HomeMy WebLinkAboutConsolidated Contract2018 -2020
WASHINGTON STATE
DEPARTMENT OF HEALTH
CONSOLIDATED CONTRACT
Page 1 of 17
DOH CONTRACT #: CLH18249
DOH CONTRACT #: CLH18249
Table of Contents
1. Purpose ........................................................................... ~ ........................................................ '. 3
2. Statements of Work " .... , ..... , .... , ......................................................... , .............. , .. , .... " .... , .. , ..... 3
3. Exhibits .................................................................................................................................... 3
4. Definitions .................................................................................................... "." ...................... 3
5. Funding and Billing .... " ............ " .................................................................... " .. " .................... 4
6. Contract Management ........ , ..................................................................................................... 5
7. Access to Records .................. , ........................................................... , .......... , ........ , .. , ..... , .. , ..... 5
8. All Writings Contained Herein ................................................................................................ 5
9. Assignment .............................................................................................................................. 5
10. Assurances ............................................................................................................... " ............... 5
11. Confidential Information ......................................................................................................... 6
12. Ethics ....................................................................................................................................... 6
13. Debarment Certification .......................................................................................................... 6
14. Disputes .............................. , ................................... , ................................................................ 6
15. Equipment Purchases ............................................................................................................... 6
16. Governing Law and Venue ...................................................................................................... 7
17. Independent Capacity ............................................................................................................... 7
18. Insurance ................................................................................................. ,~ ................................. 7
19. Licensing, Accreditation and Registration ............................................................................. , 7
20. Maintenance of Records .......................................................................................................... 7
21. Modifications and Waivers ...... , ................................................................................................ 7
22. No Third-Party Rights Created ................................................................................................ 7
23. Nondiscrimination ................................................................................................................... 7
24. Order of Precedence ...................................................................................................... , ......... 8
25. Ownership of Material/Rights in Data ..................................................................................... 8
26. Publications ................................................................................................................................ 8
27. Responsibility for Actions ..................................... ; ................................................................. 8
28. Loss or Reduction of Funding ................................................................................................. 8
29. Severability ............................................................. , ........ , ....................................................... 8
30. Subcontracts ............................................................................................................................. 8
31. Subrecipient ............................................................................................................................. 9
32. Survivability ............................................................................................................................ 9
33. Term ......................................................................................................................................... 9
34. Termination for Convenience .................................................................................................. 9
35. Termination for Default ........................................................................................................... 9
36. Termination Procedure ............................................................................................................. 9
Standard Federal Certifications and Assurances ................. · ....................................................... 11
Federal Assurances -Non-Construction Programs .................................................................... 16
2018-2020 Consolidated Contract Page 2 of 17
DOH CONTRACT #: CLH18249
1. Purpose
CONSOLIDATED CONTRACT
between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
(Referred to as "DOH")
and
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
(Referred to as "LHJ")
for
THE DELIVERY OF PUBLIC HEALTH SERVICES
FOR THE PERIOD OF
January 1, 2018 through December 31, 2020
This Contract is entered into in accordance with RCW 43.70.520, RCW 43.70.580, the general statutory powers ofthe
Secretary of the Department of Health (DOH), including at RCW 43.70.040, the general statutory powers of local
health jurisdictions (LHJs), including at RCW 70.05.060, RCW 70.08.020, and RCW 70.46.060, and the authority for
joint or cooperative action provided for under chapter 39.34 RCW. The purpose of this Contract is to define the
parties' joint and cooperative relationship. The contract and all statements of work adopted under its provisions are
intended to implement applicable objectives under the Public Health Improvement Plan and to facilitate the delivery
of public health services to the people in Washington State. This Contract is the result of cooperative planning efforts
between the LHJ and DOH.
2. Statements of Work
The individual program activities, requirements, and outcomes/deliverables to be achieved by the parties under this
Contract are described in Exhibit A, Statements of Work. Each statement of work shall comply with the performance-
based criteria under RCW 43.70.580(2)(b).
The LHJ shall furnish the necessary personnel, equipment, material and/or services and otherwise do all things
necessary for or incidental to the performance of the work as set forth in Exhibit A, Statements of Work.
3. Exhibits
This Contract incorporates by reference the following Exhibits:
• Exhibit A -Statements of Work
• Exhibit B -Allocations
• Exhibit C -Schedule of Federal Awards
4. Definitions
As used throughout this Contract and unless amended for a particular Statement of Work, the following terms shall
have the meanings set forth below:
"Budget, Accounting, and Reporting System (BARS)": The system designed by the State Auditor's office for
collecting, consolidating, and reporting financial budgeting and accounting information from all local
governmental units.
"Client": An agency, firm, organization, individual or other entity applying for or receiving services provided by
the LHJ under this Contract.
"Catalog of Federal Domestic Assistance (CFDA)": The unique identifying code assigned to a federal assistance
program which identifies the awarding agency.
"Confidential Information": Information protected from disclosure under federal or state law.
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DOH CONTRACT #: CLH18249
"Contract Coordinator": Each party's designated contact for all notices required or pennitted under this Contract.
"Contracting Officer": The DOH Contracts and Procurement Office Director 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 Exhibit A, Statements of Work.
"Federal Assistance": Assistance provided by a federal agency in the form of grants, contracts, loans, loan
guarantees, property, cooperative agreements, interest subsidies, insurance, or direct appropriations, but does not
include direct federal cash assistance to individuals.
"F ederal Funding Accountability and Transparency Act (FF AT A or the Transparency Act)": A federal act to
make information available online so the public can see how federal funds are spent.
"Fixed Assets": Fixed assets are property and/or equipment obtained through donation, gift, purchase, capital
lease, or construction with a service life of more than one year.
"Program Contact": Each party's designated contact for those purposes identified in the Exhibit A, Statements of
Work.
"Subcontractor": Any individual or group contracted with the LHJ to perform all or part of the services included
in this Contract. This term will also apply to situations where an LHJ's subcontractor contracts with another
individual or group to perform all or part of the services included in its agreement with the LHJ.
"Subrecipient" or "Subgrantee": A non-federal entity that receives a subaward of federal grant money or goods
directly or indirectly from DOH and makes decisions regarding who can receive what federal assistance; has its
performance measured against the objectives contained in the DOH agreement with the federal government;
makes decisions on how to operate the program to accomplish the program goals; has the obligation to comply
with federal subrecipient requirements; and/or use federal funds to carry out a program for the public purpose
specified in the authorizing statute.
5. Funding and Billing
A. DOH shall pay the LHJ for services as set forth in the Exhibit A, Statements of Work, not to exceed funding
amounts as detailed in the Contract Allocations, Exhibit B, for those services provided herein.
The LHJ will advise the Program Contact identified in the applicable Statement of Work in writing 90 calendar
days prior to the end of the funded period, or as soon as practicable thereafter, if the LHJ anticipates not using all
Contract funding.
B. If the Exhibit A, Statement of Work, is supported by federal funds that require compliance with FFATA (the
Transparency Act), the corresponding checkbox on the statement of work will be checked.
C. Total consideration for this Contract is $72,03_8, 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.
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DOH CONTRACT #: CLH18249
D. The LHJ will submit a BARS A financial report by April 15 for the prior calendar year .
6. Contract Management
Unless otherwise specified in the Contract, the following individuals are the contacts ("Contract Coordinators") for all
notices required or permitted under this Contract:
LHJ Contract Coordinator: DOH Contract Coordinator:
Name: Candi Blackford Name: Brenda Henrikson
Title: Contracts Specialist
Mailing Address: Mailing Address:
509 N. Nanum Street, Suite 102 PO Box 47905, Olympia WA 98504-7905 Ellensburg W A 98926-2886
Physical Address: Physical Address:
Same as above 101 Israel Rd. SE, Tumwater WA 98501-5570
Phone: 509-962-7515 I Fax: 509-962-7581 Phone: 360-236-3933 I Fax: 360-236-2401
Email Address: Email Address:
candi. blackford@co.kittitas.wa.us brenda.henrikson@doh.wa.gov
A party may change its Contract Coordinator or its Program Contact by providing written notice to the other party.
DOH Program Contacts can be found in the Exhibit A, Statements of Work, and on the DOH website at
www.doh.wa.gov.
7. Access to Records
To the extent authorized by applicable federal and state law, the parties shall provide access to records relevant to this
Contract to each other, the Joint Legislative Audit and Review Committee, the State Auditor, and authorized federal
officials, at no additional cost. Inspections shall occur at reasonable times and upon reasonable notice.
8. All Writings Contained Herein
This Contract contains all the terms and conditions agreed upon by the parties. No other understandings, oral or
otherwise, regarding the subject matter of this Contract shall be deemed to exist or to bind any of the parties hereto. The
individuals signing this Contract certify by their signatures that they are authorized to sign this Contract on behalf of
their respective entity.
9. Assignment
Except for subcontracting as authorized in this Contract, the LHJ shall not assign or delegate, in whole or in part, this
Contract or any of its rights, duties, obligations, or responsibilities, without the prior written consent of DOH's
Contracting Officer, which consent shall not be unreasonably withheld.
10. Assurances
The parties agree that all activity pursuant to this Contract shall be in accordance with all applicable current federal,
state and local laws, rules, and regulations.
The LHJ acknowledges its agreement to comply with federal certifications and assurances by signing and returning
the following:
1. Standard Federal Certifications and Assurances
2. Federal Assurances for Non-Construction Programs
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DOH CONTRACT #: CLH 18249
11. Confidential Information
The parties agree to comply with all state and federal statutes and regulations relating to Confidential Information.
DOH and LHJ wi11limit 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 InformationINotice
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 (5) business days prior to the date of disclosure, to
allow the party objecting to disclosure to seek a protective order from the proper tribunal.
DOH and LHJ agree to establish, document and maintain security practices and safeguards consistent with state and
federal laws, regulations, standards, and guidelines to prevent unauthorized access, use, or disclosure of Confidential
Information in any form. In accordance with federal and state contracting requirements, DOH may monitor, audit, or
investigate LHJ management of Confidential Information relating to this Contract. Working together, the LHJ and
DOH may use any and all tools available to track Contract related Confidential Information.
If one of the parties becomes aware of an actual or suspected breach of confidentiality, that party will promptly notify
the Contract Coordinator for the other party of the facts. The parties will work within their respective organizations to
take any steps necessary to determine the scope of the breach and to restore reasonable security to the Confidential
Information. Both parties agree to mitigate any known harmful effects of a breach in confidentiality, including
notifying affected individuals to the extent required by law. The parties will also reasonably cooperate with law
enforcement as appropriate.
12. Ethics
Both parties and their officers shall comply with all ethics laws applicable to their activities under this Contract,
including Chapters 42.23 and 42.52 RCW. If a violation occurs and is not cured within a reasonable time after notice,
the other party shall have the right to terminate this Contract. This section is expressly subject to the Disputes section
of this Contract.
13. Debarment Certification
The LHJ, by signing this Contract, certifies that the LHJ is not presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participating in this Contract by any federal department
or agency. The LHJ also agrees to include the above requirement in all subcontracts into which it enters. The LHJ
will notify DOH of any such events that may occur during the term of the Contract.
14. Disputes
Except as otherwise provided in this contract, when a dispute arises between the parties and it cannot be resolved by
direct negotiation, the parties agree to participate in good faith in non-binding mediation. The mediator shall be
chosen by agreement of the parties. If the parties cannot agree on a mediator, the parties shall use a mediation service
located in Washington State that selects a qualified mediator for the parties. Each party shall bear its own costs for
mediation and each party shall contribute equally to the mediator's fee, if any. The parties agree that mediation shall
precede any action in a judicial tribunal.
