HomeMy WebLinkAboutCC Amendment 3KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
2018 -2020 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH18249 AMENDMENT NUMBER: 3
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEAL TH hereinafter referred to as
"DOH", and KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT hereinafter referred to as "LHJ", pursuant to the
Modifications/Waivers clause, and to make necessary changes within the scope of this contract and any subsequent
amendments thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work, attached and incorporated by this reference, are amended as follows:
~ Adds Statements of Work for the following programs:
• FPHS Communicable Disease & Support Capabilities -Effective January 1, 2018
• OICP-Promotion oflmmunizations to Improve Vaccination Rates -Effective July 1, 2018
~ Amends Statements of Work for the following programs:
• Office of Drinking Water Group A Program -Effective January 1, 2018
• Office of Drinking Water Group B Program -Effective January 1, 2018
D Deletes Statements of Work for the following programs:
2. Exhibit B-3 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-2 Allocations as
follows:
~ Increase of$57,600 for a revised maximum consideration of $151,121 .
• Decrease of __ for a revised maximum consideration of __
D No change in the maximum consideration of __ .
Exhibit B Allocations are attached only for informational purposes.
3. Exhibit C-3 Schedule of Federal Awards, attached and incorporated by this reference, amends and replaces
Exhibit C-2.
Unless designated otherwise herein, the effective date ofthis amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force
and effect.
IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.
KITTITAS COUNTY PUBLIC HEAL TH DEPARTMENT
<&/1:?J/I g
RECEIVE ODate
AUG 2 0 2018
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
APPROVED AS TO FORM ONLY
Assistant Attorney General
DOH Contracts Office Page 1 of 13
2018-2020 CONSOLIDATED CONTRACT
EXHIBIT A
STATEMENTS OF WORK
TABLE OF CONTENTS
AMENDMENT #3
DOH Program Name or Title: FPHS Communicable Disease & Support Capabilities -Effective January 1, 2018 .......................................................................... 3
DOH Program Name or Title: Office of Drinking Water Group A Program-Effective January 1, 2018 .......................................................................................... 6
DOH Program Name or Title: Office of Drinking Water Group B Program-Effective January 1, 2018 ........................................................................................ 10
DOH Program Name or Title: OICP-Promotion of Immunizations to Improve Vaccination Rates -Effective July 1, 2018 ................... , ....................................... 12
Exhibit A, Statements of Work
Revised as of May 15, 2018
Page 2 of13 Contract Number CLH18249-3
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #3
DOH Program Name or Title: FPHS Communicable Disease & Support
Capabilities -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
D Federal <Select One> (check if applicable) D Reimbursement
Period of Performance: January 1, 2018 through August 15, 2019 [8J State D FFATA (Transparency Act) [8J One-Time
D Other D Research & Develo_pment Distribution
Statement of Work Purpose: The purpose of this statement of work is to specify how Foundational Public Health Services (FPHS) state funds will be used.
Note: The total lump sum payment for SFY18 (07/01/17-06/30/18) was distributed to LHJs in their 2015-2017 Consolidated Contracts that ended 12/31/17. This statement of
work is to include tasks and deliverables for the remainder ofSFY18 (01/01/18-06/30/18) and SFY19 (07/01/18-06/30/19) in the 2018-2020 Consolidated Contracts.
Revision Purpose: NI A
Chart of Accounts Program Name or Title
FPHS FUNDING FOR LHJS DIR (Funding for SFY18 was
distributed to LHJs in 2015-2017 Consolidated Contracts. The
funding amount shown as Current Consideration in this
Statement of Work is for Informational Purposes Only.)
