HomeMy WebLinkAboutCon Con 2018-2020(1)Today's Date
12/18/2017
Fund/Department
116 -Public Health
Kittitas County
Review Form
Grants & Contract Agreement
Agenda Date
Contract/Grant Information
Contract /Grant Agency: Consolidated Contract 2018-2020
Period Begin Date: 01/01/2018 Period End Date: 12/31/2020
Total Grant/Contract Amount: $79,038.00
Grant/Contract Number: CLH18249
Contract/Grant Summary:
The purpose of this Contract is to define the parties' joint and cooperative relationship. The contract and all
statements of work adopted under its provisions are intended to implement applicable objectives under the
Public Health Improvement Plan and to facilitate the delivery of public health services to the people in
Washington State. This Contract is the result of cooperative planning efforts between Kittitas County Public
Health and DOH.
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 Date
Signature of Board of Health member Date
Financial Information
Total Amount $79.038.00
Percentage County Funds
State Funds $11,800
Matching Funds $
Federal Funds $ 67,238
CFDA#
10.561$10,302
Grant/Contract Review Page 1
Y
N11 I' a nPITY
Contract/Grant Information
Contract /Grant Agency: Consolidated Contract 2018-2020
Period Begin Date: 01/01/2018 Period End Date: 12/31/2020
Total Grant/Contract Amount: $79,038.00
Grant/Contract Number: CLH18249
Contract/Grant Summary:
The purpose of this Contract is to define the parties' joint and cooperative relationship. The contract and all
statements of work adopted under its provisions are intended to implement applicable objectives under the
Public Health Improvement Plan and to facilitate the delivery of public health services to the people in
Washington State. This Contract is the result of cooperative planning efforts between Kittitas County Public
Health and DOH.
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 Date
Signature of Board of Health member Date
Financial Information
Total Amount $79.038.00
Percentage County Funds
State Funds $11,800
Matching Funds $
Federal Funds $ 67,238
CFDA#
10.561$10,302
Grant/Contract Review Page 1
In -Kind $
Is Equipment being purchased? Who owns equii
New Personnel being hired? Contact HR hirin
Future impacts or liability to Kittitas County:
L..
Budget Information
Budget Amendment Needed? Yes ❑ attach budget form
New Division Created?
Revenue Codes:
116.61294.333.10.56 $10,302
116.612883.333.93.06 $19,833
116.6123212.333.93.26 $616
116.6123211.333.93.26 $2,226
116.6123213.333.93.26 $1,114
116.6122211.333.93.99 $2,351.25
116.6122212.333.93.99 $20,295.75
116.6122214.333.93.99 $10,500
116.61523.334.04.901$5,000
116.61522.346.26.64 $2,400
116.61522.346.26.65 $2,400
116.61522.346.26.66 $2,400
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub -Contract Approved Date:
93.069 $19,833
93.268 $3,956
93.994 $33,147
ent?
— reportinp, requirements
No D
Why not? Already budgeted for
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes Q No
County Departments Impacted
I
Auditor
Facilities Maintenance
Information Services
Human Resource
Prosecutor
Treasurer
Grant/Contract Review Page 2
Submitted
Signature:
Department:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
1. Reviewer Date
Grant/Contract Review Page 3
DOH CONTRACT #: CLH18249
2018-2020
WASHINGTON STATE
DEPARTMENT OF HEALTH
CONSOLIDATED CONTRACT
Page 1 of 17
DOH CONTRACT #: CLH18249
Table of Contents
1.
Purpose.................................................................................................................................... 3
2.
Statements of Work.................................................................................................................
3
3.
Exhibits....................................................................................................................................
3
4.
Definitions...............................................................................................................................3
5.
Funding and Billing.................................................................................................................4
6.
Contract Management..............................................................................................................
5
7.
Access to Records....................................................................................................................5
8.
All Writings Contained Herein................................................................................................5
9.
Assignment..............................................................................................................................
5
10.
Assurances...............................................................................................................................
5
11.
Confidential Information.........................................................................................................6
12.
Ethics.......................................................................................................................................6
13.
Debarment Certification..........................................................................................................
6
14.
Disputes.............................................................................................................................__.
6
15.
Equipment Purchases...............................................................................................................6
16.
Governing Law and Venue......................................................................................................
7
17.
Independent Capacity..............................................................................................................
7
18.
Insurance..................................................................................................................................
7
19.
Licensing, Accreditation and Registration..............................................................................
7
20.
Maintenance of Records..........................................................................................................7
21.
Modifications and Waivers......................................................................................................7
22.
No Third -Party Rights Created................................................................................................
7
23.
Nondiscrimination...................................................................................................................
7
24.
Order of Precedence................................................................................................................
8
25.
Ownership of Material/Rights in Data.....................................................................................
8
26.
Publications..............................................................................................................................8
27.
Responsibility for Actions.......................................................................................................
8
28.
Loss or Reduction of Funding.................................................................................................
8
29.
Severability..............................................................................................................................8
30.
Subcontracts.............................................................................................................................8
31.
Subrecipient.............................................................................................................................
9
32.
Survivability............................................................................................................................9
33.
Term.........................................................................................................................................9
34.