Nothing in this contract shall be construed to limit the parties' choice of a mutually acceptable alternate dispute
resolution method in addition to the dispute resolution procedure outlined above.
15. Equipment Purchases
Equipment purchased by the LHJ for use by the LHJ or its subcontractors during the term of this Contract using
federal funds, in whole or in part, shall be the property of the LHJ. The use, management and disposal of the
equipment must comply with federal requirements. These requirements are found in the Office of Management and
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DOH CONTRACT #: CLH18249
Budget's (OMB's) Unifonn Guidance, Title 2 Code of Federal Regulations Part 200 (2 CFR 200) -Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, or are included in the
federal funding agency's regulations.
16. Governing Law and Venue
The laws of the state of Washington govern this Contract. In the event of a lawsuit by the LHJ against DOH arising
under this Contract, venue shall be proper only in Thurston County, Washington. In the event of a lawsuit by DOH
against the LHJ arising under this Contract, venue shall be proper only in the county in which the LHJ is located or in
either of the two nearest judicial districts within the meaning ofRCW 36.01.050.
17. Independent Capacity
The employees or agents of each party who are engaged in the perfonnance of this Contract shall continue to be
employees or agents of that party and shall not be considered for any purpose to be employees or agents of the other
party.
18. Insurance
The LHJ certifies that it is self-insured, is a member of a risk pool, or maintains insurance coverage as required by this
Contract. Each party shall pay for losses for which it is found liable. The LHJ agrees to require all subcontractors to
maintain insurance in types and with limits as may be determined by the LHJ and/or its risk manager, unless the LHJ and
DOH agree otherwise.
19. Licensing, Accreditation and Registration
The LHJ shall comply with all applicable local, state, and federal licensing, accreditation and registration
requirements and standards, necessary for the perfonnance of this Contract.
20. Maintenance of Records
Each party to this Contract shall maintain books, records, documents and other evidence that sufficiently and properly
reflect all direct and indirect costs expended by it. All books, records, documents, and other material relevant to this
Contract will be retained for six (6) years after expiration. If any litigation, claim or audit is started before the
expiration of the six-year period, the records shall be retained until all litigation, claims, or audit findings involving
the records have been resolved.
Each party will use reasonable security procedures and protections to assure that records and documents provide\i 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 tenn 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 perfonnance of this Contract, the LHJ and DOH shall comply with all federal and state nondiscrimination
laws, regulations and policies. In the event of the LHJ's noncompliance or refusal to comply with any nondiscrimination
law, regulation or policy, this Contract may be rescinded, canceled or terminated in whole or in part, and the LHJ may be
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DOH CONTRACT #: CLH18249
declared ineligible for further contracts with DOH. The LHJ shall, however, be given a reasonable time in which to cure
this noncompliance. Any dispute may be resolved in accordance with the "Disputes" procedure set forth herein.
24. Order of Precedence
In the event of an inconsistency in the terms of this Contract, or between its terms and any applicable statute or rule,
the inconsistency shall be resolved by giving precedence in the following order:
• Applicable state and federal statutes, and local laws, rules and regulations.
• Terms and conditions of this Contract.
• Statements of Work.
• Any other provisions of this Contract, including other materials incorporated by reference.
25. Ownership of 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 informat~on gathered through use of local funds must acknowledge receipt of such local
support .
27. Responsibility for Actions
Each party to this Contract shall be solely responsible for the acts and omissions of its own officers, employees, and
agents in the performance of this Contract. Neither party to this Contract will be responsible for the acts and
omissions of entities or individuals not party to this Contract. DOH and the LHJ shall cooperate in the defense of tort
lawsuits, when possible.
28. Loss or Reduction of Funding
In the event funding from state, federal, or other sources is withdrawn, reduced, or limited in any way after the
effective date of this contract and prior to normal completion, DOH may elect to suspend or terminate the contract, in
whole or in part, under the "Termination for Convenience" clause with a ten (10) business day notice to LHJ, to the
extent possible, subject to renegotiation at DOH's discretion under those new funding limitations and conditions.
29. Severability
If any term or condition of this Contract is held invalid, such invalidity shall not affect the validity of the other terms
or conditions of this Contract, provided, however, that the remaining terms and conditions can still fairly be given
effect.
30. Subcontracts
The LHJ may subcontract any or all of the services or other obligations specified in this Contract. The LHJ will
require the subcontractor to comply with all the applicable terms and conditions of this Contract, including all terms,
conditions, certifications and assurances. The LHJ agrees it is responsible for assuring adequate performance on the
part of the subcontractor.
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DOH CONTRACT #: CLH18249
The parties agree that all subcontractors must be responsible for any liabilities created by their actions or omissions.
In the event DOH, LHJ, and subcontractor are found by a jury or trier of fact to be jointly and severally liable for
personal injury damages arising from any act or omission, then each entity shall be responsible for its proportionate
share.
31. Subrecipient
For those activities designated as "subrecipient" on Exhibit A, Statements of Work, the LHJ must comply with
applicable federal requirements, including but not limited to OMB's Uniform Guidance at 2 CFR 200, Subparts D
(Administrative Requirements), E (Cost Principles) and F (Audit Requirements), and program specific federal
regulations. If the LHJ expends $500,000 or more in federal awards from all sources, it is responsible for obtaining
appropriate audits. If the LHJ expends $750,000 or more in federal grants or awards from all sources, it is responsible
for obtaining the required single audit.
32. Survivability
The terms and conditions contained in this Contract, which by their sense and context are intended to survive the
expiration of the Contract, shall survive. Surviving terms include, but are not limited to: Access to Records,
Confidential Information, Disputes, Responsibility for Actions, Maintenance of Records, Ownership of
MateriallRights in Data, Subcontracts, Termination for Convenience, Termination for Default, and Termination
Procedure.
33. Term
This Contract will be in effect following execution by the parties from January 1, 2018 through December 31,2020,
unless terminated earlier as provided herein.
34. Termination for Convenience
Except as otherwise provided in this Contract, either party may terminate or suspend this Contract, or any program
hereunder, for convenience by providing at least thirty (30) days' advance written notice to the other party.
If DOH elects to suspend the Contract, in whole or in part, LHJ shall stop work as of the effective date of DOH's
written notice of suspension. During suspension, each Party will reasonably notify the other of any conditions that
may affect resumption of performance. Upon DOH's written notice to resume performance, LHJ shall resume work
unless the LHJ provides notice to DOH that services cannot be resumed. If LHJ cannot resume performance, the
Contract or affected Exhibit A, Statement of Work, will be deemed terminated upon the date the LHJ received notice
to suspend performance.
35. Termination for Default
(a) In the event of a default by either party under this Contract, the nondefaulting party may give written notice to the
defaulting party that it intends to terminate this Contract, or any program hereunder, if the default is not cured
within thirty (30) days of the date of the notice, or such longer period of time as may be reasonable under the
circumstances. If the default is not cured within that time, the nondefaulting party may then notify the defaulting
party in writing that this Contract is terminated. In the event of such termination, the nondefaulting party shall
have all rights and remedies available to it under general law .
(b) A disputed termination for default is expressly subject to the Disputes section of this Contract.
36. Termination Procedure
Upon termination DOH may require the LHJ to deliver to DOH any non-LHJ-owned equipment, data, or other
property specifically produced or acquired for the performance of such part of this Contract as has been terminated.
DOH shall pay to the LHJ the agreed upon price, if separately stated, for completed work and services accepted by
DOH. In addition DOH shall pay the amount determined by DOH's Contracting Officer for (a) completed work and
services for which no separate price is stated, (b) partially completed work and services, (c) other property or services
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DOH CONTRACT #: CLH18249
which are accepted by DOH, and (d) the protection and preservation of the property. Disagreement by the LHJ with
the determination of DOH's Contracting Officer that relates to the obligations or amounts due to the LHJ shall be
considered a dispute within the meaning of the "Disputes" clause of this Contract.
DOH may withhold from any amounts due the LHJ for such completed work or services such sum as DOH's
Contracting Officer reasonably determines to be necessary to protect DOH against potential loss or liability.
The rights and remedies of DOH provided in this section shall not be exclusive and are in addition to any other rights
and remedies provided by law or under this Contract.
After receipt of a written notice of termination, the LHJ shall:
• Stop work under the Contract on the date and to the extent specified in the notice;
• Place no further orders or subcontracts for materials, services, or facilities, except as necessary to complete
such portion of the work not terminated;
• Assign to DOH, to the extent reasonably directed by DOH's Contracting Officer and to the extent that the LHJ
has the legal right to do so, all of the right, title, and interest of the LHJ under the orders and subcontracts in
which case DOH has the right, at its reasonable discretion, to settle or pay any or all claims arising out of the
termination of such orders and subcontracts.
• Settle all outstanding liabilities and all claims arising out of orders or subcontracts, with the approval or
ratification of DOH's Contracting Officer to the extent he/she may reasonably require, which approval or
ratification shall be final for all the purposes of this clause;
• Transfer title to DOH and deliver, as reasonably directed by DOH's Contracting Officer, any property which, if
the Contract had been completed, would have been required to be furnished to DOH;
• Complete performance of such part of the work not terminated by DOH's Contracting Officer; and,
• Take such action as may be necessary, or as DOH's Contracting Officer may reasonably direct, for the
protection and preservation of the property related to this Contract which is in the possession of the LHJ, or its
subcontractors, and in which DOH has or may acquire an interest.
IN WITNESS WHEREOF, the parties have executed this Contract.
KITTITAS COUNTY PUBLIC HEALTH
DEPARTMENT
~-
Signature
Date: OL (I ~( l ?(
2018-2020 Consolidated Contract
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
Signature
Print Name:
&~:&.a. +\.ronKSl>y')
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DOH CONTRACT #: CLH 18249
Standard Federal Certifications and Assurances
Following are the Assurances, Certifications, and Special Conditions that apply to all federally-funded (in whole or in
part) agreements administered by the Washington State Department of Health.
CERTIFICATIONS
1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
The undersigned (authorized official signing for the contracting organization) certifies to the best of his or her
knowledge and belief, that the contractor, defined as the primary participant in accordance with 45 CFR Part 76, and
its principals:
A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal Department or agency;
Have not within a 3-year period preceding this contract been convicted of or had a civil judgment rendered
against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
B. Are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or
local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and
C. Have not within a 3-year period preceding this contract had one or more public transactions (Federal, State, or
local) terminated for cause or default.
Should the contractor not be able to provide this certification, an explanation as to why should be placed after the
assurances page in the contract.
The contractor agrees by signing this contract that it will include, without modification, the clause titled Certification
Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion--Lower Tier Covered Transactions in all
lower tier covered transactions (i.e., transactions with sub-grantees and/or contractors) and in all solicitations for
lower tier covered transactions in accordance with 45 CFR Part 76.
