HomeMy WebLinkAboutRes-2016-160 12-06-2016BOARD OF COUNTY COMMISSIONERS
COUNTY OF KITTITAS
STATE OF WASHINGTON
RESOLUTION
NO. 2016~ / & (J
RESOLUTION TO AUTHORIZE EXECUTION OF AN AMENDMENT TO AN
INTERLOCAL AGREEMENT BETWEEN THE KITTITAS COUNTY PUBLIC
HEALTH DEPARTMENT AND THE GRANT COUNTY HEALTH DISTRICT
WHEREAS, RCW 39 .34, the Interlocal Cooperation Act, provides the capability for public
agencies to cooperate for mutual advantage; and
WHEREAS, Kittitas County, through the Kittitas County Public Health Department is charged
with the preservation, promotion, and improvement of health in the County; and
WHEREAS, the Kittitas County Public Health Department and the Grant County Health District
previously executed an Interlocal Agreement for the purpose of collaborating on
priory health improvement initiatives associated with tobacco prevention and
control in Central Washington; and
WHEREAS, the terms and conditions of said Interlocal Agreement provided that the parties
may mutually amend the agreement in writing; and
WHEREAS, the Kittitas County Public Health Department and the Grant County Health District
are agreeable to such amendment under the terms and conditions of the amended
Interlocal Agreement attached hereto, and incorporated herein by reference, which
shall replace the original Interlocal Agreement in its entirety; and
NOW THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Kittitas
County, Washington, authorizes the Director of the Kittitas County Public Health
Department to execute the amended Interlocal Agreement with the Grant County
Health District that is attached hereto, and incorporated herein by reference.
DATED this I.t th day of /Y/'lU'Yl-ttr-,2016, at Ellensburg, Washington.
ATTEST:
BOARD OF COUNTY COMMISSIONERS
KITTITAS COUNTY W b SHINGTON
~Q?a2-J-
ABSENT
Commissioner
tL
INTERAGENCY AGREEMENT ~_D1e.!ldment #2
Between
GRANT COUNTY HEALTH DISTRICT
And
Kittitas County Public Health Department
January 1, 2015 -September 30,2017
THIS INTERAGENCY AGREEMENT is made and entered into pursuant to Chapter 39.34 RCW, the Inter
local Cooperation Act, by and between the Grant County Health District, hereinafter referred to as
"GRANT" acting as the Community Lead Organization (CLO) to coordinate the HealtR'( CeR'lR'll:lnities
Q~tVrDlabl!tes , H4Hl rt Di seas A tF&ke--Youth Tobacco Prevention Program and the Kittitas County
Public Health Department hereinafter referred to as "PARTICIPANT", as funded by the Washington State
Department of Health).
IT IS THE PURPOSE OF THIS AGREEMENT to provide a mechanism for the collaborative work,
completion of deJiverables, and transfer of funds necessary to carry out the priority health improvement
initiatives associated with tobacco prevention and control in Central Washington.
IT IS, THEREFORE, MUTUALLY AGREED THAT:
Statement of Work
PARTICIPANT shall furnish the necessary personnel and services and otherwise do all things necessary
for or Incidental to the performance of the work set forth in Exhibit "A" attached hereto and
incorporated herein. Unless otherwise specified, PARTICIPANT shall be responsible for performing all
fiscal and program responsibilities as set forth in Exhibit "A."
Terms and Conditions
All rights and obligation of the parties to this contract shall be subject to and governed by the special
terms and conditions contained in the text of this agreement.
Period of Performance
Subject to its other provisions, the period of performance of this agreement shall commence on January
1, 2015 and conclude on September 30, 2017 unless continued by written agreement or terminated
sooner as provided herein.
In consideration whereof:
Upon receipt of a properly executed A-19 Invoice Voucher and complete billing documentation, GRANT
shall pay to PARTICIPANT the reimbursed sum as agreed upon in Exhibit "A". Parties may mutually
agree to additional sums and deliverables as additional funding is available .
Services and Reporting Requirements
PARTICIPANT will report to GRANT on any services and/or reporting requirements that may be required
under this agreement.
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
10/28//6 Page 1
Approved Expenses
Allowable expenses are for reasonable program purposes, including personnel, travel, supplies and
services such as contractual (refer to Omni circular ). The primary recipient must perform a substantial
role in carrying out project objectives and not merely serve as a conduit for an award to another party
or provider who may be ineligible. No expenses will be reimbursed for any lobbying efforts of any kind
or for any clinical care. Any type of equipment purchase must be pre-approved by GRANT.
