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Home My WebLink AboutCon Contract Amend 5KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT 2018 -2020 CONSOLIDATED CONTRACT CONTRACT NUMBER: CLH18249 AMENDMENT NUMBER: 5 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: 1. Exhibit A Statements of Work, attached and incorporated by this reference, are amended as follows: D Adds Statements of Work for the following programs: ~ Amends Statements of Work for the following programs: • Office of Emergency Preparedness & Response -Effective July 1, 2018 D Deletes Statements of Work for the following programs: 2. Exhibit B-5 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-4 Allocations as follows: ~ Increase of $885 for a revised maximum consideration of $269,554. • 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-5 Schedule of Federal Awards, attached and incorporated by this reference, amends and replaces Exhibit C-4. 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 STATE OF WASHINGTON DEPARTMENT OF HEALTH Date ~ lin j1 0 /1 ~ Date Page 1 of6 APPROVED AS TO FORM ONLY Assistant Attorney General 2018-2020 CONSOLIDATED CONTRACT EXHIBIT A STATEMENTS OF WORK TABLE OF CONTENTS AMENDMENT #5 DOH Program Name or Title: Office of Emergency Preparedness & Response-Effective July I, 2018 .......................................................................... ,, .. , ............ 3 Exhibit A, Statements of Work Revised as of September 17 , 2018 Page 2 of6 Contract Number CLH18249-5 Exhibit A Statement of Work Contract Term: 2018-2020 AMENDMENT #5 DOH Program Name or Title: Office of E m er eencv Pr e paredness & Resoonse - Effective July 1, 2018 Local Health Jurisdiction Name: Kittitas County Public .Health Department Contract Number: CLH18249 SOW Type: Revision Revision # (for this SOW) 1 Period of Performance: July 1, 2018 through June 30, 2019 Funding Source Federal Compliance Type of P ayment £2] Federal Subrecipient (check if applicable) f2l Reimburse men t D State f2l FFAT A (Transparency A ct) 0 Fixed Price D Other D Res¢arch & D ev elopment Statement of Work Purpose: The pmpose 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: The pmpose of this revision is to increase PHEP funds and make changes to task activities . Chart of Accounts Program Name or Title FFY18 EPR PHEP BPl SUPP LHJ FUNDING TOTALS Task Number Task/ Activityffiescription FFY18 EPR PREP BPl SUPP LHJ 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 September 1 7, 2018 CFDA# BARS Master Funding Period Revenue Index (LHJ Use Only) Code Code Start Date End Date 93.069 333.93.06 18101580 07/01 /18 I 06/30/19 *May Support PHAB Standards/Measures Deliverables/Outcomes . -~ Submit summary on the mid-y ear and end of year progress report. - Submit completed templates to DOH ' Submit mid-year and end-of-year I progress reports Page 3 of6 Current Change rrotal Consideration Increase(+) Consideration 48 ,249 885 49,1 34 48_.249 885 49,134 Due Date/Time Payment Frame Information and/or Amount Reimbursement for actual costs not to exceed total funding December 31 , 2018 consideration amount. and June 28, 2019 Upon request by DOH December 31 , 2018 and June 28 , 2019 Contract Number CLH18249-5 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 LHJs, as needed, on utilizing WASECURES. LHJs may choose to utilize other notification systems in addition to W ASECURES to alert staff durin2 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 September 1 7, 2018 I I AMENDMENT #5 *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 LHJ. - -Document participation in June 28, 2019 = 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 4 of6 Contract Number CLHl 8249-5 Task Number Task/ Activity/Description 7 Provide notification to the DOH Duty Officer at 360-888-0838 or hanalert@doh.wa .gov for all response incidents involving utilization of emergency response plans (ERPs) and structures . 8 Provide LHJ situation reports to DOH during all incidents involving an emergency response by the LHJ . 9 Submit essential elements of information (EEis) during incident response upon request by DOH. 10 Participate in the regional healthcare coalition (HCC) and attend coalition meetings as necessary. 11 Fe1< e/J f.:H.h tkai l,:e't,e identified a .J.-l!th-foP ,•ce::eip~ efmediea! COWf!EFR,CR9l.Fre!J/rem DOH during disasters: • Pm'lieipate-m--the W:Ji) 7'-ReJE medieatien disl'Fibu,ie 11 e;.~·~is,e by ,-eeei,.;ing .f!l 5hipmettt ef eJEercise medicatiensfrem DOH at the designe.1ed l-eett.UJub Participate in the T-REX 2019 Medical Materiel Management and Distribution exercise by: a) Determine level ofplay through Extent of Play Agreement that outlines at minimum receipt of simulated medical countermeasures at the jurisdiction's designated hub Point of Dispensing (POD) location/s b) Identify a hub POD location to be a delivery site for receiving, staging, and storing medical countermeasures c) Receive a shipment of simulated medical countermeasures from DOH at the jurisdiction's designated hub locationl s d) Participate in After Action Review process with DOH Exhibit A, Statements of Work Revised as of September 17, 2018 I AMENDMENT #5 *May Support PHAB Due Date/Time Payment Standards/Measures Deliverables/Outcomes Frame Information and/or Amount Submit mid-year and end-of-year December 31, 2018 -progress reports and June 28, 2019 -Documentation that notification to June 2 8, 2019 DOH was provided; or statement that no incident re so onse occurred . -Submit mid-year and end-of-year December 31, 2018 progress reports and June 28 , 2019 - .. Submit Situation Reoorts . During all responses -Submit mid-year and end-of-year December 31, 2018 progress reports and June 28, 2019 - Provide information upon request. Upon request bv DOH ' Submit m id-year and end-of-year December 31 , 2018 progress reports and June 28 , 2019 Provide a summary of participation June 28 , 2 019 in coalition activities. Submit mid-year and end-of-year December 31, 2018 progress reports and June 28, 2019 I Deeumentatiert ef partieipatiert in Jurte 28, 20}9 the exercise - Submit a completed Extent of Play December 1, 2018 Agreement form -provided by I -DOH Submit a completed Distribution December 1, 2018 hub POD Information form - provided by DOH Summarize participation in T-REX June 28, 2019 Page 5 of6 Contract Number CLH18249-5 AMENDMENT #5 Task *May Support PHAB Due Date/Time Payment Number Task/ Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or Amount 2019 exercise and participation in LHJs are not required to test dispensing, After Action Review with DOH in transportation, or redistribution during the T-Rex the end-of-year report. 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: http://www.phaboard.org/wp-contentluploads/PHAB-Standards-and-Measures-Version-1.0.pdf .Program Specific Requirements/N arrative Any subcontract/s must be approved by DOH prior to executing the conlTact/s . Deliverables are to be submitted to the ConCon deliverables mailbox at concondeliverables@doh.wa .gov Special Requirements .Federal Funding Accountabilitv and Transparencv 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: btt:ps:/JWW\v.ecfr.2ov/c•gi-bin/retrieve'ECFR?gp =l&SJD=58ffddb5363a27f26e9 d l2ccec462549&tv=lITML&h=L&mc=true&t=.PARI&n=p 12.1 .200#se2 .l.200 .1439 DOH Program Contact Jennifer Albertson, Contract and Finance Specialist Department of Health P O Box 47960, Olympia, WA 98504-7960 360-236-4596 I jennifer.alberts on@doh.wa.gov Exhibit A, Statements of Work Revised as of September 17, 2018 Page 6 of6 Contract Number CLH18249-5 EXHIBIT B-5 Kittitas County Public Health Department ALLOCATIONS Contract Number: CLH18249 Contract Term: 2018-2020 Date: September 17, 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 or Accounts Funding Chart of Federal Award Revenue Funding Period Funding Period Period Accounts ~ of Accouna P-ru_g,ram Title_ ldentific:ation.# AmCDd11 CFDA* Code** Start Date End Ollte Su.rt D:ne f lldJ)ate Alll.OUDl Sub Total ·rollll FFYI 9 CSS lAR SNAP Ed Program Mgnt NGA Not Received Amd4 10 .561 333.10.56 10/01 /18 09/30/19 10/01/18 09/30/19 $19,745 $19,745 $44,930 FFYI 8 CSS !AR SNAP Ed Program Mgnt CF 187WAWA5Q3903 Amd4 10,561 333.10.56 10101 118 09130/19 10101118 09130/19 $858 $858 FFY18 CSS !AR SNAP Ed Program Mgnt 187WAWA5Q3903 Amd4 10.561 333.10 .56 01 101/18 09/30/18 10/01/17 09130118 $3 ,000 $22,855 FFY 18 CSS !AR SNAP ED Program Mgnt 187WAWA5Q3903 Amd2 10.561 333. 10.56 01101 118 09130/18 10101/17 89/30/18 $11,025 FFYI 8 CSS !AR SNAP ED Program Mgnt 187W AW A5Q3903 NIA 10.561 333.10.56 01/01 118 09130118 10101117 09/30118 $8 ,830 FFYI 7 CSS !AR SNAP ED Program Mgnt CF 1717WAWA5Q390 NIA 10.561 333.10.56 OIIOI/J8 09/30/18 10/01117 09130/18 $1 ,472 $1,472 FFYI 7 EPR PHEP BPI LHJ Funding NU90TP921889-0l Amd2 93.069 333.93.06 01 /01 118 06130/1 8 07101/17 07102/18 $565 $20,398 $20,398 FFYI 7 EPR PHEP BPI LHJ Funding NU90TP921889-01 NIA 93.069 333 .93.06 01 101/18 06130/18 07101117 07102118 $19,833 FFY18 EPR PHEP BPI Supp LHJ Funding NU90TP921889-01 Amd5 93.069 333.93.06 07101118 06130119 07101118 06130119 $885 $49,134 $49,134 FFYI 8 EPR PHEP BPI Supp LHJ Funding NU90TP92 I 889-0 I Amd4 93.069 333.93.06 07 /01 /18 06130/19 07101118 06/30/19 $48,249 FFY17 317 Ops 5NH23IP000762-05-00 NIA 93.268 333.93.26 01 101 118 06130/1 8 04/01117 06/30/18 $616 $616 $616 FFY17 AFIX SNH23IP000762-05-00 NIA 93.268 333 .93 .26 01 101 /\8 06130/18 04101/17 06130118 $2,226 $2,226 $2,226 FFYI 7 Increasing Immunization Rates NH23IP000762 Amd 3,4 93.268 333 .93 .26 07101/18 06130119 07/01118 06/30/19 $5 ,600 $5,600 $5 ,600 FFYI 7 VFC Ops 5NH23IP000762-05-00 NIA 93.268 333.93 .26 01/01 /18 06130/18 04101/17 06130/18 $1,114 $1,114 $1 ,114 FFYl9 MCHBG LHJ Contracts NGA Not Received Amd4 93 .994 333.93 .99 10/01 /IR 09/30/19 10101118 09130/19 $44,196 $44,196 $78,236 FFYI 8 MCHBG LHJ Contracts B04MC31524 Amd2 93.994 333.93.99 01 /01/18 09/30/18 10101117 09130/18 $893 $34,040 FFY18 MCHBG LHJ Contracts B04MC31524 NIA 93.994 333.93.99 01 /01/18 09/30/18 10/01/17 09/30/18 $33,147 GFS -Group B (FO-E) NIA NIA 334.04.90 01101/18 06/30/18 07/01/17 06/30/19 $5,000 $5,000 $5,000 FY2 Group B Programs for OW (FO-E) Amd3 NIA 334.04.90 07/01118 06130119 071@1117 06130119 $10,000 $10,000 $10,000 SFY2 Lead Environments of Children Amd4 NIA 334.04.93 07/01/18 06/30/19 07/01/18 06/30/19 $1,500 $1,500 $3,500 SFYI Lead Environments of Children Amdl NIA 334.04.93 01 /01 /18 06130118 07/01/17 06/30/18 $2,000 $2,000 FPHS Funding for LHJs Dir Amd3 NIA 336.04.25 07/01 /18 06/30119 07101117 06/30/19 $42,000 $42 ,000 $42,000 YR 20 SRF -Local Asst (15%) (FS) SS Amd3 NIA 346.26.64 01 101/18 12/3 I/ 18 07101115 12/31118 ($2 ,400) $0 $0 YR 20 SRF-Local Asst (15%) (FS) SS NIA, Amd 3 NIA 346.26,64 Ol/01/18 12131 /18 07101/15 12/]I /J 8 $2,400 Page 1 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 Pro&ram Tille YR 21 SRF -Local Asst (15%)(FS) SS Sanitary Survey Fees (FO-E) SS-State YR 20 SRF -Local Asst (I 5%) (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 ldcn.tification #c $268,669 $885 $269,554 ••Federal revenue codes begin with "333". State revenue codes begin with "334". ,._ Amend Ii Amd3 NIA, Amd 3 Amd3 NIA, Amd 3 Amd3 EXHIBITB-5 ALLOCATIONS Contract Tenn: 2018-2020 BARS Statement of Work Revenue Funding Period l>Oll ll~b (?DI) CJtiu1 or l\1:i:oOJ1' _ Fu111Jt,n_g l~IW CFDA* Code*., Start Date Eud Due Star4 l>ate End U:1~ NIA 346.26.64 01/01/18 12/31/18 07l01'1 NIA 346.26.65 01/01118 12/31/18 U7tOl/l NIA 346.26.66 01101/18 12/31/18 0711)1/J':5 12la-Utl> NIA 346.26.66 01/01/18 12131/18 07/0111'5 IWW8 NIA 346.26.66 01101118 12/31/18 1)71'1Jl'17 Page2 of2 Amount $2,400 $2,400 ($2,000) $2 ,000 $2,000 $269,554 Contract Number: Date: Funding Period Sub Total $2,400 $2 ,400 $0 $2,000 $269,554 GRANDTOTAL Total Fed Total State CLH18249 September 17, 2018 Chart of Accounts Total $2,400 $2,400 $0 $2,000 $269,554 $202,254 $67,300 Exhibit C-5 Schedule of Federal Awards AMENDMENT #5 Date: September 17, 2018 KITTITAS COUNTY HEALTH DEPT-SWV0010475-07 CONTRACT CLH18249-Kittitas County Public Health Department CONTRACT PERIOD: 01/01/2018-12/31/2020 DOH Total Amt Allocation Period Chart of Accounts Program Title BARS Federal Federal Start End Contract Amt CFDA CFDA Program Title Federal Award AwanJ Date Award Date Date Federal Agency Name Identification Number Federal Grant Award Name FFY19 CSS IAR SNAP ED PROG MGNT NGA Not NGA_ Not 1 O/O 1118 State Administrative Matching Department of Agriculture Food and 333 10.56 09/30/19 $19,745 10.561 Grants for the Supplemental NGA Not Received NGA Not Received Received Rece1ved Nutrition Service Nutrition Assistance Program State Administrative Matching Department of Agriculture Food and 2018 SUPPLEMENTAL NUTRITION FFY18 CSS IAR SNAP-ED PROGRAM MGNT CF 333.10 56 09/28117 $5,300,000 10/01/18 09/30/19 $858 10,561 Grants for the Supplemental 187WAWA5Q3903 ASSISTANCE PROGRAM EDUCATION Nutrition Assistance Program Nutrition Service (SNAP-ED) State Administrative Matching Department of Agriculture Food and 2018 SUPPLEMENTAL NUTRITION FFY18 CSS IAR SNAP-ED PROGRAM MGNT 333.10.56 09128117 $5,300,000 01/01/18 09/30/18 $22,855 10 561 Grants for the Supplemental 187WAWA5Q3903 ASSISTANCE PROGRAM EDUCATION Nutrition Assistance Program Nutrition Service (SNAP-ED) State Administrative Matching Department of Agriculture Food and 2018 SUPPLEMENTAL NUTRITION FFY17 CSS IAR SNAP-ED PROGRAM MGNT CF 333.10.56 09/10/16 $5,739,856 01/01/18 09/30/18 $1,472 10.561 Grants for the Supplemental 1717WAWA5Q390 ASSISTANCE PROGRAM EDUCATION Nutrition Assistance Program Nutrition Service (SNAP-ED) Department of Health and Human HOSPITAL PRe:PARE.0,~ FFY18 EPR PHEP BP1 SUPP LHJ FUNDING 333 93.06 08/01/18 $11,062,782 07/01/18 06/30/19 $49,134 93.069 Public Health Emergency Services Centers for Disease Control NU90TP921889-01 PROGRAM AND PUBLIC HEAL TH Preparedness and Prevention EMERGENCY PREPAREDNESS COOPERATIVE AGREEMENT Public Health Emergency Department of Health and Human HPP AND PHEP COOPERATIVE FFY17 EPR PHEP BP1 LHJ FUNDING 333.93.06 07/18/17 $11,062,782 01/01/18 06/30/18 $20,398 93.069 Preparedness Services Centers for Disease Control NU90TP921889-01 AGREEMENT and Prevention Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND FFY17 VFC OPS 333,93 26 03/03/17 $1,201 ,605 01/01/18 06/30/18 $1,114 93.268 Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S Agreements and Prevention PROGRAM - Immunization Cooperative Department of Heallh and Human IMMUNIZATION GRANT AND FFY17 INCREASING IMMUNIZATION RATES 333 .93.26 06/29/18 $1,722,443 07/01/18 06/30/19 $5,600 93.268 Services Centers for Disease Control NH231P000762 VACCINES FOR CHILDREN'S Agreements and Prevention PROGRAM Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND FFY17 AFIX 333,93.26 03/03/17 $1 ,672,289 01/01/18 06/30/18 $2,226 93268 Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S Agreements and Prevention PROGRAM - Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND FFY17 317 OPS 333.93-26 03/03/17 $575,969 01 /01/18 06/30/18 $616 93.268 Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S Agreements and Prevention PROGRAM NGA Not t,IGA_ Not 10/01/18 Maternal and Child Health Department of Health and Human FFY19 MCHBG LHJ CONTRACTS 333,93 99 09/30/19 $44,196 93 994 Services Block Grant to the Services Health Resources and NGA Not Received NGA Not Received Received Rt!c;:e1ved States Services Administration Maternal and Child Health Department of Health and Human MATERNAL AND CHILD HEAL TH FFY1 B MCHBG LHJ CONTRACTS 333 93.99 10/20/17 $1,650,528 01/01/18 09/30/18 $34,040 93 ,994 Services Block Grant to the Services Health Resources and B04MC31524 SERVICES States Services Administration TOTAL $202,254 Page 1 of 1 Kittitas County Review Form Grants & Contract Agreement Today's Date 11/06/2018 Fund/Department 116-Public Health Contract/Grant Information Agenda Date } ;)_ } L/ Contract /Grant Agency: Consolidated Contract Amendment 5 Period Begin Date: 01/01/2018 I I Period End Date: 12/31/2020 Total Grant/Contract Amount: $269,544.00 {Increase of 885.00) Grant/Contract Number: CLH18249 Contract/Grant Summary: The Consolidated Contract amends Statements of Work for the following program: • Office of Emergency Preparedness and Response-Effective July 1, 2018 Exhibit B-5 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-4 Allocations as follows: • Increase of $885.00 for a revised maximum consideration of $269,554.00 Recommendation for Board of Health and Board of Health Review on Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment: APP ROV ED A TO FORM : Date Signature of Board of Health member Date Financial Information I Total Amount$ 885.00 I State Funds $ 0 I Federal Funds $ 885.00 Grant/Contract Review Page 1 Percentage County Funds Matching Funds $ j CFDA# 93.069 EPR PHEP In-Kind$ Explain Is Equipment being purchased? Who owns equipment? New Personnel being hired? Contact HR hiring -reporting requirements Future impacts or liability to Kittitas County: Budge t Information Budget Amendment Needed? Yes • attach budget form No[] Why not -already in budget New Division Created? Revenue Code 612.88.3.333.93.06 EPR PHEP $885.00 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 Tracki ng Information Auditor's Office Human Resource Prosecutor's Office Who Signed the grant application I Reviewer [ Date Grant/Contract Review Page 2