2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
The undersigned (authorized official signing for the contracting organization) certifies that the contractor will, or will
continue to, provide a drug-free workplace in accordance with 45 CFR Part 76 by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession
or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be
taken against employees for violation of such prohibition;
B. Establishing an ongoing drug-free awareness program to inform employees about:
1) The Dangers of drug abuse in the workplace;
2) The contractor's policy of maintaining a drug-free workplace;
3) Any available drug counseling, rehabilitation, and employee assistance programs; and
4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
C. Making it a requirement that each employee to be engaged in the performance of the contract be given a copy of
the statement required by paragraph 1) above;
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D. Notifying the employee in the statement required by paragraph 1), above, that, as a condition of employment
under the contract, the employee will:
1) Abide by the terms of the statement; and
2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring
in the workplace no later than five calendar days after such conviction;
E. Notifying the agency in writing within ten calendar days after receiving notice under paragraph D. 2) from an
employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must
provide notice, including position title, to every contract officer or other designee on whose contract activity the
convicted employee was working, unless the Federal agency has designated a central point for the receipt of
such notices. Notice shall include the identification number(s) of each affected grant;
F. Taking one of the following actions, within 30 calendar days of receiving notice under paragraph D. 2) with
respect to any employee who is so convicted:
1) Taking appropriate personnel action against such an employee, up to and including termination,
consistent with the requirements of the Rehabilitation Act of 1973, as amended; or
2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate
agency;
G. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs
(A), (B), (C), (D), (E), and (F).
For purposes of paragraph (E) regarding agency notification of criminal drug convictions, DOH has designated
the following central point for receipt of such notices:
Compliance and Internal Control Officer
Office of Grants Management
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:
A. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of
any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
B. If any funds other than Federally appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer
or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract,
grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL,
"Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, Standard Form-LLL,
2018-2020 Consolidated Contract Page 12 ofl7
DOH CONTRACT #: CLH18249
"Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this
application form.)
C. The undersigned shall require that the language of this certification be included in the award documents for all
subcontracts at all tiers (including subcontracts, subcontracts, and contracts under grants, loans and cooperative
agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by Section 1352, U.S. Code. Any person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA)
The undersigned (authorized official signing for the contracting organization) certifies that the statements herein are
true, complete, and accurate to the best of his or her knowledge, and that he or she is aware that any false, fictitious,
or fraudulent statements or claims may subject him or her to criminal, civil, or administrative penalties. The
undersigned agrees that the contracting organization will comply with the Public Health Service terms and
conditions of award if a contract is awarded.
5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in
any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for
the provision of health, day care, early childhood development services, education or library services to children
under the age of 18, if the services are funded by Federal programs either directly or through State or local
governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are
provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not
apply to children's services provided in private residence, portions of facilities used for inpatient drug or alcohol
treatment, service providers whose sole source of applicable Federal funds is Medicare or Medicaid, or facilities
where WIC coupons are redeemed.
Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to
$1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.
By signing the certification, the undersigned certifies that the contracting organization will comply with the
requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision
of services for children as defined by the Act.
The contracting organization agrees that it will require that the language of this certification be included in any
subcontracts which contain provisions for children's services and that all subrecipients shall certify accordingly.
The Public Health Services strongly encourages all recipients to provide a smoke-free workplace and promote the
non-use of tobacco products. This is consistent with the PHS mission to protect and advance the physical and
mental health of the American people.
6. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSmILITY
MATTERS -INSTRUCTIONS FOR CERTIFICATION
By signing and submitting this proposal, the prospective contractor is providing the certification set out below.
A. The inability of a person to provide the certification required below will not necessarily result in denial of
participation in this covered transaction. The prospective contractor shall submit an explanation of why it
cannot provide the certification set out below. The certification or explanation will be considered in connection
with the department or agency's determination whether to enter into this transaction. However, failure of the
prospective contractor to furnish a certification or an explanation shall disqualify such person from participation
in this transaction.
2018-2020 Consolidated Contract Page 13 of 17
DOH CONTRACT #: CLH 18249
B. The certification in this clause is a material representation of fact upon which reliance was placed when the
department or agency detennined to enter into this transaction. If it is later detennined that the prospective
contractor knowingly rendered an erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency may tenninate this transaction for cause of default.
C. The prospective contractor shall provide immediate written notice to the department or agency to whom this
contract is submitted if at any time the prospective contractor learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
D. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have
the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order
12549. You may contact the person to whom this contract is submitted for assistance in obtaining a copy of
those regulations.
E. The prospective contractor agrees by submitting this contract that, should the proposed covered transaction be
entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred,
suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless
authorized by DOH.
F. The prospective contractor further agrees by submitting this contract that it will include the clause titled
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion --Lower Tier Covered
Transaction, provided by HHS, without modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
G. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it detennines the eligibility of its principals. Each participant may, but is not required to,
check the Nonprocurement List (of excluded parties).
H. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is
not required to exceed that which is normally possessed by a prudent person in the ordinary course of business
dealings.
1. 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 tenninate this transaction for cause or default.
7. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSffiILITY
MATTERS -PRIMARY COVERED TRANSACTIONS
A. The prospective contractor certifies to the best of its knowledge and belief, that it and its principals:
1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal department or agency;
2) Have not within a three-year period preceding this contract been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or perfonning a public (Federal, State or local) transaction or contract under a public
transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving stolen property;
3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State or local) with commission of any of the offenses enumerated in paragraph 1. B. of this certification;
and
2018-2020 Consolidated Contract Page 14 of 17
DOH CONTRACT #: CLH18249
4) Have not within a three-year period preceding this contract had one or more public transactions (Federal,
State or local) terminated for cause or default.
B. Where the prospective contractor is unable to certify to any of the statements in this certification, such
prospective contractor shall attach an explanation to this contract.
AUTHORIZED SIGNATURE REQUIRED
SIGNATURE OF AUTH ORI ZED CERTIFYING OFFICIAL TITLE AllM l~"~~
ORG DATE
2018-2020 Consolidated Contract Page 15 of 17
DOH CONTRACT #: CLH18249
Federal Assurances -Non-Construction Programs
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0040), Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please
contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the contractor, I certify that the contractor:
1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share of project cost) to ensure proper planning, management, and
completion of the project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through
any authorized representative, access to and the right to examine all records, books , papers, or documents related to
the award; and will establish a proper accounting system in accordance with generally accepted accounting standards
or agency directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents
the appearance of personal or organizational conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency .
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.s.c. =:J C4728-4763) relating to prescribed
standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A
ofOPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6 . Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI
of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national
origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U .S.C. C:::J 1681-1683, 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.J 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S .C . [~=:J 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) =:J C 523 and 527 of
the Public Health Service Act of 1912 (42 U.S.C .. J I. 290 dd-3 and 290 ee 3), as amended, relating to confidentiality
of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. ~I 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 (j) the
requirements of any other nondiscrimination statute(s) which may apply to the application.
7 . Will comply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of
persons displaced or whose property is acquired as a result of Federal or federally assisted programs . These
requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in
purchases.
2018-2020 Consolidated Contract Page 16 of 17
DOH CONTRACT #: CLH18249
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. 'J [J 1501-1508 and 7324-7328) which limit
the political activities of employees whose principal employment activities are funded in whole or in part with Federal
funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. 0 C276a to 276a-7), the Copeland
Act (40 U.S.C. IJ276c and 18 U.S.C. 00874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. J 0
327-333), regarding labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. DO 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans
under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. J =17401 et seq.); (g) protection of
underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and
(h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. JOl721 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. J470), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C. J [J469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and
related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. C C2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities
supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. J 04801 et seq.) which prohibits the use
of lead-based paint in construction or rehabilitation of residence structures.
17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Uniform Guidance at 2 CFR 200, Subpart F.
18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies
governing this program.
la-rIO
2018-2020 Consolidated Contract Page 17 of 17
KITTITAS COUNTY PUBLIC HEAL TH DEPARTMENT
2018-2020 CONSOLIDATED CONTRACT #CLH18249
EXHIBIT A -STATEMENTS OF WORK
TABLE OF CONTENTS
DOH Program Name or Title: Maternal & Child Health Block Grant-Effective January 1, 2018 ........................... : ................................ , ................................................................. 2
DOH Program Name or Title: Office of Drinking Water Group A Program -Effective January 1,2018
DOH Program Name or Title: Office of Drinking Water Group B Program -Effective January 1, 2018 ............................................................... , ................................................... 10
DOH Program Name or Title: Office of Emergency Preparedness & Response -Effective January 1, 2018 ............................................................................................................ 11
DOH Program Name or Title: Office ofImmunization & Child Profile -Effective January 1, 2018 ........................................................................................................................ 16
DOH Program Name or Title: Supplemental Nutrition Assistance Program-Education Effective January 1, 2018 ................................................................................................... 22
Exhibit A, Statements of Work Page 1 of28 Contract Number CLH18249
DOH Program Name or Title: Maternal & Child Health Block Grant-
~ffective January 1, 2018
SOW Type: Original Revision # (for this SOW)
Period of Performance: January 1, 2018 through September 30, 2018
Exhibit A
Statement of Work
Contract Term: 2018-2020
Local Health Jurisdiction Name: Kittitas Countv Public Health Denartment
Contract Number: CLH18249
Funding Source Federal Compliance Type of Payment
~ Federal Subrecipient (check if applicable) rgJ Reimbursement o State rgJ FFATA (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: N/ A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration
Code Code Start Date End Date
FFY18 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120281 01101118 I 09/30/18 0 33,147 33,147
TOTALS 0 33,147 33,147
Task *May Support PHAB Payment
Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Maternal and Child Health Block Grant (MCHBG) Administration
1a Participate in calls, at a minimum of every Designated LHJ staff will September 30,2018 Reimbursement for
quarter, with DOH contract manager. Dates and participate in contract management actual costs, not to
time for calls are mutually agreed upon between calls. exceed total funding
DOHandLHJ consideration.
Ib Report actual expenditures for October 1, 2017 Submit actual expenditures using May 26,2018 Action Plan and
through March 31, 2018 the MCHBG Budget Workbook to Progress Reports
DOH contract manager must only reflect
1c Develop 2018-2019 MCHBG Budget Workbook Submit MCHBG Budget September 5,2018 activities paid for
for October 1,2018 through September 30,2019 Workbook to DOH contract with funds provided
using DOH provided template. manager in this statement of
work for the
specified funding
period.
See Program
Exhibit A, Statements of Work Page 2 of28 Contract Number CLH18249
Task *May Support PHAB Payment
Number Taskl ActivitylDescription StandardsflVleasures Deliverables/Outcomes Due DatelTime Frame Information and/or
Amount
Specific
Requirements and
Special Billing
Requirements.
MCHBG Assessment and Evaluation
2a Participate in project evaluation activities Documentation using report September 30,2018 Reimbursement for
developed and coordinated by DOH, as template provided by DOH actual costs, not to
requested. exceed total funding
2b Report program level strategy measure data Documentation using report January 15, 2018 consideration.
(CSHCN, UDS, ACEs). template provided by DOH April 15 ,2018
July 15, 2018 See Program
Specific
Requirements and
Special Billing
Requirements .
MCHBG Implementation
3a Develop 2018-2019 MCHBG Action Plan for Submit MCHBG Action Plan to Draft August 17, 2018 Reimbursement for
October 1,2018 through September 30,2019 DOH contract manager Final September 5,2018 actual costs, not to
using DOH -provided template. exceed total funding
3b Report activities and outcomes of2017-2018 Submit Action Plan monthly Monthly, on or before consideration.
MCHBG Action Plan using DOH-provided I reports to DOH contract manager the 15 th of the following Action Plan and
template . I month Progress Reports
must only reflect
activities paid for
with funds provided
in this statement of
work for the
specified funding
period.
See Program
Specific
Requirements and
Special Billing
Requirements.