Indirect Costs and Line Item Budget Requirements
Indirect costs are limited to the organization's approved overhead rate. PARTICIPANT need not amend
the budget if they anticipate going over in any line item within by less than 10 percent of total direct
charges. However, if they anticipate going over by more than 10 percent of total direct charges for any
line item they will be required to amend their budget before being refunded for costs that exceed 10
percent in respective line items.
Monitoring of fund allocation spending
There will be two check-in points (1) mid-year and (2) two months before statement of work end date :
(1) At mid-year, GRANT will evaluate how much of the PARTICIPANT funds have been spent. If less
than 30% of the funds have been billed, GRANT reserves the right to amend the contract and
reduce the funding allocation.
(2) Two months before the end of the statement of work deliverables, GRANT will evaluate how
much PARTICIPANT funds have been spent. If less than 80% of the funds have been billed and if
the PARTICIPANT doesn't have a reasonable explanation for how they will use the remainder of
the funds, GRANT reserves the right to amend the contract and reduce the funding allocation.
Non-Discrimination
In the performance of this agreement, PARTICIPANT shall not discriminate on the grounds of race, color,
national origin, sex, religion, marital status, age, creed, Vietnam era and disabled veterans status, or the
presence of any sensory, mental, or physical handicap in:
a. Any terms or conditions of employment to include taking affirmative action necessary to
accomplish the objectives of this part; and
b. Denying an individual the opportunity to participate in any program provided by this
agreement through the provision of services, or otherwise afforded others.
Records Maintenance
PARTICIPANT and GRANT shall each maintain sufficient records to demonstrate that funds allocated
under this contract have been expended in accordance with the terms and conditions of the Federal
Hea'~I'\~ CQlflmt#'l l tie~ oeesitYI Oi~etQ§, ~Iea,.t (;}isease aA~ ~Y outh Tobacco Prevention
Program Statement of Work guidelines and any federal terms and conditions that may apply.
Audit Requirements:
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
10/28/16 Page 2
An organization that expends $ 750 ,000 or more In a year in Federal awards shall have a single or
program-specific audit conducted for that year in accordance with the provision s of Omni Circular . The
audit must be completed along with a data collection form, and the reporting package shall be
submitted within the earlier of 30 days after receipt of the auditor's report(s), or nine months after the
end of the audit period . The audit report must' be sent to Federal Audit Clearing House; Bureau of the
Census; 1201 East 10th st; Jeffersonville, IN 47132.
All duly authorized auditors or their representatives of the State of Washington and of the CLO, GRANT,
shall have full access and the rights to examine any of these materials during this period, subject to
confidentiality laws and regulations. These records shall be retained for five (5) years .
PARTICIPANT shall adhere to all other Federal Grant requirements.
Restrictions on Funds (what funds can be used for which activities, not di rect payments/ etc):
1. Recipients may not use funds for research.
2. Recipients may not use funds for clinical care.
3. Recipients may only expend funds for reasonable program purposes, including personnel, travel,
supplies, and services, such as contractual .
4 . Recipients may not generally use HHS/CDC/ATSDR funding for the purchase of furniture or
equipment. However, if equipment purchase is integral to a selected strategy, it will be
considered. Any such proposed spending must be identified in the budget.
5. Recipients may not use funding for construction.
6. The direct and primary recipient in a cooperative agreement program must perform a
substantial role in carrying out project objectives and not merely serve as a conduit for an award
to another party or provider who is ineligible.
7. Reimbursement of pre-award costs is not allowed.
8. Recipients may not use funds for abortions in accordance with Executive Order 13535.
If requesting indirect costs in the budget a copy of the indirect cost rate agreement is required. If the
indirect cost rate is a provisional rate, the agreement should be less than 12. months of age. As per Omni
Circular if participant has never had a negotiated indirect rate they can request 10% de minimis rate .
Agreement Al terations and Ame n dments
GRANT and PARTICIPANT may mutually amend this agreement. Such amendments shall not by binding
unless they are in writing and signed by personnel authorized to bind PARTICIPANT and GRANT.
Indemnification
Each party shall defend, protect and hold harmless the other party from and against all claims, suits
and/or actions arising from any negligent or intentional act or omission of that party's employees,
agency and/or authorized subcontractor (5) while performing this contract.