Termination for Convenience..........................................................................:......................
9
35.
Termination for Default...........................................................................................................9
36.
Termination Procedure........................................................................................................9
Standard Federal Certifications and Assurances........................................................................
l l
Federal
Assurances - Non -Construction Programs....................................................................16
2018-2020 Consolidated Contract Page 2 of 17
DOH CONTRACT #: CLH 18249
CONSOLIDATED CONTRACT
between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
(Referred to as "DOH")
and
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
(Referred to as "LHJ")
for
THE DELIVERY OF PUBLIC HEALTH SERVICES
FOR THE PERIOD OF
January 1, 2018 through December 31, 2020
1. Purpose
This Contract is entered into in accordance with RCW 43.70.520, RCW 43.70.580, the general statutory powers of the
Secretary of the Department of Health (DOH), including at RCW 43.70.040, the general statutory powers of local
health jurisdictions (LHJs), including at RCW 70.05.060, RCW 70.08.020, and RCW 70.46.060, and the authority for
joint or cooperative action provided for under chapter 39.34 RCW. The purpose of this Contract is to define the
parties' joint and cooperative relationship. The contract and all statements of work adopted under its provisions are
intended to implement applicable objectives under the Public Health Improvement Plan and to facilitate the delivery
of public health services to the people in Washington State. This Contract is the result of cooperative planning efforts
between the LHJ and DOH.
2. Statements of Work
The individual program activities, requirements, and outcomes/deliverables to be achieved by the parties under this
Contract are described in Exhibit A, Statements of Work. Each statement of work shall comply with the performance-
based criteria under RCW 43.70.580(2)(b).
The LHJ shall furnish the necessary personnel, equipment, material and/or services and otherwise do all things
necessary for or incidental to the performance of the work as set forth in Exhibit A, Statements of Work.
3. Exhibits
This Contract incorporates by reference the following Exhibits:
• Exhibit A - Statements of Work
• Exhibit B - Allocations
• Exhibit C - Schedule of Federal Awards
4. Definitions
As used throughout this Contract and unless amended for a particular Statement of Work, the following terms shall
have the meanings set forth below:
"Budget, Accounting, and Reporting System (BARS)": The system designed by the State Auditor's office for
collecting, consolidating, and reporting financial budgeting and accounting information from all local
governmental units.
"Client": An agency, firm, organization, individual or other entity applying for or receiving services provided by
the LHJ under this Contract.
"Catalog of Federal Domestic Assistance (CFDA)": The unique identifying code assigned to a federal assistance
program which identifies the awarding agency.
"Confidential Information": Information protected from disclosure under federal or state law.
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DOH CONTRACT #: CLH18249
"Contract Coordinator": Each party's designated contact for all notices required or permitted under this Contract.
"Contracting Officer": The DOH Contracts and Procurement Office Director and his/her delegates within that
office authorized to execute this agreement on behalf of DOH.
"Contractor": An entity that provides goods or services to DOH and others. A contractor normally operates its
business in a competitive environment, provides its goods and/or services to many different purchasers during
normal business hours, and is not subject to the compliance requirements of the federal program.
"Equipment": When used in this Contract is defined as an article of non -expendable, tangible property other than
land, buildings, or fixtures which is used in operations and having a useful life of more than one year and an
acquisition cost of $5,000 or more or as otherwise provided in the Exhibit A, Statements of Work.
"Federal Assistance": Assistance provided by a federal agency in the form of grants, contracts, loans, loan
guarantees, property, cooperative agreements, interest subsidies, insurance, or direct appropriations, but does not
include direct federal cash assistance to individuals.
"Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act)": A federal act to
make information available online so the public can see how federal funds are spent.
"Fixed Assets": Fixed assets are property and/or equipment obtained through donation, gift, purchase, capital
lease, or construction with a service life of more than one year.
"Program Contact": Each party's designated contact for those purposes identified in the Exhibit A, Statements of
Work.
"Subcontractor": Any individual or group contracted with the LHJ to perform all or part of the services included
in this Contract. This term will also apply to situations where an LHJ's subcontractor contracts with another
individual or group to perform all or part of the services included in its agreement with the LHJ.
"Subrecipient" or "Subgrantee": A non-federal entity that receives a subaward of federal grant money or goods
directly or indirectly from DOH and makes decisions regarding who can receive what federal assistance; has its
performance measured against the objectives contained in the DOH agreement with the federal government;
makes decisions on how to operate the program to accomplish the program goals; has the obligation to comply
with federal subrecipient requirements; and/or use federal funds to carry out a program for the public purpose
specified in the authorizing statute.
5. Funding and Billing
A. DOH shall pay the LHJ for services as set forth in the Exhibit A, Statements of Work, not to exceed funding
amounts as detailed in the Contract Allocations, Exhibit B, for those services provided herein.
The LHJ will advise the Program Contact identified in the applicable Statement of Work in writing 90 calendar
days prior to the end of the funded period, or as soon as practicable thereafter, if the LHJ anticipates not using all
Contract funding.
B. If the Exhibit A, Statement of Work, is supported by federal funds that require compliance with FFATA (the
Transparency Act), the corresponding checkbox on the statement of work will be checked.
