HomeMy WebLinkAboutPSA KCPHD and Walla Walla Dept of Community HealthService Agreement #19-33
between
WALLA WALLA COUNTY DEPARTMENT OF COMMUNITY HEALTH
and
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
The Agreement is entered into by and between Walla Walla County Department of Community
Health, hereinafter "County," and Kittitas County Public Health Department, hereinafter
"Contractor," for services relative to the Youth Marijuana Prevention and Education Program as
outlined in the attached Statement of Work. The rights and obligations of both parties are
governed by the General Terms and Conditions, and the following Exhibits, copies of which are
attached hereto and incorporated herein by this reference as fully as if set forth herein:
Exhibit A — Statement of Work
Exhibit B — Budget
Exhibit C — Contractor Certification Form
Exhibit D — Contractor Report Form
Performance Period: The terms of this Agreement shall commence on July 1, 2019, and shall,
unless terminated or renewed as provided elsewhere in the Agreement,
terminate on June 30, 2020.
Compensation: Payment to Contractor for services rendered under this Agreement shall be
as set forth in Exhibit B — Budget. The amount of payment for the
performance period of this Agreement shall not exceed $10,000.
By their signatures below, the parties agree to the terms and conditions of this Agreement and all
documents incorporated by reference. The parties signing below certify that they are authorized
to sign this Agreement.
IN WITNESS WHEREOF, the parties hereto have signed this Agreement.
COUNTY:
Meghan DeBolt, MBA/MPH Date
Director
Department of Community Health
314 W. Main
P.O. Box 1753
Walla Walla, WA 99362
Phone: (509) 524-2650 Fax: (509) 524-2642
Telephone Number / Email Address:
CONTRACTOR:
Authorized By Date
Tristan Lamb, Administrator
Print Name & Title of Person Signing
509.962.7515
Mailing Address (Street address required in addition to PO Box.): 507 N. Nanum, #102
CFDA# (if applicable):
Ellensburg, WA 98926
Social Security or Business Tax ID#
UBI#
State Industrial Account ID # (if applicable):
91-6001349
192002673
004.093-00
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GENERAL TERMS AND CONDITIONS
1. Definitions. For the purposes of this Agreement, including all documents incorporated by
reference, terms that are defined in Washington Administrative Code (WAC) shall have
meanings defined therein. Additionally, the words and phrases listed below, as used in
the Agreement, shall each have the following definitions:
1.1. "Agreement" means this County and Contractor Agreement regarding General
Terms and Conditions and any documents incorporated by reference.
1.2. "CFR" means Code of Federal Regulations. All references in this Agreement and
any Agreement to CFR chapters or sections shall include any successor, amended,
or replacement regulation. The CFR may be accessed at
http://www.gpoaccess.jzov/cfr/index.html.
1.3. "Debarment" means an action taken by a Federal official to exclude a person or
business entity from participating in transactions involving certain federal funds.
2. Background Checks. In accordance with RCW 43.20A.710, RCW 43.43.832, RCW
74.34, and RCW 71A.10.020, when applicable, Contractor's staff, subcontractors or
volunteers who work with or have unsupervised access to children or vulnerable adults
are required to have a background check, and all persons convicted of crimes listed in
RCW 43.43.830 and RCW 43.43.842 are prohibited from having access to clients.
Contractor will provide verification these background checks have been completed to the
County.
3. Contractor shall submit monthly progress reports and invoices that reflect work
performed and funding spent.
4. Suggested Guidance. Contractor is encouraged to understand and adhere to the guidance
and requirements in the Youth Marijuana Prevention and Education Program Regional
Implementation Guide and is encouraged to contact the County before making contact
with Washington State Marijuana Prevention and Education Program staff.
5. Billing and Payment for Contractor Services: County shall pay Contractor for
services on a reimbursement basis, pursuant to terms set forth in Exhibit B — Budget. No
payment shall be made for any service that is not identified within this Agreement.
5.1. Contractor shall submit claims for reimbursement by the tenth (10th) working day
following the end of the month in which the expenses claimed were incurred.