Termination
Except as otherwise provided in this agreement, either party may terminate this agreement upon 90
days written notification . If this agreement is so terminated, the termination party shall be liable only
Youth Tobacco Interagency Agreement-Kittitas Amendment#2
10/28/16 Page 3
for performance in accordance with the terms of this agreement for performance rendered prior to the
effective date of term ination.
Administrator
Pursuant to RCW 39,34.U3U(4)(a), the administrator for this agreement shaii be Theresa Adkinson of the
Grant County Health District. Nothing in this agreement shall be deemed to establish a separate legal
entity to conduct the cooperative undertaking described herein.
Property
Unless otherwise specifically agreed by the parties in writing, all property, personal and real, utilized by
the parties hereto in the execution of this Agreement shall remain the property of that party initially
owning it.
All notices, reports, and correspondence to the respective parties of this Agreement shall be sent to the
following address:
To GRANT:
Primary Contact:
To PARTICIPANT:
Primary Contact:
Savings
Grant County Health District
1038 W. Ivy St.
Moses lake, WA 98837
Theresa Adkinson , Administrator
Kittitas County Public Health Department
507 N Nanum St, # 102
Ellensburg, WA 98926
Robin Read, Administrator
In the event that funding from state or federal funds is withdrawn, reduced, or limited in any way after
the effective date of this contract and prior to normal completion, GRANT may terminate the contract
under the "termination" clause, or reduce to the new funding limitations and conditions.
Disputes
In the event that a dispute arises under this agreement, it shall be determined in the following manner:
GRANT shall appoint a member to the Dispute board. PARTICIPANT shall appoint a member to the
Dispute board. GRANT and PARTICIPANT shall jointly appoint a member to the Dispute Board. The
Dispute Board shall evaluate the dispute and make a determination of the dispute. The determination
of the Dispute Board shall be final and binding on the parties hereto,
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
W/2 8/16 Page 4
Pursuant to RCW 39.34.040, this Agreement shall be filed with the county auditor of the parties hereto
or, alternatively, listed by subject on a public agency's web site or other electronically retrievable public
source of the parties hereto.
Refer to Exhibit "s"
All Writings co nt ai ned herein
This agreement contains all the terms and conditions agreed upon by the parties. No other
understandings, oral or otherwise, regarding the subject matter of this agreement shall be deemed to
exist or to bind any of the parties hereto.
IN WITNESS WHEREOF, the parties have executed this agreement.
Kittitas County Public Health Department Grant County Health District
Signature
Rob;n Read. Administrator Theresa Adkinson , Administrator
(Print) (Print)
\~1 q lIte , 1.2 \1l,P
Date Date
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
10/28/1 6 Page 5
EXHIB IT "A"
Chalto; CFDA ~ BARS Fundilig Period C UI~(en t Change rotal
ACCO:_JnlS fh~vel-IUe (LHJ Use O'iiV) C Ollsidera~ion inrrp.ase Consideration
Program Nillne Code Start Date End Date (+l
or ritle
Youth Tobacco N/A 3340493 01/01/15 OGnO/l S 5750 (U94) 4,456
Prevent'on
FFYl4 PHBG 93758 333 .93 75 01/01/15 09/30/15 11,750 (4.478) 7,272
CBP Tobacco·-
PPHF
FFY15 PHBG 93758 333~93 75 10/01/15 09/30/16 1,000 478 1,478
CBP Tobacco-
PPHF
FreY15 CDC 93305 33393 30 03/29/15 03/28/16 2,000 (452) 1548
Tobacco
Prevention
Youth Tobacco N/A 334049, 07/01/15 06/10/Hi 4,000 (188.97) 3811 .03
Prevention
FFYl5 PHBG 93 .758 333.93.75 7/01/2016 6/30/2017 0 6250 6250
CBP Tobacco -
PPHF
FFY15 CDC 93.305 333.93.30 03/29/16 3/28/2017 0 4000 4000
Tobacco
Prevention
Youth Tobacco N/A 334.04.93 7/01/2016 6/30/2017 4500 4500
Prevention -
Vaping
TOTAlS 24,500 8,815 .03 33,315.03
Bil ling Info rmati o n:
All A-19 Invoice billings with original Signatures and detailed documentation attached ;are to be sent to
Grant County Health District 1038 W Ivy Ave Suite I, Moses Lake WA 98837 attn: Ryan Brimacombe.
Please indicate the costs for each separate component on your A-19.
Billings should be submitted monthly within 30 days after the close of a month. Exception: For the
month after a funding source's expiration date please have the billing submitted within 25 days after the
close of the month.
Youth Tobacco Inte ragency Agreement -Kittitas Arnendment#2
10/28/16 Page 6
liRe IteFR Ihuilget;
I(iu itas 9",dge' 1010' " :lOJ,i '''Ri~
D8!!iGfi~'iaR BwdtIet
DIAI!(ri:;
ialaFies ~
Yenetit!!i ~
~oo~s & 'e~iGe!!i ~,-wg
:J:etal giF8Gt 'asts; ~
INDIAI!c;J;
QI"8Fi:lead $1,01i
:J:otall="R~ing p,ggg
Statement of Work I n formation (To be com pIe ed~l!!!e 30 20 1& ~
Task
Number Task/Activity /Oesc ription Oeliverables/Outcomes
Gaal PREVENT YOUTH FROM IN/TIA TING TOBACCO AND NICOTINE USE
Objective 1.1-Enhance community participation
in youth tobacco prevention and control
PZlrticlpure In quarterly (~:,g[onal P2rtCH:'( ronferf'm p
(tills to discuss 'Nork plan progress and neL\lork
with regional partners
PrJrtncr with ~(hool districts :.:ind 10(fll puhlic i1e?llth
to address tobacco and c (lgLlrette u~olge
Wor'" WIU, schcni di:::,tnct 'J..'.Jchers, str:ltf
;:tnd admin;sl ration on tOQClCCO
2ducatlcfl, e clg.nettes/1japmg ,Jnd
currenI trends, in order to inClude
>?Iectronic cigarettes into :-;chcol policy
Coordil1atr~ (~AI\lS a'jse~.'lment!i with ~HJS Jrld
prevention coalitions in at :ea~t four commun:tles
Detf'mllf~e J CANS wer,= rionp:n ihe
pasl, icncJ data to the GCHIJ
Traill yOJtt'l to ,:olluucl C.c\'i\JS dsseSSrrlp.lll
,!S(:lg adult F',\J.rJ(~'J ,11;(1 ,hp "H·'lW to"
PowerPoint
Complete 20-3D new C,"\NS Asses,)lllpnt~
and retiJrn d.,ti3 ro GCHD
WOI~ with 1~2 tobacco relalicrs to
RpLluce the number \.)f wb(1[cC)
,JclvertiSetllent~ dl:,pI3V~d In Lhe
bU51i1E:'SS
r!:-1'jl' l' p,jlctn~2r blr1.l1 d(1I.~-~' -;Jlgl)
displayed aT the cash rCiliSICf
A:'i'-,I<;t thE-' I(IJIJtr, to:
Ci Sh,-lrp lAi\lS finllln~s witil.=it if.ast
1 2 eily Council BDdid ~)f Hedlth or
other group or eiecLcd officials
(J RecogniZ\~ otJbtanciing LobilCCO
retdliel \ and share C~NS findif'gs
Attendance at rneetings and
conterence cails GCHO WII!
mJintJin Jtrendanc12 document
Documentalion using reporting
[2rnplale proVl(ied b', GCHD
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
10/28/16
Due
Date/Time
Frame
6/30/2016
6(30/2016
9/29/2015
6130/20 1 6
-
Payment
Information and/or
Amount
Reimbursement for
actu"1 expenditures,
(lot to exc~ed total
funding
consid e(ation
Page 7
Task
Number Task/ Activity/Description
til! ougll i1:(~did ~1.~It:'dSe,> -If'cl/'ll
SOUr! rnedi.-1
Objective 1 l Strengthen school and campus
tobacco-free policies
Provide ,moke-free and vape-free college campus
technic'll assistance to regional college and
workplace carnpuses
Work with LrlrCe local employers to
ImplemenT tohacea free policies on therr
campus
~);:!' hler N til ~rl(~ City sr Fllcpsburg 0df b dr1d
Rec:reJ~IOfl tu enhallCf. Cur rent ~l)t)rlCU! frpe tJr:J! <s
cS incluue '/dJ)InA and eiectron:c ClJ:.arettes
Delivera bles/Outcomes
Doc umentation using reporting
tepl[l dte provided bV GCHD
Stateml!J1 at Work Information
Task Due
Task/Activity/Description Deliverables/Outcomes Date/Time Number Frame
Goal: PREVENT YOUTH FROM INITIATING TOBACCO AND NICOTINE USE
Objective 1.1-Enhance
1 community participation in
youth tobacco prevention and
control
Participate in quarterly regional Attendance at meetings
and conference calls. partner conference calis to GCHD will maintain discuss work plan progress and attendance document. 6/30/2017
network with regional partners .
