HomeMy WebLinkAboutAmendment 4KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
2018 -2020 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH18249 AMENDMENT NUMBER: 4
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH 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 :
I. Exhibit A Statements of Work, attached and incorporated by this reference, are amended as follows:
[8J Adds Statements of Work for the following programs:
• Office of Emergency Preparedness & Response -Effective July 1, 2018
• Supplemental Nutrition Assistance Program-Education -Effective October 1, 2018
[8J Amends Statements of Work for the following programs:
• Childhood Lead Poisoning Prevention Program -Effective January 1, 2018
• Maternal & Child Health Block Grant -Effective January 1, 2018
• OICP-Promotion oflmmunizations to Improve Vaccination Rates -Effective July 1, 2018
• Supplemental Nutrition Assistance Program-Education -Effective January 1, 2018
D Deletes Statements of Work for the following programs:
2. Exhibit B-4 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-3 Allocations as follows :
[8J Increase of$117,548 for a revised maximum consideration of$281,644.
• 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-4 Schedule of Federal Awards, attached and incorporated by this reference, amends and replaces Exhibit C-3.
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 subsequent amendments remain in full force and effect.
IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
//)~
Date
STATE OF WASHINGTON
D PARTMENT Or TJEALT H
J,uu~b J o [2.itl I~
Date
APPROVED AS TO FORM ONLY
Assistant Attorney General
Page 1 of32
2018-2020 CONSOLIDATED CONTRACT
EXHIBIT A
STATEMENTS OF WORK
TABLE OF CONTENTS
AMENDMENT #4
DOH Program Name or Title: Childhood Lead Poisoning Prevention Program-Effective January 1, 2018 .................................................................................... 3
DOH Program Name or Title: Maternal & Child Health Block Grant -Effective January 1, 2018 .................................................................................................... 7
DOH Program Name or Title: Office of Emergency Preparedness & Response-Effective July 1, 2018 ......................................................................................... 12
DOH Program Name or Title: OICP-Promotion oflmmunizations to hnprove Vaccination Rates -Effective July 1, 2018 .............................. ,., .......................... 16
DOH Program Name or Title: Supplemental Nutrition Assistance Program-Education -Effective January 1, 2018 ...................................................................... 18
DOH Program Name or Title: Supplemental Nutrition Assistance Program-Education -Effective October 1, 2018 ............................ , .... , ....... , ............................ 25
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 2 of32 Contract Number CLH18249-4
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #4
DOH Program Name or Title: Childhood l.ead Poisoning Prevention 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) [8J Reimbursement
Period of Performance: January 1, 2018 through June 30, 2019 [8J State D FFATA (Transparency Act) D Fixed Price
D Other D Research & Development
Statement of Work Purpose: The purpose ofthis statement of work is to support local interventions with the case management of elevated blood lead levels in children 14 years
of age and younger. The focus of this program in 2018 is to build local capacity statewide to provide standard case management services to all children with elevated blood lead
levels.
Revision Purpose: The purpose of this revision is to extend the period of performance from June 30, 2018 to June 30, 2019, add SFY2 funding and update the statement of work.
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
SFYl Lead Environments of Children (proviso funds) NIA 334.04.93 25715110 01101118 I 06/30/18 2,000 0 2,000
SFY2 Lead Environments of Children (proviso funds) NIA 334.04.93 25715120 01101118 I 06130119 0 1,500 1,500
TOTALS 2,000 1,500 3,500
Task *May Support PHAB Due Date/Time Payment
Number Task/ Activityillescription Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
1 Contact the provider to gather complete information on Submit the cempleted updated Ch il-d Mom/i/>,r, 9}' Jh c Reimbursement of up
~~ the assigned elevated blood lead case to conduct an
environmental assessment
a) Verify the blood lead level (BLL) is confirmed.
Reference Centers for Disease Control and
Prevention's (CDC's) confirmed case definition:
b1 tp_s :/ I wwwn .cdc. 2ov/nnds s/condi1ions/lead-
elevated-blood-lev.el s'ease-definition/20 16/
b) Call family and schedule a home visit. If
interpretation services are needed, contact DOH
at lead@doh.wa.gov. Note : Interpretation
services will not be reimbursed through the
ConCon process.
c) Visit the child's residence (or other sites where
the child spends significant amounts of time) at
least once
Exhibit A, Statements of Work
Revised as of July 16, 2018
-IJ.lef:ld f(!(,w. fflH!5'1f;rJ,'l'fJ!l 3~f Child to $500 maximum per
Blood Lead Investigation Form via fel'-tJ1,,iflU. 9'0'•1q •· .. ·o •. •7 •• ~ home visit, p er child.
Washington Disease Reporting Submit as needed Up to two (2) home
System (WDRS) available through within 60 days visits per child not to
WA DOH indicating: after completion. exceed total funding
consideration .
a) Confirmed BLL
b) Date LHJ contacted the family Note: this excludes
c) Date the environmental indirect costs
assessment was completed
d) Date the interview was
completed
e) Specify if the home is Section 8
or HUD Housing and if the
child is Medicaid enrolled
Page 3 of32 Contract Number CLH18249-4
Task
Number Task/ Activity/Description
d) Interview the caregivers using the Child Blood
Lead Investigation Form and conduct an
environmental assessment to identify factors that
may impact the child's blood lead level. If
laboratory services are needed, contact DOH at
lead@doh . wa . gov.
Note: Laboratory services will not be reimbursed
through the ConCon process.
e) Determine if the family lives in Section 8 or HUD
Housing. If the child is Medicaid enrolled collect
the Provider One number
f) Provide educational material to the child 's
caregivers in the family 's primary language
g) (Optional) If warranted, contact DOH to request
technical or environmental investigation
assistance with an X-ray fluorescent (XRF)
analyzer
Have the child retested following the Pediatric
Environmental Health Specialty Units (PEHSU)
medical management guidelines. If the lead level
remains 2:5 µg /dL the LHJ will conduct a second home
visit to connect the family to other service providers as
needed.
PEHSU medical management guidelines:
htms://Y!_ww.11ehsu.ne t/ Llbrarv/fa c ts/medical -m~mnl-
childhood-lead-exposure-June-?O 13.pdf
If the second lead level drops to <5 µg/dL, the LHJ has
the option to: 1) Mail the child's caregivers a letter
recommending a developmental and nutritional
screening, the letter will include providers in the
child's residential area . The LHJ may then close the
case. (DOH will provide a template letter.); or
2) proceed to Task 2 and conduct a second home visit.
2 The purpose of the second home visit is to connect the
family to other service providers as needed:
a) LHJ staff will facilitate and guide the child's
caregiver in completing the WithinReach
Exhibit A, Statements of Work
Revised as of July 16, 2018
AMENDMENT #4
*May Support PHAB Due Date/Time Payment
Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
f) (If applicable) IfDOH
assistance is requested , list the
DOH contact and date contacted
g) (If applicable) If the LHJ opts to
close the case after verifying
that the second lead level has
dropped to <5 µg/dL , it must
submit a copy of the letter
mailed to the family
Submit a written report summarizing
the environmental assessment lab test
results and a Plan of Care that lists
recommendations on how to remove
and remediate lead exposure via
WDRS . Include the educational
material provided to the family that
addresses the child's needs. (DOH
will provide a generic template.) The
LHJ will fH'0+'ide upload a copy of
the report to DOH via WDRS , and
provide a copy to the child's
caregivers and provider.
Submit an updated Plan of Care to Memh!;,·. e_;• .the Reimbursement of up
DOH via WDRS and provide a copy .J.if'-efake to $500 maximum per
to the child's caregivers and provider ~,;g-mem-ltc-home visit, per child.
that includes: Submit as needed Up to two (2) home
Page 4 of32 Contract Number CLH18249-4
AMENDMENT #4
Task *May Support PHAB Due Date/Time Payment
Task/Activity/Description Deliverables/Outcomes Information and/or Number Standards/Measures Frame Amount
Developmental Screening Questionnaire online a) Completion date and results of within 60 days visits per child not to
ht!Q://www.Qarenthe1Q123 .org/. The LHJ must the online WithinReach after completion. exceed total funding
provide a hard copy of the developmental Developmental Screening consideration.
screening in case it cannot be submitted online. In Questionnaire
unusual, and DOH approved cases, in which the b) If blood lead testing of at-risk Note: this excludes
WithinReach assessment cannot be performed, family members was indirect costs.
the LHJ may refer the family to the child 's recommended, list the
physician or to another entity that is trained to individuals
administer developmental screening tests c) The referral date and provider of
b) Encourage blood lead testing of other children the nutritional assessment,
less than 72 months of age and pregnant or include all other referrals
nursing caregivers in the home d) The members of the case
c) If appropriate, refer the child's caregivers to the management team, their
Women, Infants, and Children (WIC) program or involvement, and the case
a Registered Dietitian Nutritionist (RON) for a information provided to them
nutritional assessment and to other service
providers as appropriate
d) Coordinate services and communicate regularly
with members of the case management team
3 DOH will reimburse LHJ staff for DOH-approved case Attend approved training and submit As needed Reimbursement for
management related training opportunities and travel training invoices and receipts to DOH-approved
including training fees if applicable and mileage, DOH trainingfees, mileage
lodging and meals at the current federal GSA rates at and per diem not to
the time of travel. exceed total funding
consideration.