C. Total consideration for this Contract is $79,038, or as amended.
The LHJ will submit accurate and timely billings which, for clarity and consistency, will be prepared using the
form provided and following the instructions located on the DOH website, www.doh.wa.gov.
DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for allowable
costs as outlined in the statement of work and/or budget.
2018-2020 Consolidated Contract Page 4 of 17
DOH CONTRACT #: CLH18249
D. The LHJ will submit a BARS A financial report by April 15 for the prior calendar year.
6. Contract Management
Unless otherwise specified in the Contract, the following individuals are the contacts ("Contract Coordinators") for all
notices required or permitted under this Contract:
LHJ Contract Coordinator:
DOH Contract Coordinator:
Name: Candi Blackford
Name: Brenda Henrikson
Mailing Address:
509 N. Nanum Street, Suite 102
Ellensburg WA 98926-2886
Title: Contracts Specialist
Mailing Address:
PO Box 47905, Olympia WA 98504-7905
Physical Address:
Physical Address:
Same as above
101 Israel Rd. SE, Tumwater WA 98501-5570
Phone: 509-962-7515 Fax: 509-962-7581
Phone: 360-236-3933 Fax: 360-236-2401
Email Address:
...........
Email Address:
candi.blackford@co.kittitas.wa.us
brenda.henrikson@doh.wa.gov
A party may change its Contract Coordinator or its Program Contact by providing written notice to the other party.
DOH Program Contacts can be found in the Exhibit A, Statements of Work, and on the DOH website at
www.doh.wa.gov.
7. Access to Records
To the extent authorized by applicable federal and state law, the parties shall provide access to records relevant to this
Contract to each other, the Joint Legislative Audit and Review Committee, the State Auditor, and authorized federal
officials, at no additional cost. Inspections shall occur at reasonable times and upon reasonable notice.
8. All Writings Contained Herein
This Contract contains all the terms and conditions agreed upon by the parties. No other understandings, oral or
otherwise, regarding the subject matter of this Contract shall be deemed to exist or to bind any of the parties hereto. The
individuals signing this Contract certify by their signatures that they are authorized to sign this Contract on behalf of
their respective entity.
9. Assignment
Except for subcontracting as authorized in this Contract, the LHJ shall not assign or delegate, in whole or in part, this
Contract or any of its rights, duties, obligations, or responsibilities, without the prior written consent of DOH's
Contracting Officer, which consent shall not be unreasonably withheld.
10. Assurances
The parties agree that all activity pursuant to this Contract shall be in accordance with all applicable current federal,
state and local laws, rules, and regulations.
The LHJ acknowledges its agreement to comply with federal certifications and assurances by signing and returning
the following:
1. Standard Federal Certifications and Assurances
2. Federal Assurances for Non -Construction Programs
2018-2020 Consolidated Contract Page 5 of 17
DOH CONTRACT #: CLH18249
11. Confidential Information
The parties agree to comply with all state and federal statutes and regulations relating to Confidential Information.
DOH and LHJ will limit access to the Confidential Information to the fewest number of people necessary to complete
the work. Everyone having access to Confidential Information covered by this Contract must agree to protect the
confidentiality of the information.
Either party to this Contract may designate certain Confidential Information as "Confidential Information/Notice
Requested." The designation shall be made by clearly stamping, watermarking, or otherwise marking each page of the
Confidential Information. If a third party requestor seeks information that has been marked "Confidential
Information/Notice Requested," notice shall be given to the marking party prior to release of the information. Such
notice shall be provided to the program contact no less than five (5) business days prior to the date of disclosure, to
allow the party objecting to disclosure to seek a protective order from the proper tribunal.
DOH and LHJ agree to establish, document and maintain security practices and safeguards consistent with state and
federal laws, regulations, standards, and guidelines to prevent unauthorized access, use, or disclosure of Confidential
Information in any form. In accordance with federal and state contracting requirements, DOH may monitor, audit, or
investigate LHJ management of Confidential Information relating to this Contract. Working together, the LHJ and
DOH may use any and all tools available to track Contract related Confidential Information.
If one of the parties becomes aware of an actual or suspected breach of confidentiality, that party will promptly notify
the Contract Coordinator for the other party of the facts. The parties will work within their respective organizations to
take any steps necessary to determine the scope of the breach and to restore reasonable security to the Confidential
Information. Both parties agree to mitigate any known harmful effects of a breach in confidentiality, including
notifying affected individuals to the extent required by law. The parties will also reasonably cooperate with law
enforcement as appropriate.
12. Ethics
Both parties and their officers shall comply with all ethics laws applicable to their activities under this Contract,
including Chapters 42.23 and 42.52 RCW. If a violation occurs and is not cured within a reasonable time after notice,
the other party shall have the right to terminate this Contract. This section is expressly subject to the Disputes section
of this Contract.
13. Debarment Certification
The LHJ, by signing this Contract, certifies that the LHJ is not presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participating in this Contract by any federal department
or agency. The LHJ also agrees to include the above requirement in all subcontracts into which it enters. The LHJ
will notify DOH of any such events that may occur during the term of the Contract.