Coordinate CANS assessments with
LHJs and prevention coalitions in at
least four communities.
Train youth to conduct
CANS assessment using
adult guides and the
{tHow-to" PowerPoint · Complete 20-30 new CANS
Assessments and return
data to GCHD · Work with 1-2 tobacco Documentation using retailers to: reporting template provided 6/30/2017
0 Reduce the number
of tobacco by GCHD.
advertisements
displayed in the
business.
0 Have a "purchaser
birth date" sign
displayed at the cash
register. · Assist the youth to:
0 Share CANS findings
with at least 1-2 City
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
I tJ/lB/16
Due
Date/Time
Frame
9/29/2015
S/3CJ/2Cl16
Payment
Information and/or
Amount
Payment Information
and/or Amount
Reimbursement for actual
expenditures, not to exceed
total funding consideration.
Reimbursemen t for actual
expenditures, not to exceed
total funding consideration.
Page 8
-
Task Due
Task/Activity/Description Dellverables/Outcomes Date/Time Number Frame
Council, Board of
Health or other
group of elected
officials.
Objective 1.3 Develop youth
1 leaders who work to create
healthier communities
Educate retailers about the new
state and federal laws. Of the 48
retailers in Kittitas County, the Documentation using
focus should be on retailers near reporting template provided 06/30/2017
schools, parks or with previous by GCHD.
tobacco violations.
Objective 1.4 Implement
strategies to address new state
vapor product prevention law
(E5586328) through:
-Polley development
-Pollcymaker outreach and
education
-Community education and
awareness
-Retailer education
Policy Maker outreach and
education through two official Documentation using
board meetings, individual reporting template provided 6/30/2017
contacts and PSA/media by GCHD.
campaign
Objective 4.1-lncrease the
4 number of multi-unit housing
complexes that have a no-
smoking policy
Coordinate with Hopesource
housing to adopt a tobacco policy Documentation using for emergency and transitional, reporting tem plate provided 6/30/2017 housing. Activity to address by GCHD. policy for multi-unit housing
residents.
Objective 4.2-lncrease the Documentation using 4 number of worksltes that have a 6/30/2017
no-smoking policy reporting template
provided bv GCHD.
Coordinate with Kittitas County
Fairgrounds and Elmview, a
private non-profit working with Documentation using
people with developmental reporting tem plate provided 6/30/2017
disabilities, to adopt a tobacco by GCHD.
policy for all staff. Activity to
address colicV cha l!~ for staff.
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
10/28/1 6
Payment Information
and/or Amount
Reimbursement for actual
expenditures, not to exceed
total funding consideration.
Reimbursement for actual
expenditures, not to exceed
total Funding consideration.
Reimbursement for actual
expenditures, not to exceed
total funding consideration
Reimbursement for actual
expenditures, not to exceed
total funding consideration.
Reimbursement for actual
expenditures, not to exceed
total funding consideration
Page 9
Form
A19-1A
(Rev. 11191,
State of Washington
INVOICE VOUCHER
AGENCY NAME
Grant County Health District
1038 W Ivy Ave
Moses Lake, WA 98837
VE NDOR OR CLAIMANT (Warrant is to be payable to)
Month
Decription Amount
Contract
Goods & Services
Indirect Costs
Total
Prepared by Date
Agency Usa Only
Agency Location Code
No.
INSTRUCll0NS TO VENDOR OR CLAIMANT:
P.R. or
Auth. No.
Submit this form to claim payment for materials, merchandise or services.
Show complete detail for eech Item.
Vendor's Certificate: I hereby certify under penalty of perjury that the
items and total. listed herein are propar charges for materials ,
merchandise or services furnished to the State of Washington, and that all
goods fuml.hlld andlor services rendered havI bean provided without
dl.crlmlnatlon because of agl, Bell, merltal statUI, race, crelld, color,
natJonal origin, handicap, religion, or Vietnam era or dl8abled veterans
atatua.