(See Special Billing
Requirements 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:
http ://www .phaboard .org/wp -conten t/up loads/PHA.13 -Standards-and -Measures-Version • l . 0. odf
Program Specific Reg uirements/N arrative
Program Manual, Handbook, Policy References
Guide for Public Health Case Management of Children with Elevated Blood Lead Levels
https://www. doh. wa. gov/Portals/ 1 /Documents/4000/334-414.pdf
A Targeted Approach to Blood Lead Screening in Children, Washington State
Exhibit A , Statements of Work
Revised as of July 16 , 2018
Page 5 of32 Contract Number CLH18249-4
AMENDMENT #4
Pubs/334-383 .pdf
Special References (RCWs, WACs, etc)
Laboratories are required to report to the Department of Health all Blood Lead test results (WAC 246-101-201). Elevated results (~5 mcg/dL) must be reported within two (2)
days; non-elevated results :'.S5 mcg/dL need to be reported within one (1) month .
Monitoring Visits (frequency, type)
Telephone calls with contract manager at least once every quarter.
Definitions
BLL-Blood Lead Level
EBLL-Elevated Blood Lead Level
PEHSU-Pediatric Environmental Health Specialty Units
Special Billing Requirements
Reimbursement for pre-approved travel expenses including mileage. lodging and meals will be calculated at the current federal General Services Administration (GSA) rates at
the time of travel. Current per diem rates by state can be found at: https J/www. gsa , godJravel/vlan-booldper-diem-rate.slper-diem-rates-lookue
Special Instructions
Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable written report to include a plan of care. 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 ~ may be submitted fHRRihl)' b_r rite JOi/1 -ef
eac.~ .went.II fa!lewing tlie memh in whieh-lJ~11di~uN6' ll'e<re me,u-.':ef/ as needed within 60 days after home visit completion and must be based on actual allowahle direct
program costs . Billing for services on a monthly fraction of the 'Total Consideration" will not be accepted or approved . If needed, additional funding may be added upon request
and DOH approval while funds are available. Contact lead@,doh. iva.gov for additional information.
Note: blood lead case management reimbursement excludes indirect costs.
DOH Program Contact
Araceli Mendez, Health Services Consultant
Office of Environmental Public Health Sciences
Washington State Department of Health
Street Address : 310 Israel Rd SE, Tumwater, WA 98501
Telephone: 360-236-3392 / Fax: 360-236-3059
Email: araceli.mendez@doh.wa.gov
DOH Fiscal Contact
Victoria Reyes, Management Analyst 1
Assistant Secretary's Office
Telephone: 360-236-3071
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 6 of32 Contract Number CLH18249-4
DOH Program Name or Title: Maternal & Child Health Block Grant -
Effective January 1, 2018
SOW Type : Revision Revision # (for this SOW) 2
Period of Performance: January 1, 2018 through September 30, 2019
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #4
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
Funding Source Federal Compliance Type of Payment
[8l Federal Subrecipient (check if applicable) [8l Reimbursement
0 State ~ FFATA (Transparency Act) 0 Fixed Price
D Other D 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: The purpose of this revision is to provide additional funding, add activities and deliverable due dates, and extend the period of performance and funding period
from September 30, 2018 to September 30, 2019 for continuation ofMCHBG related activities.
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period
Revenue Index (LBJ Use Only)
Code Code Start Date End Date
FFY18 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120281 01101118 I 09;30118
FFY19 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120291 10101118 I 09130119
TOTALS
Task *May Support PHAB Task/ Activity/Description Deliverables/Outcomes Number Standards/Measures
Maternal and Child Health Block Grant (MCHBG) Administration
la Participate in calls, at a minimum of every Designated LHJ staff will
quarter, with DOH contract manager. Dates and participate in contract management
time for calls are mutually agreed upon between calls.
DOHandLHJ
lb Report actual expenditures for October 1, 2017 Submit actual expenditures using
through March 31, 2018 the MCHBG Budget Workbook to
DOH contract manager
le Develop 2018-2019 MCHBG Budget Workbook Submit MCHBG Budget
for October 1, 2018 through September 30, 2019 Workbook to DOH contract
using DOH provided template . manager
Exhibit A , Statements of Work
Revised as of July 16, 2018
Page 7 of32
Current Change lfotal
Consideration Increase(+) Consideration
34,040 0 34,040
0 44 196 44 ,196
34,040 44_,196 78,236
Payment
Due Date/Time Frame Information and/or
Amount
September 30, 2018 Reimbursement for
September 30, 2019 actual costs, not to
exceed total funding
consideration.
May 26, 2018 Action Plan and
Progress Reports
must only reflect
September 5, 2018 activities paid for
with funds provided
in this statement of
work for the
specified funding
Contract Number CLH18249-4
Task
Number Task/ Activityillescription
Id Report actual expenditures for October 1, 2018
through March 31, 2019
le Develop 2019-2020 MCHBG Budget Workbook
for October 1, 2019 through September 30, 2020
using DOH provided template.
If Report actual expenditures for October 1, 2017
through September 30, 2018
MCHBG Assessment and Evaluation
2a Participate in project evaluation activities
developed and coordinated by DOH, as
requested.
2b Report program level strategy measure data
(CSHCN, UDS, ACEs).
2c Conduct a Maternal and Child Health (MCH)
Needs Assessment.
MCHBG Implementation
3a Develop 2018-2019 MCHBG Action Plan for
October 1, 2018 through September 30, 2019
using DOH-provided template.
3b Report activities and outcomes of2017-2018
MCHBG Action Plan using DOH-provided
temJJlate.
Exhibit A, Statements of Work
Revised as of July 16, 2018
*May Support PHAB
Standards/Measures Deliverables/Outcomes
Submit actual expenditures using
the MCHBG Budget Workbook to
DOH contract manager.
Submit MCHBG Budget Workbook
to DOH contract manager
Submit actual expenditures using
the MCHBG Budget Workbook to
DOH contract manager.
Documentation using report
template provided by DOH
Documentation using report
template provided by DOH
Submit Needs Assessment
documentation to DOH contract
manager using templates provided
byDOH
Submit MCHBG Action Plan to
DOH contract manager
Submit Action Plan monthly
reports to DOH contract manager
Page 8 of32
AMENDMENT #4
Payment
Due Date/Time Frame Information and/or
Amount
May 24, 2019 period.
See Program
Specific
Requirements and
September 5, 2019 Special Billing
Requirements.
November 30, 2018
September 30, 2018 Reimbursement for
September 30, 2019 actual costs, not to
exceed total funding
January 15, 2018 consideration.
April15,2018
July 15, 2018 See Program
October 15, 2018 Specific
January 15, 2019 Requirements and
April 15, 2019 Special Billing
July 15, 2019 Requirements.
May 24, 2019
Draft August 17, 2018 Reimbursement for
Final September 5, 2018 actual costs, not to
exceed total funding
Monthly, on or before consideration.
the 15th of the following Action Plan and
month Progress Reports
Contract Number CLH18249-4
AMENDMENT #4
Task *May Support PHAB Payment
Number Task/ Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Jc Develop 2019-2020 MCHBG Action Plan for Submit MCHBG Action Plan to Draft August 17, 2019 must only reflect
October 1, 2019 through September 30, 2020 DOH contract manager Final-September 5, activities paid for
using DOH-:]Jrovided temylate. 2019 with funds provided
3d Report activities and outcomes of 2018-2019 Submit Action Plan monthly Monthly, on or before in this statement of
MCHBG Action Plan using DOH-provided reports to DOH contract manager the 15 1
" of the following work for the
template. month specified funding
period.
See Program
Specific
Requirements and
Special Billing
Requirements.
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. October 15, 2018 consideration.