14. Disputes
Except as otherwise provided in this contract, when a dispute arises between the parties and it cannot be resolved by
direct negotiation, the parties agree to participate in good faith in non-binding mediation. The mediator shall be
chosen by agreement of the parties. If the parties cannot agree on a mediator, the parties shall use a mediation service
located in Washington State that selects a qualified mediator for the parties. Each party shall bear its own costs for
mediation and each party shall contribute equally to the mediator's fee, if any. The parties agree that mediation shall
precede any action in a judicial tribunal.
Nothing in this contract shall be construed to limit the parties' choice of a mutually acceptable alternate dispute
resolution method in addition to the dispute resolution procedure outlined above.
15. Equipment Purchases
Equipment purchased by the LHJ for use by the LHJ or its subcontractors during the term of this Contract using
federal funds, in whole or in part, shall be the property of the LHJ. The use, management and disposal of the
equipment must comply with federal requirements. These requirements are found in the Office of Management and
2018-2020 Consolidated Contract Page 6 of 17
DOH CONTRACT #: CLH18249
Budget's (OMB's) Uniform Guidance, Title 2 Code of Federal Regulations Part 200 (2 CFR 200) - Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, or are included in the
federal funding agency's regulations.
16. Governing Law and Venue
The laws of the state of Washington govern this Contract. In the event of a lawsuit by the LHJ against DOH arising
under this Contract, venue shall be proper only in Thurston County, Washington. In the event of a lawsuit by DOH
against the LHJ arising under this Contract, venue shall be proper only in the county in which the LHJ is located or in
either of the two nearest judicial districts within the meaning of RCW 36.01.050.
17. Independent Capacity
The employees or agents of each party who are engaged in the performance of this Contract shall continue to be
employees or agents of that party and shall not be considered for any purpose to be employees or agents of the other
party.
18. Insurance
The LHJ certifies that it is self-insured, is a member of a risk pool, or maintains insurance coverage as required by this
Contract. Each party shall pay for losses for which it is found liable. The LHJ agrees to require all subcontractors to
maintain insurance in types and with limits as may be determined by the LHJ and/or its risk manager, unless the LHJ and
DOH agree otherwise.
19. Licensing, Accreditation and Registration
The LHJ shall comply with all applicable local, state, and federal licensing, accreditation and registration
requirements and standards, necessary for the performance of this Contract.
20. Maintenance of Records
Each party to this Contract shall maintain books, records, documents and other evidence that sufficiently and properly
reflect all direct and indirect costs expended by it. All books, records, documents, and other material relevant to this
Contract will be retained for six (6) years after expiration. If any litigation, claim or audit is started before the
expiration of the six-year period, the records shall be retained until all litigation, claims, or audit findings involving
the records have been resolved.
Each party will use reasonable security procedures and protections to assure that records and documents provided by
the other party are not erroneously disclosed to third parties. Both parties agree to continue protecting records until
such time as the information is destroyed in accordance with applicable state and federal records retention laws.
21. Modifications and Waivers
This Contract, or any term or condition, may be modified only by a written amendment signed by the DOH
Contracting Officer and the authorized representative for the LHJ. Either party may propose an amendment.
Failure or delay on the part of either party to exercise any right, power, privilege or remedy provided under this Contract
shall not constitute a waiver. No provision of this Contract may be waived by either party except in a writing signed by the
DOH Contracting Officer or the authorized representative of the LHJ.
22. No Third -Party Rights Created
This Contract, or any program hereunder, is entered into solely for the benefit of the two parties thereto and shall not
be construed as giving rise to any right, remedy or expectancy of any kind or nature on the part of any third party.
23. Nondiscrimination
During the performance of this Contract, the LHJ and DOH shall comply with all federal and state nondiscrimination
laws, regulations and policies. In the event of the LHJ's noncompliance or refusal to comply with any nondiscrimination
law, regulation or policy, this Contract may be rescinded, canceled or terminated in whole or in part, and the LHJ may be
2018-2020 Consolidated Contract Page 7 of 17
DOH CONTRACT #: CLH18249
declared ineligible for further contracts with DOH. The LHJ shall, however, be given a reasonable time in which to cure
this noncompliance. Any dispute may be resolved in accordance with the "Disputes" procedure set forth herein.
24. Order of Precedence
In the event of an inconsistency in the terms of this Contract, or between its terms and any applicable statute or rule,
the inconsistency shall be resolved by giving precedence in the following order:
• Applicable state and federal statutes, and local laws, rules and regulations.
• Terms and conditions of this Contract.
• Statements of Work.
• Any other provisions of this Contract, including other materials incorporated by reference.
25. Ownership of Material/Rights in Data
Records and other documents relevant to this Contract, in any medium, furnished by one party to this Contract to the
other party, will remain the property of the furnishing party, unless otherwise agreed. Data which is delivered under
the Contract shall be transferred to DOH with a nonexclusive, royalty -free, perpetual, irrevocable license to publish,
translate, reproduce, modify, deliver, perform, dispose of, and to authorize others to do so; provided that such license
shall be limited to the extent which the LHJ has a right to grant such a license. The LHJ shall exert all reasonable
effort to advise DOH, at the time of delivery of data furnished under this Contract, of all known or potential invasions
of privacy contained therein and of any portion of such document which was not produced in the performance of this
Contract. DOH shall receive prompt written notice of each notice or claim or copyright infringement received by the
LHJ with respect to any data delivered under this Contract. DOH shall have the right to modify or remove any
restrictive markings placed upon the data by the LHJ, provided that if DOH modifies or removes such markings
without the LHJ's approval, it assumes all liability for doing so.