(Signature)
By
(11tI8) (Date)
I Agency Approval I Date
Youth Tobacco Interagency Agreement -Kittitas Amendment#2
10/28/1 6 Page 10
-
1
Ii
i ii
Iv
v
vi
vii
v iii
Ix
x (a)
x
(b)
x (c)
xi
xii
xiii
Exhibit "B"-§200 331 reQuirements for Das s-through entities
is this a subaward? Yes Yes Yes Yes
Federal Award identification 8010T009058 U58DP006004 U58DP006004
#'s 8010T009058
Subrecipient Name Kittitas County Pub!ic Heal[h
Subrecipient DUNS # 01-0202547
Federal Award Identification # B01OT009058 8010T009058 U58DP006004
Federal Award Date 7/2/2014 3/23/2015 3/23/15
i<muary l , October 1, 2015 -March 29 , 2015
Subaward Period of 2015 OeEeFflBer lQ , -l'V i arch 28,
Performance Start and End September 30, ~September 2016
Date 2015 30,2016
Amount of Federal Funds ~$45 ,OOO $25,000
Obligated by this action ~45,000
Total Amount of Federal Funds S!.OOQ $1,478 ~$1,548
Obligated to the 5ubrecipient $7,272
Federal award project
FFY14 PHBG FFY15 PH BG CBP ~FY15 CDC
CBP Tobacco-Tobacco-PPHF Tobacco
description PPfiF f'reverti0 1
Depart!1 1ent of Depa r tment o f Department of
Name of Federal awarding Health and Heal l h an d Health and
agency :1uma,l Htln1dn Servic es, Human Services,
Services, CDC CDC CDC
Department of Department of Department of
Pass-through entity Health Health Health
Contact information for Grant County Grant County Grant County
awarding official Health District Health District Health District
CFDA # (note dollar amount 93 .758 93.305
awarded for this CFDA# in "vii"
above 93758
Is the award for R&D (research No No
and development)? No
Indirect Cost Rate for 40.25 r7; of salaries
Subrecipient Award
Youth Tobacco Interagency Agreement -Kittitas Am e ndm e nt#2
1 0/28/16
U58DP006004
TBA
March 29,
2016 -March
28,2017
$27,500
$4,000
CDC
Department of
Health and
Human
Services, CDC
Department of
Health
Grant County
Health District
93 .305
No
Yes
BOlOT009058
B010T009058
TBA
July 1, 2016 -
June 30, 2017
$33,750
$6,250
FFY16 PHBG
HCPPPHF
Department of
Health and
Human
Services, CDC
Department of
Health
Grant County
Health Distric
93 .758
No
Page 11
Today's Date
11/2/2016
Fund/Department
116-Public Health
Kittitas County
Review Form
Grants & Contract Agreement
Agenda Date
Contract/Grant Information
\2
Contract /Grant Agency: Interagency Agreement Amendment 2 between Grant County and Kittitas
County Public Health Department
Period Begin Date: January 1,2015 I I Period End Date: September 30, 2017
Total Grant/Contract Amount: Total Consideration of $16,228.00
Grant/Contract Number: Amendment 2
Contract/Grant Summary:
The interagency Agreement between Grant County and Kittitas County is established to provide a
mechanism for the collaborative work, completion of deliverables, and transfer of funds necessary to
carry out the priority health improvement initiatives associated with tobacco prevention and control in
Central Washington.
Recommendation for Board of Health and Board of Health Review on
~-~ l I Department Head Signature: _~...I" .• __ ~:........:==-_~_. Administrator Date: 1/;2,'1 1 ~
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APP ROVED AS TO FOR M:
Date
Signature of Board of Health member Date
Financial Information
Total Amount $16,228.00 State Funds $4,500.00 Federal Funds $11,728
Percentage County Funds Matching Funds $ CFDA# 93.758, 93.305
Grant/Contract Review Page 1
In -Kind $
Explain
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes D attach budget form No [RJ Why not
New Division Created? Included in 2016/2017 budgeting process
Revenue Code
116-612.44.03.333.93.758 -$7,728
116-612.44.03.333.93.305 -$4,000
116-612.44.03.334.04.93 -$4,500
I
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review
[, Has the Prosecutor reviewed this agreement? IvesD No 0
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature: I Date:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer
Grant/Contract Review
I Date
Page 2