Exhibit A, Statements of Work Page 3 of28 Contract Number CLH18249
Task *May Support PHAB Payment
Number Task! Activity /Description Standardsfl\feasures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Children with Special Health Care Needs (CSHCN)
4a Complete Child Health Intake Form (CHIF) Submit CHIF data into Secure File January 15, 2018 Reimbursement for
using the CHIF Automated System on all infants Transport (SFT) website: April 15,2018 actual costs, not to
and children served by the CSHCN Program as https://sft.wa.gov July 15, 2018 exceed total funding
referenced in CSHCN Program Manual. consideration.
Ensure client data is collected on all children Action Plan and
served by CSHCN contractors, including Progress Reports
neurodevelopmental centers, regional must only reflect
maxillofacial coordinators, and the DOH activities paid for
Newborn Screening Program. with funds provided
4b Administer requested DOH Diagnostic and Submit completed Health Services 30 days after forms are in this statement of
Treatment funds for infants and children per Authorization forms and Central completed. work for the
CSHCN Program Manual when funds are used. Treatment Fund requests directly specified funding
to the CSHCN Program as needed. period.
4c Participate in the CSHCN Regional System and Submit Action Plan monthly Monthly, on or before
quarterly meetings as described in the CSHCN reports including number of the 15th of the following See Program
Program Manual. regional meetings attended to the month Specific
DOH contract manager. Requirements and
Special Billing
Requirements.
*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
Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) StandardslMeasures that may apply can be found at:
hnp;/!www.phaboard.org/wp-contenVuploadsIPHAB-Standards-and-Measures-Version -I .D.pdf
Program Specific Reguirements/Narrative
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 (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 USASpending.gov by DOH as required by P.L. 109-282.
Program Manual, Handbook, Policy References
Children with Special Health Care Needs Manual-http ://www .doh. wa.govJPQrtals1JlDocUJDen~slPubsl9?O-20 9 -CSHCN-Manual.pdf
Exhibit A, Statements of Work Page 4 of28 Contract Number CLH18249
Health Services Authorization (HSA) Fonn
httrdfwww.doh. wa.(i()v/Po rtals/ I.lDocuments/Pubsl9 ) 0-002 -ApprovedllSAdocx
Restrictions on Funds (what funds can be used for which activities, not direct payments, etc)
1. 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.
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 under 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 (l)(D)].
Monitoring Visits (frequency, type)
Telephone calls with contract manager at least one every quarter, and annual site visit.
Special Billing Requirements
Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable A19-1A 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 monthly by the 30th of each month
following the month in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a monthly fraction of the "Total
Consideration" will not be accepted or approved.
DOH Program Contact
Mary Dussol
Community Consultant
Office of Family and Community Health Improvement
Washington State Department of Health
Street Address: 310 Israel Rd SE, Tumwater, WA 98501
Mailing Address: PO Box 47848, Olympia, W A 98504
Telephone: 360-236-3781 / Fax: 360-236-3646
Email: marv.dussol@doh.wa.gov
Exhibit A, Statements of Work Page 5 of28 Contract Number CLH18249
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Office o f Drinking Water Group A Program -
Effective January 1, 2018
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
SOW Type: Original Revision # (for this SOW) Funding Source Federal Compliance Type of Payment
[gJ Federal Contractor (check if applicable) D Reimbursement
[gJ State D FFATA (Transparency Act) [gJ Fixed Price
D Other D Research & Development
Period of Performance: January 1, 2018 through December 31, 2020
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: N/ A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration
Code Code Start Date End Date
Yr 20 SRF -Local Asst (15%) (FS) SS N/A 346.26.64 24139220 01101118 12/31120 0 2,400 2400
Sanitary Survey Fees (FO-E) SS-State N/A 346.26.65 24242522 01101118 12/31120 0 2_,400 2,400
Yr 20 SRF -Local Asst (15%) (FS) TA N/A 346.26.66 24139220 01101118 12/31120 0 2,000 2,000
TOTALS 0 6,800 6,800
Task Task! Activityillescription *May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information and/or Amount Number StandardslMeasures Frame
1 Trained LHJ staff will conduct Provide Final* Sanitary Final Sanitary Survey Upon ODW acceptance of the Final
sanitary surveys of small community Survey Reports to ODW Reports must be Sanitary Survey Report, the LHJ shall be
and non-community Group A water Regional Office. Complete received by the ODW paid $400 for each sanitary survey of a
systems identified by the DOH Office Sanitary Survey Reports shall Regional Office non-community system with three or
of Drinking Water (ODW) Regional include: within 30 calendar fewer connections.
Office. 1. Cover letter identifying days of conducting
significant deficiencies, the sanitary survey. Upon ODW acceptance of the Final
See Special Instructions for task significant findings, Sanitary Survey Report, the LHJ shall be
activity. observations, paid $800 for each sanitary survey of a
recommendations, and non-community system with four or more
referrals for further connections and each community system.
ODW follow-up.
2. Completed Small Water Payment is inclusive of all associated
System checklist. costs such as travel, lodging, per diem.
3. Updated Water Facilities
Exhibit A, Statements of Work Page 6 of28 Contract Number CLH18249
Task Task! Activity/Description *May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information and/or Amount I
Number StandardslMeasures Frame
Inventory (WFI). Payment is authorized upon receipt and
I 4. Photos of water system acceptance of the Final Sanitary Survey
with text identifying Report within the 30-day deadline.
features
5 . Any other supporting Late or incomplete reports may not be
documents. accepted for payment.
*F inal Reports reviewed and
accepted by the ODW
Regional Office.
The LHJ surveyor will record
DOH will provide a tablet and GPS at least two (2) GPS data
unit for the LHJ to gather source data points, for each source, into
during a routine sanitary survey. DOH the preloaded Excel template
expects the LHJ to commit to using on the tablet and submit that
the tablet and GPS for a five-year data file with the associated
period. sanitary survey.
2 Trained LHJ staff will conduct Provide completed SPI Completed SPI Upon acceptance of the completed SPI
Special Purpose Investigations (SPI) Report and any supporting Reports must be Report, the LHJ shall be paid $800 for
of small community and non-documents and photos to received by the ODW each SPI.
community Group A water systems ODW Regional Office. Regional Office
identified by the ODW Regional within 2 working Payment is inclusive of all associated
Office . days of the service costs such as travel, lodging, per diem.
request.
See Special Instructions for task Payment is authorized upon receipt and
activity. acceptance of completed SPI Report
within the 2 working day deadline.
Late or incomplete reports may not be
accepted for ~ayment.
3 Trained LHJ staff will provide direct Provide completed T A Completed T A Upon acceptance of the completed TA
technical assistance (T A) to small Report and any supporting Report must be Report, the LHJ shall be paid for each
community and non-community documents and photos to received by the ODW technical assistance activity as follows :
Group A water systems identified by ODW Regional Office. Regional Office • Up to 3 hours of work: $250
the ODW Regional Office. within 30 calendar • 3-6 hours of work: $500
days of providing • More than 6 hours of work: $750
See Special Instructions for task technical assistance.
activity. Payment is inclusive of all associated
costs such as consulting fee, travel,
lodging, per diem.
Exhibit A, Statements of Work Page 7 of28 Contract Number CLH18249
Task Task! ActivitylDescription *May Support PHAB Deliverables/Outcomes Due DatelTime Payment Information and/or Amount Number StandardslMeasures Frame
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 staff performing the activities Prior to attending the Annually LHJ shall be paid mileage, per diem,
under tasks 1,2 and 3 must have training, submit an lodging, and registration costs as
completed the mandatory Sanitary "Authorization for Travel approved on the pre-authorization form in
Survey Training. (Non-Employee)" DOH accordance with the current rates listed on
Form 710-013 to the ODW the OFM Website
See Special Instructions for task Program Contact below for ht!Il://www.ofm.wa.gov/resources/travel.a I
activity. approval (to ensure that ~
enough funds are available),
*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
StandardlMeasure. More detail on these and/or other Public Health Accreditation Board (PHAB) StandardslMeasures that may apply can be found at:
htto jlwww .phaboard. org/wp-contentluBloadsIPHAB-Standards-and-Measures-Version-I. O. pdf
Program Specific Reguirements/Narrative
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
SPIs, and provide technical assistance) for small community and non-community water systems with surface water sources, large water systems, and systems with complex
treatment.
LHJ staff assigned to perform activities under tasks I , 2 , and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4, below.
Special Billing Requirements
The LHJ shall 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 fo r.
Payment cannot exceed a maximum accumulative fee of $4,800 for Task 1, and $2,000 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 invoicing for sanitarY survevs, bill halfto BARS Revenue Code 346.26.64 and half to BARS Revenue Code
346.26.65.
When invoicing for Task 1, submit the list ofWS Name, ID #, Amount Billed, Survey Date and Letter Date that you are requesting payment.
When invoicing for Task 2-3, submit the list ofWS Name, ID #, TA Date and description ofTA work performed, and Amount Billed.
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 A19-IA Invoice
Voucher to the DOH Grants Management, billing to BARS Revenue Code 346.26.66 under Technical Assistance (TA).
Special Instructions
Exhibit A, Statements of Work Page 8 of28 Contract Number CLHl8249
Task 1
Trained LHJ staffwill 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 Guide for San itary 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; fmished 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 8 surveys of non-community systems with three or fewer connections to be completed between January 1, 2018 and December 31,2018.
o No more than 2 surveys of non-community systems with four or more connections and all community systems to be completed between January 1, 2018 and
December 31,2018.
The process for assignment of surveys to the illJ, 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 staff will perform Special Purpose Investigations (SPIs) as assigned by ODW. SPIs are inspections to determine the cause of positive coliform 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 SPIs is described in the Field
Guide. The ODW Regional Office must authoriz e in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staff will conduct Technical assistance as assigned by ODW. Technical Assistance includes assisting water system personnel in completing work or verifying work
has been addressed as required, requested, or advised by the ODW to meet applicable drinking water regulations. 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 perform activities under ta sks 1, 2, and 3 must be trained and approved by ODW prior to performing work. LHJ staff performing the activities under 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 staff performing activities under
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.
If required trainings, workshops or meetings are not available, 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 perform the activities under tasks 1, 2, and 3 without completing
the training that has been arranged and approved by ODW.
Program Manual, Handbook, Policy References
http://www.doh . \Va .go v/Portalsi IlDocumen tsfPubsI331-486.pdf
DOH Program Contact
Mark Steward
DOH Office of Drinking Water
16201 E. Indiana Ave, Suite 1500
Spokane Valley, WA 99216
Mark.Steward@doh.wa.gov
(509) 329-2136
Exhibit A, Statements of Work
DOH Fiscal Contact
Karena McGovern
DOH Office of Drinking Water
243 Israel Rd SE
Tumwater, WA 98501
Karena.McGovern@doh.wa.gov
(360) 236-3094
Page 9 of28 Contract Number CLH18249
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Office of Drinking Water Group B Program-
Effective January 1, 2018
SOW Type: Original Revision # (for this SOW)
Period of Performance: January 1, 2018 through June 30, 2018
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
Funding Source Federal Compliance Type of Payment o Federal <Select One> (check if applicable) o Reimbursement
[8J State D FFATA (Transparency Act) [8J Fixed Price
D Other D Research & Development
Statement of Work Purpose: The purpose of this statement of work is to provide fmancial support to LHJs implementing local Group B water system programs.