FPHS FUNDING FOR LHJS DIR
TOTALS
Task Task/ Activity/Description Number
1 These funds are for delivering ANY or all of the
FPHS communicable disease service and can also
be used for the FPHS capabilities that support
FPHS communicable disease services as defined
in the most current version of FPHS Definitions -
Version 1.3 (November 2017}
Control of Communicable Disease and Other
Notifiable Conditions
1-1. Provide timely, statewide, locally relevant
and accurate information statewide and to
Exhibit A, Statements of Work
Revised as of May 15, 2018
CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
NIA 336 .04.25 91106102 01/01/18 06/30/18 42,000 0 42,000
NIA 336.04.25 91106102 07/01/18 06/30/19 0 42,000 42,000
42,000 42,000 84,000
Impact Measures Deliverables/Outcomes Due Date/Time Payment Information
Frame and/or Amount
Percent of toddlers and SFY18 (07/01/17-06/30/18) By 08/15/18 SFY19 (07/01/18-06/30/19)
school age children that Report: Actual Activities funds are available
have completed the and Estimated Expenditures beginning July 1, 2018 and
standard series of the full year allocation will
recommended vaccinations. SFY19 (07/01/18-06/30/19) By 08/15/18 be dispersed upon receipt of
Work Plan: Planned the SFY18 Report and
Percent of new positive Activities and Projected SFY19 Work Plan.
Hepatitis C lab reports that Spending
are received electronically
which have a completed SFY19 (07/01/18-06/30/19)
case report. Report: Actual Activities
and Estimated Expenditures By 08/15/19
Page 3 of 13 Contract Number CLH18249-3
Task Task/ Activity illescription Impact Measures Deliverables/Outcomes Due Date/Time
Number Frame
communities on prevention and control of Percent of new positive
communicable disease and other notifiable Hepatitis C case reports (Note: Use DOH online
conditions. with completed tool for reports and work
investigations. plans. See Special
1-2. Identify statewide and local community Instructions below.)
assets for the control of communicable diseases Percent of Gonorrhea cases
and other notifiable conditions, develop and investigated.
implement a prioritized control plan addressing
communicable diseases and other notifiable Percent of Gonorrhea cases
conditions, seek resources and advocate for high investigated that are
priority prevention and control policies and receiving dual treatment
initiatives regarding communicable diseases and ( treatment for both
other notifiable conditions . Gonorrhea and Chlamydia
at the same time)
1-3. Promote immunization through evidence
based strategies and collaboration with schools, Percent of newly diagnosed
health care providers and other community syphilis cases that receive
partners to increase immunization rates . partner services interview.
1-4. Ensure disease surveillance, investigation
and control for communicable disease and
notifiable conditions in accordance with local,
state and federal mandates and guidelines . See
activities in the definitions.
Program Specific Requirements/Narrative
Special References (RCWs, WACs, etc)
• Immunizations -http ://www.doh.wa .gov/Y ouandYourFa.milyllmmun ization
• Notifiable Conditions -httpJ/Mvw.doh.wa.!wv/.F orPllblicHealthandHealthcareProviders/NotifiableConditions
• Sexually Transmitted Diseases (STD) -bttp:/lwww.dol1.wa.gov/Y ouandYourFamily/lllnes...<:andDiseas e/Sexual lyTransmittedDisease
• Human Immunodeficiency Virus (HIV) -http ://www.doh.wa.gov/Y ouandYourFarnilv/I1lnessandbisease/HlV AIDS
• Tuberculosis (TB) -http://www.doh . wa.e.ov/Y ouandYourFamily/lllnessandDiseaseffuberculosis
• Hepatitis C (HCV) -https://www.doh.wa.gov/ForPublicHea.ltha:nd.BealthcareProvidersfNoti:fiableCondiLions/HepatitisC
Definitions
• FPHS Definitions . Version 1.3, November 20 l
Special Instructions
Exhibit A, Statements of Work
Revised as of May 15, 2018
Page 4 of 13
AMENDMENT #3
Payment Information
and/or Amount
Contract Number CLH18249-3
AMENDMENT #3
There are two different BARS Revenue Codes for "state flexible funds" to be tracked separately and reported separately on your annual BARS report . These two BARS Revenue
Codes and definitions from the State Auditor's Office (SAO 's) are listed below along with a link to the BARS Manual. 336.04.25 is the new BARS Revenue Code to use for the
Foundational Public Health Services (FPHS) funds included in this statement of work.
336.04.24 -County Public Health Assistance
Use this account for the state distribution authorized by the 2013 2ESSB 5034, section 710. The local health jurisdictions are required to provide reports regarding expenditures
to the legislature from this revenue source.