Ensure client data is collected on all children January 15, 2019 Action Plan and
served by CSHCN contractors , including April 15, 2019 Progress Reports
neurodevelopmental centers, regional July 15, 2019 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 15 th of the following See Program
Pn~gnm, Me1m-m Focus of Work . regional meetings attended to the month Specific
DOH contract manager. Requirements and
4d Develop and update CYSHCN County Resource Submit completed resource list September 30, 2019 Special Billing
List and share with partners as described in the electronically to the DOH contract Requirements.
CSHCN Focus of Work. manager.
*For Information Only:
Funding is not tied to the revised Standards/M easures 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 :
hrtp :// ww-w .phaboard. org/,.,P:contentfuploads/PHAB-Standards-and-.M.easures-Version-J . O.pd!
Program Specific Requirements/Narrative
Exhibit A , Statements of Work
Revised as of July 16, 2018
Page 9 of32 Contract Number CLH18249-4
AMENDMENT #4
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:Jlwww.doh.wa.gov/Portals/l /Documents/Pubs!970-209-CSHCN-Manua1.pdf
Health Services Authorization (HSA) Form
http://www.doh. wa.go v/PonaJs/ l/Documems/Pubs/910-002 -ApprovedllSA.docx
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 Admin istration (HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land , the purchase, construction, or permanent 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 trainin g 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 Al 9-lA 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.
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 10 of32 Contract Number CLH18249-4
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 4 7848, Olympia, WA 98504
Telephone: 360-236-3781 / Fax: 360-236-3646
Email: Mary.Dussol@doh.wa.gov
Exhibit A, Statements of Work
Revised as of July 16, 2018
AMENDMENT #4
Page 11 of32 Contract Number CLH18249-4
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #4
DOH Program Name or Title: Office ofEmergencv Preparedness & Response-
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
~ Federal Subrecipient (check if applicable) ~ Reimbursement
Period of Performance: July 1, 2018 through June 30, 2019 D State ~ FFATA (Transparency Act) D Fixed Price
D Other D Research & Development
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 2018 grant period.
Revision Purpose: N/ A
Chart of Accounts Program Name or Title
FFY18 EPR PHEP BPI SUPP LHJ FUNDING
TOTALS
Task
Number Task/ Activity/Description
FFY18 EPR PHEP BPl SUPP LBJ FUNDING
1 Attend emergency preparedness events , ( e.g.
trainings , meetings , conference calls , and
conferences) as necessary to advance LHJ
preparedness or complete the deliverables in this
statement of work.
2 Complete reporting templates as requested by
DOH to comply with program and federal grant
requirements ( e.g. performance measures , gap
analysis, mid-year and end-of-year reporting
templates , etc.)
3 Training & Evaluation:
3.1) Provide training for appropriate staff who
Exhibit A, Statements of Work
Revised as of July 16, 2018
CFDA# BARS Master Funding Period
Revenue Index (LBJ Use Only)
Code Code Start Date End Date
93 .069 333 .93.06 18101580 01101118 I 06130119
*May Support PHAB
Standards/Measures Deliverables/Outcomes
Submit summary on the mid-year
and end of year progres s report .
Submit completed templates to
DOH
Submit mid-year and end-of-year
progress reports
Page 12 of32
Current Change Total
Consideration Increase(+) Consideration
0 48~249 48 ,249
0 48,249 48,249
Due Date/Time Payment
Frame Information and/or
Amount
Reimbursement for
actual costs not to
December 31 , 2018 exceed total funding
and June 28 , 2019 consideration amount.
I
Upon request by DOH
December 31 , 2018
and June 28 , 2019
Contract Number CLH18249-4
Task
Number Task/ Activity/Description
serve in the Emergency Operations Center (EOC)
and the Emergency Support Function (ESF#8) role
on the Incident Command System, ESF#8 response
plans and policies.
3.2) Participate in an evaluation of response
capabilities based on a standard evaluation tool
created by DOH.
4 Maintain Washington Secure Electronic
Communication, Urgent Response and Exchange
System (W ASECURES) program as the primary
emergency notification system within the LHJ and
include all critical LHJ positions as registered
users.
4.1) Conduct a notification drill using
WASECURES.
Notes: Registered users must log in quarterly at a
minimum . DOH will provide on-site technical
assistance to LHJ s, as needed , on utilizing
WASECURES . LHJs may choose to utilize other
notification systems in addition to W ASECURES
to alert staff during incidents.
5 Participate in situational awareness during an
incident training.
6 Review and, if necessary, update plan to request,
receive and dispense medical countermeasures .
Plans should include the addresses of all local
distribution sites (Hub) identified by the LHJ.
Note: Not all LHJs require a distribution site ; LHJs
may partner with others to create a centralized
distribution location .
Exhibit A, Statements of Work
Revised as of July 16, 2018
AMENDMENT #4
*May Support PHAB Due Date/Time Payment
Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
Provide agenda and sign in sheets June 28 , 2019
of trainings conducted, with
attendee signatures and contact
information, or registrations if
training is not conducted by the
I
LHJ.
Document participation in June 28 , 2019
I evaluation on midyear and end of
year progress report.
Submit mid-year and end-of-year December 31 , 2018
progress reports and June 28 , 2019
Submit list of registered users to June 28, 2019
include their title and role in the
emergency response plan.
Submit results of notification drill. June 28, 2019
Submit mid-year and end-of-year December 31, 2018
progress reports and June 28 , 2019
Agendas and sign in sheets, June 28 , 2019
including attendee signatures and
contact information, for trainings
conducted.
Submit mid-year and end-of-year December 31 , 2018
progress reports and June 28 , 2019
Submit updated plan to request, June 28, 2019
receive and dispense medical
countermeasures including to
DOH.
Page 13 of32 Contract Number CLH 18249-4
AMENDMENT #4
Task *May Support PHAB Due Date/Time Payment
Task/ Activity/Description Deliverables/Outcomes Information and/or Number Standards/Measures Frame Amount
7 Provide notification to the DOH Duty Officer at Submit mid-year and end-of-year December 31, 2018
360-888-0838 or hanalert@doh.wa.gov for all progress reports and June 28, 2019
response incidents involving utilization of
emergency response plans (ERPs) and structures. Documentation that notification to June 28, 2019
DOH was provided; or statement
that no incident response occurred.
8 Provide LHJ situation reports to DOH during all Submit mid-year and end-of-year December 31, 2018
incidents involving an emergency response by the progress reports and June 28, 2019
LHJ.
Submit Situation Reports. During all responses
9 Submit essential elements of information (EEis) Submit mid-year and end-of-year December 31, 2018
during incident response upon request by DOH. progress reports and June 28, 2019
Provide information upon request. Upon request by DOH
10 Participate in the regional healthcare coalition Submit mid-year and end-of-year December 31, 2018
(HCC) and attend coalition meetings as necessary. progress reports and June 28, 2019
Provide a summary of participation June 28, 2019
in coalition activities.
11 For all LHJs that have identified a Hub for receipt Submit mid-year and end-of-year December 31, 2018
of medical countermeasures from DOH during progress reports and June 28, 2019
disasters:
• Participate in the 2019 T-Rex medication Documentation of participation in June 28, 2019
distribution exercise by receiving a shipment the exercise
of exercise medications from DOH at the
designated local Hub
• LHJ are not required to test dispensing,
transportation, or redistribution during the
T-Rex exercise.
*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:
httn://www.phaboard.org/wp-comeru/up !oads/PHA.B-Standards-and-lwlt:asures-Version-1.0.pdf
Program Specific Reg uirements/N arrative
Any subco ntract/s must be approv€d by DOH 2rior to executing the contract/s.
Deli verables are to be suhJ111ittcd to ihe ConCon de-Jiverable s mailbox at ccm 0o nde1ive.1.rbles(a d.oh. wa.gov
Special Requirements
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 14 of32 Contract Number CLH18249-4
AMENDMENT #4
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.
Restrictions on Funds (what funds can be used for which activities, not direct payments, etc)
Please reference the Code of Federal Regulations:
https:f/www.ecfr.gov/cei-bin/retrieveECFR?i:rp= I &S1D =58ffddb.5363a2 7.f26e9d12ccec4 6? 549&lv'=HTML&h= L&mc=troe&i=eART &n=pt2. l .200#se2. l .200 14 39
DOH Program Contact
Jennifer Albertson, Contract and Finance Specialist
Department of Health
P O Box 4 7960, Olympia, WA 98504-7960
360-236-4596 I jennifer.albertson@doh.wa.gov
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 15 of32 Contract Number CLH18249-4
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #4
DOH Program Name or Title: OICP-Promotion oflmmunizations to Improve
Vaccination Rates -Effective July 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
[gl Federal Subrecipient (check if applicable) [gl Reimbursement
Period of Performance: July 1, 2018 through June 30, 2019 D State [gl 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: The purpose of this revision is to correct the Chart of Accounts Program Name/Title and the Master Index Code.