26. Publications
Any program reports, articles, and publications that result from information gathered through use of state and federal
funds must acknowledge receiving support from DOH and/or the appropriate federal agencies. Correspondingly, such
documents resulting from information gathered through use of local funds must acknowledge receipt of such local
support.
27. Responsibility for Actions
Each party to this Contract shall be solely responsible for the acts and omissions of its own officers, employees, and
agents in the performance of this Contract. Neither party to this Contract will be responsible for the acts and
omissions of entities or individuals not party to this Contract. DOH and the LHJ shall cooperate in the defense of tort
lawsuits, when possible.
28. Loss or Reduction of Funding
In the event funding from state, federal, or other sources is withdrawn, reduced, or limited in any way after the
effective date of this contract and prior to normal completion, DOH may elect to suspend or terminate the contract, in
whole or in part, under the "Termination for Convenience" clause with a ten (10) business day notice to LHJ, to the
extent possible, subject to renegotiation at DOH's discretion under those new funding limitations and conditions.
29. Severability
If any term or condition of this Contract is held invalid, such invalidity shall not affect the validity of the other terms
or conditions of this Contract, provided, however, that the remaining terms and conditions can still fairly be given
effect.
30. Subcontracts
The LHJ may subcontract any or all of the services or other obligations specified in this Contract. The LHJ will
require the subcontractor to comply with all the applicable terms and conditions of this Contract, including all terms,
conditions, certifications and assurances. The LHJ agrees it is responsible for assuring adequate performance on the
part of the subcontractor.
2018-2020 Consolidated Contract Page 8 of 17
DOH CONTRACT #: CLH18249
The parties agree that all subcontractors must be responsible for any liabilities created by their actions or omissions.
In the event DOH, LHJ, and subcontractor are found by a jury or trier of fact to be jointly and severally liable for
personal injury damages arising from any act or omission, then each entity shall be responsible for its proportionate
share.
31. Subrecipient
For those activities designated as "subrecipient" on Exhibit A, Statements of Work, the LHJ must comply with
applicable federal requirements, including but not limited to OMB's Uniform Guidance at 2 CFR 200, Subparts D
(Administrative Requirements), E (Cost Principles) and F (Audit Requirements), and program specific federal
regulations. If the LHJ expends $500,000 or more in federal awards from all sources, it is responsible for obtaining
appropriate audits. If the LHJ expends $750,000 or more in federal grants or awards from all sources, it is responsible
for obtaining the required single audit.
32. Survivability
The terms and conditions contained in this Contract, which by their sense and context are intended to survive the
expiration of the Contract, shall survive. Surviving terms include, but are not limited to: Access to Records,
Confidential Information, Disputes, Responsibility for Actions, Maintenance of Records, Ownership of
Material/Rights in Data, Subcontracts, Termination for Convenience, Termination for Default, and Termination
Procedure.
33. Term
This Contract will be in effect following execution by the parties from January 1, 2018 through December 31, 2020,
unless terminated earlier as provided herein.
34. Termination for Convenience
Except as otherwise provided in this Contract, either party may terminate or suspend this Contract, or any program
hereunder, for convenience by providing at least thirty (30) days' advance written notice to the other party.
If DOH elects to suspend the Contract, in whole or in part, LHJ shall stop work as of the effective date of DOH's
written notice of suspension. During suspension, each Party will reasonably notify the other of any conditions that
may affect resumption of performance. Upon DOH's written notice to resume performance, LHJ shall resume work
unless the LHJ provides notice to DOH that services cannot be resumed. If LHJ cannot resume performance, the
Contract or affected Exhibit A, Statement of Work, will be deemed terminated upon the date the LHJ received notice
to suspend performance.
35. Termination for Default
(a) In the event of a default by either party under this Contract, the nondefaulting party may give written notice to the
defaulting party that it intends to terminate this Contract, or any program hereunder, if the default is not cured
within thirty (30) days of the date of the notice, or such longer period of time as may be reasonable under the
circumstances. If the default is not cured within that time, the nondefaulting party may then notify the defaulting
party in writing that this Contract is terminated. In the event of such termination, the nondefaulting party shall
have all rights and remedies available to it under general law.
(b) A disputed termination for default is expressly subject to the Disputes section of this Contract.
36. Termination Procedure
Upon termination DOH may require the LHJ to deliver to DOH any non-LHJ-owned equipment, data, or other
property specifically produced or acquired for the performance of such part of this Contract as has been terminated.