336.04.25 -Foundational Public Health Services
Use this account for the funding designated for the local health jurisdictions to provide a set of core services that government is responsible for in all communities in the WA
state. This set of core services provides the foundation to support the work of the broader public health system and community partners. At this time the funding from this
account is for delivering ANY or all of the FPHS communicable disease services (listed above) and can also be used for the FPHS capabilities that support FPHS communicable
disease services as defined in the most current version ofFPHS Definitions -Version 1.3._November 201
ARSManual.~x
Deliverables are to be submitted via the DOH online reporting tool at: hrms:/l www.surveymonkey.com/r/FPHS 2018
Note: This online tool replaces previously provided Word document reporting templates.
DOH Program Contact
Marie Flake, Special Projects, Foundational Public Health Services
Washington State Department of Health
PO Box 47890, Olympia, WA 98504-7890
Phone 360-236-4063 / Mobile 360-951-7566
Fax 360 .236.4024 I marie .flake@doh.wa.gov
Exhibit A, Statements of Work
Revised as of May 15, 2018
DOH Program Contact
Jaimie Hayes, Health Services Consultant
Health Systems Transformation and Innovation
Washington State Department of Health
PO Box 47890 , Olympia, WA 98504-7890
Phone 360-236-4262 / jaimie.hayes@doh.wa .gov
Page 5 of 13 Contract Number CLH18249-3
AMENDMENT #3
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Office of Drinking Water Group A Program -
Effective January l, 2018
SOW Type: Revision Revision # (for this SOW) 1
Period of Performance: January l, 2018 through December 31, 2020
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
Funding Source Federal Compliance Type of Payment
~ Federal Contractor (check if applicable) D Reimbursement
~ State D FFATA (Transparency Act) ~ Fixed Price
D Other D Research & Development
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: The purpose of this revision is to change end date in Funding Period from 12/31/20 to 12/31/18 and change chart of accounts title and MI for SS and TA
Chart of Accounts Program Name or Title
Yr 20 SRF -Local Asst (15%_) (FS) ss
Sanitary Survey Fees (FO-E) SS-State
Yr 20 SRF -Local Asst (15%) (FS) TA
Yr 21 SRF -Local Asst (15%) (FS) ss
Yr 21 SRF -Local Asst (15%) (FS) TA
TOTALS
Task Task/Activity/Description Number
1 Trained LHJ staff will conduct
sanitary surveys of small community
and non-community Group A water
systems identified by the DOH Office
of Drinking Water (ODW) Regional
Office.
See Special Instructions for task
activity.
DOH will provide a tablet and GPS
unit for the LHJ to 2ather source data
Exhibit A, Statements of Work
Revised as of May 15, 2018
CFDA#
NIA
NIA
NIA
NIA
NIA
*May Support PHAB
Standards/Measures
BARS Master Funding Period Current Change Total
Revenue Index (LBJ Use Only) Consideration None Consideration
Code Code Start Date End Date
346.26.64 24139220 01/01/18 12/31/18 2,400 -2 ,400 0
346 .26 .65 24242522 01/01/18 12/31/18 2,400 0 2,400
346.26 .66 24139220 01/01/18 12/31/18 2,000 -2 ,000 0
346.26.64 24139221 01/01/18 12/31/18 0 2,400 2,400
346.26.66 24139221 01/01/18 12/31/18 0 2 ,000 2,000
6,800 0 6,800
Deliverables/Outcomes Due Date/Time Payment Information and/or Amount Frame
Provide Final* Sanitary Final Sanitary Survey Upon ODW acceptance of the Final
Survey Reports to ODW Reports must be Sanitary Survey Report, the LHJ shall
Regional Office. Complete received by the ODW be paid $400 for each sanitary survey of
Sanitary Survey Reports shall Regional Office a non-community system with three or
include: within 30 calendar fewer connections.
1. Cover letter identifying days of conducting
significant deficiencies, the sanitary survey. Upon ODW acceptance of the Final
significant findings, Sanitary Survey Report, the LHJ shall
observations, be paid $800 for each sanitary survey of
recommendations, and a non-community system with four or
referrals for further more connections and each community
ODW follow-up. system.
2. Completed Small Water
System checklist. Payment is inclusive of all associated
3. Updated Water Facilities costs such as travel, lodging, _per diem.
Page 6 of 13 Contract Number CLH18249-3
'
Task Task/ Activity/Description Number
during a routine sanitary survey. DOH
expects the LHJ to commit to using
the tablet and GPS for a five-year
period.