County agrees to make payment with County warrants, as approved by the Auditor
of County, within forty-five (45) working days following receipt of Contractor's
approved claim for reimbursement, contingent on the availability of funds.
5.1.1. Claims for reimbursement shall be submitted through AmpliFund, the
Department of Community Health's grant management system.
5.1.2. Submitting a Final Payment Request through AmpliFund will signify that
the Contractor certifies under penalty of perjury that the items and totals
listed herein are proper charges for materials, merchandise or services
furnished to the County of Walla Walla and that all goods furnished and/or
#19-33 GT&C.KITTITAS COUNTY PUBLIC HEALTH DEPT.YR 3.YMPEP Page 2 of 1 I
services rendered have been provided without discrimination because of
age, sex, marital status, race, creed, color, national origin, handicap,
religion, or Vietnam era or disabled veterans status and the claim is just,
due and unpaid obligation against the County of Walla Walla and that I am
authorized to authenticate and certify to said claim.
5.1.3. Payment shall be based upon itemized billings supported by accompanying
documentation.
5.1.4. County shall compensate Contractor no more often than monthly for
Contractor's service. No payment shall be made in the month services are
rendered unless otherwise approved by County.
6. In the event Contractor fails to perform any substantial obligation under this Agreement
and said failure has not been cured, County may, upon written notice, withhold all
monies due and payable to Contractor, without penalty, until such failure to perform is
cured or otherwise adjudicated. Compliance with Applicable Law. At all times during
the term of this Agreement, Contractor shall comply with all applicable federal, state, and
local laws, regulations, and rules, including but not limited to, nondiscrimination laws
and regulations.
7. Confidentiality. Contractor, its employees, subcontractors, and their employees shall
maintain the confidentiality of all information provided by County or acquired by
Contractor in performance of this Agreement, except upon the prior written consent of
Walla Walla County Prosecuting Attorney, or an order entered by a court after having
acquired jurisdiction over County. Contractor shall immediately give to County notice of
any judicial proceeding seeking disclosure of such information. Contractor shall
indemnify and hold harmless County, its officials, agents or employees from all loss or
expense, including, but not limited to settlements, judgments, setoffs, attorneys' fees and
costs resulting from Contractor's breach of this provision. The parties to this Agreement
shall comply with applicable Federal and State laws and regulations governing privacy,
confidentiality or security of patient information, including without limitation Chapter
70.02 RCW, Medical Records — Health Care Information Access and Disclosure; Chapter
42.17 RCW, Disclosure — Campaign Finances — Lobbying — Records; and the Health
Insurance Portability and Accountability Act, including but not limited to the "HIPAA
Privacy Rule," 45 CFR Parts 160 and 164.
8. Conflict of Interest. Contractor shall, in all matters concerning this Agreement, avoid
any actions that may constitute a conflict of interest.
9. Debarment Certification. Contractor certifies that neither it nor its principals are
presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participating in transactions by any Federal department or
agency.
10. Disputes. Except in the event of a dispute arising from County's decision to terminate
this Agreement for default, County and Contractor agree to first attempt resolution of
disputes informally, by a mutually negotiated process.
11. Entire Agreement. This Agreement, including all documents incorporated by reference,
contains all terms and conditions agreed upon by the parties. No other understandings or
#19-33 GT&C.KITTITAS COUNTY PUBLIC HEALTH DEPT.YR 3.YMPEP Page 3 of I 1
representations, oral or otherwise, regarding the subject matter of the Agreement shall be
deemed to exist or bind the parties.
12. Execution and Amendment. This Agreement shall be binding on the parties only upon
execution by authorized representatives of County and Contractor. This Agreement may
be altered only by a written amendment executed by authorized representatives of County
and Contractor.
13. Financial Certification. Within 60 days of the execution of the Contract, Contractor
shall submit to the County, Contractor Certification Documentation form including the
Contractor status as Non -Profit, Corporation, Governmental, Individual or Other Entity.
The applicable financial certification documents must also be submitted to the County
once every 12 months:
13.1. W-9 Form, Request for Taxpayer Identification
13.2. Last Audited Financial Statements, or Form 990; or Form 990T; or Form 1120 for
Corporations; or Schedule C from 1040 for individuals.
