HomeMy WebLinkAboutGroup Health Foundation grant AgreementI
July 5, 2018
Dear Kasey,
GROUP HEALTH
FOUNDATI ON
Grant Agreement
We are grateful for this opportunity to support your efforts.
This document describes the agreement between Group Health Foundation (EIN 91-1246278, "the
Foundation") and your organization as described below. (Please provide any updates or corrections to your
information.)
Current information: Updates or corrections:
Organization (must be Kittitas County Public Health Department
the legal entity that will
receive the grant)
EIN 91-6001349
Street address 507 N Nanum St Suite 102
City, state, and zip code Ellensburg, WA 98926
Primary contact (name) Kasey Knutson
Primary contact (email) Kasey.knutson@co .kittitas.wa.us
You will receive a grant in the amount of $13,300. Grant funds are to be used exclusively for the following
purpose:
• Increase HPV vaccination rates by implementing strategies to identify opportunities to address
Kittitas County's low completion rates for the 1:1:3 (Tdap, MCV, HPV) vaccine series. Conduct a post-
implementation survey to measure the effectiveness of the implementation strategies and share
learnings broadly.
More generally, grant funds must be used only for purposes described in Section 501(c)(3) of the Internal
Revenue Code of 1986, as amended (the "Code."). Grant funds may not be used to participate or intervene in
any political campaign on behalf of or in opposition to any candidate for public office, including the
publishing or distributing of statements. No part of this grant is earmarked to carry on propaganda or
otherwise attempt to influence legislation.
Grant funds shall be used for the purposes described in this agreement by 12/30/2019 (unless a written
extension request is approved by the Foundation). You agree to return to the Foundation any grant funds
unused as of this date (or an extended deadline, if applicable).
By signing this agreement, you represent that your organization is (please check the correct box):
D Qualified as an organization described in Section 501(c)(3) of the Code, and that you do not know of
any proposal by or reason for the IRS to revoke or change that status;
D A duly established agency of the United States government, or of the government of a state or a
political subdivision of a state such as a county, city, or special district; or
D A Tribal government.
By signing this agreement, you agree to provide a two-to three -page grant report within two months of the
grant completion date listed above. Grant reports should include responses to the following:
• Please discuss the progress you made toward the goals/objectives outlined in your attached
proposal.
• What major challenges or issues did you encounter along the way?
• What were the most significant things you learned?
• Please provide a breakdown of all expenses that were covered by this grant.
• If you have disseminated results or findings from this project, please provide links to any reports (or
include them as an attachment).
In carrying out work supported by this grant, you agree that you will not unlawfully discriminate in your
employment practices, volunteer opportunities, or the delivery of programs or services on the basis of race,
ethnicity, national origin, ancestry, religion, gender, gender identity/expression, age, medical condition,
disability, veteran status, marital status, sexual orientation, or any other characteristic protected by
applicable federal, state, or local law.
Please note that the Foundation is not seeking any recognition or publicity for this grant. If it helpful to your
organization to publicize the award, you are welcome to mention that support was provided by The
Momentum Fund at Group Health Foundation.
Terms of agreement accepted by:
For gran~ recipient~r ization
Signature -~--"'----""'-'------"=--oi!,,----------
Printed name -,;-,6 l-A m.b
Title /n-/CY/Y11 Mm lnisfrtd-o-r-
Date g'--IJ;-1 f?
For the Foundation
Signature
Printed name
Title
Date
Cory Sbarbaro
Acting President & CEO
I
Today's Date
July 7, 2018
Fund/Department
116-Public Health
Kittitas County
Review Form
Grants & Contract Agreement
Agenda Date
Contract/Grant Information
Contract /Grant Agency: Group Health Foundation (HPV Promotion)
<i>.f1 .f 'te:,
Period Begin Date: Upon Signature I [ Period End Date: December 30, 2019
Total Grant/Contract Amount: $13,300.00
Grant/Contract Number:
Contract/Grant Summary:
The Group Health Foundation Grant Agreement is awarded to Kittitas County Public Health to increase
promotion of the HPV vaccination to increase Kittitas County HPV completion rates .
Recommendation for Board of Health and Board of Health Review on
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
AP PROV ED AS TO FORM: r '
Vi Ill ' iu/4?, h& ~Y: IZ:~~
Date
Date
Signature of61 oard o1 Health member
Financial Information
Total Amount $13,300 State Funds$ Federal Funds$
Percentage County Funds Matching Funds$ CFDA#
In-Kind$
Explain
Is Equipment being purchased? No Who owns equipment?
Grant/Contract Review Page 1
New Personnel being hired? No I Contact HR hiring-reporting requirements
Future impacts or liability to Kittitas County:
Bu dget Information
Budget Amendment Needed? Yes[] attach budget form No D Why not
New Division Created? No To be entered in budget center
Revenue Code 116.612.50.367.00
Pass Th r ough Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review
[ Has the Prosecutor reviewed this agreement? j Yes • No D
Coun ty De partments Im pa cted
Auditor Facilities Maintenance
I
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