2 Trained LHJ staff will conduct
Special Purpose Investigations (SPI)
of small community and non-
community Group A water systems
identified by the ODW Regional
Office.
See Special Instructions for task
activity.
3 Trained LHJ staff will provide direct
technical assistance (TA) to small
community and non-community
Group A water systems identified by
the ODW Regional Office.
See Special Instructions for task
activity.
Exhibit A, Statements of Work
Revised as of May 15, 2018
*May Support PHAB
Standards/Measures
I
I
Deliverables/Outcomes
Inventory (WFI).
4. Photos of water system
with text identifying
features
5 . Any other supporting
documents.
*Final Reports reviewed and
accepted by the ODW
Regional Office .
The LHJ surveyor will record
at least two (2) GPS data
points, for each source, into
the preloaded Excel template
on the tablet and submit that
data file with the associated
sanitary survey.
Provide completed SPI
Report and any supporting
documents and photos to
ODW Regional Office.
I
Provide completed TA
Report and any supporting
documents and photos to
ODW Regional Office.
Page 7 of 13
AMENDMENT #3
Due Date/Time
Frame Payment Information and/or Amount
Payment is authorized upon receipt and
acceptance of the Final Sanitary Survey
Report within the 30-day deadline.
Late or incomplete reports may not be
accepted for payment.
Completed SPI Upon acceptance of the completed SPI
Reports must be Report, the LHJ shall be paid $800 for
received by the ODW each SPI.
Regional Office
within 2 working Payment is inclusive of all associated
days of the service costs such as travel, lodging, per diem.
request.
Payment is authorized upon receipt and
acceptance of completed SPI Report
within the 2 working day deadline.
Late or incomplete reports may not be
accepted for payment.
Completed TA Upon acceptance of the completed TA
Report must be Report, the LHJ shall be paid for each
received by the ODW technical assistance activity as follows:
Regional Office • Up to 3 hours of work: $250
within 30 calendar • 3-6 hours of work: $500
days of providing • More than 6 hours of work: $750
technical assistance.
Payment is inclusive of all associated
costs such as consulting fee, travel,
lodging, per diem.
Contract Number CLH18249-3
I
AMENDMENT #3
Task Task/ Activity/Description *May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information and/or Amount Number Standards/Measures Frame
Payment is authorized upon receipt and
acceptance of completed TA Report
within the 30-day deadline.
Late or incomplete reports may not be
acce_Qted 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
Survey Training. (Non-Employee)" DOH in accordance with the current rates
Form 710-013 to the ODW listed on the OFM Website
See Special Instructions for task Program Contact below for htm://www.ofm . wa .!!ov/r~,;o urces/travel
activity. approval (to ensure that .asp
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
Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
hltp://www.phab~ard.org/wo-content/uoloads/PHAB -S tandards-and-Measures-Version-!. 0 .pdf
Program Specific Requirements/Narrative
Special References (RCWs, WACs, etc)
Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work, ODW contracts with the LHJ to conduct sanitary surveys (and SP Is, 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 1, 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 for.
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 surveys. bill h alf to BARS Revenue Code 3 46 .2 6 .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 of TA 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 Al9-1A Invoice
Voucher to the DOH Grants Management, billing to BARS Revenue Code 346.26 .66 under Technical Assistance (TA).
Special Instructions
Task 1
Exhibit A, Statements of Work
Revised as of May 15, 2018
Page 8 of 13 Contract Number CLH18249-3
AMENDMENT #3
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW. Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance (Field Guide). The sanitary survey will include an
evaluation of the following eight elements: source; treatment; distribution system; finished water storage; pumps, pump facilities and controls; monitoring, reporting and data
verification; system management and operation; and certified operator compliance. If a system is more complex than anticipated or other significant issues arise, the LHJ may
request ODW assistance.
• No more than 8 surveys of non-community systems with three or fewer connections to be completed between January 1, 2018 and December 31, 2018.
• 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 LHJ, notification of the water system, and ODW follow-up with unresponsive water systems; and other roles and responsibilities of
the LHJ are described in the Field Guide.
Task2
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 authorize in advance any SPI conducted by LHJ staff.
Task3
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.
