to Contractor that County determines necessary to protect County
against loss or additional liability. County shall be entitled to all remedies
available at law, in equity or under this Agreement. If it is later determined that
Contractor was not in default, Contractor shall be entitled to all remedies available
at law, in equity, or under this Agreement.
29.4. The rights and remedies provided to County in this paragraph are in addition to
any other rights and remedies provided at law, in equity, and/or under this
Agreement, including consequential damages and incidental damages. The
Contractor may request dispute resolution as provided in this Agreement.
30. No Third Party Beneficiary: The parties do not intend by this Agreement to assume any
contractual obligations to anyone other than each other. This Agreement is not entered
into with the intent that it shall benefit any other entity or person(s) except those
expressly described herein, and no other such entity or person(s) shall be entitled to be
treated as a third party beneficiary to the agreement.
31. Waiver. Waiver of any breach or default of this Agreement on any occasion shall not be
deemed to be a waiver of any subsequent breach or default. Waiver shall not be construed
to be a modification of the terms of the contract unless stated to be such in writing, signed
by an authorized representative of County. County's failure to insist upon the strict
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 9 of 10
performance of any provision of this Agreement or to exercise any right based upon
breach thereof or the acceptance of any performance during such breach, shall not
constitute a waiver of any right under this is Agreement.
#17-76 ACH Engagement Columbia Co— General Terms and Conditions Page 10 of 10
Grantee Name:
Agreement Number:
Exhibit A
BUDGET
Kittitas County Public Health
17-76 Contract Period: July 1, 2017 — December 31,
2017
This Agreement includes / X does not include, in the SPECIFIC TERMS AND
CONDITIONS, requirements to which payment of budgeted funds is contingent.
Line Item/Deseription Amount
Personnel Costs $1000
Travel to and From GCACH Meetings, $0.27/mile $374
TOTAL: $1,374
Funded By:
WA State Department of Health ACH Engagement Special Funding
#BUDGET Page 1 of 1
Grantee Name:
Agreement Number:
Exhibit B
STATEMENT OF WORK
Kittitas County Public Health
17-76 Contract Period:
Task Task/Activity/
Number Description
Participate in
Monthly ACH
meetings and
LHJ/ACH
engagement calls
2 Map county level
partnerships and
existing
community
coalitions
July 1, 2017 —Dec. 31, 2017
Update Regional Health Inventory
for county level partnership contact
information.
# SOW Page 1 of 1
expenditures
Due: To be
10/15/2017 charged
monthly
based upon
reported and
approved
time and
effort
Due
Payment
Deliverables/Outcomes
Date/Time
Information
Frame
and/or
_Amount
Participate in monthly ACH
rMonthly —
To be
Leadership Council meetings and
July 2017
charged
appropriate Demonstration Project
through
monthly
Groups. Participate in monthly
December
based upon
LHJ/ACH engagement calls hosted
2017
time and
my Walla Walla County.
effort and
Update Regional Health Inventory
for county level partnership contact
information.
# SOW Page 1 of 1
expenditures
Due: To be
10/15/2017 charged
monthly
based upon
reported and
approved
time and
effort
Expenditure Report Form (ERF)
INSTRUCTIONS TO VENDOR OR CLAIMANT.
STATEMENT FOR SERVICES- Claim payment for materials, merchandise or services. Show complete detail for each item.
Vendor's CertiJlcate. I hereby certify under penalty of perjury that
Submit this form to Contractor: the items and totals listed herein are proper charges for materials, merchandise
or services furnished to the County of Walla Walla and that all goods furnished
County of Walla Walla, Washington and/or services rendered have been provided without discrimination because of
Department of Community Health age, sex, marital status, race, creed, color, national origin, handicap, religion, or
Vietnam era or disabled veterans status and the claim is just, due and unpaid
PO Box 1753 obligation against the County of Walla Walla and that I am authorized to
Walla Walla WA 99362
Emnil to: DCHContia •ts$illin a c walia-walla.wa.us
CLAIMANT
BY:
(SIGN IN tNK)
(TITLE) IRATE)
Program-
rogram:Agreement Number:
Agreement
Claim Period:
DATE
DESCRIPTION OF
SERVICES
AMOUNT
TOTAL PAYMENT REQUESTED WITH THIS ERF:
$0.00
PREPARED BY
TELEPHONE NUMBER :OATE
FOR COUNTY FINANCE USE ONLY
VENDOR NUMBER
U6I NUMBEk
FUND Code Distribution
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WARRANT TOTAL JVW
RANT N01ui?RR
KAVMW 011710
0]
110
I'-,
-110
F��
�
V
H
V
V
V
rD
p
rD
p
rD
Q
D
3
3
3
rr
d
O
to
(0
rm
O
r0
m
fD
3
CD -
O
O
O
Oro
(D
(D
rr
7
UQ
rb
G)
G)rb
D
n
n
�
a
0
3
a-
3
S
ao
O
Q
rD
rb
3•
a
rD
3
O
rD
(D
rD
�
N
�
3
�
r
O
n
ro
3
_
O
3
rD
3
O
(D
rr
(D
3. 0
(D
O
O
N
�+ O
3
O
O
O
O
O
O
O
S r•r
O �
0
0
o
fD