Chart of Accounts Program Name or Title
FFY18 Increasing lmmzs Rates ConCon
FFY I 7 Increasing Immunization Rates
TOTALS
Task Task/ Activity/Description Number
1 Develop a proposal to improve 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 Opportunity, Promotion of Immunizations
to Increase Vaccination Rates announcement.
2 Upon approval of proposal, implement the plan to
increase immunization coverage rates with the
target population identified.
Exhibit A, Statements of Work
Revised as ofJuly 16, 2018
CFDA# BARS Master Funding Period
Revenue Index (LHJ Use Only)
Code Code Start Date End Date
93.268 333 .93.26 74310285 01101118 I 06/30/19
93.268 333 .93.26 74310276 01 101118 I 06/30119
*May Support PHAB Deliverables/Outcomes Standards/Measures
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)
Page 16 of32
Current Change Total
Consideration None Consideration
5,600 -5,600 0
0 5,600 5,600
5,600 0 5,600
Due Date/Time Payment
Information and/or Frame 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 costs incurred,
March 31, 2019 not to exceed total
funding consideration
amount.
See Restrictions on
Funds below
Contract Number CLH18249-4
AMENDMENT #4
Task *May Support PHAB Due Date/Time Payment
Task/ Activity /Description Deliverables/Outcomes Information and/or Number Standards/Measures Frame Amount
3 Conduct an evaluation of the interventions Final written report, including a June 15, 2019 Reimbursement for
implemented. report showing ending actual costs incurred,
immunization rates for the target not to exceed total
population (template will be funding consideration
provided) amount.
See Restrictions on
Funds below
*F'or Information Onlv:
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:
hrtp:l/www . phaboard .Org/WD;:COnten l/ up loads/PH AB -S tandards--and-Measures-Version-1. .0 .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 ATA 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.
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, MP A
Budget and Operations Manager
Office oflmmunization 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 ofJuly 16, 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 17 of32 Contract Number CLH 18249-4
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #4
DOH Program Name or Title: Supplemental Nutrition Assistance Program-
Education -Effective January 1, 2018
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH18249
SOW Type: Revision Revision # (for this SOW) 2 Funding Source Federal Compliance Type of Payment
cgJ Federal Subrecipient (check if applicable) !ZI Reimbursement
Period of Performance: January 1, 2018 through September 30, 2018 0 State !ZI FFATA (Transparency Act) D Fixed Price
D Other D Research & Develo_pment
Statement of Work Purpose: The purpose of this 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: The purpose ofthis revision is to add FFY18 CSS IAR SNAP ED funding to complete approved FFY18 activities, shorten the Period of Performance from
09/30/20 to 09/30/18 and revise deliverable due dates.
Chart of Accounts Program Name or Title
FFY18 CSS IAR SNAP ED PROG MGNT
FFYl 7 CSS IAR SNAP ED PROG MGNT CF
TOTALS
Task
Number Task/ Activity /Description
1.0 For SNAP-Ed, the LHJ will perform work as
described in LHJ's approved FFY18 SNAP-Ed
project description and work plans approved
by Department of Health (DOH), Department
of Social and Health Services (DSHS), and
United States Department of Agriculture
(USDA) that was submitted to them via DOH
email.
Exhibit A, Statements of Work
Revised as of July 16, 2018
CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
10.561 333.10.56 76211981 01101118 I 09130118 19,855 3,000 22,855
10.561 333.10.56 76211971 01101118 I 09130118 1,472 0 1,472
21 ,327 3~000 24,327
*May Support PHAB Payment
Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount -
• Project qualified target For the Period: Reimbursement upon
audiences reached. 01/01/18-09/30/:z?.O 18 receipt and approval
• Project activities completed Due: per the approved work of deliverables for the
(# direct education, PSE, plan and no later than funding period will
etc.) noted in project plans 09/30/:z?.O I 8. not exceed $21,327
and workbook. $24,327.
• Required demographic data
collected. Kittitas County
• Evaluation activities Public Health
completed per the state Department will be
evaluation team (pre and paid the allowable
post surveys, PSE tracking, costs incurred based
success stories etc.). on their approved
budget and program
allowability. See
Page 18 of32 Contract Number CLH18249-4
Task
Number Task/ Activity/Description
2.0 Quarterly Progress Reports
The following data is to be collected and
submitted within DOH provided form /system:
1. Project major achievements
2. Project major challenges
3. If projects are running on time with
original timeline? If not, why, and how
will LHJ correct the timeline?
4. Any policy, system, and environment
(PSE) progress
5. Any success stories to date
2.1 Education and Administrative Reporting
System (EARS) Data and Reports
The following EARS data is required for each
project and in order to count clients toward
unduplicated direct reach. Required entry for
the PEARS Database includes but is not
limited to:
• Unduplicated number of clients served
per project.
• # unduplicated clients served per
project based on the following:
Exhibit A, Statements of Work
Revised as of July 16, 2018
*May Support PHAB
Standards/Measures Deliverables/Outcomes
Submit Quarterly Progress
Report for all SNAP-Ed projects
within the DOH approved
form/system.
-Submit EARS data for all
project(s).
LHJs are required to collect and
submit EARS data electronically
or within a template provided by
DOH.
This must be done in real time.
Real time = As you provide
services and no later than one
Page 19 of32
AMENDMENT #4
Payment
Due Date/Time Frame Information and/or
Amount
special billing
requirements section.
**NOTE: The
SNAP-Ed program
will deny payment
for any costs not
submitted by the due
date and without
prior DOH approval
in writing.
Quarterly Progress Reports See payment
due: information as
referenced in task
• 2nd quarter report for the number 1.0.
work completed during
01/01/18 to 03/31/18.
Final Due: COB
04/06/18.
• 3rd quarter report for the
work completed during
04/01/ 18 to 06/30/18.
Final Due: COB
07/06/18.
• Final report for all work
not already reported.
Final Due: COB
09/21/18.
Data should be collected in See payment
real time and submitted to the information as
state office by the following referenced in task
dates: number 1.0.
• EARS data collected
01/01/18 to 09/13/18.
Due: In real time and no
later than one week after
services are provided.
Contract Number CLH18249-4
Task
Number Task/ Activityillescription
0 Race/ethnicity
0 Gender
0 Age
• % SNAP eligible per site
• 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
The following evaluation activities* and
information is required for all projects based
on your approved project/plan
• Formative
• Process
• PSE
• Outcome
• Qualitative
*Please Note: the deliverables may change
based on state evaluation team requirements.
Exhibit A, Statements of Work
Revised as ofJuly 16, 2018
AMENDMENT #4
*May Support PHAB Payment
Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
week after data is collected.
I 1. Collect and report any 1. Due: Submit within See payment
formative and process data Quarterly reporting listed information as
completed based on above in task 2.0. referenced in task
approved project plan. number 1.0.
2. Submit PSE progress and 2. Due: quarterly
outcomes based on approved • 2nd quarter due by
project plan. 04/06/18
• 3rd quarter due by
07/06/18
• Final report for all
other work due
09/21/18.
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.
Page 20 of32 Contract Number CLH18249-4
Task
Number Task/ Activity/Description
3.0 Civil Rights Training
All staff must be trained each fiscal year in
civil rights .
3.1 Other Agency Training
The following trainings are required for all
agencies:
• Fiscal -fiscal lead and coordinator
• Data collection and reporting -
coordinator and program staff who
are reporting data
*It is required that all staff making any SNAP-
Ed purchases or reporting data be trained .
4.0 SNAP-Ed Inventory List
Keep an up-to-date inventory list that includes
all non-capital equipment, purchased
curriculum, and other SNAP-Ed paid items
that are not disposable. This list should include
items purchased in prior fiscal years and be
updated yearly.
5.0 SNAP-Ed A19 Invoices
Use the Al9-1A specific to SNAP-Ed
program. This document was sent to all LHJ's
prior to October 2017 .
*For Information Only:
Exhibit A, Statements of Work
Revised as of July 16, 2018
*May Support PHAB
Standards/Measures Deliverables/Outcomes
Submit documentation showing
Civil Rights training was
completed for all SNAP-Ed paid
staff. Documentation must
include:
• Training and source
• Who attended
• Date completed
Fiscal and Data reporting
training completed.
SNAP-Ed inventory list.
Submit SNAP-Ed Al9 invoices
and detailed ledger supporting
the costs to be reviewed by
SNAP-Ed program before
approval of payment.
Documentation of all costs
incurred shall be accompanied
by an agency financial system
report. If LHJ does not have a
financial reporting system, LHJ
must check with the DOH
SNAP-Ed program for further
guidance.
Page 21 of32
AMENDMENT #4
Payment
Due Date/Time Frame Information and/or
Amount
Due: 12 /31/18 See payment
information as
referenced in task
number 1.0.
Due: New staff trained See payment
within 30 days of starting information as
SNAP-Ed activities and again referenced in task
at least once every five years. number 1.0.
If the data collection system
changes in FFYl 8 every staff
member entering data into
the electronic system will be
required to take training on
the new system.
Due: Yearly, at the time of a See payment
fiscal monitoring and/or site information as
visit. referenced in task
number 1.0.
Due: Monthly -Submit See payment
invoices to DOH no later information as
than 30 days after the end of referenced in task
the preceding month. number 1.0 .
(e .g. October Al9 invoice
submitted no later than
November 30 and so on ... )
Final invoice is due
10/30/18
Contract Number CLH 18249-4
AMENDMENT #4
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. phaboard.orn/wp-content/uploads!P HAB -S tandards-and-Measw:es -Version-!. 0 . odf
Program Specific Reg uirements/N arrative
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 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/10.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) -hnp://www .fns .usda.!!ov/sites/default/files/1 13-l.pdf "Training is required so
that people involved in all levels of adminis trat ion 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 .
Overtime
Exhibit A, Statements of Work
Revised as of July 16 , 2018
Page 22 of32 Contract Number CLH18249-4
AMENDMENT #4
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 normal completion DOH may
terminate 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 determined
to be unacceptable and will be disallowed.
Monitoring Visits (frequency, 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
h1tps://snapeclfns.usda.gov/nati0nal-snap-ed/sna]J::ed-pl.an-guidance-and-temp lates)
• 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 0MB 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 Requirements:
1. All invoices, billing and reimbursements must be in compliance with all applicable Federal laws, rules, regulations including the FFYl 8 SNAP-Ed Guidance and 0MB
circulars governing cost issues.
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 23 of32 Contract Number CLH18249-4
AMENDMENT #4
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 Al9-1A Invoice voucher
b. A SNAP-Ed specific Al9-1A 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. If for ANY reason a LHJ is unable to submit
the SNAP-Ed A-19-lA 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 Al9-1A.
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
Source
USDA
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
Revised as of July 16, 2018
Amount
$21.327 $24!327
DOH Fiscal Contact
Kim Henderson, Fiscal Analyst
Department of Health
PO Box47886
Olympia, WA 98504-7886
Kim.Henderson@doh. wa. gov
360-236-3491
Page 24 of32 Contract Number CLH18249-4
Exhibit A
Statement of Work
Contract Term: 2018-2020
AMENDMENT #4
DOH Program Name or Title: Suppl emental Nutri tion Assistance Program-
Education -Effective October 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
igJ Federal Subrecipient (check if applicable) r8J Reimbursement
Period of Performance: October 1, 2018 through September 30, 2020 0 State r8] FFATA (Transparency Act) D Fixed Price
0 Other D Research & Development
Statement of Work Purpose: The purpose of this 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: N/ A
Chart of Accounts Program Name or Title
FFY18 CSS IAR SNAP ED PROG MGNT CF
FFY19 CSS IAR SNAP ED PROG MGNT
TOTALS
:it Task/ Activity/Description .:c
"' = E--,
1.0 For SNAP-Ed, the LHJ will
perform work as described in their
approved:
• FFY19 SNAP-Ed project
description and work plans
approved by DOH,
Department of Social and
Health Services (DSHS), and
United States Department of
Agriculture (USDA) that was
submitted to them via DOH
email.
Exhibit A, Statements of Work
Revised as of July 16, 2018
I
*May
Support
PHAB
Standards/
Measures
•
•
•
•
CFDA# BARS Master Funding Period Current Change rrotal
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
10.561 330.10.56 76211993 10101118 I 09 /30/19 0 858 858
10.561 330.10.56 76211991 10101118 I 09 ;30;19 0 19 ,745 19,745
0 20,603 20,603
FFY19 FFY20 Payment Information Deliverables/Outcomes Due Date/Time Frame Due Date/Time Frame and/or Amount
Project qualified target For the Period: For the Period: Reimbursement upon
audiences reached 10/01/18 to 09/30/19 10/01/19 to 09/30/20 receipt and approval of
Project activities deliverables for the
completed(# direct Due: per the approved Due: per the approved funding period will not
education, PSE, Etc.) work plan and no later work plan and no later exceed $20,603.
noted in project plans and than 09 /30/19 than 09 /30/20
workbooks. Kittitas County
Required demographic Public Health
data collected. Department will be
Evaluation activities paid the allowable
completed per the costs incurred based
implementing agency and on their approved
state evaluation team fore budget and program
Page 25 of32 Contract Number CLH18249-4
:;t Task/ Activity/Description .:,,:
"' ~
E--
• FFY 20 SNAP-Ed project
description and work plans
approved by DOH,
Department of Social and
Health Services (DSHS), and
United States Department of
Agriculture (USDA) that was
submitted to them via DOH
email.
2.0 Quarterly Progress Reports
The following data is collected
and submitted within DOH
provided form /system:
1. Project major achievements .
2 . Project major challenges.
3. If projects are running on time
with original timeline? If not
why, and how will you correct
the timeline?
4. Any PSE progress.
5. Any success stories to date.
Exhibit A , Statements of Work
Revised as of July 16 , 2018
~Ma y
Support
PBAB-
S tandards/
M e_asu.res
I
'
AMENDMENT #4
FFY19 FFY20 Payment Information Deliverables/Outcomes Due Date/Time Frame Due Date/Time Frame and/or Amount
and post surveys, PSE allowability. See
tracking, success stories special billing
etc.). requirements section.
**NOTE: The SNAP-
Ed program will deny
payment for any costs
not submitted by the
due date and without
prior DOH approval in
writing.
Submit Quarterly Progress FFY19 Quarterly Progress FFY20 Quarterly Progress See payment
Report for all SNAP-Ed Reports due : Reports due: information as
projects within the DOH referenced in task
approved form/system. • 1st quarter report for • 1st quarter report for number 1.0
the work completed the work completed
during 10/01/18 to during 10/0 l /19 to
12/31 /18. 12/3 1/19.
Final Due: COB Final Due: COB
01/10/19 01/10/20
• 2nd quarter report for • 2nd quarter report for
the work completed the work completed
I during 01/01/19 to during O 1/01/20 to
03 /31/19 . 03/31/20.
Final Due: COB Final Due: COB
I 04/11/19 04/11/20
• 3rd quarter report for • 3rd quarter report for
the work completed the work completed
during 04/01/19 to during 04/01/20 to
06 /30/19. 06/30/20.
Final Due: COB Final Due: COB
07/11/19 07/11/20
• Final report for all • Final report for all
work not already work not already
reported. reported.
Final Due: COB Final Due: COB
Page 26 of32 Contract Number CLH18249-4
11
I
=Ii: Task/ Activity /Description .::i:
"' C'II
E-o
2.1 Education and Administrative
Reporting System (EARS) Data
and Reports
EARS data is required for each
project and in order to count clients
toward unduplicated direct reach.
Required entry for the PEARS
database includes, but is not
limited to:
• Unduplicated number of
clients served per project.
• # unduplicated clients
served per project based on
the following :
0 Race/ethnicity
0 Gender
0 Age
• % SNAP eligible per site
• Setting type -school,
church etc.
• Top key messages
delivered per project.
• # partners
• Partnership sectors
This information is collected
through the following modules in
PEARS: Program Activity (direct
education), Indirect Activity
(indirect intervention channels),
PSE, and Partnerships .
2.2 Evaluation Data and Reports
The following evaluation activities
and information is required for all
projects based on your approved
project/plan
• Formative
Exhibit A , Statements of Work
Revised as of July 16, 2018
*May
Support
PHAB
Standards/
Measures
-
AMENDMENT #4
FFY19 FFY20 Payment Information Deliverables/Outcomes Due Date/Time Frame Due Date/Time Frame and/or Amount
09 /21 /19 09 /21/20
Submit EARS data for all FFY19 data should be FFY20 data should be See payment
project(s). collected in real time and collected in real time and information as
submitted to the state submitted to the state referenced in task
LHJs are required to collect and office by the following office by the following number 1.0
submit EARS data dates: dates:
electronically or within a
template provided by DOH. • EARS data collected • EARS data collected
10/01/18 to 09/13/19. 10/01 /19 to 09/13/20 .
Direct education and completed Due: In real time Due: In real time
activities should be reported in and no later than one and no later than one
real time. Real time = As you (I) week after (I) week after
provide services and no later services are provided. services are provided.
than one week after data is
collected.
I
PSE and partnerships (new or
updates) may be reported
quarterly.
1. Collect and report any 1-4. Due: At minimum 1-4. Due: At minimum See payment
formative and process data quarterly. quarterly. information as
completed based on • 1st quarter • 1st quarter referenced in task
approved project plan. report due by report due by number 1.0
01/10/19 01/10/20
2. Submit PSE progress and • 2nd quarter due • 2nd quarter due
Page 27 of32 Contract Number CLH18249-4
=It Task/ Activity/Description .:a=
"' ell
E--,
• Process
• PSE
• Outcome
• Qualitative
Please Note: the deliverables may
change based on state evaluation
team requirements .
3.0 Civil Rights
All staff must be trained each fiscal
year in civil rights.
*See special requirements section-
civil rights
3.1 Other Agency Training
The following trainings are
required for all agencies:
• Fiscal -fiscal lead,
coordinator, and any staff
who will purchase items for
the SNAP-Ed program.
• Data collection and
reporting -coordinator and
program staff who are
reporting data.
Exhibit A, Statements of Work
Revised as of July 16, 2018
*May
Support
PHAB
Standards/
Measures
AMENDMENT #4
FFY19 FFY20 Payment Information Deliverables/Outcomes Due Date/Time Frame Due Date/Time Frame and/or Amount
outcomes based on by 04 /11/19 by 04/11/20
approved project plan. • 3rd quarter due • 3rd quarter due
by 07/11/19 by 07/11/20
3. Capture and submit • Final report for • Final report for
qualitative (success stories, all other work all other work
pictures, etc.) information due 09 /21/19 due 09/21/20
in PEARS per your
approved work plan.
4. Submit a required release
for all photos submitted.
5. Conduct and submit/mail 5-6. Due: Monthly 5-6. Due: Monthly
pretest surveys for each No later than 30 days No later than 30 days
project class series. after the end of the after the end of the
previous month. (E.g. previous month. (E.g.
6. Conduct and submit/mail October pre and post October pre and post
posttest surveys for each surveys submitted no later surveys submitted no later
project class series. than November 30 and so than November 30 and so
on ... ). on ... ).
Submit documentation showing Due: 12/31/19 Due: 12/31/20 See payment
Civil Rights training was information as
completed for all SNAP-Ed referenced in task
paid staff. Documentation must number 1.0
include:
• Training and source
• Who attended
• Date completed
Fiscal and Data reporting Due: New staff trained Due: New staff trained See payment
training completed. within 30 days of starting within 30 days of starting information as
SNAP-Ed activities and SNAP-Ed activities and referenced in task
again at least once every again at least once every number 1.0
five years. five years.
If the data collection If the data collection
system changes in FFY19 system changes in FFY20
every staff member every staff member
entering data into the entering data into the
electronic system will be electronic system will be
required to take training required to take training
Page 28 of32 Contract Number CLH18249-4
=It Task/ Activityillescription ~
"' c:,;
f-,
4.0 SNAP-Ed Inventory List
Keep an up-to-date inventory list
that includes all non-capital
equipment, purchased curriculum,
and other SNAP-Ed paid items that
are not disposable . This list should
include items purchased in prior
fiscal years and be updated yearly.
*See special requirements section-
monitoring.
5.0 SNAP-Ed A19 Invoices
Use the Al 9-lA specific to the
DOH SNAP-Ed program. This
document will be sent to all LHJ s
prior to October 16th based on the
current fiscal year.
Exhibit A , Statements of Work
Revised as ofJuly 16, 2018
*May
Support
PHAB
Standards/
Measures
FFY19 Deliverables/Outcomes Due Date/Time Frame
on new expectations or
system changes.
SNAP-Ed inventory list Due: Yearly, at the time
of a fi scal monitoring
and/or site visit. It can
also be requested when
deemed necessary.
Submit SNAP-Ed A19 invoices Due: Monthly -Submit
and detailed ledger supporting invoices to DOH no later
the costs to be reviewed by than 30 days after the end
SNAP-Ed program before of the preceding month.
approval of payment. (E.g. October A19 invoice
submitted no later than
Documentation of all costs November 30 and so
incurred shall be accompanied on ... ).
by an agency financial system
report. If your agency does not Final invoice is due
have a financial reporting October 30, 2019
system you must check with the
SNAP-Ed program for further Or
guidance.
*If pre-approved in
writing by contract
manager, LHJ can submit
invoices every two (2)
months . Invoices must be
received by DOH no later
than dates listed below:
0 Oct and Nov
due: 12/29/18
0 Dec and Jan
due: 02/28/19
0 Feb and Mar
Page 29 of32
AMENDMENT #4
FFY20 Payment Information
Due Date/Time Frame and/or Amount
on any new expectations
or system changes.
Due: Yearly, at the time See payment
of a fiscal monitoring information as
and/or site visit. It can referenced in task
also be requested when number 1.0
deemed necessary.
Due: Monthly -Submit See payment
invoices to DOH no later information as
than 30 days after the end referenced in task
of the preceding month. number 1.0
(E.g. October A19 invoice
submitted no later than
November 30 and so
on ... )
Final invoice is due
October 30 , 2020
Or
*If pre-approved in
writing by contract
manager, LHJ can submit
invoices every two (2)
months. Invoices must be
received by DOH no later
than dates listed below:
0 Oct and Nov
due: 12/29/19
0 Dec and Jan
due : 02/28/20
0 Feb and Mar
Contract Number CLH18249-4
AMENDMENT #4
*May
Support FFY19 FFY20 Payment Information =It Task/ Activity/Description PHAB Deliverables/Outcomes Due Date/Time Frame Due Date/Time Frame and/or Amount .:,c
<I> Standards/ C:
fa.. Measures
due: 04 /30/19 due: 04/30/20
0 Apr and May 0 Apr and May
due: 06/29/19 due: 06/29/20
0 Jun and Jul 0 Jun and Jul
due: 08/31/19 due: 08/31/20
0 Aug and Sept 0 Aug and Sept
due: 10/30/19 due: 10/30/20
*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.phaboard:ore/wp-concent/uoloads/PBAB ~St.andar.ds-and-Measures-Vers.iun~ LO .pdf
Special Requirements
Federal Funding Accountabilitv .and Transparcncv Act {FFA'.tA)
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 contractor must have a Data Universal Numbering System (DUNS®) number.
Information about the contractor and this statement of work will be made available on USASpending .gov by DOH as required by P.L. 109-282 .
*Program Specific Requirements/Narrative
Staff Requirements
Upon request by DOH, contractor must demon strate that SNAP-Ed staff meet requirements appropriate to their positions including but not limited to : background checks , food
handlers' permits, qualifications, and training required by DOH.
SNAP-Ed Assurances: The following assurances must be followed (see program Guidance
https://snaped.fns .usda.gov/national-srurp-ed/snap-ed-p lan-guidance-and-ternp !ates)
• The LHJ is fiscally responsible for activities funded with Supplemental Nutrition Assistance Program Education funds and is liable for repayment ofunallowable 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 0MB regulations governing cost issues.
• Program activities do not supplant ex isting 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.
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 30 of32 Contract Number CLH18249-4
AMENDMENT #4
• All materials developed 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.
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 program 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.
Curriculum Requirements
Agencies are expected to communicate with, respond to, and comply with all state curriculum team requests, sites visits, approved curriculum list, training and curriculum fidelity
findings.
Any curriculum modifications should be developed and executed based on the most current curriculum modification guidance. Local Agencies must consult their DOH contract
manager as directed. https ://s3 . wo.wsu.edu/uploads!sites/?090/2017/01 /Guidance-for-Curriculum-Modification-FFY"0 18 -Modmed-10.9 .17 -PDF.pdf
Indirect Rate/Allocation Plan
All indirect rate/allocation plans must be submitted and preapproved by the DOH grants office 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 rate and/or cost allocation plan approved by the appropriate agency. The LHJ cannot bill indirect costs that
are determined to be unacceptable and will be disallowed.
Annual Civil Rights Training Requirement (see FNS Instruction Number 113-1 Chapter XI) htto://www.fns.usda.gov/sites!default/files/J D-Lpdf "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.
Local agencies 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."
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 (6) years from fiscal closure. This requirement applies to fiscal records, program reports, and client information
(pre/post surveys, demographics etc.). Supporting documentation may be kept at the sub-grantee level, but shall be available for review for six (6) years from the date of quarterly
claim submittal. Any costs that cannot be substantiated by source documents will be disallowed as charges to SNAP-Ed.
Travel
The LHJ is expected to comply with the Offic e of Financial Management's Travel Management Requirement and Restrictions as found in policy 10.10.
http://www.ofm.wa.gov/policy/1 0.htm
Amendments
Agencies should check with the DOH contract manager to know what kinds of changes they can make on their own and what changes require an amendment and pre-approval in
writing. Agencies must submit a written amendment request to DOH, and receive written pre-approval from DOH, prior to making/implementing any changes within their project
or budget. Any requests needing FNS approval must be submitted to DOH no later than April 1st of each fiscal year. If agencies are making smaller changes that do not require
FNS approval, DOH can review those and make approvals on a case by case basis. All of these non FNS amendments should be submitted to DOH no later than July 16th of each
fiscal year.
Overtime
Staff 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.
Exhibit A, Statements of Work
Revised as of July 16, 2018
Page 31 of32 Contract Number CLH18249-4
AMENDMENT #4
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 normal completion DOH may
terminate task(s), remove funds, or reallocate funds at DO H'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 (7) working days upon notice by the funding source of funding availability.
Special Billing Requirements
1. All invoices, billing, and reimbursements must be in compliance with all applicable Federal laws, rules, regulations including the current year SNAP-Ed Guidance and 0MB
circulars governing cost issues.
2. Total costs billed will not exceed the USDA-approved budget amount listed in the box below.
• Bills must be for only SNAP-Ed specific activities, using a DOH Al9-1A Invoice Voucher.
• A SNAP-Ed specific A19-1A must be submitted to the agency's designated DOH SNAP-Ed staff member within 30 days of the last day of the month for which
the work is being billed, OR
• An agency may request pre-approval to bill every two (2) months instead, in which case, that agency is required to adhere to the billing due dates listed in Task 5
(see above)
3. In FFY19 and FFY20 the SNAP-Ed program will deny payment for any costs not submitted by the due date without prior approval. If for ANY reason the LHJ is unable to
submit the SNAP-Ed Al9-1A on the due date, the LHJ is required to submit a request for an exception to the DOH no later than seven (7) 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.
• At the very least this means a copy of an agency's financial expanded/detailed general ledger level report.
• Additionally, all receipts, timecards and other supporting documentation, as noted by USDA, must be available upon request.
5. If an agency meets one of the criteria below, they will need to submit all SNAP-Ed backup documentation with each bill and this requirement will continue until further notice
by DOH SNAP-Ed program.
• All new SNAP-Ed contractors within their 1st fiscal year.
• Contractors with current fiscal findings.
• Contractors who have not submitted adequate or accurate backup documentation within the last year.
BUDGET
Source
USDA
DOH Program Contact
Jamie Wells, SNAP-Ed Contract Manager
Department of Health
PO Box 47886, Olympia, WA 98504-7886
Jamie.Wells@doh.wa.gov / 360-236-3668
Exhibit A, Statements of Work
Revised as of July 16, 2018
Amount
$20,603
DOH Fiscal Contact
Kim Henderson, Fiscal Analyst
Department of Health
PO Box 47886, Olympia, WA 98504-7886
Kim.Henderson@doh.wa.gov / 360-236-3491
Page 32 of32 Contract Number CLH18249-4
EXHIBIT B-4
Kittitas County Public Health Department ALLOCATIONS Contract Number: CLH18249
Contract Term: 2018-2020 Date: July 16, 2018
Indirect Rate as of January 2018: 29.50% Public Health Dept & 12.50% County Central Svcs
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Revenue Funding Period Funding Period Period Accounts
Chart of Accounts Pro,&ram Title Identification # Amend# CFDA* Code** Start Date End Date Start Date End Date Amount Sub Total Total
FFY19 CSS JAR SNAP Ed Program Mgnt NGA Not Received Amd4 10.561 333.10.56 10101118 09130/19 10101/18 09130119 $19,745 $19,745 $44,930
FFY18 CSS JAR SNAP Ed Program Mgnt CF NGA Not Received Amd4 10.561 333.10.56 10101/18 09130/19 10101/18 09130/19 $858 $858
FFYl8 CSS JAR SNAP Ed Program Mgnt 187W AW A5Q3903 Amd4 10.561 333.10.56 01/01/18 09130/18 10101/17 09130118 $3,000 $22,855
FFYI 8 CSS !AR SNAP ED Program Mgnt 187W AW A5Q3903 Amd2 10.561 333. 10.56 01/01/18 09130/18 10101117 09130118 $11,025
FFYl8 CSS !AR SNAP ED Program Mgnt 187W AW A5Q3903 NIA 10.561 333.10.56 01/01118 09130/18 10101117 09130118 $8,830
FFYI 7 CSS JAR SNAP ED Program Mgnt CF l 717WA WA5Q390 NIA 10.561 333.10.56 01/01/18 09130118 10/01/17 09/30/18 $1,472 $1,472
FFYI 7 EPR PHEP BPI LHJ Funding NU90TP921889-0I Amd2 93.069 333.93.06 01/01/18 06/30/18 07101/17 07/02118 $565 $20,398 $20,398
FFYI 7 EPR PHEP BPI LHJ Funding NU90TP921889-0l NIA 93.069 333.93.06 01/01/18 06130/18 07101117 07/02118 $19,833
FFY18 EPR PHEP BPI Supp LHJ Funding NU90TP921889-01 Amd4 93.069 333.93.06 07/01/18 06130/19 07101/18 06/30119 $48,249 $48,249 $48,249
FFYl73170ps 5NH23IP000762-05-00 NIA 93.268 333.93.26 OIIOl/18 06130118 04101/17 06130/18 $616 $616 $616
FFY17 AFIX 5NH23IP000762-05-00 NIA 93.268 333.93.26 0 I /Ol /18 06130118 04101/17 06/30/18 $2,226 $2,226 $2,226
FFY17 Increasing Immunization Rates NGA Not Received Amd 3, 4 93 .268 333.93.26 07101/18 06130/19 07101/18 06130/19 $5,600 $5,600 $5,600
FFY17 VFC Ops 5NH23IP000762-05-00 NIA 93268 333.93.26 01101118 06130/18 04101117 06130118 $1,114 $1,114 $1,114
FFY19 MCHBG LHJ Contracts NGA Not Received Amd4 93.994 333.93.99 !OIOI/18 09130/19 10101118 09130119 $44,196 $44,196 $78,236
FFYl8 MCHBG LHJ Contracts B04MC31524 Amd2 93.994 333.93.99 01/01/18 09130/18 10101117 09130118 $893 $34,040
FFYl8 MCHBG LHJ Contracts B04MC31524 NIA 93.994 333.93.99 01101/18 09130118 10101/17 09130/18 $33,147
GFS-Group B (FO-E) NIA NIA 334.04.90 01101/18 06130/18 07101/17 06130119 $5,000 $5,000 $5,000
FY2 Group B Programs for OW (FO-E) Amd3 NIA 334.04.90 07101/18 06130/19 07101/17 06130/19 $10,000 $10,000 $10,000
SFY2 Lead Environments of Children Amd4 NIA 334.04.93 07101/18 06130119 07/01/18 06130/19 $1,500 $1,500 $3,500
SFYI Lead Environments of Children Amd I NIA 334.04.93 01/01/18 06130/18 07101117 06130118 $2,000 $2,000
FPHS Funding for LHJs Dir Amd3 NIA 336.04.25 07101/18 06130/19 07101/17 06130119 $42,000 $42,000 $42,000
YR 20 SRF -Local Asst (I 5%) (FS) SS Amd3 NIA 346.26.64 01/01/18 12131/18 07101/15 12131118 ($2,400) $0 $0
YR 20 SRF -Local Asst (15%) (FS) SS NIA,Amd3 NIA 346.26.64 01/01/18 12131/18 07101/15 12131118 $2,400
YR 21 SRF -Local Asst (15%) (FS) SS Amd3 NIA 346.26.64 01101/18 12131/18 07101/17 06130119 $2,400 $2,400 $2,400
Page I of2
Kittitas County Public Health Department
Indirect Rate as of January 2018: 29.50% Public Health Dept & 12.50% County Central Svcs
Chart of Accounts Prognm Title
Sanitary Survey Fees (FO-E) SS-State
YR 20 SRF -Local Asst (15%) (FS) TA
YR 20 SRF -Local Asst (15%) (FS) TA
YR 21 SRF -Local Asst (15%) (FS) TA
TOTAL
Total consideration:
GRAND TOTAL
•Catalog of Federal Domestic Assistance
Federal Award
Identification #
$151,121
$117,548
$268,669
••Federal revenue codes begin with "333". State revenue codes begin with "334",
Amcnd,/1
NIA, Amd 3
Amd3
NIA, Amd 3
Amd3
EXHIBIT 8-4
ALLOCATIONS
Contract Term: 2018-2020
BARS Statement of Work
Revenue Funding Period
oou tlse.O,~·
~hllr'f of Acc.ou:dt.r; :.-. _,,__ ~ ,._.