Task4
LHJ staff assigned to perform activities under tasks 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.wa.gov/Portals/1/Documents/Pubs/331-486.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
Revised as of May 15, 2018
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 of 13 Contract Number CLH18249-3
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #3
DOH Program Name or Title: Office of Drinking Water Group B Program -
Effective January 1, 2018
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
SOW Type: Revision Revision # (for this SOW) 1 Funding Source Federal Compliance Type of Payment
D Federal <Select One> (check if applicable) D Reimbursement
Period of Performance: January 1, 2018 through June 30, 2019 r8J State D FFATA (Transparency Act) r8] Fixed Price
D Other D Research & Development
Statement of Work Purpose: The purpose of this statement of work is to provide financial support to LHJ s implementing local Group B water system programs.
Revision Purpose: The purpose of this revision is to extend the Period of Performance from June 30, 2018 to June 30, 2019, increase Current Consideration, and revise Special
Billing Requirements.
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LBJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
GFS -Group B (FO-E) NIA 334.04.90 24240103 01101118 I 06130/18 5,000 0 5,000
FY2 Group B Programs for DW (FO-E) NIA 334.04.90 24240105 01101118 I 06/30/19 0 10,000 10,000
TOTALS 5,000 10.000 15,000
Task *May Support PHAB Memorandum of Payment
Task/ Activity/Description Deliverables/Outcomes Information and/or Number Standards/Measures Agreement Number Amount
1 Implement a full Group B water system program. An executed joint plan of Reference DOH JPR Lump sum payment
responsibility (JPR) with DOH #Nl9411 (See Special Billing
identifying responsibilities of a full Requirements)
Group B.
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
http ://www.pha board .org/wp-con-1ent/upl0ad s/PHAB-Standar<ts-and-Measures -V ers ion -l .O .pdf
Program Specific Requirements/Narrative
Special Billing Requirements
Exhibit A, Statements of Work
Revised as of May 15, 2018
Page 10 of 13 Contract Number CLH18249-3
AMENDMENT #3
The LHJsheU ~mbmit « $5. ()(}(} inveiee hefe;:e ;'da_,: 15, 10.18. The LHJ shall submit three semi-annual invoices as follows: $5,000 in the first half of each calendar year (no later
than May 15) and $5,000 in the second half of each calendar )Wlr (no later than November 15). Payment cannot exceed a maximum cumulative fee of$10,000 per year.
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
Revised as of May 15, 2018
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 11 of 13 Contract Number CLH18249-3
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #3
DOH Program Name or Title : O[CP-Promotion oflmmunizations 16 lmprove
Vaccination Rates -Effective July 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
lz;J Federal Subrecipient (check if applicable) lz;J Reimbursement
Period of Performance: July 1. 2018 through June 30. 2019 0 State lz;J FF AT A (Transparency Act) D Fixed Price
D Other D Research & Development
Statement of Work Purpose: The purpose of this statement of work is to contract with local health to conduct activities to improve immunization coverage rates.
Revision Purpose: N/ A
Chart of Accounts Program Name or Title
FFY18 Increasing Immzs Rates ConCon
TOTALS
Task
Number Task/Activity/Description
1 Develop a proposal to improv e immunization
coverage rates for a target population by increasing
promotion activities and collaborating with
community partners. The proposal must meet
guidelines outlined in the Local Health Jurisdiction
Funding O1mortunity, Promotion oflmmunizations
to Increase Vaccination Rates announcement.
2 Upon approval of proposal, implement the plan to
increase immunization coverage rates with the
target population identified.
3 Conduct an evaluation of the interventions
implemented.
Exhibit A , Statements of Work
Revised as of May 15, 2018
CFDA# BARS Master Funding Period
Revenue Index (LHJ Use Only)
Code Code Start Date End Date
93.268 333 .93.26 74310285 07101 118 I 06/30119
*May Support PHAB
Standards/Measures Deliverables/Outcomes
Written proposal and a report that
shows starting immunization rates
for the target population
Written report describing the
progress made on reaching
milestones for activities identified
in the plan (template will be
provided)
Final written report, including a
report showing ending
immunization rates for the target
Page 12 of 13
Current Change Total
Consideration Increase(+) Consideration
0 5,600 5 ,600
0 5,600 5,600
Due Date/Time Payment
Frame Information and/or
Amount
August 1, 2018 Reimbursement for
actual costs incurred,
not to exceed total
funding consideration
amount.