Revision Purpose: NI A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration
Code Code Start Date End Date
GFS -Group B (FO-E) N/A 334.04.90 24240103 01101118 I 06/30/18 0 5,000 5,000
TOTALS 0 5,000 5,000
Task *May Support PHAB Memorandum of Payment
Task! Activity/Description Deliverables/Outcomes Information and/or Number StandardslMeasures Agreement Number Amount
1 Implement a full Group B water An executed joint plan of responsibility (JPR) Reference DOH JPR Lump sum payment
system program. with DOH identifying responsibilities of a full #NI9411 (See Special Billing
Group B. Requirements)
*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:
httJj :ll www.p hahoard .o rglwp -eoruent/uploadSfPHAB-Standards-and-Measures -Vim>ion-l.O.pdf
Program Specific Reguirements/Narrative
Special Billing Requirements
The LHJ shall submit a $5,000 invoice before May 15, 2018.
DOH Program Contact
Dorothy Tibbetts, MS MPH
Eastern Regional Manager
DOH Office of Drinking Water
16201 E Indiana Ave, Suite 1500
Spokane Valley, WA 99216
Dorothy. Tibbetts@doh.wa.gov
(509) 329-2105
Exhibit A, Statements of Work
DOH Fiscal Contact
Karena McGovern
DOH Office of Drinking Water
243 Israel Rd SE
Tumwater, WA 98501
Karena.Mcgovern@doh.wa.gov
(360) 236-3094
Page 10 of28 Contract Number CLH18249
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: O ffice of Emergency Preparedness & Response-
Effective January 1, 2018
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18 249
SOW Type: Original Revision # (for this SOW) Funding Source Federal Compliance Type of Payment
181 Federal Subrecipient (check if applicable) I:8J Reimbursement
D State I:8J FFATA (Transparency Act) D Fixed Price o Other D Research & Development
Period of Performance: January 1, 2018 through June 30, 2018
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 2017 grant period.
Revision Purpose: NI A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration
Code Code Start Date End Date
FFY17 EPR PHEP BPI LHJ FUNDING 93 .069 333 .93.06 18101380 01101118 I 06 /30/18 0 19 ,833 19,833
TOTALS 0 19,833 19,833
Task *May Support PHAB Due Date/Time Payment
Task! Activityillescription Deliverables/Outcomes Information andlor Number StandardslMeasures Frame Amount
1 Attend emergency preparedness events, (e .g . Complete the end of year progress June 30, 2018 Reimbursement for
trainings, meetings, conference calls, and report. actual costs not to
conferences) as necessary to advance LHJ exceed total funding
preparedness or complete the deliverables in this consideration amount.
statement of work.
2 Complete reporting templates as requested by Submit completed templates to June 30 , 2018
DOH to comply with program and federal grant DOH
requirements (e.g. performance measures, gap
analysis , mid-year and end-of-year reporting
templates , etc.)
3 Develop or update written procedures to activate a Submit end of year progress report. June 30, 2018
comprehensive emergency response plan within
the jurisdiction. Include: Submit the most recent Emergency
• Describe how the command structure is Response Plan (ERP).
utilized to manage emergency response
• Describe the relationship between the LHJ
and the county Emergency Operations Center
,
I
Exhibit A, Statements of Work Page 11 of28 Contract Number CLH 18249
Task *May Support PHAB Due Date/Time Payment
Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Frame Information and/or
Amount
(EOC) during a response.
• Identify an EOC location from which public
health will coordinate the Emergency Support
Function #8 (ESF#8) response
• Describe the process for notifying and
mobilizing staff during an incident.
3.1) Provide training for appropriate staff who
serve in the EOC and the ESF#8 role on the Provide agenda and sign-in sheets
Incident Command System, ESF#8 response plans of trainings conducted.
and policies .
3.2) Train appropriate public health emergency
response staff on Web EOC or applicable Provide sign-in sheets of trainings
information management system utilized by local conducted, with attendee
emergency management in the county. signatures and contact information,
or registrations if training is not
conducted by the LHJ
4 Develop a decision making protocol to support the Submit end of year progress report. June 30, 2018
Local Health Officer and the Public Health
Administrator in making policy level decisions Submit completed protocol to
during an emergency. DOH
4.1 Document that Public Health, Medical and Submit written Public Health,
Mortuary Response is identified in the Public Medical and Mortuary Response
Health Emergency Plan and is integrated with the documentation showing inclusion
City and County Emergency Plans. in city and county plans.
5 Maintain Washington Secure Electronic Submit end of year progress report. June 30, 2018
Communication, Urgent Response and Exchange
System (WASECURES) program as the primary A list of registered users to include
emergency notification system within the LHJ and their title and role in the
include all critical LHJ positions as registered emergency response plan.
users.
5.1) Conduct a notification drill using Results of notification drill.
WASECURES.
Notes: Registered users must log in quarterly at a
minimum. DOH will provide on-site technical
assistance to LHJs , as needed, on utilizing
WASECURES. LHJs may choose to utilize other
notification systems in addition to W ASECURES
to alert staff during incidents .
Exhibit A, Statements of Work Page 12 of28 Contract Number CLH18249
Task *May Support PHAB Due Date/Time Payment I
Task! Activity /Description Deliverables/Outcomes Information and/or I
Number StandardsIMeasures Frame Amount
6 Update and maintain procedures for defining how Submit end of year progress report. June 30, 2018
your LHJ will request assistance from the local
Emergency Operations Center (EOC), neighboring The most current procedures for
LHJs, and DOH during disasters. requesting assistance during
• Identify how resources are coordinated with disasters to DOH
the local EOC .
• Identify how to coordinate the logistical issues
to receive resources from DOH and other
partners. (IfLHJs rely on local Emergency
Management (EM) or other partners to
coordinate logistical issues for receiving
resources , and the local EM plan documents
this fact , that documentation will suffice.)
Note: DOH will provide technical assistance to
LHJs , as requested, on updating plans to address
resource requests .
7 Update or develop procedures and tools to inform Submit end of year progress report. June 30 , 2018
the public of threats to health and safety by various
means. Include a list of the various mechanisms Submit the most current
used by your LHJ for releasing information to the procedures used to inform the
public during drills , exercises or incident response . public during drills , exercise or
incident response . Include a
7.1) Create and maintain templates for news summary of how communication
releases for categories of public health hazards. tools were used.
Submit sample templates.
8 Participate in evaluation of response capabilities Submit end of year progress report. June 30 , 2018
based on a standard evaluation tool created by
DOH.
9 Develop and maintain procedures and forms to Submit end of year progress report. June 30 , 2018
gain and maintain situational awareness during an
incident to include the following key data Submit procedures and situational
elements: awareness form templates that
• The functionality of critical public health include the data elements listed .
operations
• The functionality of critical healthcare
facilities and the services they provide
(hospitals, skilled nursing facilities, blood
centers, dialysis centers)
• The functionality of critical infrastructure
serving public health and healthcare facilities
(roads, water, sewer, power, communications)
Exhibit A , Statements of Work Page 13 of28 Contract Number CLH18249
Task *May Support PHAB Due Daterrime Payment
Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Frame Information and/or
Amount
• Number of disease cases
• Number of fatalities attributed to an incident
• If key elements are collected by others, such
as local EM or Health Care Coalition (HCC),
describe how the LHJ gains access to that
information.
9.1) Create an ESF#8 situation report form based
on an established planning cycle to include, at a Submit an ESF#8 situation report
minimum, the data elements listed above ! template.
9.2) Develop procedures for disseminating I
situation reports to ESF#8 response partners Submit procedures for
disseminating a situation report.
9.3) Train staff on all procedures established to
maintain situational awareness during an incident. Submit agendas and sign-in sheets
that include attendee signatures
and contact information for
trainings conducted.
10 Update or develop procedures to request, receive Submit end of year progress report. June 30 , 2018
and dispense medical countermeasures.
Submit up to date procedure to
request, receive and dispense
medical countermeasures .
11 Develop or update a continuity of operations plan Submit end of year progress report. June 30 , 2018
(COOP) plan for your jurisdiction.
Plan shall include: The most current COOP plan
• Definition and identification of essential which includes the elements listed.
services to sustain LHJ mission and
operations An AAR documenting COOP
• Line of succession and written delegation of implementation demonstrating the I
authority for select critical positions in the elements listed.
LHJ, including LHO .
• Plans for temporarily discontinuing select
LHJ functions to sustain critical services
12 Provide notification to DOH for all instances Submit end of year progress report. June 30, 2018
involving a public health response by the LHJ to an
emergency utilizing emergency response plans and Submit Incident Action Plans,
structures. Situation Reports and After Action
Reports produced for each
response.
Exhibit A , Statements of Work Page 14 of28 Contract Number CLH18249
Task *May Support PHAB Due Date/Time Payment
Task! ActivitylDescription Deliverables/Outcomes Information and/or Number StandardslMeasures Frame Amount
13 Provide LHJ situation reports to DOH during all Submit end of year progress report. June 30, 2018
incidents involving an emergency response by the
LHJ. Submit Situation Reports.
14 Submit essential elements of information (EEls) Submit end of year progress report. June 30, 2018
during incident response upon request by DOH.
Provide information upon request.
15 Participate in the regional healthcare coalition and Submit end of year progress report June 30, 2018
attend coalition meetings as necessary with a summary of participation in
coalition activities .
*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:
hrip:llw\vw.phaboard.orglwp-contentlunloacWPRAB-Standards-and -Measures -Version-I.O .pdf
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 (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 USASpending.gov by DOH as required by P.L. 109-282.
DOH Program Contact:
Jennifer Albertson, Contract and Finance Specialist
Department of Health
POBox 47960, Olympia, WA 98504-7960
j ennifer.albertson@doh. wa. gov
PHEP/HPP Deliverable Submission email address: concondeliverablesftildoh.Wll.gov
Exhibit A, Statements of Work Page 15 of28 Contract Number CLHI8249
DOH Program Name or Title: Office of Immunization & Child Profile -
Effective January 1, 2018
SOW Type: Original Revision # (for this SOW)
Exhibit A
Statement of Work
Contract Term: 2018-2020
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
Funding Source Federal Compliance Type of Payment
1:8] Federal Subrecipient (check if applicable) 1:8] Reimbursement
D State 1:8] FFATA (Transparency Act) D Fixed Price
D Other o Research &_Development
Period of Performance: January 1, 2018 through June 30, 2018
Statement of Work Purpose: The purpose of this statement of work is to define required immunization tasks, deliverables, and funding for the period January 1,2018 through
June 30, 2018 .
Revision Purpose: N/ 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
FFY 17 VFC Ops 93.268 333 .93.26 74310271 01101118 06/30/18 0 1,114 1,114
FFY17 317 Ops 93.268 333 .93 .26 74310270 01101118 06/30/18 0 616 616
FFY17 AFIX 93.268 333.93.26 74310272 01101/18 06/30/18 0 2,226 2,226
'"
TOTALS 0 3.956 3,956
Task *May Support PHAB Due Date/Time Payment
Task! ActivitylDescription Deliverables/Outcomes Information and/or Number StandardslMeasures Frame Amount
Perform 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 visits, fraud and abuse reporting, monthly accountability reports , andprivate provider report of vaccine usage.
I Facilitate annual renewal of the provider agreement Provider Agreements for Receipt Annually, per Annual Reimbursement for
for receipt of state supplied vaccine for all of State Supplied Vaccine received VFC Provider actual costs incurred,
healthcare providers receiving state-supplied online via the Washington Agreement Update not to exceed total
childhood vaccine Immunization Information System. Schedule funding consideration
amount.
