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Today's Date <br />03/07/2016 <br />Fund/Department <br />116 -Public Health <br />Kittitas County <br />Review Form <br />Grants & Contract Agreement <br />Agenda Date <br />>v r rita� i n� r r <br />Contract/Grant Information <br />Contract /Grant Agency: <br />Period Begin Date: Upon execution I I Period End Date: 1 year from date of execution <br />Total Grant/Contract Amount: $49.59 for adults (single view) and $71.14 for children (two view) <br />Grant/Contract Number: <br />Contract/Grant Summary: <br />The Professional Services Agreement between Kittitas County (KCPHD) and Kittitas Valley Healthcare <br />(KVH) is an agreement entered into that allows the health department to send clients to KVH for <br />screening x-rays. The agreement includes a set fee for these services. <br />Recommendation for Board of Health and Board of Health Review on <br />Department Head Signature: <br />Administrator Date: <br />Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment: <br />APPROVED AS TO FORM: <br />Signature rosecutor's O� Date <br />e&l X L11M (11 <br />Signature ofudi is Office Date <br />Signature of Board of Health member Date <br />Financial Information <br />Total Amount $ <br />State Funds $ <br />Federal Funds $ <br />Percentage County Funds <br />Matching Funds $ <br />CFDA# <br />In -Kind $ <br />Explain <br />Grant/Contract Review Page 1 <br />