14. Indemnification and Hold Harmless. Contractor will indemnify, hold harmless and
defend the County from all claims, costs, damages or expenses including reasonable legal
expenses arising out of the negligence or wrongful acts of the Contractor, its
subcontractors, its successors or assigns, or its agents, servants, or employees. In the case
of negligence of both County and Contractor any damages allowed shall be levied in
proportion to the percentage of negligence attributable to each party. Each party to this
Agreement hereby assumes responsibility for claims and/or damages to persons and/or
property resulting from any act or omission on the part of itself, its employees, its
subconsultants, its officers, and its agents.
15. Industrial Insurance Waiver: With respect to the performance of this agreement and as
to claims against the County, its officers, agents and employees, the Contractor
expressly waives its immunity under Title 51 of the Revised Code of Washington, the
Industrial Insurance Act, for injuries to its employees and agrees that the obligations to
indemnify, defend and hold harmless provided in this agreement extend to any claim
brought by or on behalf of any employee of the Contractor. This waiver is mutually
negotiated by the parties to this agreement.
16. Independent Status/Contractor. Contractor's services shall be furnished as an
independent contractor and nothing herein contained shall be construed to create a
relationship of employer-employee or master -servant. All payments made hereunder and
all services performed shall be made and performed pursuant to this Agreement by
Contractor as an independent contractor. It is understood and agreed that County is not
responsible for payroll deductions of any kind, including but not limited to, Federal
Taxes, FICA and/or employee benefits.
17. Inspection. During the term of this Agreement and for one (1) year following
termination or expiration of this Agreement, Contractor shall provide reasonable access
to Contractor's place of business, Contractor records, and client records, to County and to
any authorized agent of the state of Washington or the federal government in order to
monitor, audit, and evaluate Contractor's performance and compliance with applicable
laws, regulations, and this Agreement. Such representatives shall be permitted to audit,
#19-33 GT&C.KITTITAS COUNTY PUBLIC HEALTH DEPT.YR 3.YMPEP Page 4 of 11
examine, and make excerpts or transcripts from such records and to make audits of all
contracts, invoices, materials, payroll, and records of matters covered by this Agreement.
18. Insurance. CONTRACTOR is a member of the Washington Counties Risk Pool.
CONTRACTOR shall notify COUNTY forty-five (45) days before cancellation or
reduction in CONTRACTOR's insurance coverage.
18.1. Professional Liability Insurance: In the event that services delivered under this
Agreement, either directly or indirectly include the provision of professional
services, Professional Liability Insurance, including coverage for losses caused by
errors and omissions, with minimum limits of $1,000,000 each occurrence and
$2,000,000 aggregate. For the purposes of this Agreement, "Professional
Services" shall mean any services provided by a physician, psychologist or other
licensed professional.
18.2. Auto Liability Insurance: In the event that services delivered pursuant to this
agreement involve the use of vehicles or the transportation of clients, automobile
liability insurance shall be required for any owned or leased vehicle used in the
performance of these contract services. If Contractor -owned personal vehicles are
used, a Business Automobile Policy covering at a minimum Code 2 "owned autos
only" must be secured. If Contractor employee's vehicles are used, Contractor
must also include under the Business Automobile Policy Code 9, coverage for
"non -owned autos." The minimum limit for automobile is $1,000,000 per
occurrence, using a combined single limit for bodily injury and property damage.
18.3. Worker's Compensation lnsurancc: If applicable, Contractor shall show proof of
Worker's Compensation coverage by providing its State Industrial Account
Identification Number. Provision of this number will be Contractors assurance
that coverage is in effect.
19. Licensure. Contractor shall obtain and maintain continuously for the duration of this
Agreement, all licenses, certifications and/or registrations required for carrying out the
contracted services.
20. Non -Discrimination. Contractor shall not unlawfully discriminate against any employee,
applicant for employment, recipient of services or programs, or applicant for services or
programs, on the basis of race, creed, color, sex, age, marital status, national origin,
Vietnam era or disable veteran status, or the presence of any sensory, mental or physical
handicap. Contractor shall comply with the Americans with Disabilities Act.
