HomeMy WebLinkAboutContract Amendment 1KITTITAS COUNTY HEALTH DEPARTMENT
2017-2018 CONTRACT
CONTRACT NUMBER: 17-83 AMENDMENT NUMBER: 1
PURPOSE OF CHANGE: To amend the above contract, dated July 1, 2017 through June 30, 2018
between WALLA WALLA COUNTY DEPARTMENT OF COMMUNITY HEALTH hereinafter referred to as
"DCH" and KITTITAS COUNTY HEALTH DEPARTMENT hereinafter referred to as "LHJ", and to make
necessary changes to the scope of these contract and any subsequent amendments thereto .
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statement of Work, attached and incorporated by this reference, is amended as follows :
Adds Statements of Work:
Payment
Task Task/Activity/
Deliverables/Outcomes
Due Date/Time Information
Number Description Frame and/or
Amount
1 Monthly Report Complete monthly report form and June 10, 2018 N/A
email to YMPEP Program July 10, 2018
Coordinator
2 Community Email list of contacts, website, June 30, 2018 Invoiced
Outreach Activities letter, meetings
3 Retailer Contacts Retailer education materi al creation June 30, 2018 Invoiced
and visits
4 Adult Education Distribute educational materials June 30, 2018 Invoiced
regarding keeping marijuana out of
the hands of youth.
2. Exhibit B -Allocations, attached and incorporated by this reference, amends and replaces Exhibit B
allocations as follows:
Increase of $2,856 for a revised maximum consideration of $5,856.
3. Exhibit D-YMPEP Reporting Form, attached and incorporated by this reference amends and replaces,
Exhibit D, reporting as follows:
The YMPEP reporting form is due on the 10th day of the month for the previous month . No payments will
be issued to the prior to the receipt of completed monthly reporting form.
Unless designated otherwise herein, the effective date of this amendment is the date of execution .
ALL OTHER TERMS AND CONDITIONS of the original contract and any previous amendments remain in
full force and effect.
IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.
KITTITAS COUNTY HEALTH DEPARTMENT WALLA WALLA COUNTY DEP'T OF COMMUNITY
HEALTH
Grantee Name:
Kittitas County
Health Department
Exhibit B
BUDGET
Agreement Number: 17-83 Contract Period: July 1, 2017 -June 30, 2018
This Agreement __ includes / _x_ does not include, in the SPECIFIC TERMS AND
CONDITIONS, requirements to which payment of budgeted funds is contingent.
Line Item/Description Amount
Total budget allocation to meet deliverables $2,856
TOTAL: $2,856
Funded By:
WA State Department of Health Youth Marijuana Prevention and Education Program
#BUDGET Page 1 of 1
YMPEP Reporting Form
Month: I
Agency: Kittitas County Public Heal1 th Department
County: Kittitas I
Task 1: Community Outreach
Task 2:. Retailer Contacts
Task 3 : Adult Education
Other
Expenditure Report Form (ERF)
INSTRUCTIONS TO VENDOR OR CLAIMANT:
STATEMENT FOR SERVICES • Claim payment for materials, merchandise or services. Show complete detail for each item. -------Vendor's Certificate. I hereby certify under penalty of perjury that
Submit this form ,fo Confra"1"r--the items and totals listed herein are proper charges for materials, merchandise
County of Walla Walla, Washington or services furnished to the County of Walla Walla and that all goods furnished
and/or services rendered have been provided without discrimination because of
Department of Community Health a ge, sex, marital status, race, creed, color, national origin, handicap, religion, or
Vietnam era or disabled vet e rans status and the claim is just, due and unpaid
PO Box 1753 obligation against the County of Walla Walla and that I am authorized to
Walla Walla WA 99362
Emai l IQ: :Q !:;l·l !:;Qntra.Qt~Ri11ing @ co.walln-wnll 11 .w11 .u~
tU!AlMAN'r BY :
Kittitas County Public Health Department (SlGN IN INK)
(TITLE ) (DATE )
Program: YMPEP
Agreement Number: 17-83
Claim Perlod:4/1/18-6130/18
DATE DESCRIPTION OF SERVICES AMOUNT
Salary and benefits
Program expenses, materials, goods and services
Indirect rate (personnel costs on ly)
TOTAL PAYMENT REQUESTED WITH THIS E~F'; $0:0 0
PREPARED BY !TELEPHONE tIUM BER IOATE
I l
F()Rc;uuNTY,f(N,Yle£1JSEONLY ...
