HomeMy WebLinkAboutGrant Administration ContractGRANT ADMINISTRATION CONTRACT
THIS GRANT ADMINISTRATION CONTRACT ("Contract") is entered into by and between Kittitas
County Health Network ("Manager") and Kittitas County Public Health Department
("Contractor") effective September 1, 2019 ("Effective Date") and, unless earlier terminated,
terminates on August 31, 2022 ("Termination Date").
RECITALS
A. Manager has been awarded the Health Resources and Services Administration Rural
Communities Opioid Response Program (RCORP) Implementation Grant ("Grant") for the
management of the Grant within Manager's jurisdiction. The purpose of the Grant is to reduce
the morbidity and mortality of Substance Use Disorder (SUD), including Opioid Use Disorder
(OUD) in rural communities by strengthening and expanding SUD/OUD prevention, treatment,
and recovery services.
B. Contractor possesses specific skills related to prevention, treatment, and recovery services for
SUD/OUD as set forth in the Grant.
C. Manager desires to engage the services of Contractor to provide Services for Kittitas County
Opioid Use Disorder Prevention, Treatment, and Recovery Project ("Project") as defined in Exhibit
2 "Services & Deliverables", incorporated herein by this reference, and subject to the terms and
conditions as required by Manager under this Contract, pursuant to the terms and conditions in
the "Health Resources and Services Administration (HRSA) Notice of Award Authorization" as
defined in Exhibit 1, incorporated herein by this reference.
NOW, THEREFORE, in consideration of the mutual benefits and burdens as set forth below, the
receipt and sufficiency of which are hereby acknowledged, Manager and Contractor agree as
follows:
1. Protect Scope of Work. Contractor will be responsible for assisting with the administration
of the Grant activities and services in Kittitas County, over which Manager has jurisdiction
as set forth in the Grant ("Services"). Contractor agrees to increase community access to
Naloxone, provide education about prescribing opioids, connect syringe service clients
with treatment services, conduct harm reduction education, and conduct education
about drug take back services.
2. Deliverables and Schedule. Contractor shall promptly and effectively deliver to Manager
the "Deliverables" at the times identified by Manager in Exhibit 2 "Services &
Deliverables".
3. Fees and Payment. Conditioned upon and in consideration of Contractor's timely, full and
faithful performance of the Services and timely submission of Deliverables as stated in
Exhibit 2 "Services & Deliverables", and timely, full and faithful performance of all terms
and conditions of this Contract, Manager agrees to pay Contractor "Contractor's Fees" on
the dates listed on the attached Exhibit 3 "Contractor's Fees", incorporated herein by this
reference. All requests for payments for Contractor's Fees will be remitted by Contractor
to Manager at the Manager Payment Contact as stated in Exhibit 3 following receipt of an
invoice for Services rendered during the preceding quarter, along with supporting
documentation, submitted no later than the Invoice Deadline Dates as set forth in Exhibit
3.
4. Termination. This Contract may be terminated by Contractor upon Thirty (30) days
written notice to the Manager. Manager may terminate this Contract upon not less than
Ten (10) days written notice to Contractor, in Manager's discretion.
5. Works For 1-fire/Protected Health Information. All nonprotected, public research, findings,
formulas and statistics that arise out of or are related to this Contract shall be considered
"works for hire" (as defined in 17 U.S.C. §101) and shall be considered assigned and
irrevocably licensed to Managgr, and, if not protected, in and part of the public domain.
Contractor hereby knowingly and voluntarily assigns any and all intellectual property that
results out of or is related to this Contract and the Services to Manager. At all times,
including after termination of this Contract, secure and forbid disclosure of protected
health information and comply with all provisions of the Health Insurance Portability and
Accountability Act ("HIPAA" found at 45 CFR Part 160 and 164) and the HIPAA Privacy
Rules and Security Rules promulgated thereunder.
6. Notices. With exception to the Manager Payment Contact, any and all Notices required
hereunder shall be to the persons and at the places as identified on the attached Exhibit
4, incorporated herein by this reference. Manager and Contractor may change the Notice
contact person or address effective the date as set forth on a Notice of change of contact
person/place to the other party.