Funds available for
this task*:
FFY17 AFIX
74310272
Exhibit A, Statements of Work Page 16 of28 Contract Number CLH 18249
Task *May Support PHAB Due Daterrime Payment
Number TaskJActivitylDescription StandardslMeasures Deliverables/Outcomes Frame Information and/or
Amount
*See Restrictions on
Funds below
2 Enroll new providers. Conduct an enrollment site Provider Agreement for Receipt of Within ten (10) days Reimbursement for
visit to all new providers, and gather information State Supplied Vaccine with after the date of the actual costs incurred,
needed to complete Program enrollment original signature -DOH 348-002 provider enrollment not to exceed total
(NOTE: a photocopy will not be visit funding consideration
accepted) amount.
Funds available for
this task*:
FFY17 AFIX
74310272
*See Restrictions on
I Funds below I
3 Use and facilitate provider use of the Washington Electronic submission of provider Based on provider Reimbursement for
Immunization Information System to place and vaccine orders via the Washington order schedules actual costs incurred,
approve provider vaccine orders. Monitor provider Immunization Information System not to exceed total
orders for appropriateness (including: accuracy of funding consideration
shipping information, order frequency, timing , amount.
quantity and type) and approve vaccine order
online after assuring the appropriateness of the Funds available for
order. this task*:
FFY 17 VFC Ops
74310271
FFY17 317 Ops
74310270
*See Restrictions on
Funds below
4 Monitor and assure electronic or paper submission a) Monthly Vaccine a) By the 25th of Reimbursement for
of vaccine accountability reports for compliance Accountability Report each month actual costs incurred,
with Provider Agreement related to vaccine (DOH 348-006 not to exceed total
management (ordering, inventory management, funding consideration
reconciliation, compliance with storage and b) Report of Vaccine Storage b) Within seven (7) amount.
handling , and reporting of all vaccine incidents and Incidents (DOH 348-154) days of the
returns). complete with reason and incident Funds available for
corrective action as needed. this task*:
Exhibit A, Statements of Work Page 17 of28 Contract Number CLH18249
Task *May Support PHAB Due Date/Time Payment
Number TaskiActivityillescription StandardslMeasures Deliverables/Outcomes Frame Information and/or
Amount
c) Report all cases (or suspected FFY17 AFIX
cases) of vaccine fraud or c) Within seven (7) 74310272
abuse. days of the
incident *See Restrictions on
Funds below
5 Provide communication, technical assistance, Summary of LHJ Technical June 30, 2018 Reimbursement for
consultation, and education to providers about Assistance Form (DOH 348-257) actual costs incurred,
vaccine quality assurance, accountability, program not to exceed total
participation and vaccine management. funding consideration
amount.
Funds available for
this task*:
FFYl7 VFC Ops
74310271
FFYl7 317 Ops
74310270
*See Restrictions on
Funds below
6 Conduct a total of one (1) VFC Compliance Site a) Enter responses from the VFC a) At the time of the Reimbursement for
Visits at the assigned provider site(s) within your Compliance Site Visit VFC Compliance actual costs incurred,
jurisdiction. DOH will assign provider site(s) via Reviewer Guide into the VFC Site Visit or not to exceed total
the VFC Site Visit Selection Tool. Provider Education, within five (5) funding consideration
Assessment, and Reporting business days of amount.
Site visits should address all requirements outlined (PEAR) online system for the site visit.
in the Provider Agreement, the CDC Vaccines for each Compliance Site Visit. Funds available for
Children Operations Guide, and messages from the Follow all corrective action this task*:
Childhood Vaccine Program. and follow-up guidance
provided by PEAR and the
Conduct VFC Compliance Site Visit Follow-Up to Childhood Vaccine Program FFY17 AFIX
assure providers resolve all follow-up actions for each incorrect response. 74310272
identified during the initial visit. Follow-up
actions may include another physical site visit or b) Attach copy of signed b) Within five (5) *See Restrictions on
verification by email, fax, or mail that follow-up Acknowledgement of Receipt days of the site Funds below
actions were completed. Documentation for each form to the Site Visit in visit
VFC Site Visit follow-up action must be uploaded PEAR.
into PEAR and/or properly notated in the Reviewer
Notes section of PEAR. c) Attach a copy of any
documents and/or emails c) Within five (5)
Exhibit A, Statements of Work Page 18 of28 Contract Number CLH18249
Task *May Support PHAB Due Date/Time Payment
Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Frame Information and/or
Amount
All assigned VFC Compliance Site Visits submitted by the provider to days of receiving
including follow-up actions must be completed resolve follow-up actions to the document(s)
by May 15,2018 for the January -June the site visit in PEAR. and/or email.
contract period.
7 NOTE: During tb.is period of perl'onna.llee, !!2 Enter the following data in the Within five (5) days Reimbursement for
new AFIX visits ·shall be conducted . This task Exchange tab of the AFIX Online of visit. actual costs incurred,
will focus on follOW-Up oLt...FlX visirs thaI Were Tool for follow-up visits: not to exceed total
conducted during the previous contract .year . • Clinic progress on funding consideration
implementing quality amount.
Conduct AFIX follow-up visits with all provider improvement strategies.
sites that received an AFIX visit between April 1, • Follow-up coverage Funds available for
2017 and December 31, 2017. Follow-up visits assessment results (from this task*:
can be conducted in-person, by telephone, or by CoCASA reports).
webinar. All AFIX follow-up visits must be FFY17 AFIX
completed six (6) months after the feedback visit. 74310272
Continue following up with provider sites until *See Restrictions on
they fully implement their selected quality Funds below
improvement activities.
8 a) In coordination with hospitals , health care a) Enter information for each a) by the last day of Reimbursement for
providers, and health plans (if applicable), conduct case identified into the each month actual costs incurred,
activities to prevent perinatal hepatitis B infection Perinatal Hepatitis B module not to exceed total
in accordance with the Perinatal Hepatitis B of the W A Immunization funding consideration
Prevention Program Guidelines, including the Information System amount.
following:
1) identification ofHBsAg-positive pregnant Funds available for
women, and pregnant women with unknown b) Annual Perinatal Hepatitis B b) June 15,2018 this task*:
HBsAg status Outreach Summary
2) reporting ofHBsAg-positive women and their (DOH 348-268) FFY17 317 Ops
infants 74310270
3) Case management for infants born to HBsAg-
positive women to ensure administration ofHBIG *See Restrictions on
and hepatitis B vaccine within 12 hours of birth, I
Funds below
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 .
Exhibit A, Statements of Work Page 19 of28 Contract Number CLHl8249
Task *May Support PHAB Due Date/Time Payment
Task! ActivitylDescription Deliverables/Outcomes Information and/or Number StandardslMeasures Frame Amount
c). Report all perinatal hepatitis B investigations,
including HBsAg-positive infants, in the Perinatal
Hepatitis B Module of the Washington State
Immunization Information Sys~m.
--
*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 andlor other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
http://www.pilaboard .org/wp-comentlupioadstpHAB -S tandards-and -Measures-Vel1lion -1 .0 . pdf
Program Specific Reguirements/Narrative
This section is for program specific information not included elsewhere.
• All LHJ staff who conducts VFC Compliance Site Visits and AFIX visits must participate in an annual VFC and AFIX training, conducted by DOH Office of Immunization
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 (FFATA)
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 USASpending.gov by DOH as required by P.L. lO9-282 .
Program Manual, Handbook, Policy References
Office of Immunization 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 of Immunization 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 outlined in this statement of work.
Exhibit A, Statements of Work Page 20 of28 Contract Number CLH18249
Restrictions on Funds (what funds can be used for which activities, not direct payments, etc.)
Allowable expenses with 317 and VFC FA Operations Funds (dated September 16 , 2016) document is posted on the DOH Consolidated Contract website at this linle In addition
to the funding listed in the Payment Information and/or Amount column for each task, FFY18 317 Ops funding may be used for any activity in this statement of work conducted
between January 1,2018 and June 30, 2018, per funding availability and period of performance.
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 DOH
Office ofImmunization and Child Profile.
DOH Program Contact
Tawney Harper, MP A
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
Vanessa Mojica, Special Projects Coordinator
Office of Immunization and Child Profile
PO Box 47843, Olympia WA 98504-7843
V anessa.mojica@doh.wa.gov, 360-236-3802
Exhibit A, Statements of Work
Deliverables may be sent electronically via email at oicpcontracts@doh.wa.gov,
by fax to 360-236-3590, or by mail to PO Box 47843, Olympia WA 98504-7843
Page 21 of28 Contract Number CLH18249
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Supplemental Nutrition Assisranc.e P ro gram-Educati o n
Effective January 1, 2018
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
SOW Type: Original Revision # (for this SOW) Funding Source Federal Compliance Type of Payment
~ Federal Subrecipient (check if applicable) ~ Reimbursement o State (g) FFATA (Transparency Act) o Fixed Price o Other o Research & Development
Period of Performance: January 1, 2018 through September 30,2020
Statement of Work Purpose: The purpose ofthis statement of work is to provide Supplemental Nutrition Assistance Program-Education (SNAP-Ed) to improve the likelihood
that persons eligible for SNAP (Food Stamps) will make healthy food choices within a limited budget and choose active lifestyles consistent with the current USDA dietary
guidance system .
Revision Purpose: NI A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration
Code Code Start Date End Date
FFY18 CSS IAR SNAP ED PROG MGNT 10.561 333.10.56 76211981 01101118 I 09 /3011 8 0 8,830 8,830
FFY17 CSS IAR SNAP ED PROG MGNT CF 10.561 333.10.56 76211971 01101118 I 09 /30/18 0 1,472 1,472
TOTALS 0 10 ,302 10,302
Task *May Support PHAB Payment
Task! ActivitylDescription DeliverableslOutcomes Due Date/Time Frame Information and/or Number StandardsIMeasures Amount
1.0 For SNAP-Ed, the LHJ will perform work as • Project qualified target For the Period: Reimbursement upon
described in LHJ's approved FFY18 SNAP-Ed audiences reached. 01101118-09 /30 /20 receipt and approval
project description and work plans approved • Project activities completed Due: per the approved work of deliverables for the
by Department of Health (DOH), Department (# direct education, PSE, plan and no later than funding period will
of Social and Health Services (DSHS), and etc .) noted in project plans 09 /30/20 . not exceed $10,302.
United States Department of Agriculture and workbook.
(USDA) that was submitted to them via DOH • Required demographic data Kittitas County
email. collected. Public Health
• Evaluation activities Department will be
completed per the state paid the allowable
evaluation team (pre and costs incurred based
post surveys , PSE tracking , on their approved
success stories etc.). budget and program
allowability . See
special billing
requirements section.
--
Exhibit A, Statements of Work Page 22 of28 Contract Number CLH 18249
Task *May Support PHAB Payment
Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
**NOTE: The
I SNAP-Ed program
will deny payment
for any costs not
submitted by the due
date and without
prior DOH approval
in writing .
2.0 Quarterly Progress Reports Submit Quarterly Progress Quarterly Progress Reports See payment
The following data is to be collected and Report for all SNAP-Ed projects due: information as
submitted within DOH provided form Isystem: within the DOH approved • 2nd quarter report for the referenced in task
1. Project major achievements form/system. work completed during number 1.0.
2. Project major challenges 01101118 to 03 /31/18.
3. If projects are running on time with Final Due: COB
original timeline? If not, why, and how 04/06/18 .
will LHJ correct the timeline?
I 4. Any policy, system, and environment • 3rd quarter report for the
(PSE) progress work completed during
5 . Any success stories to date 04/01118 to 06/30/18.
I Final Due: COB
I 07 /06/18 .
I
• Final report for all work
not already reported .
Final Due: COB
09/21118 .
2.1 Education and Administrative Reporting Submit EARS data for all Data should be collected in See payment
System (EARS) Data and Reports project(s). real time and submitted to the information as
The following EARS data is required for each state office by the following referenced in task
project and in order to count clients toward LHJs are required to collect and dates: number 1.0 .
unduplicated direct reach. Required entry for submit EARS data electronically • EARS data collected
the PEARS Database includes but is not or within a template provided by 01101/18 to 09/13 /18 .
limited to: DOH . Due: In real time and no
• Unduplicated number of clients served later than one week after
per project. This must be done in real time. services are provided.
• # unduplicated clients served per Real time = As you provide
project based on the following : services and no later than one
0 Race/ethnicity week after data is collected.
0 Gender
0 Age
• % SNAP eligible per site
Exhibit A, Statements of Work Page 23 of28 Contract Number CLH 18249
Task *May Support PHAB Payment
Number Task! ActivityfDescription StandardslMeasures Deliverables/Outcomes Due DatelTime Frame Information and/or
Amount
• Setting type -school, church, etc .
• Top Key Messages delivered per
project
LHJs are required to submit data electronically
or within the template provided by DOH.
2.2 Evaluation Data and Reports 1. Collect and report any 1. Due: Submit within
The following evaluation activities· and formative and process data Quarterly reporting listed
information is required for all projects based completed based on above in task 2 .0 .
on your approved project/plan approved project plan.
• Formative
• Process 2 . Submit PSE progress and 2. Due: quarterly
• PSE outcomes based on approved • 2nd quarter due by
• Outcome project plan. 04/06118
• Qualitative • 3rd quarter due by
07/06/18
·Please Note : the deliverables may change • Final report for all
based on state evaluation team requirements . other work due
09/21118 .
3. Conduct and submit/mail 3. Due: Within 30 days after
pretest surveys for each completed. Submit all
project class series. pretests surveys/data when
they are completed for a
specific project.
4. Conduct and submit/mail 4. Due: Within 30 days after
posttest surveys for each completed. Submit all
project class series . posttest surveys/data when
they are completed for a
specific project.
5. Capture and submit 5. Due: Submit within
qualitative (success stories, Quarterly reporting listed
pictures) information per above in task 2 .0 along with
your approved work plan. photo releases.
3.0 Civil Rights Training Submit documentation showing Due: 12/31118 See payment
All staff must be trained each fiscal year in Civil Rights training was information as
civil rights . completed for all SNAP-Ed paid referenced in task
staff. Documentation must number 1.0 . I
Exhibit A, Statements of Work Page 24 of28 Contract Number CLH18249
Task *May Support PHAB Payment
Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Due DatelTime Frame Information and/or
Amount
include:
• Training and source
• Who attended
• Date completed
3.1 Other Agency Training Fiscal and Data reporting Due: New staff trained See payment
The following trainings are required for all training completed. within 30 days of starting information as
agencies: SNAP-Ed activities and again referenced in task
• Fiscal-fiscal lead and coordinator at least once every five years. number 1.0 .
I If the data collection system
• Data collection and reporting -changes in FFY18 every staff
coordinator and program staff who member entering data into
are reporting data the electronic system will be
required to take training on
*It is required that all staff making any SNAP-the new system.
Ed purchases or reporting data be trained.
4.0 SNAP-Ed Inventory List SNAP-Ed inventory list. Due: Yearly, at the time of a See payment
Keep an up-to-date inventory list that includes fiscal monitoring andlor site information as
all non-capital equipment, purchased visit. referenced in task
curriculum, and other SNAP-Ed paid items number 1.0.
that are not disposable. This list should include
items purchased in prior fiscal years and be
updated yearly.
5.0 SNAP-Ed A19 Invoices Submit SNAP-Ed A19 invoices Due: Monthly -Submit See payment
Use the AI9-lA specific to SNAP-Ed and detailed ledger supporting invoices to DOH no later information as
program. This document was sent to all LHJ's the costs to be reviewed by than 30 days after the end of referenced in task
prior to October 2017. SNAP-Ed program before the preceding month. number 1.0.
approval of payment. (e.g. October A19 invoice
Documentation of all costs submitted no later than
incurred shall be accompanied November 30 and so on ... )
by an agency financial system
report. IfLHJ does not have a
financial reporting system, LHJ Final invoice is due
must check with the DOH 10/30/18
SNAP-Ed program for further
guidance.
*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 andlor other Public Health Accreditation Board (PHAB) StandardslMeasures that may apply can be found at:
bttp :/lw\I;w.phaboard.org/wp-contenvuploadsIPHAB-Standards-and,Measures-Version-I.O.pdf
Exhibit A, Statements of Work Page 25 of28 Contract Number CLH18249
Program Specific RequirementsiNarrative
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 (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 USASpending.gov by DOH as required by P.L. 109-282.
Travel
The LHJ is expected to comply with the Office of Financial Management's Travel Management Requirement and Restrictions as found in policy 10.10.
http://www.ofm.wa.gov/policy/l0.htm
Curriculum Requirements
Agencies are expected to communicate with, respond to, and comply with all state curriculum team requests, sites visits, approved curriculum list, and curriculum fidelity findings.
Program Manual, Handbook, Policy References:
Records -Record Retention and Management-State Agency and All Sub-grantees 7CFR 272.2
SNAP-Ed regulations require that all records be retained for six years from fiscal closure. This requirement applies to fiscal records, reports and client information. Supporting
documentation may be kept at the sub-grantee level, but shall be available for review for six years from the date of quarterly claim submittal. Any costs that cannot be
substantiated by source documents will be disallowed as charges to SNAP.
Staffing Requirements:
Upon request by DOH, LHJ must demonstrate that SNAP-Ed staff meet requirements appropriate to their positions including but not limited to : background checks, food
handlers' permits, and training required by DOH.
Annual Civil Rights Training Requirement (see FNS Instruction Number 113-1 Chapter XI) -http://www.fns.usda.gov/sites/defaultlfiles/113-1.pdf "Training is required so
that people involved in all levels of administration of programs that receive Federal financial assistance understand civil rights related laws, regulations, procedures, and directives.
The local governmental agency, Indian Tribal Organization or non-Governmental Agency are responsible for training their subrecipients, including 'frontline staff.' 'Frontline
staff who interact with program applicants or participants, and those persons who supervise 'frontline staff' must be provided civil rights training on an annual basis."
Restrictions on Funds:
Amendments
Agencies must submit a request to DOH to amend a project plan and/or budget for prior approval whenever they wish to change the USDA-approved scope of activities and/or
budget. All requests for amendments must be submitted no later than April 1, 2018.
*Please Note:
• No changes may be incorporated into the project plan until an amendment request is approved by DOH and/or USDA.
• Any requests submitted after April 1, 2018 will NOT be approved.
Exhibit A, Statements of Work Page 26 of28 Contract Number CLH18249
Overtime
Overtime is not billable in the DOH SNAP-Ed program unless it has been reviewed and preapproved by the state DOH SNAP-Ed program in advance and was approved in writing.
Budget Revisions
All changes to the budget must be pre-approved in writing by DOH SNAP-Ed.
Special Funding Requirements
Payment for deliverables as specified herein is dependent on receipt of funding from the USDA funding sources . In the event funding is not received, DOH is under no obligation
to make payments for the deliverables as specified. If funding is reduced or limited in any way after the effective date of this contract and prior to nonnal completion DOH may
tenninate task(s), remove funds, or reallocate funds at DOH's discretion under new funding limitations and conditions. DOH will make payments only upon the receipt of the
funding. DOH will notify the LHJ within seven working days upon notice by the funding source of funding availability.
Indirect Rate
All indirect rates must be submitted and preapproved by DOH and the DOH SNAP-Ed program. The LHJ is responsible for ensuring that indirect costs included in the LHJ's
SNAP-Ed plan are supported by an indirect cost agreement and/or cost allocation plan approved by the appropriate agency. The LHJ cannot bill indirect costs that are detennined
to be unacceptable and will be disallowed.
Monitoring Visits (freguency. type):
Audits
The LHJ must make State financial and program audits or reviews conducted by other entities available to the DOH, DSHS, USDA, or its designee.
Monitoring expectations
The LHJ's premises and records will be made available upon request to DOH, DSHS, and USDA staff for the purposes of observing nutrition education activities and reviewing
for program and fiscal compliance. All non-capital equipment and reusable educational materials should be tracked in an inventory list and available for review upon request.
SNAP-Ed Assurances:
The following assurances must be followed (see program Guidance
hnps:lIsnaped.fns. usda. gov/nalional -snap-edlsnap-ed-plan-g uidaD ce~and-lemp Jales )
• The LHJ is fiscally responsible for nutrition education activities funded with Supplemental Nutrition Assistance Program Education funds and is liable for repayment of
unallowable costs.
• Efforts are made to target SNAP-Ed to the SNAP-Ed target audience.
• Only expanded or additional coverage of those activities funded under the Expanded Food and Nutrition Education Program (EFNEP) may be claimed under the SNAP-Ed
grant. Approved activities are those designed to expand the State's current EFNEP coverage in order to serve additional SNAP-Ed targeted individuals . In no case may
activities funded under the EFNEP grant be included in the budget for SNAP-Ed.
• Contracts are procured through competitive bid procedures governed by State procurement regulations .
• Program activities are conducted in compliance with all applicable Federal laws, rules, and regulations including Civil Rights and OMB circulars governing cost issues.
• Program activities do not supplant existing nutrition education and obesity prevention programs, and where operating in conjunction with existing programs, enhance as well
as supplement them. This applies to all activities and costs under the Federal budget.
• Program activities are reasonable and necessary to accomplish SNAP-Ed objectives and goals.
• All materials developed or printed with SNAP-Ed funds include the appropriate USDA non-discrimination statement and credit SNAP as a funding source in standard font
that is easily readable.
Special Billing Reguirements:
1. All invoices, billing and reimbursements must be in compliance with all applicable Federal laws , rules, regulations including the FFY18 SNAP-Ed Guidance and OMB
circulars governing cost issues.
Exhibit A, Statements of Work Page 27 of28 Contract Number CLH18249
2. Total costs billed will not exceed the USDA-approved budget amount listed in the box below.
a. Bills must be for only SNAP-Ed specific activities, using a DOH A19-1A Invoice voucher
b. A SNAP-Ed specific A19-1A must be submitted to the agency's designated DOH SNAP-Ed contract manager within 30 days of the last day of the month for which the
work is being billed, OR
c. An agency may request pre-approval to bill every two months instead, in which case, that agency is required to adhere to the billing due dates listed in Task 5 (see above)
3. NOTE: In FFY18 the SNAP-Ed program will deny payment for any costs not submitted by the due date without prior approval. Iffor ANY reason a LHJ is unable to submit
the SNAP-Ed A-19-1A on the due date, the LHJ is required to submit a request for an exception to the DOH no later than seven days prior to due date to the DOH SNAP-Ed
program. The SNAP-Ed program reserves the right and responsibility to either approve or deny the request for an exception and will reply to the request.
4. Supporting documentation for each month must be submitted with each SNAP-Ed A19-1A.
a. At the very least this means a copy of an agency's financial expanded/detailed general ledger level report.
b. Additionally, all receipts, timecards and other supporting documentation, as noted by USDA, must be available upon request.
5. PLEASE NOTE: If an agency is a new SNAP-Ed LHJ or has had a fiscal finding, or does not submit adequate and/or accurate backup documentation within the last year, all
SNAP-Ed backup documentation must be submitted with each bill and this requirement will continue until further notice by DOH SNAP-Ed program.