DOH shall pay to the LHJ the agreed upon price, if separately stated, for completed work and services accepted by
DOH. In addition DOH shall pay the amount determined by DOH's Contracting Officer for (a) completed work and
services for which no separate price is stated, (b) partially completed work and services, (c) other property or services
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DOH CONTRACT #: CLH18249
which are accepted by DOH, and (d) the protection and preservation of the property. Disagreement by the LHJ with
the determination of DOH's Contracting Officer that relates to the obligations or amounts due to the LIU shall be
considered a dispute within the meaning of the "Disputes" clause of this Contract.
DOH may withhold from any amounts due the LHJ for such completed work or services such sum as DOH's
Contracting Officer reasonably determines to be necessary to protect DOH against potential loss or liability.
The rights and remedies of DOH provided in this section shall not be exclusive and are in addition to any other rights
and remedies provided by law or under this Contract.
After receipt of a written notice of termination, the LHJ shall:
• Stop work under the Contract on the date and to the extent specified in the notice;
• Place no further orders or subcontracts for materials, services, or facilities, except as necessary to complete
such portion of the work not terminated;
• Assign to DOH, to the extent reasonably directed by DOH's Contracting Officer and to the extent that the LHJ
has the legal right to do so, all of the right, title, and interest of the LHJ under the orders and subcontracts in
which case DOH has the right, at its reasonable discretion, to settle or pay any or all claims arising out of the
termination of such orders and subcontracts.
• Settle all outstanding liabilities and all claims arising out of orders or subcontracts, with the approval or
ratification of DOH's Contracting Officer to the extent he/she may reasonably require, which approval or
ratification shall be final for all the purposes of this clause;
■ Transfer title to DOH and deliver, as reasonably directed by DOH's Contracting Officer, any property which, if
the Contract had been completed, would have been required to be furnished to DOH;
• Complete performance of such part of the work not terminated by DOH's Contracting Officer; and,
• Take such action as may be necessary, or as DOH's Contracting Officer may reasonably direct, for the
protection and preservation of the property related to this Contract which is in the possession of the LHJ, or its
subcontractors, and in which DOH has or may acquire an interest.
IN WITNESS WHEREOF, the parties have executed this Contract.
KITTITAS COUNTY PUBLIC HEALTH STATE OF WASHINGTON
DEPARTMENT DEPARTMENT OF HEALTH
Signature
Title:
Print Name:
Date:
Signature
Title:
Print Name:
Date:
2018-2020 Consolidated Contract Page 10 of 17
DOH CONTRACT #: CLH 18249
Standard Federal Certifications and Assurances
Following are the Assurances, Certifications, and Special Conditions that apply to all federally -funded (in whole or in
part) agreements administered by the Washington State Department of Health.
CERTIFICATIONS
1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
The undersigned (authorized official signing for the contracting organization) certifies to the best of his or her
knowledge and belief, that the contractor, defined as the primary participant in accordance with 45 CFR Part 76, and
its principals:
A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal Department or agency;
Have not within a 3 -year period preceding this contract been convicted of or had a civil judgment rendered
against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
B. Are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or
local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and
C. Have not within a 3 -year period preceding this contract had one or more public transactions (Federal, State, or
local) terminated for cause or default.
Should the contractor not be able to provide this certification, an explanation as to why should be placed after the
assurances page in the contract.
The contractor agrees by signing this contract that it will include, without modification, the clause titled Certification
Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion --Lower Tier Covered Transactions in all
lower tier covered transactions (i.e., transactions with sub- grantees and/or contractors) and in all solicitations for
lower tier covered transactions in accordance with 45 CFR Part 76.
2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
The undersigned (authorized official signing for the contracting organization) certifies that the contractor will, or will
continue to, provide a drug-free workplace in accordance with 45 CFR Part 76 by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession
or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be
taken against employees for violation of such prohibition;
B. Establishing an ongoing drug-free awareness program to inform employees about:
1) The Dangers of drug abuse in the workplace;
2) The contractor's policy of maintaining a drug-free workplace;
3) Any available drug counseling, rehabilitation, and employee assistance programs; and
4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
C. Making it a requirement that each employee to be engaged in the performance of the contract be given a copy of
the statement required by paragraph 1) above;
2018-2020 Consolidated Contract Page 11 of 17
DOH CONTRACT #: CLH 18249
D. Notifying the employee in the statement required by paragraph 1), above, that, as a condition of employment
under the contract, the employee will:
1) Abide by the terms of the statement; and
2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring
in the workplace no later than five calendar days after such conviction;
E. Notifying the agency in writing within ten calendar days after receiving notice under paragraph D. 2) from an
employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must
provide notice, including position title, to every contract officer or other designee on whose contract activity the
convicted employee was working, unless the Federal agency has designated a central point for the receipt of
such notices. Notice shall include the identification number(s) of each affected grant;
F. Taking one of the following actions, within 30 calendar days of receiving notice under paragraph D. 2) with
respect to any employee who is so convicted:
1) Taking appropriate personnel action against such an employee, up to and including termination,
consistent with the requirements of the Rehabilitation Act of 1973, as amended; or
2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate
agency;
G. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs
(A), (B), (C), (D), (E), and (F).