20.1. In Employment. Contractor shall not discriminate against any employee or
employment because of race, color, sex, religion, national origin, creed, marital
status, age Vietnam era or disable veterans status, or the presence of any sensory,
Intellectual, or physical disability, or the use of any trained dog guide or service
animal by a person with a disability. Contractor shall take affirmative action to
ensure that employees are employed and treated during employment without
discrimination. Such action shall include, but not be limited to, the following:
employment upgrading, demotion, or transfer; or recruitment or selection for
training, including apprenticeships and volunteers.
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20.2. In Services. Contractor shall not discriminate against any person eligible for
services or participation in the program because of race, color, sex, religion,
national origin, creed, marital status, age, Vietnam Era or disabled veterans, status
or the presence of any sensory, intellectual or physical disability, or the use of any
trained dog guide or service animal by a person with a disability, or the use of any
trained dog guide or service animal by a person with disabilities.
21. Notice, Venue and Choice of Law. Any notices, payments and communications
permitted or required between County and Contractor shall be given or made by personal
delivery or by mailing the same to the other party at the addresses on the first page of this
Agreement, or such address as either party may in writing hereinafter indicate. In the
event litigation should arise concerning the enforcement, construction or interpretation of
any of the terms of this Agreement, the venue of such action of litigation shall be in the
courts of the State of Washington in and for the County of Walla Walla. This Agreement
shall be governed by the laws of the State of Washington.
22. Order of Precedence. In the event of an inconsistency in this Agreement, unless
otherwise provided herein, the inconsistency shall be resolved by giving precedence, in
the following order, to:
19.1 Applicable federal and State of Washington statutes and regulations;
19.2 General Terms and Conditions contained in this Agreement;
19.3 Special Terms and Conditions contained in this Agreement;
19.4 Exhibits, if any, as indicated on page one (1) of this Agreement;
19.5 Any other material incorporated herein by reference.
23. Ownership of Material. Material created by Contractor and paid for by County as a part
of this Agreement shall be owned by County and shall be "work made for hire" as
defined by Title 17 USCA, Section 101. This material includes, but is not limited to:
books; computer programs; documents; films; pamphlets; reports; sound reproductions;
studies; surveys; tapes; and/or training materials. Material which Contractor uses to
perform this Agreement but which is not created for or paid for by County is owned by
Contractor.
24. Records. The parties to this Agreement shall comply with all Federal and State laws and
regulations governing privacy, confidentiality or security of records, including without
limitation, the Washington Uniform Healthcare Information Act, Chapter 70.02 RCW,
Medical Records — Health Care Information Access and Disclosure; RCW 42.56, Public
Records Act; and the Health Insurance Portability and Accountability Act, including but
not limited to the "HIPAA Privacy Rule," 45 CFR Parts 160 and 164.
24.1. Financial Records. Contractor shall have a system of accounting and internal
controls in compliance with generally accepted accounting principles and
standards, and shall maintain sufficient books, records, documents, reports and
other evidence to accurately document all costs incurred in relationship to
contracted services.
24.2. Clinical/Consumer Service Records. The Contractor shall comply with all state
and federal requirements regarding the maintenance and content of records relating
to services provided to individual clients under this Agreement.
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25. Right to Review and Record Retention. This Agreement may be subject to review by
any Federal or State auditor. County or its designee shall have the right to review and
monitor the financial and service components of this program by whatever means are
deemed expedient by County. Such review may occur with or without notice, and may
include, but is not limited to, on site inspection by County Agents or employees,
inspection of all records or other materials which County deems pertinent to the
Agreement and its performance, and any and all communications with or evaluations by
service recipients under this Agreement. Contractor shall preserve and maintain all
financial records and records relating to the performance of work under this Agreement
for six (6) years after Agreement termination, and shall make them available for review,
upon request, within Walla Walla County, State of Washington
26. Severability. The provisions of this Agreement are severable. If any court holds any
provision of this Agreement, including any provision of any document incorporated by
reference, invalid, that invalidity shall not affect the other provisions of the Agreement.