Jilfnding Berfod
CFDA* Code** Start Date End Date S1::trt tf>a~ _En,d Oak
NIA 346.26.65 01101118 12131118 Wf'.i1 111:; U6'31:111 19
NI A 346.26.66 01/01/18 12131118 ()1/01 11~ tilat/1~
NIA 346.26.66 01 101118 12131/18 01i(J JI IS ll/3•11 I8
NIA 346.26.66 01101118 12131/18 Q:7/lJJ'/17 o..&38119
Page2 of2
AmoUJTl
$2,400
($2,000)
$2,000
$2,000
$268,669
Contract Number:
Date:
Funding
Period
Sub Total
$2,400
$0
$2,000
$268,669
GRAND TOTAL
Total Fed
Total State
CLH18249
July 16, 2018
Chart of
Accounts
'roraJ
$2,400
$0
$2,000
$268,669
$201,369
$67,300
Exhibit C-4 Schedule of Federal Awards
KITTITAS COUNTY HEALTH 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
FFY19 CSS IAR SNAP ED PROG MGNT 333.10.56 NGA Not
Received
FFY18 CSS 1AR SNAP-ED PROGRAM MGNT CF 333.10 56 NGA Not
Received
FFY18 CSS IAR SNAP-ED PROGRAM MGNT 333,10,56 09128117
FFY17 CSS IAR SNAP-ED PROGRAM MGNT CF 333 10,56 09/10116
FFY18 EPR PHEP BP1 SUPP LHJ FUNDING 333,93.06 06101116
FFY17 EPR PHEP BP1 LHJ FUNDING 333.93.06 07/18117
FFY17 VFC OPS 333.93 2 6 03/03117
FFY17 INCREASING IMMUNIZATION RATES 333 93 26 NGA Not
Received
FFY17 AFlX 333.93.26 03/03117
FFY17 317 OPS 333.93 26 03/03117
NGA Not FFY19 MCHBG LHJ CONTRACTS 333.93.99 Received
FFY18 MCHBG LHJ CONTRACTS 333.93.99 10/20/17
Total Amt Allocation Period
Federal Start End
Award Dale El.ale
NGA_ Not 10101118
Rb'.ll1ved 09130119
NGA _Not 10/01118
Rl!OQ1ved 09130/19
$5,300,000 01101118 09/30118
$5,739.856 01/01118 09/30/18
$11,062,782 07101118 06130/19
$11,062.782 01101/18 06/30118
$1,201,605 01101/18 06/30/18
NGA_Not 07101/18
Rece,ved 06/30/19
$1,672,289 01101118 06/30118
$575,969 01/01/18 06130/18
NGA_Not 10101118
R~G<l1ved 09/30119
$1,650,528 01101/18 09/30118
TOTAL
Contract Ami CFDA
$19,745 10.561
$858 10,561
$22,855 10-561
$1,472 10561
$48,249 93 069
$20,398 93 069
$1,114 93,268
$5,600 93 268
$2,226 93.268
$616 93 268
$44,196 93.994
$34,040 93 994
$201 ,369
CFDA Program Title
State Administrative Matching
Grants for the Supplemental
Nutrition Assistance Program
Slate Administrative Malching
Granls for the Supplemental
Nutrition Assistance Program
State Administrative Matching
Grants for the Supplemental
Nutrition Assistance Program
Slate Administrative Malching
Grants for the Supplemental
Nutrition Assistance Program
Public Health Emergency
Preparedness
Public Health Emergency
Preparedness
Immunization Cooperative
Agreements
Immunization Cooperative
Agreements
Immunization Cooperative
Agreements
Immunization Cooperative
Agreements
Maternal and Child Health
Services Block Grant to the
States
Maternal and Child Health
Services Block Grant to the
States
Page 1 of 1
Federal Agency Name
Depar1ment of Agriculture Food and
Nutrition Service
Department of Agriculture Food and
Nutrition Service
Department of Agriculture Food and
Nutrition Service
Department of Agriculture Food and
Nutrition Service
Department of Health and Human
Federal Award
ldcntiflca t1o n ·N um~
NGA Not Received
NGA Not Received
187WAWA5Q3903
1717WAWA5O390
Services Centers for Disease Control NU90TP921889-01
and Prevention
Department of Health and Human
Services Centers for Disease Control NU90TP92't869-,0t
and Prevention
Department of Health and Human
Services Centers for Disease Control 5:NH2'31P-GC-07&2--0S.00
and Prevention
Department of Health and Human
Services Centers for Disease Control NGA. fM R,k:lli
and Prevention
Department of Health and Human
Services Cenlers for Disease Control 5NH231P000762-05-00
and Prevention
Department of Health and Human
Services Centers for Disease Control Sf'UaJIP'OO{)ffl:2..0!i-QO
and Prevention
Departmenl of Health and Human
Services Health Resources and NG A Nol RffclWNl
Ser,.,ices Administration
Department of Heal1h and Human
Services Health Resources and
Services Administration
804MC315,2,1
AMENDMENT #4
Date: July 16, 2018
Federal Grant Award Name
NGA Not Received
NGA Not Received
2018 SUPPLEMENTAL NUTRITION
ASSISTANCE PROGRAM EDUCATION
(SNAP-ED)
2018 SUPPLEMENTAL NUTRITION
ASSISTANCE PROGRAM EDUCATION
(SNAP-ED)
HOSPITA L PREPARED NES S
PROGRAM AND PUBLIC HEALTH
EMERGENCY PREPAREDNESS
COOPERATIV E AGREE-ME NT
HPP AND PHEP COOPERATIVE
AGREEMENT
IMMU NIZAT ION GRANT A ND
VACCINES FOR CHILDREN'S
PROGRAM
NGA Not Received
IMl,il./NtlAilON GIWif f(fiO
VACCINES FOR CHILDREN·s
PROGRAM
lt,~.amJZATlON GRAM" /IND
YACQ"'ES fOI\ CHILO~,.,-.,
PROGRAM
NGA Not Received
MATERNAL AND CHILD HEALTH
SERVICES
Kittitas County
Review Form
Grants & Contract Agreement L/J <bl/
Today's Date Agenda Date tDI ll!/lcB 09/06/2018
Fund/Department
116-Public Health
Contract/Grant Information
Contract /Grant Agency: Consolidated Contract Amendment 4
Period Begin Date: January 1, 2018 I j Period End Date: December 31, 2020
Total Grant/Contract Amount: Increase of $117,548.00 for a new revised maximum consideration of
$281,644.00 -.
Grant/Contract Number: --
Contract/Grant Summary:
The Consolidated Contract Amendment 4:
Adds Statements of Work for the following programs:
Office of Emergency Preparedness and Response
Supplemental Nutrition Assistance Program and Education
Amends Statements of Work for the following programs:
Childhood Lead Poisoning Prevention Program
Maternal and Child Health Block Grant
OICP-Promotion of Immunization to Improve Vaccination Rates
Supplemental Nutrition Assistance Program
Recommendation for Board of Health and Board of Health Review on
Kittitas County Prosecutor, Auditor, an
APPROVED AS O FORM:
Date
Signature of Board of Health member Date
Grant/Contract Review Page 1
Financial Information
Total Amount$ 117,548 State Funds $ 1,500 Federal Funds $ 116,048
Percentage County Funds Matching Funds $ CFDA# 10.561 SnapEd;
In-Kind$ 93.069 EPR PHEP; 93.268 lmmz Rate
Explain 93.994 MCHGB
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County:
.1
Budget Information
Budget Amendment Needed? Yes D attach budget form No[R] Why not -already in budget
New Division Created?
Revenue Code 612.94.333.10.56 SNAP ED $23,603 ($19, 745+$858+$3,000)
612.88.3.333.93.06 EPR PHEP $48,249
612.22.333.93.99 MCHBG LHJ $44,196
612.334.04.93 LEAD ENVIRONMT $ 1,500
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 • No D
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature:
Department:
I Date:
Assignment of Tracking Information
Auditor's Office
Human Resource
I
Prosecutor's Office
Who Signed the grant application
I Reviewer I Date
Grant/Contract Review Page 2