See Restrictions on
Funds below.
November 30 , 2018 Reimbursement for
actual co sts incurred,
March 31, 2019 not to exceed total
funding consideration
amount.
See Restrictions on
Funds below
June 15 , 2019 Reimbursement for
actual costs incurred,
not to exceed total
Contract Number CLH18249-3
AMENDMENT #3
Task *May Support PHAB Due Date/Time Payment
Number Task/ Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
population (template will be funding consideration
provided) amount.
See Restrictions on
Funds below
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here . This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
htlp ://www .obaboard.ori?/wp -content/uoloads/PHAB-Standards-and-M.ensures-V ersjon-l .O:pdf
Program Specific Requirements/Narrative
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 (FF AT A or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To 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 o f work will be made available on US AS pending. gov by DOH as required by P .L. I 09-282 .
Restrictions on Funds (what funds can be used for which activities, not direct payments, etc.)
Allowable Uses of Federal Operations Funds document (dated 12/20/2017) is posted on the DOH Consolidated Contract website at this link. These federal funds may not be used
for expenses related to travel or attendance at any non-DOH sponsored conference, training, or event without prior written approval from the DOH Office oflmmunization and
Child Profile.
Other
Deliverables may be sent electronically via email to oicpcontracts@doh.wa.gov, by fax to 360-236-3590, or by mail to PO Box 47843 , Olympia WA 98504-7843
DOH Program Contact
Tawney Harper, MPA
Budget and Operations Manager
Office of Immunization and Child Profile
Department of Health
PO Box 47843, Olympia WA 98504-7843
tawney.harper@doh.wa.gov / 360-236-3525
Exhibit A, Statements of Work
Revised as of May 15, 2018
DOH Fiscal Contact
Vanessa Mojica
Special Projects Coordinator
Office of Immunization and Child Profile
Department of Health
PO Box 47843, Olympia WA 98504-7843
vanessa.mojica@doh.wa.gov /360-236-3 802
Page 13 of 13 Contract Number CLH18249-3
EXHIBITB-3
Kittitas County Public Health Department ALLOCATIONS Contract Number: CLH18249
Contract Term: 2018-2020 Date: May 15, 2018
Indirect Rate as of January 2018: 12.50'1/o County Central Svcs & 29.50% Public Health Dept
BARS Statement of Work Chart.of 1\f'e4~ Funding Chart of
Federal Award Revenue Funding Period FundhiitPeriod Period Accounts
Chart o f Accounts Pro&!!,m Tl Uc. _ Identification # Amend # CFDA* Code** Start Date End Date S1JrtJ>a 1e-1-~jfOate Amount Sub Total Total
FFY18 CSS IAR SNAP ED Program Mgnt NGA Not Received Amd2 10.561 333.10.56 01/01/18 09130118 1~!11>7 0'-)13(!!_1$ $ll,o25 $19,855 $21,327