For purposes of paragraph (E) regarding agency notification of criminal drug convictions, DOH has designated
the following central point for receipt of such notices:
Compliance and Internal Control Officer
Office of Grants Management
WA State Department of Health
PO Box 47905
Olympia, WA 98504-7905
3. CERTIFICATION REGARDING LOBBYING
Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence certain
Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative
agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the
Federal Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires
that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying
undertaken with non -Federal (nonappropriated) funds. These requirements apply to grants and cooperative
agreements EXCEEDING $100,000 in total costs (45 CFR Part 93).
The undersigned (authorized official signing for the contracting organization) certifies, to the best of his or her
knowledge and belief, that:
A. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of
any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
B. If any funds other than Federally appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer
or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract,
grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -LLL,
"Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, Standard Form -LLL,
2018-2020 Consolidated Contract Page 12 of 17
DOH CONTRACT #: CLH 18249
"Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this
application form.)
C. The undersigned shall require that the language of this certification be included in the award documents for all
subcontracts at all tiers (including subcontracts, subcontracts, and contracts under grants, loans and cooperative
agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by Section 1352, U.S. Code. Any person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA)
The undersigned (authorized official signing for the contracting organization) certifies that the statements herein are
true, complete, and accurate to the best of his or her knowledge, and that he or she is aware that any false, fictitious,
or fraudulent statements or claims may subject him or her to criminal, civil, or administrative penalties. The
undersigned agrees that the contracting organization will comply with the Public Health Service terms and
conditions of award if a contract is awarded.
5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Public Law 103-227, also known as the Pro -Children Act of 1994 (Act), requires that smoking not be permitted in
any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for
the provision of health, day care, early childhood development services, education or library services to children
under the age of 18, if the services are funded by Federal programs either directly or through State or local
governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are
provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not
apply to children's services provided in private residence, portions of facilities used for inpatient drug or alcohol
treatment, service providers whose sole source of applicable Federal funds is Medicare or Medicaid, or facilities
where WIC coupons are redeemed.
Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to
$1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.
By signing the certification, the undersigned certifies that the contracting organization will comply with the
requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision
of services for children as defined by the Act.
The contracting organization agrees that it will require that the language of this certification be included in any
subcontracts which contain provisions for children's services and that all subrecipients shall certify accordingly.
The Public Health Services strongly encourages all recipients to provide a smoke-free workplace and promote the
non-use of tobacco products. This is consistent with the PHS mission to protect and advance the physical and
mental health of the American people.
6. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS - INSTRUCTIONS FOR CERTIFICATION
By signing and submitting this proposal, the prospective contractor is providing the certification set out below.
A. The inability of a person to provide the certification required below will not necessarily result in denial of
participation in this covered transaction. The prospective contractor shall submit an explanation of why it
cannot provide the certification set out below. The certification or explanation will be considered in connection
with the department or agency's determination whether to enter into this transaction. However, failure of the
prospective contractor to furnish a certification or an explanation shall disqualify such person from participation
in this transaction.
2018-2020 Consolidated Contract Page 13 of 17
DOH CONTRACT #: CLH18249
B. The certification in this clause is a material representation of fact upon which reliance was placed when the
department or agency determined to enter into this transaction. If it is later determined that the prospective
contractor knowingly rendered an erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for cause of default.
C. The prospective contractor shall provide immediate written notice to the department or agency to whom this
contract is submitted if at any time the prospective contractor learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
D. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have
the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order
12549. You may contact the person to whom this contract is submitted for assistance in obtaining a copy of
those regulations.
E. The prospective contractor agrees by submitting this contract that, should the proposed covered transaction be
entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred,
suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless
authorized by DOH.
F. The prospective contractor further agrees by submitting this contract that it will include the clause titled
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -- Lower Tier Covered
Transaction, provided by HHS, without modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
G. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals. Each participant may, but is not required to,
check the Nonprocurement List (of excluded parties).
H. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is
not required to exceed that which is normally possessed by a prudent person in the ordinary course of business
dealings.
I. Except for transactions authorized under paragraph 6. of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available
to the Federal Government, DOH may terminate this transaction for cause or default.
7. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS - PRIMARY COVERED TRANSACTIONS
A. The prospective contractor certifies to the best of its knowledge and belief, that it and its principals:
1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal department or agency;
2) Have not within a three-year period preceding this contract been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public
transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving stolen property;
3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State or local) with commission of any of the offenses enumerated in paragraph 1. B. of this certification;
and
2018-2020 Consolidated Contract Page 14 of 17
DOH CONTRACT #: CLH18249
4) Have not within a three-year period preceding this contract had one or more public transactions (Federal,
State or local) terminated for cause or default.
B. Where the prospective contractor is unable to certify to any of the statements in this certification, such
prospective contractor shall attach an explanation to this contract.
AUTHORIZED SIGNATURE REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
TITLE
PLEASE PRINT OR TYPE NAME:
ORGANIZATION NAME: (if applicable)
DATE
2018-2020 Consolidated Contract Page 15 of 17
DOH CONTRACT #: CLH18249
Federal Assurances — Non -Construction Programs
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0040), Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please
contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the contractor, I certify that the contractor:
1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability
(including funds sufficient to pay the non -Federal share of project cost) to ensure proper planning, management, and
completion of the project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through
any authorized representative, access to and the right to examine all records, books, papers, or documents related to
the award; and will establish a proper accounting system in accordance with generally accepted accounting standards
or agency directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents
the appearance of personal or organizational conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. -11 :4728-4763) relating to prescribed
standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A
of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI
of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national
origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. C- 71681-1683, and 1685-1686),
which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29
U.S.C. 1794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. C 7 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office
and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f)
the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-
616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) 7 C 523 and 527 of
the Public Health Service Act of 1912 (42 U.S.C. :1 C 290 dd-3 and 290 ee 3), as amended, relating to confidentiality
of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 7 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination
provisions in the specific statute(s) under which application for Federal assistance is being made; and 0) the
requirements of any other nondiscrimination statute(s) which may apply to the application.
7. Will comply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of
persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These
requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in
purchases.
2018-2020 Consolidated Contract Page 16 of 17
DOH CONTRACT #: CLH18249
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. _ �] 1501-1508 and 7324-7328) which limit
the political activities of employees whose principal employment activities are funded in whole or in part with Federal
funds.
9. Will comply, as applicable, with the provisions of the Davis -Bacon Act (40 U.S.C. U U276a to 276a-7), the Copeland
Act (40 U.S.C. C276c and 18 U.S.C. U U 874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. LI E.
327-333), regarding labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. E 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans
under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. :1 -17401 et seq.); (g) protection of
underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and
(h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 0-11721 et seq.) related to protecting
components or potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of
1966, as amended (16 U.S.C. 0470), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C. :1 ❑469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and
related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. C L2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities
supported by this award of assistance.
16. Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C. :1 E 480 et seq.) which prohibits the use
of lead-based paint in construction or rehabilitation of residence structures.
17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Uniform Guidance at 2 CFR 200, Subpart F.
18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies
governing this program.
AUTHORIZED SIGNATURE REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL 1 TITLE
PLEASE PRINT OR TYPE NAME
ORGANIZATION NAME (if applicable) I DATE
2018-2020 Consolidated Contract Page 17 of 17
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Federal Funding Accountability and Transparency Act Data Collection Form
This contract is supported by federal funds that require compliance with the Federal Funding Accountability and
Transparency Act. The purpose of the Transparency Act is to make information available online so the public can see
how federal funds are spent. To comply with the act and be eligible to enter into this contract, your organization must
have a Data Universal Numbering System (DUNS®) number. If you do not already have one, you may receive a DUNS®
number free of charge by contacting Dun and Bradstreet at www.dnb.coni. The Department of Health (DOH) also
encourages registration with the System for Award Management (SAM) to reduce data entry by both DOH and your
organization. You may register with SAM free of charge at federalcontractorregistry.com. Information about your
organization and this contract will be reported by DOH to the federal government as required by P.L. 109-282. This
information will then be made available to the public by the federal government on USASpending.gov.
SUBRECIPIENT
1. Legal Name
2. DUNS Number
3. Principle Place of Performance
3a. City
3b. State
3c. Zip+4
3d. Country
4. Are you registered in SAM? ❑YES (skip to signature block. Sign, date and return) ❑NO
5. In the preceding fiscal year did your organization:
a. Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans,
subgrants, and/or cooperative agreements; and
b. $25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans,
subgrants, and/or cooperative agreements; and
c. The public does not have access to this information about the compensation of the senior executives of
your organization through periodic reports filed under section 13(a) or 15(d) of the Securities and
Exchange Act of 1934 (15 U.S.C. §§ 78m(a), 78o(d) or section 6104 of the Internal Revenue Code of
1986.
❑NO (skip to signature block. Sign, date and return)
❑YES (You must report the names and total compensation of the top 5 highly compensated officials of your
organization).
Name Of Official Total Compensation
1.
2.
3.
4.
5.
Note: "Total compensation" for purposes of this requirement generally means the cash and non-cash value earned
by the executive during the past fiscal year and includes salary and bonus; awards of stock, stock options and stock
appreciation rights; and other compensation such as severance and termination payments, and value of life
insurance paid on behalf of the employee, and as otherwise provided by FFATA and applicable OMB guidance.
iiy signing this document the Authorized Representative attests to the information.
Signature of Authorized Representative Print Name Date
The Department of Health will not endorse your sub -award until this form is completed and returned.
11Pagc (5, 2 01 6)
Federal Funding Accountability and Transparency Act Data Collection Form
FOR DEPARTMENT OF HEALTH USE ONLY
DOH Contract Number
CLH18249
Sub -award Project Description (see instructions and example below)
Instructions for Sub -award Project Description:
In the first line of the description provide a title for the sub -award that captures the main purpose of the subrecipients
work. Then, indicate the name of the subrecipient and provide a brief description that captures the overall purpose of the
sub -award, how the funds will be used, and what will be accomplished.
Example of a Sub -award Project Description:
Increase Healthy Behaviors: Educational Services District XYZ will provide training and technical assistance to chemical
dependency centers to assist the centers to integrate tobacco use into their existing addiction treatment programs.
Funds will also be used to assist centers in creating tobacco free treatment environments.
21Pagc
(5/20 16 )
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