HomeMy WebLinkAboutAmendment 17KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
2018 *202I CONSOLIDATED CONTRACT
CONTRACTNUMBER: CLH18249 AMENDMENTNUMBER: l?
PURPOSD OI: CHANCE: To antend this contract betrveen the DEPARTIVIENT OF I-IEAt,l'll hcr.cinafter retbr.r.ed to as "DOH", arrd
KITTITAS COUNTY PUBLIC HF,ALTH DEPAR'l'MENT, a Local Health Jurisdiction, hereinaller.r.cl'erred to as "l,HJ", purlsuanr to
the Modifications/Waivers clause, and to make necessaty changes rvithin the scope of this conh.act anrt any subsequent amendrnents
thereto.
n IS MUTUALLY AGREED: On February 29,2020, Goventor Jay lnslee issued Proclamation 20-05 declaring a State of
Emergency due to lhe outbreak of COVID-19. In June 2020, DOI'I and LI.IJ agreed that lo support the par.tics' ongoing l.esponse to
the emergency, the parties rvoultl extend the end date of the Co[tl'act rather thau beginning a nerv three-year contract. For ease of
teference, the Contracl as amended is attached and incor;roraled in this amendrnent shotving the insertions, deletions, an4 revisions as
follorvs: Section I Purpose and Secfion 2 Staternents of Work. Remove reference to repealed RCW 43.70.520 and IICW 43.?0.580.
Section 33 Tenn. Extend thc Contract tet'tn for a period of one yeal fi'om Deccrnber'31,2020 through Decernber il,Z02l.lleading
on page one and footers arc updated to r.eflecl the extended contract term.
Exhibit A Staternents of Work, attached and incorporated by this LefeLence, are arnended as follorvs:
A Adds Statements olWork for the following programs:
. Supplemental Nutrition Assistance Plograrn-Education - Effective October 1,202A
tr Arnends Stafemonts of Work fol the follorving programs:
r Division olErnergency Preparedness & Response pHEp - Effective July l, 2020r LSPAN-Local Strategies for Physical Activily & Nuttition - Effective February 19,2019r Maternal & Child Health Block Crant - Effective January l, 2018r OICP CARES Enhanced [nfluenza Coverage Project - Effective July l,2020r OlCP-Promotion of lmmunizations to hnprove Vaccination Rates - Effective July l, 2020
n Deletes Statements of Work for the follorving programs:
2. Exhibit B-t7 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-16 Allocations as follorvs:
X lnclease of$l554!!5 for.a revised maximurn consideration of $2.309.403.
D Decrease of _ for a revised maximnm consideration of _.
n No change in the maxirnurn consideralion of _..- Exhibit B Allocations are auached only for informational purposes.
3' Exhibit C-14 Schedule of Fede ral Arvards, attached and incorporated by this re&r'ence, amends and replaces Exhibit C- 13.
Unless designated otherrvise helein, the effective date of this amendment is the date of execulion.
ALL OTHER TERMS AND CONDITIONS of the original contract and any sub$equent arnendtnents rernain in full folce and effect
upou execution of this amendrnent.
IN WITNESS WHEREOF, the undersigned has afftxed hiVher sigrrature in execution theleofl.
KITTITAS COUN'TY PUBLIC HEALTH DEPARTMENT STATE OF WASHINGTON
DEPARTMENT OF HEALI'TI
APPITOVED AS TO FORM ONLY
Assistant Altolney Ceneral
Date Date
DOH CONTRACT #: CLH18249
2018 - 292e 2021
WASHINGTON STATE
DEPARTMENT OF HEALTH
CONSOLIDATED CONTRACT
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Table of Contents
Purpose
Statements of Work
Exhibits
Definitions
Funding and Billing
Contract Management...............
Access to Records.
All Writings Contained Herein
Assignment .................
Assurances
Confi dential Information
Ethics
Debarment Certifi cation
Disputes
Equipment Purchases
Governing Law and Venue.......
Independent Capacity
Insurance
Licensing, Accreditation and Registration .....
Maintenance of Records
Modifications and Waivers.....
No Third-Party Rights Created
Nondiscrimination
Order of Precedence ..............
Ownership of Material/Rights in Data
26. Publications...................
DOH CONTRACT #: CLH|8249
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Responsibility for Actions
Loss or Reduction of Funding ......