FFY18 CSS IAR SNAP ED Program Mgnt NGA Not Received NIA 10.561 333 .10.56 01/01/18 09130118 IO!Oli l ?i 99iJClt,1g $8 ,830
FFYI 7 CSS IAR SNAP ED Program Mgnt CF NGA Not Received NIA 10.561 333.10.56 01/01/18 09130118 IO/Ot/,17 091.30,l'l&' $1 ,472 $1,472
FFY17 EPR PHEP BPI LHJ Funding NU90TP92!889-0l Amd2 93.069 333 .93 .06 01/01/18 06130118 ()7/(),t,17 0'770YIS $565 $20,398 $20,398
FFY17 EPR PHEP BPI LHJ Funding NU90TP92I889-01 NIA 93.069 333 .93 .06 01101/18 06130118 07/01111 07f91,/III $19,833
FFY17 317 Ops 5NH231P000762-05-00 NIA 93 .268 333.93.26 01/01118 06130/18 OOl'Wl'l 06'3l)II~ $616 $616 $616
FFY17 AFIX 5NH231P000762-05-00 NIA 93.268 333 .93 .26 01/01/18 06130118 O:ilOI 1'7, 0613011$ $2,226 $2,226 $2,226
FFY18 Increasing Immzs Rates ConCon NGA Not Received Amd3 93.268 333.93.26 07101118 06130119 Q7/tlld8 ~w,,1<,i $5,600 $5,600 $5,600
FFY17 VFC Ops 5NH231P000762-05-00 NIA 93.268 333.93.26 01/01/18 06130118 04tOlrJ7 00/~QllS $1,114 $1,114 $1,114
FFY18 MCHBG LHJ Contracts B04MC3!524 Amd2 93.994 333 .93 .99 01/01/18 09/30118 Ull'OIIJ7 00130/IS $893 $34,040 $34,040
FFY18 MCHBG LHJ Contracts B04MC31524 NIA 93 .994 333 .93 .99 01101/18 09130118 U)/0"1117· [)9i3r)/18 $33,147
GFS -Group B (FO-E) NIA NIA 334.04.90 01 101/18 06130118 (11/0~ 17' (lo(J0/19 $5,000 $5,000 $5,000
FY2 Group B Programs for DW (FO-E) Amd3 NIA 334.04.90 07101118 06130119 07/01 17 (1.(J.3~'1'~ $10,000 $10,000 $10,000
SFYl Lead Environments of Children Amdl NIA 334.04.93 01/01/18 06130118 OT~IM ~3(}(.1$ $2,000 $2,000 $2,000
FPHS Funding for LHJs Dir Amd3 NIA 336.04.25 07101/18 06130119 07@-J.t l7 019,30, ,111 $42,000 $42,000 $42,000
YR 20 SRF -Local Asst (15%) (FS) SS Amd3 NIA 346.26.64 01/01/18 12131118 071!)1 .~ J!!.'3.111$' ($2,400) $0 $0
YR 20 SRF -Local Asst (15%) (FS) SS NIA,Amd3 NIA 346.26.64 01/01/18 12131/18 07101 ,1s, IW,1/18 $2,400
YR 21 SRF -Local Asst (15¾) (FS) SS Amd3 NIA 346.26.64 01/01/18 12/31/18 O'fflJ 1111 06Pl)Jl9 $2,400 $2,400 $2,400
Sanitary SUIVey Fees (FO-E) SS-State NIA, Amd 3 NIA 346.26.65 01/01118 12/31118 m07/-01 117 ()6.~)./19 $2,400 $2,400 $2,400
YR 20 SRF -Local Asst (15%) (FS) TA Amd3 NIA 346.26.66 01/01118 12131/18 .,fJ7t'Ol /1$-1~1118 ($2,000) $0 $0
YR 20 SRF -Local Asst (I 5%) (FS) TA NIA,Amd3 NIA 346.26.66 01/01/18 12/31118 07/01 IS 128111-8 $2,000
YR 21 SRF -Local Asst (15%) (FS) TA Amd3 NIA 346.26.66 01/01/18 12/31/18 07/01 117 Q6t130ll'!> $2,000 $2,000 $2,000
Page 1 of2
Kittitas County Public Health Deparbnent
Indirect Rare as of January 2018: 12.50% County Central Svcs & 29.50% Public Health Dept
Chart of Accounts Pros.ram Title
TOTAL
Total consideration:
GRAND TOTAL
*Catalog of Federal Domestic Assistance
Federal Award
Identification #
$93,521
$57,600
$151,121
**Federal revenue codes begin with "333". State revenue codes begin with "334".
Amend#
EXHIBIT 8-3
ALLOCATIONS
Contract Tenn: 2018-2020
CFDA ..
BARS
Revenue
Code**
Page2 of2
Statement of Work
Funding Period
.Start Date End Date
0.01! 1/~Qn •~
Chart of AtcowrtS'
·~l'ldiu!\ Pei;l ci:d
S~i'i. Daleo EmJ. Di lt Amount
$151,121
Contract Number:
Date:
Funding
Period
Sub TotaJ
$151,121
GRAND TOTAL
Total Fed
Total State
CLH18249
May 15, 2018
Chart of
Accounts
Total
$151,121
$85,321
$65,800
Exhibit C-3 Schedule of Federal Awards
KITTITAS COUNTY HEAL TH DEPT-SWV0010475--07
CONTRACT CLH18249-Kittitas County Public Health Department
CONTRACT PERIOD: 01/01/2018-12/31/2020
DOH
Federal Chart of Accounts Program Title BARS Award Date
NGA Not FFY18 CSS IAR SNAP-ED PROGRAM MGNT 333.10.56 Received
NGA Not FFY17 CSS IAR SNAP-ED PROGRAM MGNT CF 333.10.56 Received
FFY17 EPR PHEP BP1 LHJ FUNDING 333.93.06 07/18/17
FFY18 INCREASING IMMZS RATES CONCON 333.93.26 NGA Not
Received
FFY17 VFC OPS 333.93.26 03/03/17
FFY17 AFllC 333.93 26 03/03/17
FFY17 317 OPS 333.93.26 03/03/17
FFY18 MCHBG LHJ CONTRACTS 333,93.99 10/20/17
Total Amt Allocation Period
Federal Start End
Award Date Date
NGA_ Not 01101118 Received 09/30/18
NGA_Not 01101118 Received 09/30/18
$11,062,782 01/01/18 06/30/18
--
NGJ\Not
Roc;;ived 07/01/18 06/30/19
$1,201,605 01/01 /18 06/30/18
$1,672,289 01/01/18 06/30/18
$575,969 01/01/18 06/30118
$1,650,528 01/01/18 09/30/18
TOTAL
AMENDMENT #3
Date: May 15, 2018
Contract Amt CFDA CFDA Program Title Federal Agency Name Federal Award Federal Grant Award Name Identification Number
State Administrative Matching
$19,855 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 10.561 Grants for the Supplemental
Nutrition Assistance Program
Department of Agriculture Food and NGA Not Received NGA Not Received Nutrition Service
---
$20,398 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 -
$5,600 93.268 Immunization Cooperative
Agreements
Department of Health and Human
Services Centers for Disease Control NGA Not Received NGA Not Received
and Prevention
$1,114 93.268 Immunization Cooperative
Agreements
Department of Health and Human IMMUNIZATION GRANT AND
Services Centers for Disease Control 5NH231P000762--05-00 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 5NH231P000762--05-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM -
$616 93.268 Immunization Cooperative
Agreements
Department of Health and Human IMMUNIZATION GRANT AND
Services Centers for Disease Control 5NH231P000762--05-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM --
Maternal and Child Health
$34,040 93.994 Services Block Grant to the
States
Department of Health and Human MATERNAL AND CHILD HEAL TH Services Health Resources and B04MC31524 SERVICES Services Administration
$85,321
Page 1 of 1
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date : Agenda Date 0 / 1 //8 July 7, 2018
Fund/Department
116-Public Health
Contract /Grant Information
Contract /Grant Agen cy : Consolidated Contract Amendment 3
Period Begin Date: January 1, 2018 I I Period End Date: 12/31/2020
Total Gra nt/Contract Amount: Increase of $57,600 for a revised maximum consideration of $151,121
Grant/Contract Number: CLH18249
Contract/Grant Summary:
The Consolidated Contract Amendment "3adds Statements of Work for the FPHS Communicable Disease
and Support Capabilities and the OICP-Promotion of Immunizations to Improve Vaccination Rates. It
also amends statements of work for the Office of Drinking Water Group A and B programs. The
Consolidated Contract increases the contract amount by 57,600.00 for a new revised maximum of
$151,121.00.
Recommendation for Board of Health and Board of Health Review on
Department Head Signatur ~ ' Administrator Date : <if/lo/J'S
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
(. •r
I
ffi ce Date
Date
Signature of Board of Health member Date
Financial Information
Total Amount $57,600 State Funds $52,000 Federal Funds $5,600
percentage County Funds Matching Funds$ CFDA# 93 .268 $5,600 lmmz Rate
Grant/Contract Review Page 1
In-Kind$
fl:lph1ln
Is Eq ui p ment being purchased? No Who owns eq ui p ment?
New Personnel being hired? No Contact HR hi r i ng -reportin g requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes • attach budget form No []I Why not
New Division Created? No Already in budget
Revenue Code 612.32.333.93.26 $ 5,600 lmmz Rate Increase
612.39.17 .336.04.25 $42,000 FPHS CD
615.2.3.334.04.90 $10,000 Group B Water
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review I Has the Prosecutor reviewed this agree ment? I Yes D No D
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature :
Dep artment :
I Date:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Grant/Contract Review Page 2
I Reviewer I Date
Grant/Contract Review Page 3