vlilllXlRna•'l!-'b~ UO,n~..,ER
FUND Code Distribution
ACOOCJ NTINQ APPROVAL FOR PAYMENT 1 ~~ I WARRANT TOT AL WNm>,t,/T NUMBER
$0.00
Rev ise d 1/5/15
Kittitas County
Review Form
Grants & Contract Agreement
-
Today's Date Agenda Date / J.} Lj J J:} 10/23/2017
Fund/Department
116-Public Health
Cont ract /Grant Information
Contract /Grant Agency: Walla Walla County and KCPHD
Period Begin Date: 07/0 1/2 017 I j Period End Date: 06/30/2018
Total Grant/Contract Amount: $3000 .00
Gran t /Contract Number:
Contract/Grant Summary:
-L/Dtc/3
The agreement is entered into, by, and between Walla Walla County and Kittitas County Public Health
Department for engagement and participation in the Greater Columbia Accountable Community of
Health Youth Marijuana Prevention and Education Program Planning Team.
Recommendation for Board of Health and Board of Health Review on
. · A1JJ I\ .. . . ~ Department Head S1gnature:Shkv =-, Administrator Date: .lt:(.JJn
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FOR M :
/)i:/_d ,:/ #/J ,
'-✓ /~w~ ~ {d'4'Plt'ev,';,-.,,
Sign ature of Prosecutor's Office
. I /J ~,,
t'; ~ p -t.:.,d.-/
Signature o Date
Signature of Board of Health member Date
Financial Information
Total Amount $3000.00 State Funds $3000.00 Federal Funds S
Perce ntage Co u nty Funds Matching Funds$ CFDA#
In -Kind$
E~~la ln
Grant/Contract Review Page 1
Is Equipment being purchased? I Who owns equipment?
New Personnel being hired? I Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County :
Budget Information
Budget Amendment Needed? Yes • attach budget form No[K] Why not
New Division Created? Not an increase in bottom line, shifting of
revenues
Revenue Code
116-612.91.334.06.902 -$3000.00
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date :
Prosecutor Review
j Has the Prosecutor reviewed this agree ment? jves D No 0
Coun ty Depa rtments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I ~ignature:
Department:
I Date:
Assi gn ment of Trackin g Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer I Date I
Grant/Contract Review Page 2
Service Agreement #
between
WALLA WALLA COUNTY
and
KITTITAS COUNTY PUBLIC HEAL TH
The Agreement is entered into by and between Walla Walla County, hereinafter 'County," and
Kittitas County Public Health, hereinafter "Contractor," for engagement and participation in the
Greater Columbia Accountable Community of Health Youth Marijuana Preve11tion and
Education Program Planning Team, as outlined in the attached Statement of Work. The rights
and obligations of both parties are governed by the General Terms and Cond itions, and the
following Exhibits copie of which are attached hereto and incorporated herein by this reference
as fully as if set forth herein:
Exhibit A -Statement of Work
Exhibit B -Budget
Exhibit C -Expenditure Report Form
Exhibit D -Participation Report Form
Performance Period: The tenns of thi Agreement shall commence on July 1st, 2017 and shall,
unless terminated or renewed as provided elsewhere in the Agre ement,
tenninate on JuDe 30, 2 018 .
Compensation: Paymen to Contractor for services rendered µ.nder this Agreement sha ll be
as set forth in Exhibit B -Budget. The allocation of funding is currently
awarded for Fiscal Year 20L7: 7/1/2017 to 6/30/2018. The amount of
payment for the performance period of this Agreement shall not exceed
$3,000.
CFDA# (if applicable): ____ UBI#: ________ _
State Industrial Account ID# (if applicable): ---------
1.0 CONTRACTOR RESPONSIBILITIES:
CONTRACTOR agrees to:
• Participate in a minimum of six (6) monthly meetings of the regional planning
group for Marijuana Prevention and Education per Statement of Work, Exhibit A
CONTRACTOR is responsible for the selection of the CONTRACTOR's participant in
the regional planning meetings per Statement of Work, Exhibit A
CONTRACTOR agrees to follow all applicable statutes and regulations.
CONTRACTOR agrees to hold COUNTY harmless from all liabilities resulting from the
above-described activities and further assumes responsibility for any future audit
exceptions due to the use of these funds.
2.0 BILLING AND PAYMENT
1 !Page
The CONTRACTOR agrees to submit required deliverables as detailed in Exhibit B,
Budget.
COUNTY will reimburse the actual approved expense of the KITTITAS COUNTY
PUBLIC HEALTH up to a MAXIMUM OF $3000. See Exhibit B
Allowable expenses are for reasonable program purposes, including personnel and travel
submitted on Expenditure Report form (ERF), Exhibit C per Participation Report Form,
Exhibit D. No expenses will be reimbursed for any lobbying efforts of any kind or for
any clinical care.
Indirect costs are limited to the organization's approved overhead rate.
After approval of the billing invoices, payment will be made on the next scheduled Walla
Walla County voucher run.
All items shall be received and services rendered by midnight April 30, 2018.
COUNTY shall not be responsible for any Invoices received after June 15, 2018.
3.0 PROHIBITION AGAINST ASSIGNMENT
Neither this contract nor any interest therein may be assigned by either party without first
obtaining the consent of the other party.
4 .0 INDEPENDENT CONTRACTOR STATUS OF HEALTH DEPARTMENT
The CONTRACTOR and CONTRACTOR's employees and agents shall perform all
duties pursuant to this Contract as an independent contractor. COUNTY shall not
control or supervise the manner in which this Contract is performed nor withhold or pay
any taxes on behalf of the CONTRACTOR or the CONTRACTOR's employees or
agents.
2jPage
5.0 INDEMNIFICATION AND INSURANCE
Any and all claims which hereafter arise on the part of any and all persons as a direct or
indirect result of the CONTRACTOR or the CONTRACTOR's employees or agents
performance or failure to perform duties pursuant to this Contract, shall be the
CONTRACTOR's sole obligation, and the CONTRACTOR shall indemnify and hold
harmless COUNTY.
Insurance. CONTRACTOR is a member of the Washington Counties Risk Pool.
CONTRACTOR shall notify COUNTY forty-five (45) days before cancellation or
reduction in CONTRACTOR's insurance coverage.
6.0 SUSPENSION AND DEBARMENT
The CONTRACTOR certifies that persons responsible for this agreement are not
presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this program by any federal department or
agency.
7.0 TERMINATION
This agreement shall terminate and be null and void to the extent funds anticipated to be
made available to the COUNTY for the purposes of this agreement are not made
available to the COUNTY for any reason whatsoever.
Either party may terminate this agreement with written notice to the other party prior to
June 10, 2018.
8.0 VERBAL AGREEMENTS
This written Contract constitutes the mutual agreement of the CONTRACTOR and
COUNTY in whole. No alteration or variation of the terms of this Contract and no oral
understandings or agreements not incorporated herein, unless made in writing between
the parties hereto, shall be binding.
9.0 APPLICABLE LAW
This Contract shall be governed by the laws of the State of Washington.
10.0 NONDISCRIMINATION
No person shall, on the grounds of race, creed, color, national ongm, sex, sexual
orientation or handicapping condition be excluded from participation in, be denied the
3IPage
benefits of, or be otherwise subjected to discrimination under activities performed
pursuant to this Contract.
11.0 EFFECTIVE DATE -DURATION
This Contract shall commence on the 1st Day of July 2017, and shall terminate at
midnight on the 30 th day of June 2018, regardless of the date of execution. Section 5.0
(Indemnification) which shall continue to bind the parties their heirs and successors after
June 30, 2018.
IN WITNESS WHEREOF, COUNTY and CONTRACTOR have executed this Contract
consisting of four pages and attachments.
By their signatures below, the parties agree to the terms and conditions of this Agreement and all
documents incorporated by reference. The parties signing below certify that they are authorized
to sign this Agreement.
IN WITNESS WHEREOF, the parties hereto have signed this Agreement.
COUNTY: CONTRACTOR:
Meg a1
Director
/MPH
Department of Community Health
314 W. Main
P .O. Box 1753
Dme ~ uhori.ze<l B v
r2Jv1vi W V¾tm,n_ps~1w-
Walla Walla, WA 993 62 Print Name & Title of l'cr~on ip oin&
Phone, (509) 524-2650 Prue (509) 524-2642 ~ CJ l/L 7 S 15 .
1
Telephone Number/ Email Address : ~Wl . ~a.ct e ~D . tJ fb#l ~. tu~ c1U.S
Ma;!ing Address ''"'" '"1dre§ ""'""" "additioo <o PO•~.,, ffi N NW m jp ! /J2
~fl bW1J qJ?t12U
Social Security or Business Tax ID#: CJ l <,, o -DI 3 L/'7
4jPage
Exhibit A
STATEMENT OF WORK
Grantee Name: Kittitas County Public Health
Agreement Number: Contract Period: July 1, 2017 -June 30, 2018
Due Payment
Task Task/Activity/ Deliverables/Outcomes Date/Time Information
Number Description Frame and/or
Amount
1 Participate in Participation and attendance to Monthly-Invoiced
Monthly YMPEP monthly YMPEP Planning Team October monthly
Planning Team meetings 2017
meetings. through
March 2018
# SOW Page 1 of 1
I
Grantee Name:
Agreement Number:
Exhibit B
BUDGET
Kittitas County Public Health
Contract Period: October 1, 2017 -June 31,
2018
This Agreement __ includes / _x__ does not include, in the SPECIFIC TERMS AND
CONDITIONS, requirements to which payment of budgeted funds is contingent.
Line Item/Description Amount
Personnel Costs: Time and Effort $2000
Travel to and From YMPEP Planning Team Meetings, $0.54/mile $1000
TOTAL: $3,000
Funded By:
WA State Department of Health Youth Marijuana Prevention and Education Program
#BUDGET Pagel of l
Expenditure Report Form (ERF)
/l',/STRUaTION$ TO VE!NDOR OR CLAIMANT:
STATEMENT FOR SERVICES • Claim payment for materials, merchandise or services , Show complete detail for each item.
I Vrndar', c,rtlficaro. I herebv certify under penaltv of perjury that I
Submll lhl• ,n ,.,, I n -. ·-~! the items and totals Usted herein are proper charges for materials, merchandise I Co u nty of Walla Walla, Washington or services furnished to the County of Walla Walla and that all goods furnished
1 and/or services rendered have bll!!!en pro1Jlded without discrimination because of
' age, sex, marital status, race, creed, color, natlonal o,lgln, handicap, religion, or Department of Commu n ity Health
I Vietnam era or disabled veterans status and the cla/m is just, due and unpaid
PO Box 175 3 obligation against the Countv of Walla Walla and that I am authorized to
Wa lla Walla WA 99362
IDl.!.tli!.10.:...Un!Ql111mi.1,0illins(ii}~2,~vallo·~alh1,~'.l!II~
CLAI MANT ~ .. ,'~~: BY:
(!}l(l)lllll!ilKl
(TllUj l'Mm
Program;
Agroomon1 Number;
Claim Period :
DATE DESCRIPTION OF SERVICES AMOUNT
.
TOTAL PAYMENT REQUESTED WITH THIS ERF; $0 .00
PREPARED DY I TELEPHONE NUMBER I DATE
I I
~' <,_ ,,, •1F..O/f COUNTY FIN.ANCBUSf!'ONI. Y, ''-'!~ • .: .. v~ •
1vi=i~~"f\J~l;II j UfJI NUMeni
FUND Code Dlslt/bul/on
~CCOUNTING APPROVAL FOR PAYMENT 'DATE I WARRANT TOTAL \Y/1.JJRAr« NUMDCR
$0 .00
Re•I0~4 ,,,,.,._,
Today's Date
05/08/2018
Fund/Department
116-Public Health
Kittitas County
Review Form
Grants & Contract Agreement
Agenda Date !
,jl
Contract/Grant Information
Contract /Grant Agency: Amendment 1 to the contract between Walla Walla and Kittitas County Public
Health Department
Period Begin Date: July 1, 2017 I I Period End Date: June 30, 2018
Total Grant/Contract Amount: Increase of $2,856.00 for a new revised maximum of $5,856.00
Grant/Contract Number: 17-83
Contract/Grant Summary:
The amendment 1 to the contract between Walla Walla and Kittitas County Public Health Department
increases the contract amount by $2,856.00 for a new revised maximum of $5,856.00 for participation in
the Greater Columbia Accountable Community of Health Youth Marijuana Prevention and Education
Program. The amendment includes an amended Statement of Work and a new reporting form.
Recommendation for Board of Health and Board of Health Review on
Department Head Signature ~ , Administrator Date:{,_, {t {Qi
Date
~!;, lt P
Date
Signature of Board of Health member Date
Financial Information
Total Amount$ 2,856 State Funds$ 2,856 Federal Funds$ 0
Percentage County Funds Matching Funds$ CFDA#
Grant/Contract Review Page 1
In-Kind$
Explain
Is Equipment being purchased? no Who owns equipment?
New Personnel being hired? no Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County :
Budget Information
Budget Amendment Needed? Yes • attach budget form No []I Why not amend to increase funds
New Division Created? no
Revenue Code 116.612.91.334.06.902
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review
[ Has the Prosecutor reviewed this agreement? I Yes • No D
County Departments Im pacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
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 2