Severability
Subcontracts.................
31. Subrecipient
32. Survivability
Termination for Convenience ..........
Termination for Default.
Termination Procedure
Standard Federal Certifications and Assurances....
Federal Assurances - Non-Construction Programs
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201 81929 2 0 2 I Consolidated Contract Page 2 of 17
DOH CONTRACT #: CLHI8249
CONSOLIDATED CONTRACT
between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
(Referred to as (DOH")
and
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
(Referred to as "LHJ")
for
THE DELryERY OF PUBLIC HEALTH SERVICES
FOR THE PERIOD OF
January 1, 2018 through December 31,2A20 2021
1. Purpose
This Contract is entered into in accordance ,1i11't BeW 15,20,520, ReW 43 the general statutory powers of the
Secretary ofthe Department of Health (DOH), including at RCW 43.70.040,1he general statutory powers of local health
jurisdictions (LHJs), including at RCW 70.05.060, RCW 70.08.020, and RCW 70.46.060, and the authority for joint or
cooperative action provided for under chapter 39,34 RCW. The purpose of this Contract is to define the parties' joint
and cooperative relationship. The contract and all statements of work adopted under its provisions are intended to
implement applicable objectives under the Public Health Improvement Plan and to facilitate the delivery of public health
services to the people in Washington State. This Contract is the result of cooperative planning efforts between the LHJ
and DOH.
2. Statements of Work
The individual program activities, requirements, and outcomes/deliverables to be achieved by the parties under this
Contract are described in Exhibit A, Statements of Work. Faebstatement efwer
The LHJ shall furnish the necessary personnel, equipment, material and/or services and otherwise do all things necessary
for or incidental to the performance of the work as set forth in Exhibit A, Statements of Work.
3. Exhibits
This Contract incorporates by reference the following Exhibits:o Exhibit A - Statements of Work
o ExhibitB-Allocations
o Exhibit C - Schedule of Federal Awards
4. Definitions
As used throughout this Contract and unless amended for a particular Statement of Work, the following terms shall have
the meanings set forth below:
"Budget, Accounting, and Reporting System (BARS)": The system designed by the State Auditor's office for
collecting, consolidating, and reporting financial budgeting and accounting information from all local governmental
units.
"Client": An agency, firm, organization, individual or other entity applying for or receiving services provided by
the LHJ under this Contract.
"Catalog of Federal Domestic Assistance (CFDA)": The unique identifuing code assigned to a federal assistance
program which identifies the awarding agency.
"Confidential Information": Information protected from disclosure under federal or state law.
20 18-2+29 2 02 I Consolidated Contract Page 3 of 17
DOH CONTRACT #: CLHI8249
"Contract Coordinator": Each parfy's designated contact for all notices required or permitted under this Contract.
"Contracting Officer": The DOH Contracts and Procurement Office Director and his/trer delegates within that
office authorizedto execute this agreement on behalf of DOH.
"Contractor": An entity that provides goods or services to DOH and others. A contractor normally operates its
business in a competitive environment, provides its goods and/or services to many different purchasers during
normal business hours, and is not subject to the compliance requirements of the federal program.
"Equipment": When used in this Contract is defined as an article of non-expendable, tangible property other than
land, buildings, or fixtures which is used in operations and having a useful life of more than one year and an
acquisition cost of $5,000 or more or as otherwise provided in the Exhibit A, Statements of Work.
"Federal Assistance": Assistance provided by a federal agency in the form of grants, contracts, loans, loan
guarantees, property, cooperative agreements, interest subsidies, insurance, or direct appropriations, but does not
include direct federal cash assistance to individuals.
"Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act)": A federal act to make
information available online so the public can see how federal funds are spent.
"Fixed Assets": Fixed assets are properfy and/or equipment obtained through donation, gift, purchase, capital lease,
or construction with a service life of more than one year.
ooProgram Contact": Each party's designated contact for those purposes identified in the Exhibit A, Statements of
Work.
"Subcontractor": Any individual or group contracted with the LHJ to perform all or part of the services included
in this Contract. This term will also apply to situations where an LHJ's subcontractor contracts with another
individual or group to perform all or part of the services included in its agreement with the LHJ.
"Subrecipient" or "Subgrantee": A non-federal entity that receives a subaward of federal grant money or goods
directly or indirectly from DOH and makes decisions regarding who can receive what federal assistance; has its
performance measured against the objectives contained in the DOH agreement with the federal government; makes
decisions on how to operate the program to accomplish the program goals; has the obligation to comply with federal
subrecipient requirements; andlor use federal funds to carry out a program for the public purpose specified in the
authorizing statute.
5. Funding and Billing
A. DOH shall pay the LHJ for services as set forth in the Exhibit A, Statements of Work, not to exceed funding amounts
as detailed in the Contract Allocations, Exhibit B, for those services provided herein.
The LHJ will advise the Program Contact identified in the applicable Statement of Work in writing 90 calendar
days prior to the end ofthe funded period, or as soon as practicable thereafter, ifthe LHJ anticipates not using all
Contract funding.
B. If the Exhibit A, Statement of Work, is supported by federal funds that require compliance with FFATA (the
Transparency Act), the corresponding checkbox on the statement of work will be checked.
C. Total consideration for this Contract is $79.038, or as amended.
The LHJ will submit accurate and timely billings which, for clarity and consistency, will be prepared using the form
provided and following the instructions located on the DOH website, www.doh.wa.gov.
DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for allowable
costs as outlined in the statement of work and/or budget.
20 I 8-2e2e 2 02 I Consolidated Contract Page 4 of 17
DOH CONTRACT #: CLH|8249
D. The LHJ will submit a BARS A financial report by April 15 for the prior calendar year.
6. Contract Management
Unless otherwise specified in the Contract, the following individuals are the contacts ("Contract Coordinators") for all
notices required or permitted under this Contract:
LHJ Contract Coordinator:DOH Contract Coordinator:
Name: Candi Blackford Name: Brenda Henrikson
Title: Contracts Specialist
Mailine Address:Mailing Address:
507 N. Nanum Street, Suite 102
Ellensburg WA 98926-2886 PO Box 47905, Olympia WA 98504-7905
Physical Address:Phvsical Address:
Same as above 101 Israel Rd. SE, Tumwater WA 98501-5570
Phone: 509-962-7515 Fax: 509-962-7581 Phone: 360-236-3933 Fax: 360-236-2401
Email Address:Email Address:
candi.blackford@co.kittitas. wa.us brenda.henrikson@doh.wa.gov
A party may change its Contract Coordinator or its Program Contact by providing written notice to the other party.
DOH Program Contacts can be found in the Exhibit A, Statements of Work, and on the DOH website at
www.doh.wa.gov.
7. Access to Records
To the extent authorizsdby applicable federal and state law, the parties shall provide access to records relevant to this
Contract to each other, the Joint Legislative Audit and Review Committee, the State Auditor, and authorized federal
officials, at no additional cost. Inspections shall occur at reasonable times and upon reasonable notice.
8. All Writings Contained Herein
This Contract contains all the terms and conditions agreed upon by the parties. No other understandings, oral or otherwise,
regarding the subject matter of this Contract shall be deemed to exist or to bind any of the parties hereto. The individuals
signing this Contract certify by their signatures that they are authorized to sign this Contract on behalf of their respective
entity.
9. Assignment
Except for subcontracting as authorized in this Contract, the LHJ shall not assign or delegate, in whole or in part, this
Contract or any of its rights, duties, obligations, or responsibilities, without the prior written consent of DOH's
Contracting Officer, which consent shall not be unreasonably withheld.
10. Assurances
The parties agree that all activity pursuant to this Contract shall be in accordance with all applicable current federal,
state and local laws, rules, and regulations.
The LHJ acknowledges its agreement to comply with federal certifications and assurances by signing and returning the
following:
1. Standard Federal Certifications and Assurances
2. Federal Assurances for Non-Construction Programs
20 18-202e 2 0 2 I Consolidated Contract Page 5 of 17
DOH CONTRACT #: CLH18249
11. Confidential Information
The parties agree to comply with all state and federal statutes and regulations relating to Confidential Information. DOH
and LHJ will limit access to the Confidential Information to the fewest number of people necessary to complete the
work. Everyone having access to Confidential Information covered by this Contract must agree to protect the
confi dentiality of the information.
Either party to this Contract may designate certain Confidential Information as "Confidential InformationA.,lotice
Requested." The designation shall be made by clearly stamping, watermarking, or otherwise marking each page of the
Confidential Information. If a third party requestor seeks information that has been marked "Confidential
InformationArlotice Requested," notice shall be given to the marking party prior to release of the information. Such
notice shall be provided to the program contact no less than five (5) business days prior to the date of disclosure, to
allow the party objecting to disclosure to seek a protective order from the proper tribunal.
DOH and LHJ agree to establish, document and maintain security practices and safeguards consistent with state and
federal laws, regulations, standards, and guidelines to prevent unauthorized access, use, or disclosure of Confidential
Information in any form. In accordance with federal and state contracting requirements, DOH may monitor, audit, or
investigate LHJ management of Confidential Information relating to this Contract. Working together, the LHJ and
DOH may use any and all tools available to track Contract related Confidential Information.
If one of the parties becomes aware of an actual or suspected breach of confidentiality, that party will promptly notify
the Contract Coordinator for the other party of the facts. The parties will work within their respective organizations to
take any steps necessary to determine the scope of the breach and to restore reasonable security to the Confidential
Information. Both parties agree to mitigate any known harmful effects of a breach in confidentiality, including notifying
affected individuals to the extent required by law. The parties will also reasonably cooperate with law enforcement as
appropriate.
12. Ethics
Both parties and their officers shall comply with all ethics laws applicable to their activities under this Contract,
including Chapters 42.23 and 42.52 RCW. If a violation occurs and is not cured within a reasonable time after notice,
the other party shall have the right to terminate this Contract. This section is expressly subject to the Disputes section
oIthis Contract.
13. Debarment Certification
The LHJ, by signing this Contract, certifies that the LHJ is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participating in this Contract by any federal department or agency.
The LHJ also agrees to include the above requirement in all subcontracts into which it enters. The LHJ will notify DOH
of any such events that may occur during the term of the Contract.
14. Disputes
Except as otherwise provided in this contract, when a dispute arises between the parties and it cannot be resolved by
direct negotiation, the parties agree to participate in good faith in non-binding mediation. The mediator shall be chosen
by agreement of the parties. If the parties cannot agree on a mediator, the parties shall use a mediation service located
in Washington State that selects a qualified mediator for the parties. Each party shall bear its own costs for mediation
and each party shall contribute equally to the mediator's fee, if any. The parties agree that mediation shall precede any
action in a judicial tribunal.
Nothing in this contract shall be construed to limit the parties' choice of a mutually acceptable alternate dispute
resolution method in addition to the dispute resolution procedure outlined above.
15. Equipment Purchases
Equipment purchased by the LHJ for use by the LHJ or its subcontractors during the term of this Contract using federal
funds, in whole or in part, shall be the property of the LHJ. The use, management and disposal of the equipment must
comply with federal requirements. These requirements are found in the Office of Management and Budget's (OMB's)
20 1 8492e 2 0 2 I Consolidated Contract Page 6 of 17
DOH CONTRACT #: CLHI8249
Uniform Guidance, Title 2 Code of Federal Regulations Part 200 (2 CFR 200) - Uniform Administrative Requirements,
Cost Principles, and Audit Requirements for Federal Awards, or are included in the federal funding agency's
regulations.
16. Governing Law and Venue
The laws of the state of Washington govern this Contract. In the event of a lawsuit by the LHJ against DOH arising
under this Contract, venue shall be proper only in Thurston County, Washington. In the event of a lawsuit by DOH
against the LHJ arising under this Contract, venue shall be proper only in the county in which the LHJ is located or in
either of the two nearest judicial districts within the meaning of RCW 36.01.050.
17. Independent Capacity
The employees or agents of each party who are engaged in the performance of this Contract shall continue to be
employees or agents ofthat party and shall not be considered for any purpose to be employees or agents ofthe other
party.
18. Insurance
The LHJ certifies that it is self-insured, is a member of a risk pool, or maintains insurance coverage as required by this
Contract. Each party shall pay for losses for which it is found liable. The LHJ agrees to require all subcontractors to
maintain insurance in types and with limits as may be determined by the LHJ and/or its risk manager, unless the LHJ and
DOH agree otherwise.
19. Licensing, Accreditation and Registration
The LHJ shall comply with all applicable local, state, and federal licensing, accreditation and registration requirements
and standards, necessary for the performance ofthis Contract.
20. Maintenance of Records
Each party to this Contract shall maintain books, records, documents and other evidence that sufficiently and properly
reflect all direct and indirect costs expended by it. All books, records, documents, and other material relevant to this
Contract will be retained for six (6) years after expiration. If any litigation, claim or audit is started before the expiration
of the six-year period, the records shall be retained until all litigation, claims, or audit findings involving the records
have been resolved.
Each party will use reasonable security procedures and protections to assure that records and documents provided by
the other party are not erroneously disclosed to third parties. Both parties agree to continue protecting records until
such time as the information is destroyed in accordance with applicable state and federal records retention laws.
21. Modifications and Waivers
This Contract, or any term or condition, may be modified only by a written amendment signed by the DOH Contracting
Officer and the authorized representative for the LHJ. Either party may propose an amendment.
Failure or delay on the part of either party to exercise any right, power, privilege or remedy provided under this Contract
shall not constitute a waiver. No provision of this Contract may be waived by either party except in a writing signed by the
DOH Contracting Officer or the authorized representative of the LHJ.
22. No Third-Party Rights Created
This Contract, or any program hereunder, is entered into solely for the benefit of the two parties thereto and shall not
be construed as giving rise to any right, remedy or expectancy ofany kind or nature on the part ofany third party.
23. Nondiscrimination
During the performance of this Contract, the LHJ and DOH shall comply with all federal and state nondiscrimination laws,
regulations and policies. In the event of the LHJ's noncompliance or refusal to comply with any nondiscrimination law,
regulation or policy, this Contract may be rescinded, canceled or terminated in whole or in paft, and the LHJ may be declared
20 1 8-2029 2 0 2 I Consolidated Contract PageT of 17
DOH CONTRACT #: CLHI8249
ineligible for further contracts with DOH. The LHJ shall, however, be given a reasonable time in which to cure this
noncompliance. Any dispute may be resolved in accordance with the "Disputes" procedure set fofth herein.
24. Order of Precedence
In the event of an inconsistency in the terms of this Contract, or between its terms and any applicable statute or rule, the
inconsistency shall be resolved by giving precedence in the following order:
o Applicable state and federal statutes, and local laws, rules and regulations.
o Terms and conditions of this Contract.
o Statements of Work.
. Any other provisions of this Contract, including other materials incorporated by reference.
25. Ownership of Material/Rights in Data
Records and other documents relevant to this Contract, in any medium, furnished by one party to this Contract to the
other party, will remain the property of the fumishing party, unless otherwise agreed. Data which is delivered under
the Contract shall be transferred to DOH with a nonexclusive, royalty-free, perpetual, irrevocable license to publish,
translate, reproduce, modify, deliver, perform, dispose of, and to authorize others to do so; provided that such license
shall be limited to the extent which the LHJ has a right to grant such a license. The LHJ shall exert all reasonable effort
to advise DOH, at the time of delivery of data furnished under this Contract, of all known or potential invasions of
privacy contained therein and of any portion of such document which was not produced in the performance of this
Contract. DOH shall receive prompt written notice of each notice or claim or copyright infringement received by the
LHJ with respect to any data delivered under this Contract. DOH shall have the right to modify or remove any restrictive
markings placed upon the data by the LHJ, provided that if DOH modifies or removes such markings without the LHJ's
approval, it assumes all liability for doing so.
26. Publications
Any program reports, articles, and publications that result from information gathered through use ofstate and federal
funds must acknowledge receiving support from DOH and/or the appropriate federal agencies. Correspondingly, such
documents resulting from information gathered through use of local funds must acknowledge receipt of such local
support.
27. Responsibility for Actions
Each party to this Contract shall be solely responsible for the acts and omissions of its own officers, employees, and
agents in the performance of this Contract. Neither party to this Contract will be responsible for the acts and omissions
of entities or individuals not party to this Contract. DOH and the LHJ shall cooperate in the defense of tort lawsuits,
when possible.
28. Loss or Reduction of Funding
In the event funding from state, federal, or other sources is withdrawn, reduced, or limited in any way after the effective
date of this contract and prior to normal completion, DOH may elect to suspend or terminate the contract, in whole or
in part, under the "Termination for Convenience" clause with a ten (10) business day notice to LHJ, to the extent
possible, subject to renegotiation at DOH's discretion under those new funding limitations and conditions.
29. Severability
If any term or condition of this Contract is held invalid, such invalidity shall not affect the validity of the other terms or
conditions of this Contract, provided, however, that the remaining terms and conditions can still fairly be given effect.
30. Subcontracts
The LHJ may subcontract any or all of the services or other obligations specified in this Contract. The LHJ will require
the subcontractor to comply with all the applicable terms and conditions of this Contract, including all terms, conditions,
certifications and assurances. The LHJ agrees it is responsible for assuring adequate performance on the part of the
subcontractor.
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DOH CONTRACT #: CLHL8249
The parties agree that all subcontractors must be responsible for any liabilities created by their actions or omissions. In
the event DOH, LHJ, and subcontractor are found by a jury or trier of fact to be jointly and severally liable for personal
injury damages arising from any act or omission, then each entity shall be responsible for its proportionate share.
31. Subrecipient
For those activities designated as "subrecipient" on Exhibit A, Statements of Work, the LHJ must comply with
applicable federal requirements, including but not limited to OMB's Uniform Guidance at 2 CFR 200, Subparts D
(Administrative Requirements), E (Cost Principles) and F (Audit Requirements), and program specific federal
regulations. If the LHJ expends $500,000 or more in federal awards from all sources, it is responsible for obtaining
appropriate audits. If the LHJ expends $750,000 or more in federal grants or awards from all sources, it is responsible
for obtaining the required single audit.
32. Survivability
The terms and conditions contained in this Contract, which by their sense and context are intended to survive the
expiration of the Contract, shall survive. Surviving terms include, but are not limited to: Access to Records, Confidential
Information, Disputes, Responsibility for Actions, Maintenance of Records, Ownership of Material/Rights in Data,
Subcontracts, Termination for Convenience, Termination for Default, and Termination Procedure.
33. Term
This Contract will be in effect following execution by the parties from January 1,2018 through December 31,282e
202 I , unless terminated earlier as provided herein.
34. Termination for Convenience
Except as otherwise provided in this Contract, either party may terminate or suspend this Contract, or any program
hereunder, for convenience by providing at least thirty (30) days' advance written notice to the other parfy.
If DOH elects to suspend the Contract, in whole or in part, LHJ shall stop work as of the effective date of DOH's written
notice of suspension. During suspension, each Party will reasonably notify the other of any conditions that may affect
resumption of performance. Upon DOH's wriffen notice to resume performance, LHJ shall resume work unless the
LHJ provides notice to DOH that services cannot be resumed. If LHJ cannot resume performance, the Contract or
affected Exhibit A, Statement of Work, will be deemed terminated upon the date the LHJ received notice to suspend
performance.
35. Termination for Default
(a) In the event of a default by either party under this Contract, the nondefaulting party may give written notice to the
defaulting party that it intends to terminate this Contract, or any program hereunder, ifthe default is not cured within
thirty (30) days of the date of the notice, or such longer period of time as may be reasonable under the circumstances.
If the default is not cured within that time, the nondefaulting party may then notify the defaulting party in writing
that this Contract is terminated. In the event of such termination, the nondefaulting party shall have all rights and
remedies available to it under general law.
(b) A disputed termination for default is expressly subject to the Disputes section of this Contract.
36. Termination Procedure
Upon termination DOH may require the LHJ to deliver to DOH any non-LHJ-owned equipment, data, or other property
specifically produced or acquired for the performance of such part of this Contract as has been terminated.
DOH shall pay to the LHJ the agreed upon price, if separately stated, for completed work and services accepted by
DOH. In addition DOH shall pay the amount determined by DOH's Contracting Officer for (a) completed work and
services for which no separate price is stated, (b) partially completed work and services, (c) other property or services
which are accepted by DOH, and (d) the protection and preservation of the property. Disagreement by the LHJ with
the determination of DOH's Contracting Officer that relates to the obligations or amounts due to the LHJ shall be
considered a dispute within the meaning of the "Disputes" clause of this Contract.
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DOH CONTRACT #: CLHI8249
DOH may withhold from any amounts due the LHJ for such completed work or services such sum as DOH's Contracting
Officer reasonably determines to be necessary to protect DOH against potential loss or liability.
The rights and remedies of DOH provided in this section shall not be exclusive and are in addition to any other rights
and remedies provided by law or under this Contract.
After receipt of a written notice of termination, the LHJ shall:
. Stop work under the Contract on the date and to the extent specified in the notice;o Place no further orders or subcontracts for materials, services, or facilities, except as necessary to complete such
portion of the work not terminated;
e Assign to DOH, to the extent reasonably directed by DOH's Contracting Officer and to the extent that the LHJ
has the legal right to do so, all ofthe right, title, and interest ofthe LHJ under the orders and subcontracts in
which case DOH has the right, at its reasonable discretion, to settle or pay any or all claims arising out of the
termination ofsuch orders and subcontracts.
e Settle all outstanding liabilities and all claims arising out of orders or subcontracts, with the approval or
ratification of DOH's Contracting Officer to the extent he/she may reasonably require, which approval or
ratification shall be final for all the purposes ofthis clause;r Transfer title to DOH and deliver, as reasonably directed by DOH's Contracting Officer, any property which, if
the Contract had been completed, would have been required to be furnished to DOH;o Complete performance of such'part of the work not terminated by DOH's Contracting Officer; and,e Take such action as may be necessary, or as DOH's Contracting Officer may reasonably direct, for the protection
and preservation of the property related to this Contract which is in the possession of the LHJ, or its
subcontractors, and in which DOH has or may acquire an interest.
IN WITNESS WHEREOF, the parties have executed this Contract.
KITTITAS COUNTY PUBLIC HEALTH
DEPARTMENT
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
Signature
Title
Signature
Title:
Print Name Print Name:
Date:Date
201 84029 2 0 2 I Consolidated Contract Page 10 of l7
DOH CONTRACT #: CLHI8249
Standard X'ederal Certifications and Assurances
Following are the Assurances, Certifications, and Special Conditions that apply to all federally-funded (in whole or in part)
agreements administered by the Washington State Department of Health.
CERTIFICATIONS
1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
The undersigned (authorized official signing for the contracting organization) certifies to the best of his or her
knowledge and beliel that the contractor, defined as the primary participant in accordance with 45 CFR Part76, and
its principals:
A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
covered transactions by any Federal Department or agency;
Have not within a3-year period preceding this contract been convicted of or had a civilj udgment rendered against
them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or
performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
B. Are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or
local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and
C. Have not within a 3-year period preceding this contract had one or more public transactions (Federal, State, or
local) terminated for cause or default.
Should the contractor not be able to provide this certification, an explanation as to why should be placed after the
assurances page in the contract.
The contractor agrees by signing this contract that it will include, without modification, the clause titled Certification
Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion--Lower Tier Covered Transactions in all
lower tier covered transactions (i.e., transactions with sub- grantees and/or contractors) and in all solicitations for lower
tier covered transactions in accordance with 45 CFR Part76.
2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
The undersigned (authorized official signing for the contracting organization) certifies that the contractor will, or will
continue to, provide a drug-free workplace in accordance with 45 CFR Part 76 by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession
or use of a controlled substance is prohibited in the grantee's workplace and speciffing the actions that will be
taken against employees for violation of such prohibition;
B. Establishing an ongoing drug-free awareness program to inform employees about:
1) The Dangers of drug abuse in the workplace;
2) The contractor's policy of maintaining a drug-free workplace;
3) Any available drug counseling, rehabilitation, and employee assistance programs; and
4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
C. Making it a requirement that each employee to be engaged in the performance of the contract be given a copy of
the statement required by paragraph 1) above;
201 8-2029 2 02 I Consolidated Contract Page ll oflT
DOH CONTRACT #: CLHI8249
D. Notifying the employee in the statement required by paragraph l), above, that, as a condition of employment
under the contract, the employee will:
1) Abide by the terms of the statement; and
2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring
in the workplace no later than five calendar days after such conviction;
E. Notifying the agency in writing within ten calendar days after receiving notice under paragraph D. 2) from an
employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must
provide notice, including position title, to every contract officer or other designee on whose contract activity the
convicted employee was working, unless the Federal agency has designated a central point for the receipt of such
notices. Notice shall include the identification number(s) of each affected grant;
F. Taking one of the following actions, within 30 calendar days of receiving notice under paragraph D. 2) with
respect to any employee who is so convicted:
1) Taking appropriate personnel action against such an employee, up to and including termination, consistent
with the requirements of the Rehabilitation Act of 79.73, as amended; or
2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate
. agency;
G. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs
(A), (B), (C), (D), (E), and (F).
For purposes of paragraph (E) regarding agency notification of criminal drug convictions, DOH has designated
the following central point for receipt ofsuch notices:
Compliance and Internal Control Officer
Office of Grants Management
WA State Department of Health
PO Box 47905
Olympia, WA 98504-7905
3. CERTIFICATIONREGARDINGLOBBYING
Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence certain
Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative
agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the Federal
Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each
person who requests or receives a Federal grant or cooperative agreement must disclose lobbying undertaken with
non-Federal (nonappropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING
$ 100,000 in total costs (45 CFR Part 93).
The undersigned (authorized official signing for the contracting organization) certifies, to the best of his or her
knowledge and belief, that:
A. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer' or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
B. If any funds other than Federally appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying
20 | 8-2029 2 0 2 I Consolidated Contract Page 12 of 17
DOH CONTRACT #: CLH18249
Activities," in accordance with its instructions. (If needed, Standard Form-LLL, "Disclosure of Lobbying
Activities," its instructions, and continuation sheet are included at the end of this application form.)
C. The undersigned shall require that the language of this certification be included in the award documents for all
subcontracts at all tiers (including subcontracts, subcontracts, and contracts under grants, loans and cooperative
agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made
or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed
by Section 1352, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty
of not less than $10,000 and not more than $100,000 for each such failure.
4. CERTIFICATION REGARDING PROGRAM FRAUD CTVIL REMEDIES ACT (PFCRA)
The undersigned (authorized official signing for the contracting organization) certifies that the statements herein are
true, complete, and accurate to the best of his or her knowledge, and that he or she is aware that any false, fictitious,
or fraudulent statements or claims may subject him or her to criminal, civil, or administrative penalties. The
undersigned agrees that the contracting organization will comply with the Public Health Service terms and conditions
of award if a contract is awarded.
5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in
any portion ofany indoor facility owned or leased or contracted for by an entity and used routinely or regularly for
the provision ofhealth, day care, early childhood development services, education or library services to children under
the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by
Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor
facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's
services provided in private residence, portions of facilities used for inpatient drug or alcohol treatment, service
providers whose sole source of applicable Federal funds is Medicare or Medicaid, or facilities where WIC coupons
are redeemed.
Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to
$1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.
By signing the certification, the undersigned certifies that the contracting organization will comply with the
requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision
ofservices for children as defined by the Act.
The contracling organization agrees that it will require that the language of this certification be included in any
subcontracts which contain provisions for children's services and that all subrecipients shall certify accordingly.
The Public Health Services strongly encourages all recipients to provide a smoke-free workplace and promote the
non-use of tobacco products. This is consistent with the PHS mission to protect and advance the physical and mental
health of the American people.
6. CERTIFICATION REGARDING DEBARIVIENT, SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS - INSTRUCTIONS FOR CERTIFICATION
By signing and submitting this proposal, the prospective contractor is providing the certification set out below.
A. The inability of a person to provide the certification required below will not necessarily result in denial of
participation in this covered transaction. The prospective contractor shall submit an explanation of why it cannot
provide the certification set out below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However, failure of the prospective
contractor to furnish a certification or an explanation shall disqualify such person from participation in this
transaction.
20 18-2029 2 0 2 I Consolidated Contract Page l3 of 17
DOH CONTRACT #: CLH18249
B. The certification in this clause is a material representation of fact upon which reliance was placed when the
department or agency determined to enter into this transaction. If it is later determined that the prospective
contractor knowingly rendered an erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for cause of default.
C. The prospective contractor shall provide immediate written notice to the department or agency to whom this
contract is submitted if at any time the prospective contractor learns that its certification wis erroneous when
submitted or has become effoneous by reason of changed circumstances.
D. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the
meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You
may contact the person to whom this contract is submitted for assistance in obtaining a copy of those regulations.
E. The prospective contractor agrees by submitting this contract that, should the proposed covered transaction be
entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred,
suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless
authorized by DOH.
F. The prospective contractor further agrees by submitting this contract that it will include the clause titled
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -- Lower Tier Covered
Transaction, provided by HHS, without modification, in all lower tier covered transactions and in all solicitations
for lower tier covered transactions.
G. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency
by which it determines the eligibility of its principals. