HomeMy WebLinkAboutPSA between Kittitas County Public Health and Comm Health of Central WAPROFESSION*L SERVICES AGREEMENT
Between
KITTITA COUNTY PUBLIC HEALTH
And
COMMUNITY HEALTH OF CENTRAL WASIllNGTON
This Agreement dated as of October 1, 2016 is made by and between Kittitas County (hereinafter
"the County") and Community Health of Central Washington (hereinafter "Contractor"). The County and
Contractor agree as follows:
General Conditions;
Exhibit A (Scope of Work);
Exhibit B (Compensation);
Exhibit C (Proof of Insurance);
Exhibit D (2015-2017 Consolidated Contract #C17114, between Kittitas County
and the Washington State Department of Health)
Exhibit E (CSHCN Quarterly MCHBG Reporting Form)
Copies of which are attached hereto and incorporated herein by this reference as fully as if set forth herein.
The following documents and/or laws are incorporated by reference as fully as if set forth herein:
• HRSA -Title V Maternal and Child Health Services Block Grant Program
hrtp :J/mchb.hrsa .gov/pro!;rams /titlevgran tsi index.htmL
• Social Security Act Title V Laws:
bttp ://www.s a.gov/OP Home/ssact/title05/0500.htm
The term of this Agreement shall commence on October 1,2016 and continue until September 30,
2017 Any party may terminate this Agreement by giving thirty (30) days notice in writing either personally
delivered or mailed postage-prepaid by certified mail, return receipt requested, to the party's last known
address for the purposes of giving notice under this paragraph.
Contractor acknowledges and by signing this Agreement agrees that the Indemnification provisions
set forth in Paragraphs 7 (Independent Contractor), 9 (Taxes), 15 (Defense and Indemnity Agreement), 21
(Patent/Copyright Infringement) and 24 (Confidentiality), are totally and fully part of this Agreement and
have been mutually negotiated by the parties .
Professional Services Agreement
Page I
eN W lTNESS WHE REO ,til e pru1ie have e ecuted thi s Agreement thi '-f11 a.y of OeiohtJ':2016.
COMMUNITY HEALTH OF
CENTRAL WASHINGTON
Contractor Address:
Community Health of Central Washington
501 S 5th Ave.
Yakima, W A 98902
Contractor DUNS:
86-798-2324
Project Contact:
Paul Kaschmitter
Professional Services Agreement
Page 2
APPROVED:
BOARD OF COUNTY COMMISSIONERS
KITTITAS COUNTY, WASHINGTON
~ Oble Bri e n, Cha inna n
ABSTAINED
. Paul Jewell , Vice-Chaitman
Commissioner
County's Address:
Kittitas County Public Health Department
205 West 5th Avenue, Suite 108
Ellensburg, W A 98926
County's DUNS:
01-020-2547
Project Contact:
Kasey Knutson
--
GENERAL CONDITIONS
1. Scope of Contractors Service :
Contractor agrees to provide to the County services and any materials set forth in the project narrative
identified in Exhibit "A" during the Agreement period. No material, labor, or facilities will be furnished by
the County, unless otherwise provided for in the Agreement.
2. Performance of Work:
Contractor shall perform work in accordance with, and shall comply with, all of the provisions of this
Agreement. All work shall comply with applicable codes, ordinances and the Consolidated Contract (Exhibit
D).
3. Schedule of Performance:
Unless directed otherwise by the County, Contractor shall perform the work In accordance with any
schedules made a part of this Agreement.
4. Definitions:
4.l "Additional Insured's" means the County, its successors and assigns, and
the respective directors, officers, employees, agents and representatives of the County and its
successors and assigns.
4.2 "Support" means the following: Contractor's directors, officers, employees, agents and
representatives; and sub-Contractors of any tier; the respective directors, officers,
employees, agents and representatives of these sub-Contractors of any tier; and any other
person or entity acting under the direction or control of, or on behalf of, Contractor or any
Contractor's sub-Contractors of any tier in connection with or incident to the performance of
the Work or this Agreement.
4.3 The "Work" means all of the duties listed in Exhibit A and the performance of all other
obligations, under this Agreement by Contractor or its Support.
5. AccouIlting and Payment for Contractor Serv ices:
Payment to the Contractor for services rendered under this Agreement shall be as set forth in Exhibit
"B". Where Exhibit "B" requires payments by the County, payment shall be based upon billings, supported
unless otherwise provided in Exhibit "B", by documentation of units of work actually performed and amounts
earned, including where appropriate, the actual number of days worked each month, total number of hours for
the month, and the total dollar payment requested. Unless specifically stated in Exhibit "B" or approved in
writing in advance by the Kittitas County Board of Commissioners, the County will not reimburse the
Contractor for any costs or expenses incurred by the Contractor in performance of this Agreement.
Where required, the County shall, upon receipt of appropriate documentation, compensate the Contractor, no
more often than monthly, through the County voucher system, for the Contractor's service pursuant to the fee
schedule set forth in Exhibit "B".
6. Assignment and Subc('mtracting :
No portion of this Agreement may be assigned or subcontracted to any other individual, firm or entity
without the express and prior written approval of the County.
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Page 3
7. Ind e gend e nt Contractor:
The Contractor's services shall be furnished by the Contractor as an independent Contractor and nothing
herein contained shall be construed to create a relationship of employer-employee or master-servant, but all
payments made hereunder and all services performed shall be made and performed pursuant to this
Agreement by the Contractor as an independent Contractor.
The Contractor acknowledges that the entire compensation for this Agreement is specified in Exhibit "B" and
the Contractor is not entitled to any County benefits including, but not limited to: vacation pay, holiday pay,
sick leave pay, medical, dental, or other insurance benefits, or any other rights or privileges afforded to
Kittitas County employees.
Contractor will defend, indemnify and hold harmless the County, its Additional Insured's, officers, agents or
employees from any loss or expense, including but not limited to settlements, judgments, setoffs, attorneys'
fees or costs incurred by reason of claims or demands because of breach of the provisions of this paragrdph.
8. No G ua ra nt e o f E mploymen t:
The performance of all or part of this Agreement by the Contractor shall not operate to vest any employment
rights whatsoever and shall not be deemed to guarantee any employment of the Contractor or any employee
of the Contractor or any sub-Contractor or any employee of any sub-Contractor by the County at the present
time or in the future.
9. Taxes:
The Contractor understands and acknowledges that the County will not withhold Federal or State income
taxes. Where required by State or Federal law , the Contractor authorizes the County to make withholding for
any taxes other than income taxes (i.e. Medicare). All compensation received by the Contractor will be
reported to the Internal Revenue Service at the end ofthe calendar year in accordance with the applicable IRS
regulations. It is the responsibility of the Contractor to make the necessary estimated tax payments
throughout the year, if any, and the Contractor is solely liable for any tax obligation arising from the
Contractor's performance of this Agreement. The Contractor hereby agrees to indemnify the County against
any demand to pay taxes arising from the Contractor's failure to pay taxes on compensation earned pursuant
to this Agreement.
The County will pay sales and use taxes imposed on goods or services acquired hereunder as required by law.
The Contractor must pay all other taxes including, but not limited to: Business and Occupation Tax, taxes
based on the Contractor's gross or net income, or personal property to which the County does not hold title.
The County is exempt from Federal Excise Tax.
10. RegUlati ons an d Requirement:
This Agreement shall be subject to all laws, rules and regulations of the United States of America, and State
of Washington, and political subdivisions of the State of Washington and to any other provisions set forth
herein or in the attached exhibits. The Contractor agrees to comply with all terms and conditions of the
Consolidated Contract (Exhibit D), including all terms, conditions, assurances and certifications for the tasks
subcontracted in the Scope of Work (Exhibit A).
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11. Righ t to Revie w:
This contract is subject to review by any Federal or State auditor. The 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 the 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 the County deems pertinent to the Agreement and its performance, and any and all communications
with or evaluation by service recipients under this Agreement. The Contractor shall preserve and maintain all
financial records and records relating to the performance of work under this Agreement for 6 years after
contract termination, and shall make them available for such review, within Kittitas County, State of
Washington, upon request.
12. Modifications:
12.1 Either party may request changes in the Agreement. Any and all agreed modifications shall
be in writing, signed by each of the parties.
12.2 The County may, at any time, by written notice thereof to Contractor ("Change Notice")
make changes in the Work within the general scope of this Agreement, including, but not
limited to: (a) changes in, revisions to, substitutions for, additions to or deletions of any
Work; (b) changes in schedule; and (c) acceleration, deceleration or suspension of
performance of any Work.
12.3 If any change in the Work causes an increase or decrease on Contractor's cost of, or the time
required for, performance of the Work, an equitable adjustment in the compensation to
Contractor and in the schedule for the performance of the Work shall be made to reflect such
an increase or decrease.
12.4 Notwithstanding any dispute or delay in arnvmg at a mutually acceptable equitable
adjustment, Contractor shall proceed in accordance with all Change Notices. Contractor
must, within thirty (30) days after receipt of any Change Notice that does not set forth any
acceptable adjustment, submit to the County a written statement setting forth any adjustment
claimed.
12.5 If any change results in a decrease in the Work performed, Contractor shall be entitled to
compensation associated with changing the Work, such as revising design already
completed, revising calculations already performed, and revising documents.
13. Termination for Default:
If the Contractor defaults by failing to perform any of the obligations of the Agreement or becomes insolvent
or is declared bankrupt or commits any act of bankruptcy or insolvency or makes an assignment for the
benefit of creditors, the County may, by depositing written notice to the Contractor in the U.S. mail, postage
prepaid, terminate the Agreement, and at the County's option, obtain performance of the work elsewhere. If
the Agreement is terminated for default, the 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 the
County resulting from such default(s) shall be deducted from any money due or coming due to the
Contractor. The Contractor shall bear any extra expenses incurred by the County in completing the work, and
all damage sustained, or which may be sustained by the County by reason of such default.
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If a notice of tennination for default has been issued and it is later detennined for any reason that the
Contractor was not in default, the rights and obligations of the parties shall be the same as if the notice of
tennination had been issued pursuant to the Termination for Public Convenience paragraph hereof.
14. Termination for Public Convenience:
The County may tenninate the Agreement in whole or in part whenever the County determines, in its sole
discretion that such termination is in the best interests of the County. Whenever the Agreement is terminated
in accordance with this paragraph, the Contractor shall be entitled to payment for actual work performed at
unit contract prices for completed items of work. In the event of such termination, an equitable adjustment
shall be made in the compensation payable to Contractor.
An equitable adjustment in the contract price for partially completed items of work will be made, but such
adjustment shall not include provision for loss of anticipated profit on deleted or uncompleted work.
Termination of this Agreement by the County at any time during the term, whether for default or
convenience, shall not constitute a breach of contract by the County.