27. Subcontracting
27.1. Contractor may, without prior notice to County, subcontract with agencies
specifically identified in the Statement of Work. For subcontracts with an agency,
person, partnership, corporation or governmental entity not identified in the
Statement of Work, Contractor shall obtain written approval from County at least
forty (40) days prior to the proposed effective date of a new or amended
subcontract.
27.1.1. Contractor shall be responsible for the acts and omissions of its
subcontractors.
27.1.2. For the purpose of this Agreement, vendors used regularly by Contractor
are not subcontractors.
27.1.3. A personal services contract between Contractor and an individual does not
require prior approval by County.
27.2. All subcontracts entered into by Contractor for performance of services defined
herein shall be in writing and shall contain language substantially as provided in
the following sections of this agreement:
• Accounting
• Background Checks
• Compliance with Applicable Law
• Confidentiality
• Conflict of Interest
■ Definitions
• Debarment Certification
• Indemnification and Hold Harmless
• Independent Audit
• Inspection
• Insurance
• Licensure and Bonding
• Non-discrimination in Client
Services
• Records
• Record Maintenance and Retention
• Reporting
• Treatment of Property
• Subcontracting
• Subrecipient
27.3. County reserves the right to inspect and approve any subcontract document. In the
event of subcontract inspection by County, approval will be assumed unless
#19-33 GT&C.KITTITAS COUNTY PUBLIC HEALTH DEPT.YR 3.YMPEP Page 7 of 1I
County informs Contractor that the subcontract is disapproved within forty (40)
calendar days of receipt of the subcontract document by County.
28. Subrecipients
28.1. General. If Contractor is a subrecipient of federal awards as defined by Office of
Management and Budget (OMB) Circular A-133 and this Agreement, Contractor
shall:
28.1.1. Maintain records that identify, in its accounts, all federal awards received
and expended and the federal programs under which they were received, by
Catalog of Federal Domestic Assistance (CFDA) title and number, award
number and year, name of the federal agency, and name of the pass-
through entity;
28.1.2. Maintain internal controls that provide reasonable assurance that the
Contractor is managing federal awards in compliance with laws,
regulations, and provisions of contracts or grant agreements that could have
a material effect on each of its federal programs;
28.1.3. Prepare appropriate financial statements, including a schedule of
expenditures of federal awards;
28.1.4. Incorporate OMB Circular A-133 audit requirements into all agreements
between the Contractor and its subcontractors who are subrecipients;
28.1.5. Comply with any future amendments to OMB Circular A-133 and any
successor or replacement Circular or regulation;
28.1.6. Comply with the applicable requirements of OMB Circular A-87 and any
future amendments to OMB Circular A-87, and any successor or
replacement Circular or regulation; and
28.1.7. Comply with the Omnibus Crime Control and Safe Streets Act of 1968,
Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation
Act of 1973, Title II of the Americans with Disabilities Act of 1990, Title
IX of the Education Amendments of 1972, The Age Discrimination Act of
1975, and The Department of Justice Non -Discrimination Regulations, 28
C.F.R. Part 42, Subparts C.D.E, and G, and 28 C.F.R. Part 35 and Part 39.
(See www.oip.usdoi/gov/ocr for additional information and access to the
aforementioned Federal laws and regulations.)
28.2. Single Audit Act Compliance. If Contractor is a subrecipient and expends
$500,000 or more in federal awards from any and/or all sources in any fiscal year,
Contractor shall procure and pay for a single audit or a program -specific audit for
that fiscal year. Upon completion of each audit, Contractor shall:
28.2.1. Submit to County the data collection form and reporting package specified
in OMB Circular A-133, reports required by the program -specific audit
guide (if applicable), and a copy of any management letters issued by the
auditor;
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28.2.2. Follow-up and develop corrective action for all audit findings; in
accordance with OMB Circular A-133, and prepare a "Summary Schedule
of Prior Audit Findings."
28.3. Overpayments. If it is determined by County, or during the course of the required
audit, that Contractor has been paid unallowable costs under this Agreement,
County may require Contractor to reimburse County in accordance with OMB
Circular A-87.
29. Survivability. The terms and conditions contained in the Agreement that, by their sense
and context, are intended to survive the expiration of the Agreement shall so survive.
Surviving terms include, but are not limited to: Confidentiality, Disputes,
Indemnification and Hold Harmless, Inspection, Records, Right to Review and Record
Retention, Ownership of Material, Termination for Default, Termination Procedure.
30. Termination. The terms and conditions of this Agreement shall remain in full force and
effect during the specified Agreement period unless specifically terminated, or modified
by mutual assent of the parties hereto, regardless of the termination or modification of
any contract or subcontract of which this Agreement is a part. Termination of this
Agreement by either party in accord with the terms herein shall not constitute a breach of
contract.
30.1. Termination for Convenience. Either County or Contractor may terminate this
Agreement for convenience, in whole or in part, whenever either determines such
termination to be in its best interest. Such termination shall require notice of thirty
(30) calendar days. When the Agreement is terminated in accordance with this
paragraph, Contractor shall be entitled to payment for actual work performed at
unit contract prices for completed items of work.
30.2. Termination Due to Change in Funding. If the funds County relied upon to
establish this Agreement are withdrawn, reduced, or limited, or if additional or
modified conditions are placed on such funding, County may terminate this
Agreement by providing written notice to Contractor. Termination shall be
effective on the date specified in the notice of termination.
30.3. Termination for Default. County may terminate this Agreement for default, in
whole or in part, by written notice to Contractor, if County has a reasonable basis
to believe that Contractor has:
• Failed to meet or maintain any requirement for contracting with County;
• Failed to perform under any provision of this Agreement;
• Violated any law, regulation, rule, or ordinance applicable to the services provided
under this Agreement;
• Become insolvent or declared bankrupt, committed any act of bankruptcy or
insolvency, or made an assignment for the benefit of creditors, and/or
• Otherwise breached any provision or condition of this Agreement.
30.3.1. Before County may terminate this Agreement for default, County shall
provide Contractor with written notice of Contractor's noncompliance with
this Agreement and provide Contractor a reasonable opportunity to correct
#19-33 GT&C.KITTITAS COUNTY PUBLIC HEALTH DEPT.YR 3.YMPEP Page 9 of 11
said noncompliance. If Contractor has not corrected its noncompliance
within the period of time specified in the written notice of noncompliance,
County may then terminate this Agreement.
30.3.2. County may terminate this Agreement for default without written notice
and without opportunity for correction if County has a reasonable basis to
believe that Contractor has failed to ensure the health or safety of any client
for whom services are being provided under this Agreement, or that
Contractor has violated any law, regulation, rule or ordinance applicable to
the services provided under this Agreement.
30.3.3. If the Agreement is terminated for default, Contractor shall not be entitled
to receive any further payments under the Agreement until all work called
for has been fully performed. Any extra cost or damage to County
resulting from such default shall be deducted from any money due or
coming due to Contractor. Contractor shall be liable for actual, incidental
and consequential damages, including the reasonable cost of procuring
similar services actually procured by the County from another source to
fully execute the Contractor's duties under this Agreement.
31. Termination Procedure. The following provisions apply in the event this Agreement is
terminated:
31.1. Contractor shall cease to perform any services required by the Agreement as of the
effective date of termination and shall comply with all reasonable instructions
contained in the notice of termination which are related to the transfer of clients,
distribution of property, and termination of services
31.2. County shall be liable for and shall pay for only those services authorized and
provided through the date of termination. County may pay an amount agreed to by
the parties for partially completed work and services, if work products are useful
to or usable by County.
31.3. If this Agreement is terminated for default, County may withhold a sum from the
final payment to Contractor that County determines necessary to protect County
against loss or additional liability. County shall be entitled to all remedies
available at law, in equity or under this Agreement. If it is later determined that
Contractor was not in default, Contractor shall be entitled to all remedies available
at law, in equity, or under this Agreement.
31.4. The rights and remedies provided to County in this paragraph are in addition to
any other rights and remedies provided at law, in equity, and/or under this
Agreement, including consequential damages and incidental damages. The
Contractor may request dispute resolution as provided in this Agreement.
32. No Third -Party Beneficiary. The parties do not intend by this Agreement to assume
any contractual obligations to anyone other than each other. This Agreement is not
entered into with the intent that it shall benefit any other entity or person(s) except those
expressly described herein, and no other such entity or person(s) shall be entitled to be
treated as a third -party beneficiary to the agreement.
33. Waiver. Waiver of any breach or default of this Agreement on any occasion shall not be
#19-33 GT&C.KITTITAS COUNTY PUBLIC HEALTH DEPT.YR 3.YMPEP Page 10 of I 1
deemed to be a waiver of any subsequent breach or default. Waiver shall not be construed
to be a modification of the terms of the contract unless stated to be such in writing, signed
by an authorized representative of County. County's failure to insist upon the strict
performance of any provision of this Agreement or to exercise any right based upon
breach thereof or the acceptance of any performance during such breach, shall not
constitute a waiver of any right under this Agreement.
#19-33 GT&C.KITTITAS COUNTY PUBLIC HEALTH DEPT.YR 3.YMPEP Page 11 of 11
Exhibit A
STATEMENT OF WORK
Grantee Name: Kittitas County Public Health Department
Agreement Number: 19-33 Contract Period: 07/01/2019-06/30/2020
19 -33 -EXHIBIT A SOW Kittitas County Public Health Dept Yr 3 YMPEP Page 1 of 1
Due
Payment
Task
Task/Activity/
Deliverables/Outcomes
Date/Time
Informatio
Number
Description
Frame
nand/or
Amount
1
Monthly Report
Complete monthly report form
10` of the
N/A
and email to YMPEP Program
month for the
Coordinator
previous
month in the
contract
2
Attend YMPEP
Attend monthly YMPEP
June 30, 2020
Invoiced
regional meetings
conference call meeting and
and trainings
attend quarterly YMPEP regional
trainin s
3
Support YMPEP
Attend planning and evaluation
June 30, 2020
Invoiced
(optional)
planning and
meetings and provide data and
evaluation
input as time allows
4
Policy Maker
Reach out to local policy makers
June 30, 2020
Invoiced
Outreach
to educate about youth marijuana
prevention
5
Adult Education
Hidden in Plain Sight
June 30, 2020
Invoiced
presentations, and website
updates
6
Media Campaigns
Under the Influence of You,
June 30, 2020
Invoiced
Social Norms, other DOH
marijuana reduction campaigns
Invoiced
7
Promote
Purchase materials to promote
June 30, 2020
Recovery Hotline
recovery hotline
8
Retailer Outreach
Educate and reach out to
June 30, 2020
Invoiced
marijuana retailers in Kittitas
County to prevent youth access.
19 -33 -EXHIBIT A SOW Kittitas County Public Health Dept Yr 3 YMPEP Page 1 of 1
Exhibit B
BUDGET
Agency Name: Kittitas County Public Health Department
Agreement Number: 19-33 Contract Period: 07/01/2019-06/30/2019
Line Item/Description Award
Program Operations $10,000
TOTAL: { $10,000
Funded By:
WA State Department of Health Youth Marijuana Prevention and Education Program
19-33 EXHIBIT B Budget Kittitas County Public Health Department Yr 3 Programming YMPEP Page 1 of 1
Exhibit C
CONTRACTOR FINANCIAL CERTIFICATION FORM
Contractor Name:
Organization (if different than Contractor):
Project:
Project Address:
Project Contact:
Status:
❑ Non -Profit
❑ Corporation
❑ Governmental
❑ Individual
❑ Other:
Please complete and return the attached forms if they have not been submitted to Walla Walla
County Department of Community Health in the past 12- months, or if they are out of date:
❑ W-9, Request for Taxpayer Identification
❑ Last Audited Finance Statements, or
❑ Form 990, 990T, 1120, 1040 Schedule C
❑ Insurance Certification as required in GT&C Section 18
o Insurance. CONTRACTOR is a member of the Washington Counties Risk Pool.
CONTRACTOR shall notify COUNTY forty-five (45) days before cancellation
or reduction in CONTRACTOR's insurance coverage.
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