BUDGET j
Source I Amount
USDA $10,302
DOH Program Contact
Jamie Wells, SNAP-Ed Contract Manager
Department of Health
PO Box 47886
Olympia, WA 98504-7886
Jamie. W ells@doh.wa.gov
360-236-3668
Exhibit A, Statements of Work
DOH Fiscal Contact
Kim Henderson, Fiscal Analyst
Department of Health
PO Box 47886
Olympia, W A 98504-7886
Kim.Henderson@doh.wa.gov
360-236-3491
Page 28 of28 Contract Number CLH18249
EXHIBITB
Kittitas County Public Health Department ALLOCATIONS Contract Number: CLHI8249
Contract Term: 2018-2020 Date: October 16, 2017
Indirect Rate as of January 2018: 11.25% County Central Svcs & 29.5% Public Health Dept
iJ)d"'U~ Qnty
BARS Statement of Work €/lart Or AC~ilnt $ Funding Chart of
Federal Award Revenue Funding Period F:llndin tr Pce~Qd -Period Accounts
Chart of Accounts ProGram Title Identification # Amend IJ. CFDA* Code*'''-Start Date End Date S lllrlU:ltt .h-lidJTat.e, Amounr Sub Total Total
FFY18 CSS IAR SNAP ED Program Mgnt NGA Not Received N/A 10.561 333 .10 .56 01101118 09 /30/18 ,1'010'1117 ()9Ji3 Qt l~ $8,830 $8,830 $10,302
FFY17 CSS IAR SNAP ED Program Mgnt CF NGA Not Received N/A 10.561 333 .10 .56 01101118 09 /30 /18 J[r/(n fIJ 09/JOiJS $1 ,472 $1,472
FFY17 EPR PHEP BPI LHJ Funding NU90TP92I 889'{)1 N/A 93 .069 333 .93 .06 01101118 06 /30 /18 OJIOli ll 07lOY I'8 $19,833 $19,833 $19,833
FFYI7 317 Ops 5NH23IPOO0762'{)5'{)0 N/A 93.268 333.93 .26 01101118 06/30/18 0:;:IOV 17 ~.gH8 $616 $616 $616
FFY17 AFIX 5NH23IPOO0762'{)5-00 N/A 93 .268 333 .93 .26 01101118 06 /30 /18 Q4/01/'111 P(jl.1(),l I:R $2,226 $2,226 $2,226
FFY17 VFC Ops 5NH23IPOO0762'{)5-OO N/A 93 .268 333 .93 .26 01101118 06 /30/18 ~IO l fli1 06.:'3QH~ $1,114 $1,114 $1,114
FFYI8 MCHBG LHJ Contracts NGA Not Received N/A 93.994 333 .93 .99 01101118 09/30/18 '19/0 1117 9913f)l IS $33,147 $33,147 $33,147
GFS -Group B (FO-E) N/A N/A 334 .04 .90 01101118 06 /30 /18 WO lm Q6.ol);!19 $5,000 $5,000 $5,000
YR 20 SRF -Local Asst (15%) (FS) SS N/A N/A 346 .26 .64 01101 /18 12131120 Q7IQlIf S 12flltiO $2,400 $2,400 $2,400
Sanitary Survey Fees (FO-E) SS-State N/A N/A 346 .26.65 01101118 12/31120 (}-7101/J? 1-:2l1 1120 $2,400 $2,400 $2,400
YR 20 SRF -Local Asst (15%) (FS) TA N/A N/A 346 .26 .66 01101118 12 /31120 07!O,il l~ I r.?I3~t '2 0 $2,000 $2,000 $2,000
TOTAL 579,038 $79,038
Total consideration: $79,038 GRAND TOTAL 579,038
GRANDTOTAL $79,038 Total Fed $67,238
Total State $11,800
*Catalog of Federnl Domestic Assistance
**Federnl revenue codes begin with "333 ". State revenue codes begin with "334".
Page 1 of2
Federal Funding Accountability and Transparency Act Data Collection Form
This contract is supported by federal funds that require compliance with the Federal Funding Accountability and
Transparency Act. The purpose of the Transparency Act is to make information available online so the public can see
how federal funds are spent. To comply with the act and be eligible to enter into this contract, your organization must
have a Data Universal Numbering System (DUNS®) number. If you do not already have one, you may receive a DUNS®
number free of charge by contacting Dun and Bradstreet at www.dnb.com. The Department of Health (DOH) also
encourages registration with the System for Award Management (SAM) to reduce data entry by both DOH and your
organization. You may register with SAM free of charge at federalcontractorreglstrv .com . Information about your
organization and this contract will be reported by DOH to the federal government as required by P.L. 109-282. This
information will then be made available to the public by the federal government on USASpending.gov.
SUBRECIPIENT
DUNS Number o 1JlD~ lSLfl-
~ov
3a. 3b. State
3c . Zip+4 ~ 3d. Country
4. YES (skip to signature block. Sign, date and return) NO
5. In the preceding fiscal year did your organization:
a. Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans,
subgrants, and/or cooperative agreements; and
b. $25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans,
subgrants, and/or cooperative agreements; and
c. The public does not have access to this information about the compensation of the senior executives of
your organization through periodic reports filed under section 13( a) or 15( d) of the Securities and
Exchange Act of 1934 (15 U.S.c. §§ 78m(a), 780(d) or section 6104 of the Internal Revenue Code of
1986.
~O (skip to signature block. Sign, date and return) D~ (You must report the names and total compensation of the top 5 highly compensated officials of your
organization).
Name Of Official Total Com~ensation
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 aid on behalf of the em 10 ee and as otherwise rovided b FFATA and a Iicable OMB uidance.
nin this document the Authorized Re resentative attests to the information.
The Department of Health will not endorse your sub-award until this form is completed and returned.
IIP age (5 /2 0 1 6 )
Federal Funding Accountability and Transparency Act Data Collection Form
FOR DEPARTMENT OF HEALTH USE ONLY
DOH Contract Number
CLH18249
Sub-award Project Description (see instructions and example below)
Instructions for Sub-award Project Description:
In the first line of the description provide a title for the sub-award that captures the main purpose of the subrecipients
work. Then, indicate the name of the subrecipient and provide a brief description that captures the overall purpose of the
sub-award, how the funds will be used, and what will be accomplished.
Example of a Sub-award Project Description:
Increase Healthy Behaviors: Educational Services District XYZ will provide training and technical assistance to chemical
dependency centers to assist the centers to integrate tobacco use into their existing addiction treatment programs.
Funds will also be used to assist centers in creating tobacco free treatment environments.
21Page (5/2016)
Exhibit C Schedule of Federal Awards
KITTITAS COUNTY HEALTH DEPT-SWV0010475-07
CONTRACT ClHl 8249-Kiltilas County Public Health Department
CONTRACT PERIOD 1/1/2018-1213112020
Chart of Accounts Program Title BARS
FFY18 CSS IAR SNAP-ED PROGRAM MGNT 333.10.56
FFY17 CSS IAR SNAP-ED PROGRAM MGNT CF 333,10,56
FFY17 EPR PHEP BPI lHJ FUNDING 333.93.06
FFY17 VFC OPS 333.93 .26
FFY17 AFIX 333.93.26
FFY17 317 OPS 333 ,93 ,26
FFY18 MCHBG lHJ CONTRACTS 333,93,99
DOH
Federal
Award Date
NGANot
Received
NGANot
Received
07118117
03/03/17
03/03/17
0 3/0 3/17
NGA Not
Received
TotalAmt Allocation Period
Federal Start End
Award Date Date
NGANot 01101118
Received 09/30118
NGANot 01 101 /18
Received 09/30/18
$11,062,782 01101118 06130118
$1,201,605 01 /01 /18 06/3 0118
$1,672,289 01/01/18 06/30/18
$575,969 01101/18 06/30/18
NGANot 01/01118
Recerved 09/30/18
TOTAl
Date: October 16, 2017
Contrac1 Amt CFDA CFDA Program Title Federal Agency Name Federal Award Federal Grant Award Name Identification Number
State Administrative Matching
$8,830 10.561 Grants for the Supplemental
Nutrition Assistance Program
Department of Agriculture Food and NGA Not Received NGA Not Received Nutrition Service
State Administrative Matching
$1,472 10561 Grants for the Supplemental
Nutrition Assistance Program
Department of Agriculture Fcoc and NGA Not Received NGA Not Received Nutrition Service
$19,833 93.069 Public Health Emergency
Preparedness
Department of Health and Human HPP AND PHEP COOPERATIVE Services Centers for Disease Control NU90TP921889-01 AGREEMENT and Prevention
$1 ,114 93.26 8 Immunization Cooperative
Agreements
Department of Health and Human IMMUNIZATION GRANT AND
Services Centers for Disease Control 5NH23IPOO0762-<J5-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
$2 ,226 93.268 Immunization Cooperative
Agreements
Department of Health and Human IMMUNIZATION GRANT AND
Services Centers for Disease Control 5NH23IPOO0762-05-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
$616 93268 Immunization Cooperative
Agreements
Department of Health and Human IMMUNIZATION GRANT AND
Services Centers for Disease Control 5NH23IPOO0762-<J5-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
Maternal and Child Health Department of Heatth and Human
$33,147 93.994 Serv ices Block Grant to the Services Health Resources and NGA Not Received NGA Not Received
States Services Administration
567,238
Page 1 of 1
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date Agenda Date
12/18/2017
Fund/Department
116-Public Health
Contract/Grant Information
Contract /Grant Ag e ncy: Consolidated Contract 2018-2020
Period Begin Date: 01/01/2018 I I Period End Date: 12/31/2020
Total Grant/Contract Amount: $79,038.00
Grant/Contract Number: CLH18249
Contract/Grant Summary:
The purpose of this Contract is to define the parties' joint and cooperative relationship. The contract and all
statements of work adopted under its provisions are intended to implement applicable objectives under the
Public Health Improvement Plan and to facilitate the delivery of public health services to the people in
Washington State. This Contract is the result of cooperative planning efforts between Kittitas County Public
Health and DOH.
Recommendation for Board of Health and Board of Health Review on
Department Head Signatu r e ~ • Administrator Da te:~I6-
Signature of Board of Health member Date
Financial Information
Total Amount $79,038.00 State Funds $11,800 Federal Funds $ 67,238
Percentage County Funds Matching Funds $ CFDA#
10.561 $10,302
Grant/Contract Review Page 1
93.069 $19,833
93.268 $3,956
93.994 $33,147
In-Kind $
flcplaln
Is Equipment being purchased? Who owns eCjuipment?
New Personnel being hired? Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes 0 attach budget form NoD Why not? Already budgeted for
New Division Created?
Revenue Codes:
116.61294.333.10.56 $10,302
116.612883.333.93.06 $19,833
116.6123212.333.93.26 $616
116.6123211.333.93.26 $2,226
116.6123213.333.93.26 $1,114
116.6122211.333.93.99 $2,351.25
116.6122212.333.93.99 $20,295.75
116.6122214.333.93.99 $10,500
116.61523.334.04.90'$5,000
116.61522.346.26.64 $2,400
116.61522.346.26.65 $2,400
116.61522.346.26.66 $2,400
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review
I Has the Prosecutor reviewed this agreement? I Yes 0 -No D
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Grant/Contract Review Page 2
Submitted I Signature:
Department:
I Date :
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer I Date
Grant/Contract Review Page 3