15. Defen e & Indemnity Agreement:
The Contractor agrees to and shall defend, indemnify and hold harmless the County, its Additional Insured's,
appointed and elective officers, agents and employees, from and against all loss or expense, including but not
limited to judgments, settlements, attorney's fees and costs by reason of any and all claims and demands upon
the County, its Additional Insured's, its elected or appointed officials, agents, or employees for damages
because of personal or bodily injury, including death at any time resulting therefrom, sustained by any person
or persons and on account of damage to property including loss of use thereof, whether such injury to persons
or damage to property is due to the negligence of the Contractor, its sub-Contractors, its elected officers,
employees or their agents, except only such injury or damage as shall have been occasioned by the sole
negligence of the County, its Additional Insured's, appointed or elected officials, agents, or employees. It is
further provided that no liability shall attach to the County by reason of entering into this contract, except as
expressly provided herein.
16. Industrial Insurance Waiver:
With respect to the performance of this Agreement and as to claims against the County, its Additional
Insured's, 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 hannless 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.
17. Venue and Choice of Law:
In the event that any litigation should arise concerning the construction or interpretation of any of the terms of
this Agreement, the venue of such action of litigation shall be in the Superior Court of the State of
Washington in and for the County of Kittitas. This Agreement shall be governed by the law of the State of
Washington.
18. Withh0Lding, Pavment:
In the event the Contractor has failed to perform any obligation to be performed by the Contractor under this
Agreement within the time set forth in this Agreement, then the County may, upon written notice, withhold
all monies due and payable to Contractor, without penalty, until such failure to perfonn is cured or otherwise
adjudicated.
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19. Future Non-Allocation of Funds:
If sufficient funds are not appropriated or allocated for payment under this Agreement for any future fiscal
period, the County will not be obligated to make payments for services or amounts incurred after the end of
the current fiscal period. No penalty or expense shall accrue to the County in the event this provision applies.
20. Co ntract r Co mmitments, Warranti es an d Re prese ntations:
The Contractor represents and warrants to the County as follows:
20 .1 The Contractor is duly incorporated, validly existing and in good standing under the
laws of the State of Washington , and has all requisite corporate power and authority to
enter into and to perform its obligations under this Agreement.
20.2 The Contractor has the authority to execute this Agreement, to make the representations
and warranties set forth in it and to perform the obligations of the Contractor under this
Agreement in accordance with its terms .
20.3 This Agreement has been validly executed by an authorized representative of the
Contractor and constitutes a valid and legally binding and enforceable obligation of
Contractor.
20.4 The Contractor has or will obtain prior to the commencement date such licenses,
permits and other authorizations from federal, state and other governmental authorities,
as are necessary for the performance of its obligations under this Agreement.
20.5 The Contractor is not in violation of any applicable law, ordinance or regulation the
consequence of which will or may materially affect Contractor's ability to perform its
obligations under this Agreement. The Contractor is not subject to any order or
judgment of any court, tribunal or governmental agency which materially and adversely
affects its operations or assets in the State of Washington , or its ability to perform its
obligations under this Agreement.
20.6 None of the representations or warranties in this Agreement, and none of the documents ,
statements, certificates or schedules furnished or to be furnished by Contractor pursuant
hereto or in connection with the performance of the obligations contemplated under this
Agreement, contains or will contain any untrue statement of a material fact or omits or
will omit to state a material fact necessary to make the statements of fact contained
therein not misleading.
21. Patent; o pyri ght l nfri ngement:
Contractor will defend and indemnifY the County from any claimed action , cause or demand brought against
the County; to the extent such action is based on the claim that information supplied by the Contractor
infringes any patent or copyright. The Contractor will pay those costs and damages attributable to any such
claims that are finally awarded against the County in any action. Such defense and payments are conditioned
upon the following:
21 .1 Contractor shall be notified promptly in writing by County of any notice of such claim .
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21.2 Contractor shall have the right, hereunder, at its option and expense, to obtain for the County
the right to continue using the information, in the event such claim of infringement is made,
provided no reduction in performance or loss results to the County.
22. Disputes:
22.1 General
Differences between the Contractor and the County, arising under and by virtue of the
Agreement Documents shall be brought to the attention of the County at the earliest possible
time in order that such matters may be settled or other appropriate action promptly taken.
Except for such objections as are made of record in the manner hereinafter specified and
within the time limits stated, the records, orders, instructions, and decisions of the Kittitas
County Commissioners shall be final and conclusive.
22.2 Notice of Potential Claims
The Contractor shall not be entitled to additional compensation which otherwise may be
payable, or to extension of time for (1) any act or failure to act by the County, or (2) the
happening of any event or occurrence, unless the Contractor has given the County a written
Notice of Potential Claim within ten (10) days of the commencement of the act, failure, or
event giving rise to the claim, and before final payment by the County. The written Notice of
Potential Claim shall set forth the reasons for which the Contractor believes additional
compensation or extension of time is due, the nature of the cost involved, and insofar as
possible, the amount of the potential claim. Contractor shall keep full and complete daily
records of the work performed, labor and material used, and all costs and additional time
claimed to be additional.
22.3 . Detailed Claim
The Contractor shall not be entitled to claim any such additional compensation, or extension
of time, unless within thirty (30) days of the completion of the portion of the work from
which the claim arose, and before final payment by the County, the Contractor has given the
County a detailed written statement of each element of cost or other compensation requested
and of all elements of additional time required, and copies of any supporting documents
evidencing the amount or extension of time claimed to be due.
23. Ownership of(tems Produced:
All writings, programs, data, public records or other materials prepared by the Contractor and/or its
consultants or sub-Contractors, in connection with performance of this Agreement shall be the sole and
absolute property of the County.
24. onfidentiality:
The Contractor, its employees, sub-Contractors, and their employees shall maintain the confidentiality of all
information provided by the County or acquired by the Contractor in performance of this Agreement, except
upon the prior written consent of the Kittitas County Prosecuting Attorney or an order entered by a court after
having acquired jurisdiction over the County. Contractor shall immediately give to the County notice of any
judicial proceedings seeking disclosure of such information. Contractor shall indemnifY and hold harmless
the County, its Additional Insured's, 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.
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25. Notice_:
Except as set forth elsewhere in the Agreement, for all purposes under this Agreement, except service of
process, notice shall be given by the Contractor to the department head of the department for whom services
are rendered, and to the Kittitas County Commissioners, 205 W 5th Ave, Suite 108, Ellensburg, W A 98926.
Notice to the Contractor for all purposes under this Agreement shall be given to the address reflected on the
signature page. Notice may be given by delivery or by depositing in the U.S. Mail, first class, postage
prepaid.
26. Se erability:
If any term or condition of this Agreement or the application thereof to any person(s) or circumstances is held
invalid, such invalidity shall not affect other terms, conditions or applications which can be given effect
without the invalid term, condition or application. To this end, the terms and conditions of this Agreement
are declared severable.
27. Miscellaneous:
27.1 The County's failure or delay to insist upon strict performance of any of the provisions of
this Agreement or to exercise any rights or remedies under this Agreement shall not be
construed as a waiver or relinquishment to any extent of its right to assert or rely upon any
such provisions, rights or remedies in that or any other instance; rather the same shall be and
remain in full force and effect.
27.2 This Agreement embodies the entire Agreement between the County and Contractor, and
supersedes any and all prior agreements, regarding the Work. No change, amendment or
modification of any provisions of this Agreement shall be valid unless set forth in a written
instrument signed by the party to be bound thereby.
27.3 The rights and remedies of the County set forth in any provision of this Agreement are in
addition to and do not in any way limit any other rights of remedies afforded to the County
by any other provisions of this Agreement, by any of Contractor's Support or by law.
27.4 The headings of sections and paragraphs of this Agreement are for convenience of
reference only and are not intended to restrict, affect or be of any weight in the
interpretation or construction of the provisions of such sections or paragraphs.
28. Waiver:
Waiver of any breach or condition of this Agreement shall not be deemed a waiver of any prior or subsequent
breach. No terms or conditions of this Agreement shall be held to be waived, modified or deleted except by
an instrument, in writing, signed by the parties hereto.
29. Survival:
The provisions of paragraphs 7, 9,11,13,14,15,16,17,18,19,20,21,22,23,24,28,30, and 31, shall
survive, notwithstanding the termination or invalidity of this Agreement for any reason.
30. Nondiscrimination:
30.1 The County is an equal opportunity employer.
30.2 Nondiscrimination in Employment
In the performance of this Agreement, the Contractor will not discriminate against
any employee or applicant for employment on the grounds of race, creed, color,
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national ongm, sex, sexual orientation, marital status, age or the presence of any
sensory, mental or physical handicap; provided that the prohibition against
discrimination in employment because of handicap shall not apply if the particular
disability prevents the proper performance of the particular worker involved. The
Contractor shall ensure that applicants are employed, and that employees are
treated during employment without discrimination because of their race, creed, color,
national origin, sex, sexual orientation, marital status, age or the presence of any sensory,
mental or physical handicap. Such action shall include, but not be limited to:
employment, upgrading, demotion or transfers, recruitment or recruitment advertising,
layoff or termination, rates of payor other forms of compensation, and programs
for training including apprenticeships. The Contractor shall take such action with
respect to this Agreement as may be required to ensure full compliance with local,
state and federal laws prohibiting discrimination in employment.
30.3 Nondiscrimination in Services
The Contractor will not discriminate against any recipient of any services or benefits
provided for in this Agreement on the grounds of race, creed, color, national origin, sex,
sexual orientation, marital status, age or the presence of any sensory, mental or physical
handicap.
30.4 If any assignment and/or subcontracting has been authorized by the County, said
assignment or subcontract shall include appropriate safeguards against discrimination.
The Contractor shall take such action as may be required to ensure full
compliance with the provisions in the immediately preceding paragraphs herein.
31. Prevaili ng Wage :
Contractor shall pay the prevailing rate of wages to all workers, laborers, or mechanics employed in the
performance of any part of the Work in accordance with RCW 39.12 and the rules and regulations of the
Department of Labor and Industries. The schedule of prevailing wages rates for the locality or localities
of the Work is determined by the Industrial Statistician of the Department of Labor and Industries. It is
the Contractor's responsibility to verify the applicable prevailing wage rate. It is understood that the
Contractor is responsible for obtaining and completing all required government forms and submitting
same to the proper authorities.
Disputes regarding prevailing wage rates shall be referred for arbitration to the Director of the
Department of Labor and Industries. The arbitration decision shall be final and conclusive and binding on
all parties involved in the dispute as provided for by RCW 39.12.060.
32. Debarment Certification:
The Contractor certifies that it:
32.1 Is not presently debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded from covered transactions by any Federal department or agency.