7. Miscellaneous: Time is specifically declared to be of the essence. Manager and Contractor
agree to cooperate fully in all matters related to or arising out of this Contract. This
Contract was written by Manager and has been submitted to the scrutiny of Contractor
and Contractor's legal counsel and shall be given a fair and reasonable interpretation,
without consideration or weight being given to one of the parties. If Contractor has not
submitted this Contract to the scrutiny of its legal counsel, Contractor stipulates, despite
having the opportunity to do so, Contractor has waived the same, and elected to proceed
without the benefit of legal review. Waiver by any party of a breach of any covenant,
agreement or undertaking contained herein shall be made only by written waiver, and no
such waiver shall operate or be construed as a waiver of any prior or subsequent breach
of the same covenant, agreement or undertaking. Except as otherwise specifically
provided herein, the exercise of any remedy provided by law or otherwise and the
provisions of this Contract for any remedy, shall not exclude any other remedy. Manager
and Contractor execute this Contract solely as parties in a contractual agreement. No
partnership, joint venture or joint undertaking shall be construed from these presents,
and no third party may rely upon any provision of this Contract for its direct benefit except
as provided herein. This Contract is deemed entered into in the Washington County in
which Manager's office is situated and shall be governed under the laws of the State of
Washington. The parties hereto understand and agree that they each have a duty to act
in good faith on each and every term and condition of this Contract. Every duty and every
act which must be performed under this Contract imposes an obligation of good faith in
its performance or enforcement unless discretion is otherwise allocated to one of the
parties hereto. The parties agree that this Contract is the entire agreement between the
parties, that all preceding and contemporaneous oral and written statements,
representations and warranties, whether consistent or inconsistent herewith, are agreed
to be of no force and effect unless expressly stated herein. In that regard, Manager and
Contractor stipulate that each and every provision of this Contract has been fairly
bargained for, that the execution of this Contract memorializes the intent of Manager and
Contractor after thoughtful consideration of all risks and knowingly and voluntarily
assumed such risks. This Contract shall only be supplemented or modified in a signed
writing by Manager and Contractor. Manager and Contractor warrant that no
commissioned merchant, broker, agent, consultant, or similar person or entity has
assisted in procuring this Contract and that no broker or agent is entitled to any
commissions or fees. All exhibits, attachments and schedules are hereby incorporated
herein by this reference as if fully set forth herein. The parties agree that their signatures
that are remitted electronically to each other shall, when accumulated, operate as
originals. This Contract may be executed in counterparts.
8. Dispute Resolution. All claims and disputes relating to or arising out of this Contract that
are less than the Small Claims jurisdictional limit shall be filed in the Small Claims Division
of the District Court in the Washington County in which Manager is situated, and the
parties hereto hereby knowingly waive the provisions of Title 12 RCW prohibiting legal
counsel representation, meaning that the parties may be represented by legal counsel in
Small Claims Court. The parties hereby knowingly and voluntarily waive any right to
appeal on any Small Claims judgment, including, without limitation, alleged procedural or
evidentiary errors. All claims and disputes related to or arising out of this Contract in
excess of such jurisdictional limit, involve matters exceeding the jurisdictional limits of
Small Claims Courts or involve equitable remedies, shall be subjected to binding and non -
appealable arbitration as the sole and exclusive remedy. For all other matters, if the
parties cannot agree on an arbitrator, the Presiding Judge of the Washington County in
which Manager is situated shall appoint an arbitrator versed in the subject matter of the
claim or dispute, which arbitrator need not be a lawyer unless legal interpretation of the
Contract is required. If the arbitrator is a lawyer, the arbitrator may engage the services
of any expert to ascertain specialized factual determinations. Substantive discovery shall
be allowed in the sole discretion of the arbitrator. The arbitration shall commence not
later than ninety (90) days after an arbitration demand. The arbitrator may award
damages and injunctive relief and may register a judgment in the court of competent
jurisdiction including judgment by default. In any suit, arbitration, proceeding or action
to enforce any term, condition or covenant of this Contract or to procure an arbitration
determining the rights of the parties hereto, the most prevailing party shall be entitled to
recover from the other party reasonable sums as attorney fees and costs.
J. �BYSIGNING BELOW, ON BEHALF OF THE RESPECTIVE ENTITIES, CONTRACTOR AND
MANAGER HEREBY CONSENT TO ELECTRONIC TRANSMISSION COMMUNICATIONS FOR
ANY AND ALL NOTICES AND DISSEMINATION OF CONTRACT BUSINESS.
Manager:
Signature:4
Printed Name:
Title:
r
Date:-
Con tractor
Signature:
Printed Name:
Titl
44A, (-Ai i v -
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Date: —U
LIST OF EXHIBITS
Exhibit 1- Health Resources and Services Administration (HRSA) Notice of Award Authorization
Exhibit 2 -Services & Deliverables
Exhibit 3 -Contractors' Fees
Exhibit 4 -Primary contacts for agreement
Exhibit 1- Health Resources and Services Administration (HRSA) Notice of Award Authorization
1. Contractor shall notify Manager if they receive additional substance use disorder related
funding at any time during the effective dates of this agreement. Please submit the
following information to the Manager Primary Grant Contact listed in Exhibit 4 to
comply with this Condition:
a. Name of funding
b. Funding source
c. Dates of funding
d. Amount of award
e. Description of how the funding will supplement and/or complement activities
implemented under the RCORP Grant
f. Description of processes in place to avoid duplication of effort across RCORP
Grant implementation
g. Staffing plan (name, title, organization, FTE) for this funding if staff will be
dividing time between this funding and the RCORP Grant.
2. Contractor is required to allocate the funds from the RCORP Grant over a three-year
period of performance
3. For any given staff member, Contractor is not permitted to bill more than 1.0 Fulltime
Equivalent (FTE)across Federal awards.
4. Contractor shall respond to requests for data and information from Manager in a timely
I AMMI-laip
5. No sub -awards to any other agency are allowed under this agreement.
6. Effective December 26, 2014, all references to OMB Circulars for the administrative and
audit requirements and the cost principles that govern Federal monies associated with
this award are superseded by the Uniform Guidance 2 CFR 200 as codified by Health and
Human Services (HHS) at 45 CFR 75.
7. Contractor must comply with all terms and conditions outlined in applicable HHS Grants
Policy Statements, and requirements imposed by program statutes and regulations and
HHS Grant administration regulations, as applicable; as well as any requirements or
limitations in any applicable appropriations acts.
8. This agreement is subject to the HHS Grants Policy Statement (HHS GPS) unless
otherwise noted. Parts I through III of the HHS GPS are currently available at
http://www.hrsa.gov/grants/hhsgrantspolicy.pdf. Please note that the Terms and
Conditions explicitly noted in the award and the HHS GPS are in effect.
9. "This [project/publication/program/website] [is/was] supported by the Health
Resources and Services Administration (HRSA) of the U.S. Department of Health and
Human Services (HHS) as part of an award totaling $XX with xx percentage financed with
nongovernmental sources. The contents are those of the author(s) and do not
necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the
U.S. Government." Recipients are required to use this language when issuing
statements, press releases, requests for proposals, bid solicitations, and other HRSA
supported publications and forums describing projects or programs funded in whole or
in part with HRSA funding. Examples of HRSA supported publications include, but are
not limited to, manuals, toolkits, resource guides, case studies and issues briefs.
10. Recipients and subrecipients of Federal funds are subject to the strictures of the
Medicare and Medicaid antikickback statute (42 U.S.C. 1320a 7b(b) and should be
cognizant of the risk of criminal and administrative liability under this statute,
specifically under 42 U.S.C. 13207b(b) Illegal remunerations which states, in part, that
whoever knowingly and willfully: (A) Solicits or receives (or offers or pays) any
remuneration (including kickback, bribe, or rebate) directly or indirectly, overtly or
covertly, in cash or in kind, in return for referring (or to induce such person to refer) an
individual to a person for the furnishing or arranging for the furnishing of any item or
service, OR (B) In return for purchasing, leasing, ordering, or recommending purchasing,
leasing, or ordering, or to purchase, lease, or order, any goods, facility, services, or item
for which payment may be made in whole or in part under subchapter XIII of this
chapter or a State health care program, shall be guilty of a felony and upon conviction
thereof, shall be fined not more than $25,000 or imprisoned for not more than five
years, or both.
11. EO 13166, August 11, 2000, requires recipients receiving Federal financial assistance to
take steps to ensure that people with limited English proficiency can meaningfully
access health and social services. A program of language assistance should provide for
effective communication between the service provider and the person with limited
English proficiency to facilitate participation in, and meaningful access to, services. The
obligations of recipients are explained on the OCR website at HHS Limited English
Proficiency (LEP).
12. This award is subject to the requirements of Section 106 (g) of the Trafficking Victims
Protection Act of 2000, as amended (22 U.S.C. 7104). For the full text of the award term,
go to:
https://www.hrsa.gov/sites/default/files/hrsa/grants/manage/traffickingin persons.pdf.
13. The Department of Defense and Labor, Health and Human Services, and Education
Appropriations Act, 2019, Division H, § 202, (P.L 115245), enacted September 28, 2018,
limits the salary amount that may be awarded and charged to HRSA Grants and
cooperative agreements to the Federal Executive Pay Scale Level II rate set at $192,300,
effective January, 2019. This amount reflects an individual's base salary exclusive of
fringe benefits. An individual's institutional base salary is the annual compensation that
the recipient organization pays an individual and excludes any income an individual may
be permitted to earn outside the applicant organization duties. HRSA funds may not be
used to pay a salary in excess of this rate. This salary limitation also applies to
subrecipients under a HRSA Grant or cooperative agreement. The salary limitation does
not apply to payments made to consultants under this award although, as with all costs,
those payments must meet the test of reasonableness and be consistent with
recipient's institutional policy. None of the awarded funds may be used to pay an
individual's salary at a rate in excess of the salary limitation. Note: an individual's base
salary, per se, is NOT constrained by the legislative provision for a limitation of salary.
The rate limitation simply limits the amount that may be awarded and charged to HRSA
Grants and cooperative agreements.
14. To serve persons most in need and to comply with Federal law, services must be widely
accessible. Services must not discriminate on the basis of age, disability, sex, race, color,
national origin or religion. The HHS Office for Civil Rights provides guidance to grant and
cooperative agreement recipients on complying with civil rights laws that prohibit
discrimination on these bases. Please see
http://www.hhs.gov/civilrights/forindividuals/index.html. HHS also provides specific
guidance for recipients on meeting their legal obligation under Title VI of the Civil Rights
Act of 1964, which prohibits discrimination on the basis of race, color or national origin
in programs and activities that receive Federal financial assistance (P. L. 88352, as
amended and 45 CFR Part 75). In some instances, a recipient's failure to provide
language assistance services may have the effect of discriminating against persons on
the basis of their national origin. Please see
http://www.hhs.gov/civilrights/forindividuals/specialtopics/limitedenglishproficiency/in
dex.html to learn more about the Title VI requirement for grant and cooperative
agreement recipients to take reasonable steps to provide meaningful access to their
programs and activities by persons with limited English proficiency.
15. In any grant related activity in which family, marital, or household considerations are, by
statute or regulation, relevant for purposes of determining beneficiary eligibility or
participation, grantees must treat same sex spouses, marriages, and households on the
same terms as opposite sex spouses, marriages, and households, respectively. By "same
sex spouses," HHS means individuals of the same sex who have entered into marriages
that are valid in the jurisdiction where performed, including any of the 50 states, the
District of Columbia, or a U.S. territory or in a foreign country, regardless of whether or
not the couple resides in a jurisdiction that recognizes same sex marriage. By "same sex
marriages," HHS means marriages between two individuals validly entered into in the
jurisdiction where performed, including any of the 50 states, the District of Columbia, or
a U.S. territory or in a foreign country, regardless of whether or not the couple resides in
a jurisdiction that recognizes same sex marriage. By "marriage," HHS does not mean
registered domestic partnerships, civil unions or similar formal relationships recognized
under the law of the jurisdiction of celebration as something other than a marriage. This
term applies to all grant programs except block grants governed by 45 CFR part 96 or 45
CFR Part 98, or grant awards made under titles IVA, XIX, and XXI of the Social Security
Act; and grant programs with approved deviations.
16. §75.113 Mandatory disclosures. Consistent with 45 CFR 75.113, applicants and
nonfederal entities must disclose, in a timely manner, in writing to the HHS awarding
agency, with a copy to the HHS Office of Inspector General (OIG), all information related
to violations of federal criminal law involving fraud, bribery, or gratuity violations
potentially affecting the federal award. Subrecipients must disclose, in a timely manner,
in writing to the prime recipient (pass through entity) and the HHS OIG, all information
related to violations of federal criminal law involving fraud, bribery, or gratuity
violations potentially affecting the federal award. Disclosures must be sent in writing to
the awarding agency and to the HHS OIG at the following address:
Department of Health and Human Services
Health Resources and Services Administration
Office of Federal Assistance Management
Division of Grants Management Operations
5600 Fishers Lane, Mailstop 10SWH03
Rockville, MD 20879
AND
U.S. Department of Health and Human Services
Office of Inspector General
Attn: Mandatory Grant Disclosures, Intake Coordinator
330 Independence Avenue, SW, Cohen Building
Room 5527
Washington, DC 20201
Fax: (202)2050604
(Include: "mandatory Grant Disclosures" in subject line) or Email:
mandatoryGranteeDisclosures@oig.hhs.gov
Failure to make required disclosures can result in any of the remedies described in 45
CFR 75.371. Remedies for noncompliance, including suspension or debarment (See 2
CFR parts 180 & 376 and 31 U.S.C. 3321). The recipient must include this mandatory
disclosure requirement in all subawards and contracts under this award.
17. Non -Federal entities that have received a Federal award including the term and
condition outlined in Appendix XII are required to report certain civil, criminal, or
administrative proceedings to www.sam.gov. Failure to make required disclosures can
result in any of the remedies described in §75.371, including suspension or debarment.
(See also 2 CFR parts 180 and 376, and 31 U.S.C. 3321). Recipient integrity and
performance matters. If the total Federal share of the Federal award is more than
$500,000 over the period of performance, Appendix XII to CFR Part 200 is applicable to
this award.
Exhibit 2 -Services & Deliverables
The Services, Deliverables and Schedule for delivery to Manager are described below and shall
commence on the Effective Date. Contractor shall implement the following work plan and collect
the corresponding measures found in the Kittitas County Opioid Response Strategic Plan and the
work plan for the HRSA Rural Communities Opioid Response Program implementation Grant.
Required Grant Activity
Develop, implement, and
assess intervention models
that leverage opioid overdose
reversal and increased
naloxone availability as a
bridge to treatment and
ensure that rural communities
have sufficient access to
naloxone.
Increase the number of
providers who regularly use a
Prescription Drug Monitoring
Program (including prescribers
and pharmacists) and reduce
over -prescribing practices.
Identify and screen individuals
who are at risk of SUD/OUD
and make available prevention,
harm reduction, early
intervention services, referral
to treatment and other
supportive services to
minimize the potential for the
development of SUD/OUD.
Track, screen, prevent, and
refer to treatment patients
with SUD/OUD who have
SERVICES & DELIVERABLES
Strategies
• Work with physicians to
encourage co -prescribing of
naloxone with opioid
prescriptions
• Increase pharmacist
distribution of naloxone
Work with local pharmacies
to provide over the counter
naloxone with opioid
prescriptions
• Distribute naloxone at local
syringe service programs
■ Conduct annual provider
trainings about using the
Prescription Drug
Monitoring Program
• Conduct annual health care
provider, dentist, and
pharmacist education to
discourage over -prescribing
and encourage usage of the
Prescription Drug
Monitoring Program
• Create pathways
(screening, referrals, care
coordination) to treatment
services for people
accessing syringe exchange
programs
Conduct harm reduction
education and
HIV/hepatitis C testing in
Measures
■ Number of pharmacies
distributing naloxone
• Number of naloxone kits
distributed through syringe
exchange
1 •
Number of providers
trained
Increase in knowledge
about over -prescribing
(pre/post surveys)
• Number of people referred
to treatment
Number of education
participants
® Number of patients tested_
Required Grant Activity
infectious complications,
including HIV, viral hepatitis,
and endocarditis, particularly
among PWID.
Implement year-round drug
take -back programs.
SERVICES & DELIVERABLES
Strategies
settings with high risk
individuals (at least 4
events per year)
a Conduct pharmacist
education about drug take
back (at least 3 per year)
Measures
• Number of pharmacies
conducting drug take back
Additional Deliverables required by the Manager, in addition to those set forth in the Grant, are
as follows:
1. Participate in Kittitas County Health Network' (KCHN's) monthly Leadership Council and
Opioid Response Work Group meetings.
2. Participate in task forces addressing barriers to recovery (housing, transportation, child
care, etc.)
3. Provide quarterly reports summarizing progress on each activity in the above work plan
and providing data for the measures. Quarterly reports will be due on the same dates as
the Invoice Deadline Dates listed in Exhibit 3.
Exhibit 3 -Contractor's Fees
The total hours of work required and any costs incurred to complete the Project and the activities
listed in Exhibit 1 are the responsibility of Contractor for the Contractor's Fees. No costs will be
compensated outside of those included in the Contractor's Fees as set forth below unless by prior
written approval of Manager, in Manager's sole discretion. For Contractor's Fees for Contractor's
Services, conditioned upon the timely and effective communication of all Deliverables in
accordance with their respective Schedule, Manager shall pay Contractor the Contractor's Fees
as set forth below:
In consideration for satisfactory performance of these Services as outlined in Exhibit A,
Manager agrees to pay Contractor $123,000.00 in twelve (12) equal quarterly payments
of $10,250.00 each between September 1st, 2019 and August 311t, 2022 based upon the
completion of deliverables and satisfactory progress on the work plan. Payments will be
remitted following receipt of an invoice for services along with supporting back up
documentation of expenditures. Acceptable expenditures shall be in alignment with the
Grant budget below.
Staff Salaries & Benefits $123,000.00
TOTAL $123,000.00
Please send invoices and reports to the Manager Payment Contact listed below:
Name: Robin Read, KCHN Executive Director
Address: 400 E. Mountain View Ave. c/o KVFR, Ellensburg, WA 98926
Email: robin@healthierkittitas.org
Invoice Deadline Dates:
December 31, 2019
(for September 1 -November 30, 2019)
March 31, 2020
(for December 1, 2019 -February 28, 2020)
June 30, 2020
(for March 1 -May 31, 2020)
September 30, 2020
(for June 1 -August 31, 2020)
December 31, 2020
(for September 1 -November 30, 2020)
March 31, 2021
(for December 1, 2020 -February 28, 2021)
June 30, 2021
(for March 1 -May 31, 2021)
September 30, 2021
(for June 1 -August 31, 2021)
December 31, 2021
(for September 1 -November 30, 2021)
March 31, 2022
(for December 1, 2021 -February 28, 2022)
June 30, 2022
(for March 1 -May 31, 2022)
September 30, 2022
(for June 1 -August 31, 2022)
Exhibit 4 -Primary contacts for agreement
Contact Person/Place-Manager
Name: Robin Read, Kittitas County Health Network
Address: 400 E. Mountain View Ave., c/o KVFR, Ellensburg, WA, 98926
Email: robin@healthierkittitas.org
Contact Person/Place-Contractor
Name: Tristen Lamb, Kittitas County Public Health Department
Address: 507 N. Nanum, Suite 102, Ellensburg, WA 98926
Email: tristen.lamb@co.kittitas.wa.us
Today's Date
12/17/2019
Fund/Department
116 -Public Health
Kittitas County
Review Form
Grants & Contract Agreement
Agenda Date
�J GUS �
Contract/Grant Information
Contract /Grant Agency: Contract between Kittitas County Health Network and Kittitas County Public
Health
Period Begin Date: 09/01/2019 Period End Date: 08/31/2022
Total Grant/Contract Amount: $123,000.00
Grant/Contract Number:
Contract/Grant Summary:
The contract between Kittitas County Health Network and Kittitas County Public Health (KCPHD) is
established to allow KCPHD to provide services for Kittitas County Opiod Use Disorder Prevention,
Treatment, and recovery project.
Recommendation for Board of Health and Board of Health Review on
Administrator Date: -Z-?-)
Department Head Sigrfature:
Kittitas County Prosecutor, Auditor, and Board of Hea
APPROVED AS TO FORM:
Sture of Prosecutor's ice Date
n_
of Auditor's Office
Signature of Board of Health member
Financial Information
Total Amount $
Percentage County Funds
Date
Date
State Funds $
Matching Funds $
Federal Funds $
CFDA#
Grant/Contract Review Page 1
Budget Information
Budget Amendment Needed?
New Division Created?
Revenue Code
Pass Through Information
Yes ❑ attach budget form NO ❑ Why not
Agency to Pass Through
Amount to Pass Through $
Sub -Contract Approved Date:
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes El No ❑
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
Signature: Date:
Department:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer I Date
Grant/Contract Review Page 2