32.2 Has not within a three-year period preceding the execution of this contract with Kittitas
County, been convicted of or had a civil judgment rendered against them for commission
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of fraud or a criminal offense in connection with obtaining, attempting to obtain, or
performing a public or private agreement or transaction, violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, tax evasion, receiving stolen property,
making false claims, or obstruction of justice.
32.3 Is 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 32.2 ofthis section.
32.4 Has not within a three-year period preceding the preceding the execution of this contract
with Kittitas County had one or more public transactions (Federal, State, or local)
terminated for cause of default.
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EXHIBIT "A"
SCOPE OF WORK
In addition to providing all material and labor, the Contractor shall perform the following:
1) Employ a registered nurse, fully licensed within the State of Washington to perform the work
described below within the Children with Special Health Care Needs Program, hereinafter "CSHCN".
This work shall include:
a) Providing community access to the CSHCN program and commitment for CSHCN staff to
participate in local, regional and statewide coordinator functions, trainings, meetings and
conferences.
b) Preparation and submittal of data reports to the Kittitas County Public Health Department,
hereinafter, "KCPHD", Health Promotion Supervisor on a quarterly basis utilizing the attached
CSHCN Quarterly Maternal Child Health Block Grant Reporting Form (Exhibit E).
c) Meet annually with the KCPHD Health Promotion Supervisor for a program work plan review.
d) Perform the following requirements of the 2015-2017 Consolidated Contract between Kittitas
County and the Washington State Department of Health, Contract #C 17114, hereinafter the
"Consolidated Contract", attached hereto as Exhibit D:
i) Complete Child Health Intake Form, hereinafter "CHIF", using the CHIF Automated System
on all infants and children served by the CSHCN Program as referenced in the CSHCN
Program Manual. (Maternal and Child Health: Task 4a in Exhibit D)
ii) Administer allocated DOH Diagnostic and Treatment funds for infants and children per the
CSHCN Program Manual when funds are used. (Maternal and Child Health: Task 4b in
Exhibit D)
iii) Participate in the CSHCN Regional System and quarterly meetings as described in the
CSHCN Program Manual. (Maternal and Child Health: Task 4c in Exhibit D).
2) Contractor agrees to perform its work according to the requirements of the Consolidated Contract,
and comply with all applicable Consolidated Contract terms, conditions, assurances and certifications.
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EXlDBIT "B"
COMPENSATION
As full compensation for satisfactory performance of the work, the County shall pay Contractor
compensation not to exceed:
I) Payments of $13,258 and up to a maximum amount of $14,000 for the delivery of CSHCN care
coordination program services. These amounts are based on projected funding from the Washington
State Department of Health Maternal Child Health Block Grant, which is contingent on the final
award from the Washington State Department of Health. In the event of a reduction of funding,
Contractor agrees to an amendment of this section consistent with the reduction in funding.
Restrictions on Funds: Contractor agrees that payments received from the County under this Agreement
shall not be used for:
1) Inpatient services, other than inpatient services for children with special health care needs or high risk
pregnant women and infants, and other patient services approved by Health Resources and Services
Administration (HRSA).
2) Cash payments to intended recipients of health services.
3) The purchase or improvement of land, the purchase construction, or permanent improvement of any
building or other facility, or the purchase of major medical equipment.
4) Meeting other federal matching funds requirements.
5) Providing funds for research or training to any entity other than a public or nonprofit private entity.
6) Payment for any services furnished by a provider or entity who has been excluded under Title XVIII
(Medicare), Title XIX (Medicaid), or Title XX (social services block grant).[Sociai Security Law, Sec
504(b)}.
If any charges are imposed for the provision of health services using Title V (Maternal Child Health
Block Grant) funds, such charges will be pursuant to a public schedule of charges; will not be imposed
with respect to services provided to low income mothers or children; and will be adjusted to reflect the
income, resources, and family size of the individual provided the services. [Social Security Law, Sec. 505
(l)(D)].
The Contractor may use an approved federally recognized indirect costs rate negotiated between the
subrecipient and the federal government or, if no such rate exists, a rate negotiated between the pass-
through entity and the subrecipient or a de minimis indirect costs rate. A de minimis indirect cost rate is
defined in the Federal Office of Management and Budget Uniform Grant Guidance §200.414 as 10% of
modified total direct costs. The Contractor will inform the County as to which indirect cost rate will be
used on invoices sent to the County during the period of this agreement before the first invoice of this
agreement is paid.
Contractor agrees to submit an invoice for services provided during each calendar month. The invoice for
services is due to the Accountant at the Kittitas County Public Health Department within thirty (30) days
following the last day of each calendar month. Invoices will include a tracking spreadsheet for
expenditure breakdown, and supporting documentation for all non-payroll charges. Payroll charges must
reflect actual time worked on the program in order to comply with the Uniform Grant Guidance §200.430
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Page 13
section I Standards for Documentation of Personnel Expenses. Supporting documentation for these
charges includes copies of receipts, invoices, purchase orders, and/or mileage logs. Kittitas County will
make payments within thirty (30) days of receipt of invoice. Kittitas County is not liable for services
provided unless the invoice is received on time or prior arrangement are agreed to in a writing signed by
the Kittitas County. In no event will payments total more than $14,000 under this agreement.
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EXHIBIT "C"
PROOF OF INSURANCE
The Contractor shall secure and maintain in effect at all times during performance of the Work such
insurance as will protect Contractor, its Support and the Additional Insured's from all claims, losses,
harm, costs, liabilities, damages and expenses arising out of personal injury (including death) or property
damage that may result from performance of the work or this Agreement, whether such performance is
by Contractor or any of its Support.
All insurance shall be issued by companies admitted to do business in the State of Washington and have
a rating of A-, Class VII or better in the most recently published edition of Best's Reports unless
otherwise approved by the County. If an insurer is not admitted, all insurance policies and procedures
for issuing the insurance policies must comply with Chapter 48.15 RCW and 284-15 WAC.
The Contractor shall provide proof of insurance for:
1) Commercial Genel'al Liabilitv [tl ur8nce.
• Coverage limits not less than:
• $1,000,000 per occurrence per project
• $2,000,000 general aggregate
• $1,000,000 products & completed operations aggregate
• $1,000,000 personal and advertising injury, each offense
• Certificate Holder -Kittitas County
• The Certificate must name the County as additional insured as defined in the
Agreement
• Thirty (30) days written notice to the County of cancellation
of the insurance policy.
2) ommercial Automobi'le Liabilitv In urance.
• Automobile Liability for owned, non-owned, hired, and leased vehicles, with an
MCS 90 endorsement and a CA 9946 endorsement attached if 'pollutants' are to
be transported.
• Coverage limits not less than:
• $1,000,000 combined single limit
• Thirty (30) days written notice to the County of cancellation
of the insurance policy.
3) Worker ompensation.
• Workers' Compensation in amounts required by law.
4) Professional L iabilitv.
• The Contractor and/or its Subcontractor shall provide evidence of Professional
Liability Insurance covering professional errors and omissions. Such policy must
provide the following minimum limits:
Professional Services Agreement
Page 15
• $1,000,000 per Claim
• $1,000,000 annual aggregate
• If the scope of such design-related professional services includes work related to
pollution conditions, the Professional Liability insurance shall include Pollution
Liability coverage
• If insurance is on a claims-made form, its retroactive date, and that of all
subsequent renewals, shall be no later than the effective date of this Agreement.
Contractor shall furnish Kittitas County a certificate of insurance with Endorsement as evidence that
policies providing insurance required by this Agreement are in full force and effect. Contractor hereby
waives all rights of recourse, including any right to which another may be subrogated, against Kittitas
County for personal injury, including death, and property damage. Contractor's insurance policies
required above shall be primary insurance and shall be non-contributing with any other insurance
maintained by Kittitas County.
The Contractor shall assume full responsibility for all loss or damage from any cause whatsoever to any
tools, Contractor's employee-owned tools, machinery, equipment, or motor vehicles owned or rented by
the Contractor, or the Contractor's agents, suppliers or contractors as well as to any temporary structures,
scaffolding and protective fences.
The Contractor shall have sole responsibility for ensuring the insurance coverage and limits required are
obtained by subcontractors.
NOTE: No contract shall form until and unless a copy of the Certificate of Insurance with Endorsement,
properly completed and in the amount required, is attached hereto.
Professional Services Agreement
Page 16
EXIllBIT "D"
2015-2017 Consolidated Contract #C17114
between
Kittitas County and the Washington State Department of Health
Professional Services Agreement
Page 17
2015 -2011
WASHINGTON STATE
DEPARTMENT OF HEALTH
CONSOLTDA TED CONTRACT
Page 1 of 17
DOH CONTRACT #: C11114
DOH CONTRACT #: C 17114
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 Infonnation ......................................................................................................... 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 ofMateriallRights 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. Tenn ......................................................................................................................................... 9
34. Tennination for Convenience ................................................................................................. 9
35. Tennination for Default .......................................................................................................... 9
36. Tennination Procedure ............................................................................................................ 9
Standard Federal Certifications and Assurances ............................................................................. 11
Assurances -Non Construction Programs ...................................................................................... 16
2015-2017 Consolidated Contract Page 2 of 17
DOH CONTRACT #: C17114
1. Purpose
CONSOLIDATED CONTRACT
between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
(Referred to as "DOH")
and
KITTIT AS COUNTY PUBLIC HEALTH DEPARTMENT
(Referred to as "LHJ")
for
THE DELIVERY OF PUBLIC HEALTH SERVICES
FOR THE PERIOD OF
January 1,2015 through December 31, 2017
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, including at RCW 43.70.040, the general statutory powers of local health
jurisdictions, 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 perfonnance-
based criteria under RCW 43.70.580(2Xb).
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 tenns 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 infonnation 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 identitying code assigned to a federal assistance
program which identifies the awarding agency.
"ContidentiaIInfonnation": Information protected from disclosure under federal or state law.
2015-2017 Consolidated Contract Page 3 of l7
DOH CONTRACT #: C17114
"Contract Coordinator": Each party 's designated contact for all notices required or permitted under this Contract.
"Contracting Officer": [ndividual(s) of the Contracts Office of DOH and hislher 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 Statements of Work, Exhibit A.
"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 Statements of Work,
Exhibit A.
"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 Statements of Work, Exhibit A, 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. [f 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 _$74,349, 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.
2015-2017 Consolidated Contract Page 4 of 17
DOH CONTRACT #: C17114
D. The LHJ will submit a BARS A financial report by March 15 for the prior calendar year .
6. Contract Management
Unless otherwise specified in the Contract, the following individuals are each party's designated contact ("Contract
Coordinator") for all notices required or permitted under this Contract.
LHJ Contract Coordinator: DOH Contract Coordinator:
Name: Candi Blackford Name: Brenda Henrikson
Title: Contracts Specialist
MailiD2 Address: Mailing Address:
507 N. Nanum Street, Suite 102 PO Box 47905, Olympia WA 98504-7905 Ellensburg W A 98926
Physical Address: Physical Address:
Same as above 101 Israel Rd. SE, Tumwater WA 98501-5570
Phone: 509-962-7515 1 Fax: 509-962-7581 Phone: 360-236-3933 I Fax: 360-586-2655
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 Statements of Work, Exhibit A, and on the DOH website,
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 tenus 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 ofthe 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
2. Standard Federal Assurances for Non-Construction Programs
2015-2017 Consolidated Contract Page 5 of 17
DOH CONTRACT #: C17114
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 InformationlNotice
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
InformationINotice 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 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 notii)'
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
notii)'ing 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 sha11 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 notii)' DOH ofany 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 ajudicial 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 OMB Circular A-I 02 or are
included in the federal funding agency's regulations.
20 \5-2017 Consolidated Contract Page 6 of 17
DOH CONTRACT #: C17114
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 ofRCW 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 andlor 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 matcrial relevant to this
Contract will be retained for six years after expiration. If any litigation, claim or audit is started before the expiration
of the six (6) 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 ofthe 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
declared ineligible for further contracts with 001 I. 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.
2015-20 I 7 Consolidated Contract Page 7 of 17
DOH CONTRACT #: C17114
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 MateriallRights 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 andlor 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 oftort
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 ofthis 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, assurances and certifications. The LHJ agrees it is responsible for assuring adequate performance on the
part of the subcontractor.
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
2015-2017 Consolidated Contract Page 8 of 17
DOH CONTRACT #: C17114
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 Circular A-87, A-I02, A-l33, 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. For fiscal years starting after December 26, 2014, 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 tenns 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, Tennination for Convenience, Termination for Default, and Termination
Procedure.
33. Term
This Contract will be in effect following execution by the parties from January 1,2015 through December 31, 2017,
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 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 perfonnance. 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 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 LHI to deliver to DOH any non-LHl-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
which are accepted by DOH, and (d) the protection and preservation of the property. Disagreement by the LHJ with
the detennination of DOH's Contracting Officer that relates to the obligations or amounts due to the LHJ shall be
considered a dispute within the meaning of the "Disputes" clause of this Contract.
2015-2017 Consolidated Contract Page 9 of l7
DOH CONTRACT #: C17114
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 tenninated 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
DEPARTMENT
S ignature
Title: ---I
Print Name: t ~ 111M ~.a tl
Date: --L-f-....;,.:;--''-.-..L-----
2015-2017 Consolidated Contract
ST ATE OF WASHINGTON
DEPARTMENT OF HEALTH
Title :
Betty Brick'
Contract Spaciali ~ ___ _
Print Name:
Date:
Page 10 of17
DOH CONTRACT #: C17114
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;
b) 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;
c) 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
d) 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.
2015-2017 Consolidated 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 (Le., 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 proh ibition;
b) Establishing an ongoing drug-free awareness
program to inform employees about
(I) 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 (a) above;
Page 11 of 17
d) Notifying the employee in the statement
required by paragraph (a), above, that, as a
condition of emp loyment under the contract,
the employee will-
(l) 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;
t) 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-
(l) 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-frce workplace through
implementation of paragraphs (a), (b), (c),
(d), (e), and (t).
2015-2017 Consolidated Contract
DOH CONTRACT #: C17114
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
W A State Department of Health
PO Box 47905
Olympia, W A 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:
(1) 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
Joan, the entering into of any cooperative
agreement, and the extension, continuation,
renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative
agreement.
Page 12 of 17
(2) 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, "Disclosure of Lobbying Activities,"
its instructions, and continuation sheet are
included at the end of this application form.)
(3) 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 hercin 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.
20 \5-2017 Consolidated Contract
DOH CONTRACT #: C 17114
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.
Page 13 of 17
6. CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, AND
OTHER RESPONSIBILITY MATTERS
INSTRUCTIONS FOR
CERTIFICATION
1) By signing and submitting this proposal, the
prospective contractor is providing the
certification set out below.
2) 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.
3) 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.
4) 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.
5) 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 ofthose regulations.
2015-2017 Consolidated Contract
DOH CONTRACT #: C17114
6) 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.
7) 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.
8) 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).
9) 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.
10) 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.
Page 14 of 17
7. CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, AND
OTHER RESPONSmILITY MATTERS
--PRIMARY COVERED
TRANSACTIONS
I) The prospective contractor certifies to the
best of its knowledge and belief, that it 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;
b) 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
CONTRACTOR SIGNATURE l U)UTRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
Please also print or type name :
n b I'V) RDtul
ORGANIZATION NAME: (if applicable)
'II~~~~ C\1~
2015-2017 Consolidated Contract
DOH CONTRACT #: C17114
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;
c) 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 (I )(b)
ofthis certification; and
d) 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.
2) 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 proposal.
TITLE
DATE
Page 15 of 17
DOH CONTRACT #: C17114
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 ofthe contractor, I certify that the contractor:
I . 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. :n4728-4763) 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. 0 01681-1683, 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. 3794),
which prohibits discrimination on the basis of handicaps; (d)
the Age
2015-2017 Consolidated Contract
Discrimination Act of 1975, as amended (42 U.S.C. H
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) 33 523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. 33290 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. 3 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 G) the requirements of any
other nondiscrimination statute(s) which may apply to the
app Iication.
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.
8. Will comply, as applicable, with the provisions of the
Hatch Act (5 U.S.C. DO 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.
Page 16 of 17
9. Will comply, as applicable, with the provIsions of the
Davis-Bacon Act (40 U.S.C. 33276a to 276a-7), the
Copeland Act (40 U .S.C . 3276c and 18 U.S.C. :n874) and
the Contract Work Hours and Safety Standards Act (40
U.S.C. 33 327-333), 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 .
II. 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) IISI4; (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 . L Li 14S1 et seq.); (f) confonnity of
Federal actions to State (Clear Air) Implementation Plans
under Section I76(c) of the Clear Air Act of I95S, as
amended (42 U.S.c. nr:-J 7401 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-
20S).
CONTRACTOR SIGNATURE RK l llRE O
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
PI ~o a l,so print or typo mtm c:
~~I~rh ~e~J
ORGANIZATION NAME: (if applicable)
2015-2017 Consolidated Contract
DOH CONTRACT #: C17114
12 Will comply with the Wild and Scenic Rivers Act of 1968
(16 U .S .C . 001 721 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 lIS93
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of 1974
(16 U.S.C. 00469a-l etseq.).
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.
IS. Will comply with the Laboratory Animal Welfare Act of
1966 (P.L. 89-S44, as amended, 7 U.S.C. [J [12131 et seq.)
pertaining to the care, handling, and treatment of wann
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. j-: 14801 et seq.) which
prohibits the use of lead-based paint in construction or
rehabilitation of residence structures.
17. Will cause to be perfonned the required financial and
compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Circular No. A-133,
Audits of States, Local Governments, and Non-Profit
Organizations.
18. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations and policies
governing this program.
TITLE
DATE
Page 17 of 17
KITTITAS COUNTY PUBLIC HEALm DEPARTMENT
2015-2017 CONSOLIDATED CONTRACT #CI7114
EXHIBIT A -STATEMENTS OF WORK
TABLE OF CONTENTS
DOH Program Name or Title: Emergency Preparedness & Response -Effective January 1, 2015 .................................................................................................... 2
DOH Program Name or Title: Maternal & Child Health Block Grant -Effective January 1, 2015 .................................................................................................... 5
DOH Program Name or Title: Office of Drinking Water Group A Program -Effective January 1,2015 ........................................................................................... 9
DOH Program Name or Title: Office oflmmunization & Child Profile -Effective January 1, 2015 .............................................................................................. 14
Exhibit A, Statements of Work Page 1 of 19 Contract Number C 17114
DOH Program Name or Title: Emergency Preparedness & Response-
Effective January 1, 2015
SOW Type: Original RevisioD # (for this SOW)
Period of Performance: January 1. 2015 through June 30, 2015
Exhibit A
Statement of Work
Contract Term: 2015-2017
Loca) Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: C17114
Funding Source Federal Compliance Type of Payment
t8J Federal Subrecipient (check if applicable) [8J Reimbursement o State [8J FF A T A (Transparency Act) D Fixed Price o Other D Research & Development
Statement of Work Purpose: The purpose of this statement of work is to establish the funding and tasks for the Public Health Emergency Preparedness and Response program for
the 2015 grant period through June 30, 2015.
Revision Purpose: N/ A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change rI ota)
Revenue Index (LHJ Use Only) Consideration Increase (+) ~onsideratioD
Code Code Start Date End Date
FFY14 EPR LHJ FUNDING 93.069 333.93.06 18101630 01 /0 11 15 I 06/30115 0 23,046 23,046
TOTALS 0 23,046 23,046
Task Task! ActivitylDescription *May Support PHAB Deliverables/Outcomes Due Dateffime Frame Payment Information
Number StandardslMeasures and/or Amount
Admin 1 Complete reporting templates to comply with Submit completed templates. As required Reimbursement for costs,
federal grant requirements (e.g., performance not to exceed total funding
measures, gap analysis, etc.) consideration amount.
Admin 2 Attend emergency preparedness events (monthly Submit end-of-year reporting June 30, 2015
program update calls, quarterly workshops, etc .) template .
I hosted by DOH. I
1.1 Create a press release template for "do 1 thing" Submit end-of-year reporting June 30, 2015
and submit press releases monthly in order to template.
educate public on emergency preparedness,
identified hazards and vulnerabilities in the
county and the relationship of risk to human
impact.
1.2 Collect and assess local child care providers Submit end-of-year reporting June 30, 2015
required disaster plans. Assist agencies in template .
communicating plans to guardians/community.
3.1 Train staff in National Incident Management Submit end-of-year reporting June 30, 2015
System (NIMS) and provide emergency template.
preparedness and response professional
__ eQucational opportunities for staff.
--
Exhibit A, Statements of Work Page 2 of 19 Contract Number C17114
Task TaskiActivitylDescription "'May Support PHAB Deliverables/Outcomes Due Date/Time Frame Payment Information
Number StaDdardslMeasures and/or Amount
3.2 Assist with meeting preparation and attend Submit end-of-year reporting June 30, 2015
Kittitas County Emergency Management Council template .
(KCEMC) meetings.
4.1 Activate emergency public information system to Submit end-of-year reporting June 30 , 2015
test public information delivery during a public template .
health emergency
5.1 Prior to incident, meet with regional Submit end-of-year reporting June 30, 2015
epidemiologist, Emergency Manager, and template.
Coroner to determine public health's role in mass
fatality.
8.l Annually review and evaluate the Medical Submit end-of-year reporting June 30, 2015
Material and Distribution annex of the template.
Emergency Operation Plan (EOP) and
communicate/coordinate plan with community
partners .
9.1 Identify staffing needs for receiving sites . Submit end-of-year reporting June 30,2015
template.
9.2 Identify resources available at receiving sites and Submit end-of-year reporting June 30, 2015
update Emergency Operation Plan as necessary . template .
10.1 Annually review and evaluate the EOP , Submit end-of-year reporting June 30, 2015
incorporating lessons learned from exercises and template.
real incidents.
10.2 Task 2 : Exercise the emergency communications Submit end-of-year reporting June 30,2015
systems including Washington State's Electronic template .
Communications and Urgent Response Exchange
System (SECURES), satellite phone, and agency
phone tree. I
10.3 Represent Kittitas County Public Health at Submit end-of-year reporting June 30, 2015 I
Region 7 meetings and attend emergency template.
preparedness and response trainings for regional
systems to assist partners.
lOA Conduct an exercise for mass vaccination with Submit end-of-year reporting June 30, 2015
jurisdictional partners . template.
13.1 Provide surveillance and investigation of Submit end-of-year reporting June 30, 2015
infectious disease outbreaks. template .
14 .1 Identify medical exposure/mental health risks Submit end-of-year reporting lune 30, 2015
faced by responders based on the jurisdictional template .
risk assessment .
]4.2 Assess emergency responders for vaccine Submit end-of-year reporting June 30, 2015
preventable disease risks via vaccine records and template .
recommendations.
~ ----------
Exhibit A , Statements of Work Page 3 of 19 Contract Number C17114
Task Task! Activity /Description *May Support PHAB Deliverables/Outcomes Due DatelTime Frame Payment Information
Number StaodardsIMeasures aod/or Amount
15.1 Coordinate with existing volunteer programs and Submit end-of-year reporting June 30, 2015
partner organizations to support the pre-incident template.
recruitment of volunteers that may be needed in a
pub li c health agency response.
15 .2 Conduct Pre incident screening and verification Submit end-of-year reporting June 30,2015
of volunteers' credentials through emergency template.
system for advance registration of volunteer
health professionals (ESAR-VHP) and Medical
Reserve Corp.(MRC)
15.3 Create medical reserve corps job action sheet for Submit end-of-year reporting June 30, 2015
internal MRC for records manager and for MRC template.
Trainee Coordinator.
------------
*For lnformati on OnJy:
Funding is no t t ied to the revised StandardslMeasures listed here. This inform atio n may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. Mote detail on these and/or 9rher Public Health Accreditati on Board (PHAB) StandardslMeas ures that may apply can be foun d a l:
hltp :llwww.phaboard.or!!fwp-conten tl uploadsIP HAB.staJldards~and-Measures-Version-i .O.pd f
Program Spfi:ifi c Re.quircmcnt.sIN arrativ e
Federal FunrungAccouotability and Transparencv A ct (FF'ATA)
This statement of work is sup porte d by fe deral funds Ih at require corn pliance with the Federal Funding Accountability and Transparency Act (FF AT A or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To co mp ly with this act and be eligible to perform the activities in this statement o f work, the LHJ must have a Data Universal Numbering System (DUNS®) number.
lnfonuati on aoout the LHJ and this statement o f work will be made available on http ;/iUSASpen d in2".govby DOH as required by P.L. 109-282.
Special Requirements
For purchases of individual equipment in which the aggregate unit price of the equipment (including shipping, handling and associated costs) is $5,000 or more, the LHJ shall
obtain written prior approval from the Washington State Department of Health and adhere to all federal requirements as referenced in OMB Circular A-87 (State, Local and Indian
Tribal governments) at: hnp :llwww.wh itehouse.gov/omb/cil'1lul ars !lQ8 ? 20Q41
DOH Program Contact
Rachel McKinlay, Contract & Finance Specialist
Department of Health
PO Box 47960, Olympia, WA 98504-7960
360-236-4056
rachel.mckinlay@doh.wa.gov
PHEPR Deliverable Submission: cQnc.ondeJiverabl
Exhibit A, Statements of Work
doh .we.sao v
Page 4 of19 Contract Number C17114
I
I
I
I
j
Exhibit A
Statement of Work
Contract Term: 2015-2017
DOH Program Name or Title: Maternal & Child Health Block Grant-
Effective January 1, 2015
SOW Type: Original Revision # (for this SOW)
Period of Performance: Januarv 1. 2015 through September 30, 2015
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: Cl7114
Funding Source Federal Compliance Type of Payment
cg] Federal Subrecipient (check if applicable) t2I Reimbursement o State rgr FF A T A (Transparency Act) o Fixed Price o Other o Research & Development
Statement of Work Purpose: The purpose of this statement of work is to support local interventions that impact the target population of the Maternal and Child Health Block
Grant.
Revision Purpose: NI A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change T otal
Revenue Index (LHJ Use Only) Consideration Increase (+) Con sideratioo
Code Code Start Date End Date
FFY15 MCHBG CBP ConCon 93.994 333.93.99 78734250 01101115 I 09/30/15 0 33.147 33;147
~'fALS_ ------------.L ---'!.I _ 33,1 47
-
33.1 47
... c h' -~--------------------for all federally funded sub f -----------------------.------
CFDA# CFDA Program Title I Federal Grant Award # Federal Grant Award Name Federal Agency Name
93.994 Maternal and Child Health I lB04MC26703-xx-xx Maternal and Child Health Block Grant JlHHS-HRSA
------
Task *May Support PHAB Payment
Number Task! ActivitylDescription StandardsIMeasures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Maternal and Child Health Block Grant (MCHBG) Administration
la Participate in calls, at a minimum of every other Designated LHJ staff will September 30,2015 Reimbursement for
month, with DOH contract manager. Dates and participate in contract actual costs, not to
time for calls are mutually agreed upon between management calls. exceed total funding
DOHandLHJ . consideration. Action
Ib Participate in DOH sponsored MCHBG-related Designated LHJ staff'will September 30,2015 Plan and Progress
quarterly conference calls and/or webinars, participate in calls, webinars, and Reports must only
incloding u p to two (2) in -person me etinM. meetings. reflect activities paid
Ic Complete 2015-2016 MCHBG Budget Workbook Submit completed MCHBG September 4,2015 for with funds
for October 1,2015 through September 30,2016 Budget Workbook to DOH provided in this
using DOH provided template. contract manager. statement of work for
Exhibit A, Statements of Work Page 5 of 19 Contract Number C 17114
Task *May Support PHAB Payment
Number Task! Activity/Description StandardsiMeasures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Id Report actual expenditures for October 1, 2014 -Submit actual expenditures using February 18,2015 the specified funding
December 31, 2014. the MCHBG Budget Workbook period.
(Sections A and B only) to See Program Specific
contract manager. Requirements and
Special Billing
Requirements.
MCHBG Assessment and Evaluation
2a Participate in statewide capacity and needs Documentation using report May 1,2015 Reimbursement for
assessment activities in preparation for next template provided by DOH. actual costs, not to
statewide 5 year plan, as requested. exceed total funding
2b Participate in project evaluation activities Documentation using report September 30,2015 consideration.
developed and coordinated by DOH, as template provided by DOH. See Program Specific
requested. Requirements and
Special Billing
Requirements.
MCHBG Implementation
3a Develop 2015-2016 MCHBG Action Plan for Submit MCHBG Action Plan to Draft -August 21, 2015 Reimbursement for
October 1, 2015 through September 30, 2016 DOH contract manager. Final-September 4, 2015 actual costs, not to
using DOH provided template. exceed total funding
3b Report activities and outcomes of2014-2015 Submit Action Plan quarterly January 15,2015 consideration. Action
MCHBG Action Plan using DOH provided reports to DOH contract manager. April 15,2015 Plan and Progress
template. July 15 ,2015 Reports must only
reflect activities paid
If LHJ chooses to bill on a for with funds
monthly basis, reports-are provided in this
I due on or before the 15 th statement of work for
of the following month. the specified funding
period.
See Program Specific
Requirements and
Special Billing
Requirements .
Children with Special Health Care Needs (CSHCN)
4a Complete Child Health Intake Form (CHIF) using Submit CHIF data into Secure January 15 ,2015 Reimbursement for
the CHIF Automated System on all infants and File Transport (SFT) website: April 15, 2015 actual costs, not to i
children served by the CSHCN Program as https://sft.wa.gov July 15,2015 exceed total funding I
referenced in CSHCN Program Manual. consideration. Action I
Exhibit A, Statements of Work Page 6 of19 Contract Number C17114
Task *May Support PHAB Payment
Number TaskJ Activity /Description StandardsIMeasures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
4b Administer allocated DOH Diagnostic and Submit completed Health 30 days after fonns are Plan and Progress
Treatment funds for infants and children per Services Authorization fonns and completed. Reports must only
CSHCN Program Manual when funds are used. Central Treatment Fund requests reflect activities paid
directly to the CSHCN Program for with funds
as needed. provided in this
4c Participate in the CSHCN Regional System and Submit Action Plan quarterly January 15,2015 statement of work for
quarterly meetings as described in the CSHCN reports including number of April 15,2015 the specified funding
Program Manual. regional meetings attended to the July 15,2015 period.
DOH contract manager. See Program Specific
Requirements and
Special Billing
Requirements.
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This infonnation may be helpful in discussions of how program activities might contribute to meeting a
StandardlMeasure. More detail on these andlor other Public Health Accreditation Board (PHAB) StandardslMeasures that may apply can be found at:
http ://www .phaboard.org/wp-<--orueruluploadsIPH AB ~St:andards-and -Measures-Vers ion-I .O.pdf
Program Specific ReguirementslNarrative
Special Requirements
Federal Funding Accountability and Transparency Act (FFATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FF A TA or the Transparency Act).
The purpose of the Transparency Act is to make infonnation available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perfonn the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number.
Infonnation about the LHJ and this statement of work will be made available on http://USASpending.gov by DOH as required by P .L. 109-282.
Program Manual, Handbook, Policy References
Children with Special Health Care Needs Manual-hnp:l/www .doh .wa.g,ov/POrtal sl IIDQCumeDlsfPuhs'97~209-CSHCN ~Manulll.pdf
Restrictions on .Funds (what funds can be used for which activities, not direct payments, etc)
I. At least 30% of federal Title V funds must be used for preventive and primary care services for children and at least 30% must be used services for children with
special health care needs. [Social Security Law, Sec. 505(a)(3)).
2. Funds may not be used for:
a. Inpatient services, other than inpatient services for children with special health care needs or high risk pregnant women and infants, and other patient services approved by
Health Resources and Services Administration (HRSA).
b. Cash payments to intended recipients of health services .
c. The purchase or improvement of land, the purchase, construction, or pennanent improvement of any building or other facility, or the purchase of major medical
equipment.
Exhibit A, Statements of Work Page 7 of 19 Contract Number C17l14
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. payment for any services furnished by a provider or entity who has been excluded Wlder Title XVIII (Medicare), Title XIX (Medicaid), or Title XX (social services block
grant).[Social Security Law, Sec 504(b»).
3. If any charges are imposed for the provision of health services using Title V (MCH Block Grant) funds, such charges will be pursuant to a public schedule of charges; will not
be imposed with respect to services provided to low income mothers or children; and will be adjusted to reflect the income, resources, and family size of the individual
provided the services. [Social Security Law, Sec. 505 (I)(D»).
Monitoring Visits (frequency, type)
Telephone calls with contract manager at least one every other month .
Special BlUing Requirements
Payme-nl Is cootingent upon DOH receipt and approval of an del iverablcs and an acceptable A 19-1 A invoice voucher. Payment to completely expend the "Total Consideration"
for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted a1 least quarterly and must be based on
acrual allowable program cost's . aWing for services, on a monthly or quarterly fraction afthe "Total Consideration" will not be a~cepted or approved. Mcmtbly invoices on acroal
allowable program costs will be accepted but an updated Action Plan Progress Report must also be submitted.
DOH Program Contact
Mary Dussol
Healthy Communities Consultant
Office of Healthy CommWlities
Washington State Department of Health
Street Address: 310 Israel Rd SE, Tumwater, W A 98501
Mailing Address: PO Box 47848, Olympia, WA 98504
Telephone: 360-236-3781/ Fax: 360-236-3646
Email: marv.dussol@doh.wa.gov
Exhibit A, Statements of Work Page 8 of 19 Contract Number C 1 7114
Exhibit A
Statement of Work
Contract Term: 2015-2017
DOH Program Name or Title: Office of Drinking Water Group A Program-
Effective January 1,2015
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CI7114
SOW Type: Original Revision # (for this SOW) Funding Source Federal Compliance Type of Payment
~ Federal Contractor (check ifapplicable) o Reimbursement
~ State o FF A T A (Transparency Act) ~ Fixed Price o Other o Research & Development
Period of Performance: January 1, 2015 through December 31,2017
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non-community Group A water systems.
Revision Purpose: NI A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change rrotal
Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration
Code Code Start Date End Date
Drinking Water Group A -SS N/A 346.26.64 2421921C 01/01115 12/31115 0 2,800 2,800
Drinking Water Group A -SS State N/A 346.26.65 2421252C 01/01/15 12/31/15 o I 2,800 2,800
Drinking Water Group A - T A N/A 346.26.66 2421921D 01/01115 12/31/15 0 4,000 4,000
TOTALS 0 9,600 9.600
Task Task! ActMty /Description *May Support PHAB Deliverables/Outcomes Due Date/Time Frame Payment Information
Number StandardsIMeasures and/or Amount
1 Trained LHJ staff will conduct sanitary Provide Final* Sanitary Survey Final Sanitary Survey Upon ODWacceptance
surveys of small community and non-Reports to OOW Regional Office. Reports must be received of the Final Sanitary
community Group A water systems Complete Sanitary Survey Reports by the OOW Regional Survey Report, the LHJ
identified by the DOH Office of Drinking shall include: Office within 30 calendar shall be paid $400 for
Water (OOW) Regional Office. \. Cover letter identifying days of conducting the each sanitary survey of a
significant deficiencies, sanitary survey. non-community system
See Special Instructions for task activity . significant findings, with three or fewer
observations, recommendations, connections.
and referrals for further OOW
follow-up. Upon ODW acceptance
2. Completed Small Water System of the Final Sanitary
checklist. Survey Report, the LHJ
3. Updated Water Facilities shall be paid $800 for
Inventory (WFI). each sanitary survey of a
4. Photos of water system with text non-community system
identifying features with four or more
Exhibit A, Statements of Work Page 9 of 19 Contract Number Cl7114
Task Task! Activity/Descri ption "'May Support PHAB Deliverables/Outcomes Due DatelTime Frame Payment Information
Number StandardslMeasures and/or Amount
5. Any other supporting connections and each
documents. community system.
*Final Reports have been reviewed Payment is inclusive of
and accepted by the ODW Regional all associated costs such
Office. as travel, lodging, per
diem.
Payment is authorized
upon receipt and
acceptance of the Final
Sanitary Survey Report
within the 30 day
deadline.
Late or incomplete
reports may not be
accepted for payment.
2 Trained LHJ staff will conduct Special Provide completed SPI Report and Completed SPI Reports Upon acceptance ofthe
Purpose Investigations (SPI) of small any supporting documents and must be received by the completed SPI Report,
community and non-community Group A photos to ODW Regional Office. ODW Regional Office the LHJ shall be paid
water systems identified by the ODW within 2 working days of $800 for each SPI.
Regional Office. the service request.
Payment is inclusive of
See Special Instructions for task activity . all associated costs such
as travel, lodging, per
diem.
Payment is authorized
upon receipt and I
I
acceptance of completed
SPI Report within the 2
working day deadline.
Late or incomplete
reports may not be
accepted for payment.
3 Trained LHJ staff will provide direct Provide completed T A Report and Completed T A Report Upon acceptance of the
technical assistance (TA) to small any supporting documents and must be received by the completed T A Report,
community and non-community Group A photos to ODW Regional Office. ODW Regional Office the LHJ shall be paid for
water systems identified by the ODW within 30 calendar days of each technical assistance
Regional Office. providing technical activity as follows:
assistance.
--------
Exhibit A, Statements of Work Page 10 of 19 Contract Number C 17114
Task Task! Activity /Description *May Support PHAB Deliverables/Outcomes Payment Information
Number StandardslMeasures Due DateiTime Frame and/or Amount
See Special Instructions for task activity. • Up to 3 hours of work: I
$250
• 3-6 hours of work:
$500
• More than 6 hours of
work: $750
Payment is inclusive of
all associated costs such
as consulting fee , travel,
lodging, per diem.
Payment is authorized
upon receipt and
acceptance of completed
T A Report within the 30-
day deadline.
Late or incomplete
reports may not be
accepted for payment.
4 LHJ statTperforming the activities under Prior to attending the training, submit Annually LHJ shaH be paid
tasks 1,2 and 3 must have completed the an "Authorization for Travel (Non-mileage, per diem, and
mandatory Sanitary Survey Training. Employee)" DOH Form 710-013 to lodging costs in
the ODW Program Contact below for accordance with the
See Special Instructions for task activity . approval (to ensure that enough current rates listed on the
funds are available). OFM Website
htm://www.ofin.wa.gov/r
----
esources/travel.asQ
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure . More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
hno :llwww.ohaboal'd.o rwwp-conten tl uploadrJPHAB-Slandards-and -Measures -Version -I.O.pdf
Program Specific ReguirementslNarrative
Special References (RCWs, WACs, etc)
Chapter 246-290 WAC is the set ofmles that regulate Group A water systems. By this statement of work, ODW contracts with the LHJ to conduct sanitary surveys (and SPIs, and
provide technical assistance) for small community and non-community water systems with groundwater sources . ODW retains responsibility for conducting sanitary surveys (and
SPls, and provide technical assistance) for small community and non-community water systems with surface water sources, large water systems, and systems with complex
treahnent.
Exhibit A, Statements of Work Page 11 ofl9 Contract Number Cl7114
LHJ staff assigned to perfonn activities under tasks I, 2, and 3 must be trained and approved by ODW prior to perfonning work. See special instructions under Task 4, below.
Special Billing Requirements
The LHJ sball submit quarterly invoices within 30 days following the end of the quarter in which work was completed, noting on the invoice the quarter and year being billed for.
Payment cannot exceed a maximum accumulative fee of $5,600 for Task 1, and $4,000 for Task 2, Task 3 and Task 4 combined during the contracting period, to be paid at the
rates specified in the Payment Method/Amount section above. When invoici ne. fo r sanitarv surve\l5.. bill hafflo BARS Revenue Cod e 340 '6.64 and hairEo BARS Revenue Code
346.26.65.
When invoicing for Task 4, submit receipts and the signed pre-authorization form for non-employee travel to the ODW Program Contact below and a signed A 19-1 A Invoice
Voucher to the DOH Consolidated Contracts Office, billing to BARS Revenue Code 346.26.66 under Technical Assistance (TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW. Detailed
guidance is provided in the Field Guidejor Sanitary Surveys, Special Purpose Investigations and Technical Assistance (Field Guide). The sanitary survey will include an
evaluation of the following eight elements: source; treatment; distribution system; finished water storage; pumps, pump facilities and controls; monitoring, reporting and data
verification; system management and operation; and certified operator compliance. If a system is more complex than anticipated or other significant issues arise, the LHJ may
request ODW assistance.
• No more than 4 surveys of non-commWlity systems with three or fewer connections to be completed between January 1, 2015 and December 3 I, 2015.
• No more than 5 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2015 and
December 31,2015.
The process for assignment of surveys to the LHJ, notification of the water system, and ODW follow-up with unresponsive water systems; and other roles and responsibilities of
the LHJ are described in the Field Guide.
Task 2
Trained LHJ staffwiII perfonn Special Purpose Investigations (SPIs) as assigned by ODW. SPls are inspections to detennine the cause of positive colifonn samples or the cause of
other emergency conditions. SPIs may also include sanitary surveys of newly discovered Group A water systems. Additional detail about conducting SPJs is described in the Field
Guide. The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staffwill conduct Technical assistance as assigned by ODW. Technical Assistance includes assisting water system personnel in completing work that has been
required, requested, or advised by the ODW to meet applicable drinking water regulations, and verifying that work that has been required, requested, or advised by the ODW to
meet applicable drinking water regulations have been addressed. Examples of technical assistance activities are described in the Field Guide. The ODW Regional Office must
authorize in advance any technical assistance provided by the LHJ to a water system.
Task 4
LHJ staff assigned to perfonn activities under tasks 1,2, and 3 must be trained and approved by ODW prior to perfonning work. LHJ staffperfonning the activities WIder tasks 1,
2 and 3 must have completed, with a passing score, the ODW Online Sanitary Survey Training and the ODW Sanitary Survey Field Training. LHJ staffperfonning activities WIder
tasks 1,2, and 3 must attend the Annual ODW Sanitary Survey Workshop, and are expected to attend the Regional ODW LHJ Drinking Water Meetings.
Ifrequired trainings, workshops or meetings are not available or not scheduled, or if the LHJ staff person is unable to attend these activities prior to conducting assigned tasks, the
LHJ staff person may, with ODW approval, substitute other training activities to be determined by ODW. Such substitute activities may include one-on-one training with ODW
staff, co-surveys with ODW staff, or other activities as arranged and pre-approved by ODW. LHJ staff may not perfonn the activities under tasks 1,2, and 3 without completing
the training that has been arranged and approved by ODW.
Exhibit A, Statements of Work Page 12 of 19 Contract Number C171 14
Program Manual, Handbook, Policy References
htto:llwww.doh.wa.govlPortals/1IDocumentslPubsJ331-486.pdf
DOH Program Contact
Danielle Russell
DOH Office of Drinking Water
16201 E. Indiana Ave, Suite 1500
Spokane Valley, WA 99216
Danielle.Russell@doh.wa.gov
(509) 329-2136
Exhibit A, Statements of Work Page 13 of19 Contract Number C 17114
Exhibit A
Statement of Work
Contract Term: 2015-2017
DOH Program Name or Title: Office ofImmunization & Child Profile -
Effective January 1. 2015
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: C 17114
SOW Type: Original Revision # (for tbis SOW) Funding Source Federal Compliance Type of Payment
t8I Federal Subrecipient (check ifapplicable) t8I Reimbursement o State IZI FF ATA (Transparency Act) o Fixed Price o Other o Research & Development
Period of Performance: January 1. 2015 through December 31. 201 5
Statement of Work Purpose: The purpose of this statement of work is to define required immunization tasks , deliverables, and funding.
Revision Purpose: NI A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change [rotal
Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration
Code Code Start Date End Date
FFY15 VFC Ops 93 .268 333.93.26 74203250 OliO 1/15 12/31115 0 1,129 1,129
FFY 15 VFC Ordering 93 .268 333.93.26 74204250 01101115 12/31 /15 0 1,154 1,154
FFYI5 317 Ops 93.268 333 .93.26 74201250 01/01115 12/31/15 0 1.260 1,260
FFY15 AFIX 93.268 333 .93.26 74205250 01 /01115 12 /31115 0 5,013 5.013
TOTALS 0 8.556 8.556
Task *May Support PHAB Payment
Task! Activity /Description Deliverables/Outcomes Due Daterrime Frame Information andlor Number StandardslMeasures Amount
Perfonn accountability activities in accordance with state and federal requirements for the Vaccines for Children (VFC) Program as outlined in the Centers for Disease Control and
Prevention (CDC) VFC Operations Guide and as directed by the state administrators of the VFC program. Accountability requirements include, but are not limited to: provider
education, provider site visits and required corrective action, quality assurance activities, VFC screening, satisfaction survey, outside provider agreements , new provider enrollment
vi si ts, fraud and abuse re po rr rng, monthl)' aC COUI1t;ib ility reports., and privat e provider re:>o r! of vaccine usage.
1 Facilitate annual renewal of the Provider Provider Agreements for Receipt Annually, per Annual Reimbursement for
Agreement for Receipt of State Supplied of State Supplied Vaccine received VFC Provider Agreement actual costs incurred,
Vaccine for all health care providers receiving online via the Washington Update Schedule not to exceed total
state-supplied childhood vaccines, per Immunization Infonnation System. funding consideration
instructions at this link amount.
Funds available for
this task*:
FFY15 AFIX,
74205250
---~
Exhibit A, Statements of Work Page 14 of 19 Contract Number CI7114
,
Task *May Support PHAB Payment
Number Task! Activity /Descri ption StandardslMeasures Deliverables/Outcomes Due DatelTime Frame Information and/or
Amount
*See Restrictions on
Funds below
2 Enroll new providers. Conduct an enrollment a) Provider Agreement for Within ten (10) days after Reimbursement for
site visit to all new providers, and gather Receipt of State Supplied the date of the provider actual costs incurred,
information needed to complete Program Vaccine with original enrollment visit not to exceed total
enrollment, per instructions at this link signature (NOTE : a photocopy funding consideration
will not be accepted) amount.
: .
b) Provider Agreement Funds available for
(DOH 348-022) this task*:
c) lIS Information Sharing FFY15 AFIX,
Agreement 74205250
d) Account Application *See Restrictions on
Funds below
e) User Account Worksheet
3 Use and facilitate provider use ofthe Electronic submission of provider Based on provider order Reimbursement for
Washington Immunization Information System vaccine orders via the Washington schedules actual costs incurred,
to place and approve provider vaccine orders. Immunization Information System not to exceed total
Monitor provider orders for appropriateness funding consideration
(including: accuracy of shipping information, amount.
order frequency, timing, quantity and type) and .
approve vaccine order online after assuring the Funds available for
appropriateness of the order. this task*:
I
FFYl5 VFC Vaccine
Ordering I
74204250 I
FFY I 5 VFC Ops
74203250
FFY 317 Ops
74201250
*See Restrictions on
Funds below
4 Monitor and assure electronic or paper a) Monthly Vaccine a) By the 15th of each Reimbursement for
submission of vaccine accountability reports for Accountability Report month actual costs incurred,
compliance with Provider Agreement related to (DOH 348-006), submitted by not to exceed total
vaccine management (ordering, inventory e-mail or online in the lIS
------
_funding consideration
Exhibit A, Statements of Work Page 15 of 19 Contract Number C 17114
Task "'May Support PHAB Payment
Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Due DatelTime Frame Information and/or
Amount
management, reconciliation, compliance with amount.
storage and handling, and reporting of all b) Inclusion in the online b) based on provider
vaccine incidents and returns). ordering system of doses used order schedules Funds available for
in the last month and this task*:
inventory on hand.
FFYl5 AFIX,
c) Report of Vaccine Storage c) within seven (7) days 74205250
Incidents (DOH 348-154) of the incident
complete with reason and *See Restrictions on
corrective action as needed. Funds below
d) Report all cases (or suspected d) within seven (7) days
cases) of vaccine fraud or of the incident
abuse.
5 Provide communication, technical assistance, Summary ofLHJ Technical December 31 st Reimbursement for
consultation, and education to providers about Assistance Form (DOH 348-257) actual costs incurred,
vaccine quality assurance, accountability, not to exceed total
program participation and vaccine management. funding consideration
amount.
Funds available for
I
this task*:
I
FFY 15 VFC Ops
74203250
FFY 317 Ops
74201250
*See Restrictions on
Funds below
6 Conduct VFC site visits at two (2) private a) VFC Site Visit Selection a) January 15th Reimbursement for
provider site(s) within your jurisdiction. Site Planning tool (will be supplied actual costs incurred,
visits should address all requirements outlined in by DOH) not to exceed total
the Provider Agreement, the CDC Vaccines for funding consideration
Children (VFC) Operations Guide, and as b) Enter responses from the VFC b) At the time ofthe amount.
directed by the state administrators of the Provider Compliance Site VFC Compliance
Vaccines for Children program . All VFC site Visit questionnaire into the Site Visit or within Funds available for
visits must be conducted by September 30th. VFC Provider Education, ten (10) business this task*:
Assessment, and Reporting days of the site visit .
Conduct VFC Compliance Site Visit Follow-Up (VFC-PEAR) on-line system FFY15 AFIX,
to assure providers resolve all co~ective actions for each provider site visit. 74205250
Exhibit A, Statements of Work Page 16 ofl9 Contract Number Cl7114
Task *May Support PHAB Payment
Number Task! Activity /Description StandardslMeasures Delivera bles/Outcomes Due DatelTime Frame Information and/or
Amount
identified during the initial VFC compliance site Follow all corrective action
visit. Follow-up may include another physical and follow-up guidance *See Restrictions on
site visit or verification by email, phone, fax, or provided by VFC-PEAR for Funds below
mail that corrective actions were completed. each incorrect response.
Documentation that all VFC Site Visit corrective
actions have been completed must be available c) Submit copy of signed c) upon completion of
to DOH upon request. Acknowledgement of Receipt each training
Participate in all DOH/CDC trainings required d) Document completion of each
for site visit reviewers and supervisors (a list of required training
required trainings will be provided by DOH).
7 a) Conduct AFIX (Assessment, Feedback, a) Enter the following data in the a) At the time of the Reimbursement for
Incentive, and Exchange) visits with one (1) AFIX Online Tool: AFlX visit or within actual costs incurred,
provider sites in your jurisdiction per • General Site Visit ten (10) business not to exceed total
instructions at this link. Visits can be Information. days of the AFIX funding consideration
conducted in-person, by telephone, or by • Questionnaire responses. visit. amount.
webinar. All AFIX visits must be conducted • Coverage assessment results
by September 30th. (from CoCASA reports). Funds available for
• Feedback visit information. this task*:
b) Conduct AFIX follow-up visits with
provider sites that choose to implement b) Enter the following data in the b) At the time of the FFY15 AFIX,
quality improvement strategies during their Exchange tab of the AFIX AFIX follow-up visit 74205250
initial AFIX visit. Continue following up Online Tool for follow-up or within ten (10)
with provider sites until they fully visits: business days ofthe *See Restrictions on
implement their selected quality • Clinic progress on AFIX follow-up visit Funds below
improvement activities. Follow-up visits implementing quality
can be conducted in-person, by telephone, improvement strategies.
or by webinar. • Follow-up coverage
assessment results (from
CoCASA reports).
8 a) Tn coordination with hospitals, health care Enter information for each case By the 15th of each Reimbursement for
providers, and health plans (if applicable), identified into the Perinatal month actual costs incurred,
conduct activities to prevent perinatal hepatitis B Hepatitis B module of the WA not to exceed total
infection in accordance with the Perinatal Immunization Information System funding consideration
Hepatitis B Prevention Program Guidelines, amount.
including the following:
I I) identification ofHBsAg-positive Annual Perinatal Hepatitis B December 15th Funds available for
pregnant women, and pregnant women with Outreach Summary this task*:
WlknOwn HBsAg status (DOH 348 268)
2) reporting of HBsAg-positive women and FFY 317 Ops
their infants 74201250
3 ) case management for infants born to
Exhibit A , Statements of Work Page 17 of 19 Contract Number C17114
Task *May Support PHAB Payment
Number Taskl Activityillescription StandardslMeasures Deliverables/Outcomes Due DatelTime Frame Information and/or
Amount
HBsAg-positive women to ensure * See Restrictions on
administration of HBIG and hepatitis B Funds below
vaccine within ] 2 hours of birth, the
completion of the 3-dose hepatitis B vaccine
series, and post-vaccination serologic
testing.
b) Provide technical assistance to birthing
hospitals to encourage administration of the
hepatitis B birth dose to all newborns within 12
hours of birth, in accordance with ACIP
recommendations.
c). Report all perinatal hepatitis B investigations,
including HBsAg-positive infants, in the
Perinatal Hepatitis B Module of the Washington
State Immunization Information System. I
*For Information Only:
Funding is not tied to the revised StandardslMeasures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
StandardlMeasure. More detail on these and/or other Public Health Accreditation Board (PHAB) StandardslMeasures that may apply can be found at:
hlm:!lwww .phaboard..orwwo-come nuupJo ads (PHA B-S tan.d.a.rds -and-Measo res-Version -l .O.pdf
Program Specific Requirements/Narrative
• All LHJ staffwho conducts VFC Compliance Site Visits and AFIX visits must participate in an annual VFC and AFIX training, conducted by DOH Office ofImmunization
and Child Profile (OICP) staff or their designee.
• All new LHJ site visit reviewers are required to have at least one (1) observational visit conducted by DOH OICP staff or their designee. DOH OICP staff (or designee) will
periodically conduct observational VFC/ AFIX site visits with all other LHJ reviewers who conduct VFC Compliance Site Visits.
• LHJ staff who conducts VFC Compliance Site Visits must participate in at least one (1) joint (observational) VFC compliance visit with DOH staff every other year. The
observational visit will occur during a regularly scheduled site visit conducted by the LHJ reviewer. DOH will determine the Observational visit.
• Tasks in this statement of work may not be subcontracted without prior written approval from DOH OICP.
Special Requirements
Federal Funding Accountability and Transparency Act (FF AT A)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number.
Information about the LHJ and this statement of work will be made available on http://USASpending.gov by DOH as required by P.L. 109-282 .
Exhibit A, Statements of Work Page 18 of 19 Contract Number C 17114
Program Manual, Handbook, Policy References
Office ofImmunization and Child Profile References and Resources for vaccine management, VFC compliance site visits, AFIX visits, and Perinatal Hepatitis B activities can be
found at this link to our website.
VFC Operations Guide - A copy will be provided by the Office ofImmunization and Child Profile. (Note: All site visit reviewers are required to have access to the most current
CDC VFC Operations Guide at every VFC compliance site visit).
Staffing Requirements
Provide notification via email to oicpcontracts@doh.wa.gov within fifteen (15) days of any changes to staffing for those who conduct work outl ined in this statement of work.
Restrictions on Funds (wbat funds can be used for which activities, not direct payments, etc)
Allowable expenses with 317 and VFC FA Operations Funds (dated September 7, 20 II) document is posted on the DOH Consolidated Contract website at this link. In addition to
the funding listed in the Payment Information and/or Amount column for each task, FFY13 317 Ops funding may be used for any activity in this statement of work, per funding
availability .
These federal funds may not be used for expenses related to travel or attendance at any CDC-sponsored conference, training, or event without prior written approval from the
Office ofImmunization and Child Profile.
DOH Program Contact
Tawney Harper, MPA
Budget and Operations Manager
Office of Immunization and Child Profile
Department of Health
PO Box 47843, Olympia WA 98504-7843
tawney.harper@doh.wa.gov , 360-236-3525
DOH Fiscal Contact
Sheri Spezze
Budget Coordinator
Office of Immunization and Child Profile
PO Box 47843, Olympia WA 98504-7843
Sheri.spezze@doh.wa.gov, 360-236-3495
Exhibit A, Statements of Work
Deliverables may be sent electronically via email at oicpcontractS@doh .wa .eov,
by fax to 360-236-3590, or by mail to PO Box 47843, Olympia WA 98504-7843
Page 19 ofl9 Contract Number C 17114
EXHIBITB
Kittitas County Public Health Department ALLOCATIONS Contract Number: C171l4
Contract Term: 2015-2017 Date: October 17,2014
DOH Use Ooly
BARS Statement oeWork Chart of Accounts Funding Chart or
Federal Award Revenue Funding Period Funding Period Period Accounts
Chart of Accounts Pr~ram Title Identification Number Amcnd# CFDA* Code* .start Date End Date StanDate End Date Amount SubTotal Total
FFY 14 EPR LHJ Funding U90TPOOOSS9 NlA 93.069 333.93"06 01/011lS 06/30/1S 07/01114 06130115 $23,046 $23,046 $23,046
FFYI53170ps NGA Not Received N/A 93.268 333.93.26 OIlOI/IS 12/31115 01101115 12131115 $1,260 $1,260 $1,260
FFYI5 AFIX NGA Not Received N/A 93.268 333.93.26 01/01/15 12/31115 01/01/15 12131115 $5,013 $5,013 $5,013
FFY15 YFC Ops NGA Not Received N/A 93.268 333.93.26 01101115 12/31/15 OllOlllS 12131115 $1,129 $1,129 $1,129
FFYI5 VFC Ordering NGA Not Received N/A 93.268 333.93 .26 01/01/1S 12/3111S 01101115 12131115 $1,IS4 $1,IS4 $1,IS4
FFY 15 MCHBG CBP ConCon B04MC28134 N/A 93.994 333.93.99 OIlOIIlS 09130115 10/01114 091301)5 $33,147 $33)47 $33,147
Drinking Water Group A -SS N/A N/A 346.26.64 01/01/15 12/31/15 07101/13 12131/15 $2,800 $2,800 $2,800
Drinking Water Group A -SS State N/A N/A 346.26.6S 01101115 12/31115 07/01113 12131115 $2,800 $2,800 $2,800
Drinking WaJ:er Group A -T A N/A N/A 346.26.66 01101/15 12/31/1S 07101113 12131/15 $4,000 $4,000 $4,000
TOTAL $74,349 $74,349
Total consideration: $74,349 GRAND TOTAL $74,349
GRAND TOTAL $74,349 Total Fed $64,749
Total State $9,600
'Catalog of Federal Domestic Assistance
**Federal revenue codes begin with "333" State revenue codes begin with "334"
Page 1 of I
Exhibit C Schedule of Federal Awards
KITTITAS COUNTY HEALlH DEPT-SWVOO104T5-0T
CONTftACT Cl71t4-Klltll» County pubroc Health DepaJtmant
CONlRACT PERIOD 1111~1~1213112017
Chart of Accounts Program Title BARS
FFY14 6'R UU FUNDING 3339306
FFYfUf70PS 333.9326
FFY15AFJX 333.9326
FFYf4WCOP$ 333.9S.26
FFY15 VFC ORDERING 333,9326
FFY15 MCHBG caP CXlNCON 333.93.99
DOH
Federal
Award Date
06/3011~
NGANoI
Received
NGANot
Received
NGANoI
Recetved
NGANot
Received
1012"'4
TotalAmt AllOcatiOn PeriOcl
Federal Start End
Award Date Dilte
$12,663,227 01101115 06/30115
NGANoI o1.t1tn512131115 -
NGANot 01/01/1512131/15 Received
M>A.~O! O'I.tI1115 12131115 R--...cI
NGANot 01101115 12/31115 Received
$1,734,378 01.t11115 08130/15
TOTAl.
Date: October 17. 2014
Contract Amt CFDA CFDA program Title Federal Agency Name Federal A_rd Federal Grant Award Name kf<tntffIC<Ido!> Number
Public Health Emergency Department of Health and Human T?12-1201 HPP AND PHEP $23,046 93.069 Prepanedness Services Centers fer Disease Control U9QTPOOO559 COOPERATIVE AGREEMENTS and Prevention
~ CoopenItive EIepIortmonI ~ HeaIIh :ancI Human
$1.260 93.2SII ~ SeMcea Conan! lor.[li:!NIe GGrJIrQI NGA HoI Received NGA Not R-...cI
R Pr8venIion
Immuniza1ion Cooperative Depat1ment 01 Health and Human
$5 ,013 93268 Services Cent"", fur Disease Control NGA Not Received NGA Not Received Agreements and Prevention
~~ ~tf "'~~
S1,129 93.2Iia ~~1\V'~COmtol NGANoI_ NGANoI_ ~ !I!KI~
Immunization Cooperative Departrnem of Health and Human
51,154 93268 Services Centers for Disease Control NGA Not Received NGA Not Received Agreements and Prevention
......... and €NId HeaIII ~~_nfillnwl w,1B'tNAl AND CHl.D HEAllH $33,147 93.894 SIIMoes I!Itid< GIanI"'!he SeMcea ....... Retlualsencl ~34 SERVICES s-s SeMcea~
M4,14S
Page 1 of 1
Federal Funding Accountability and Transparency Act Data Collection Form (2-23-2011)
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.com . The Department of Health (DOH) also
encourages registration with the Central Contractor Registry (CCR) to reduce data entry by both DOH and your
organization. You may register with CCR free of charge at www.ccr.gov . 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.
CONTRACTOR lQDegal Name 2. DUNS Number
Ufl-!'vJ Of ~,+h+a/~ at -02.0 -1SLll
3. Principl e Place of Performance
tJ Ovt-
3a . City 8 [(/\,,'!t;tJ ~ 3b. State
\I'M
3c. Zlp+4 ~gq2 .~ -l ' q { 3d . Country [}S~
4. Are you registered in CCR? p YES (skip to signature block, Sign, date and return) DNO
S. In the preceding fiscal year did your organization :
\'JV a. Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans,
subgrants, and/or cooperative agreements; lmI
~~ 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 lS(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)
ES (You must report the names and total compensation of the top 5 highly compensated officials of your
organization ).
Name Of Offidal 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 emplo'lee, and as otherwise _prov ided by FFATA and applicable OMS guidance.
resentative attests to the Information.
Print Name Date
rli ;}-( IS-
The Department of Health will not endorse your subaward until this form is completed and returned.
Federal Funding Accountability and Transparency Act Data Collection Form
FOR DE PART MENT OF HEALTH USE ONLY
DOH Contract Number
C17114
Sub-award Project Description (see instructions and example below)
Instructions for Sub-award Project Description:
(2-23-2011)
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.
EXHIBIT "E"
Children with Special Health Care Needs Program
Quarterly Maternal Child Health Block Grant Reporting Form
Professional Services Agreement
Page 18
Exhibit E: CYSHCN Quarterly Report for the MCHBG
Facility reporting: CHCW-E Quarter period: Click here to enter text.
Name of reporter: Michele Cawley, RN Date CHIF entry was completed 7-6-16 Email report to
kasev.knutson@co.kittitas.Wll.US or fax: 933-8246 by the 15th of the month following the end of the quarter.
Quarter # Home # Office # Other # New # Title V # Title # other Outreach Outreach
Visits Visits communications Referrals served XIX served # community # provider
served events contacts
Description All non-Office Email, phone, All new New Medicaid Other Events & Contact
office visits text messages, referrals clients or Apple health meetings, with
visits etc. with clients entered in Health Insurance education & providers
CHIF advocacy beyond
referral
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Year-end
total
Regional Meeting Date/Type of Participation
Narrative of CYSHCN outreach activities (optional): Click here to enter text.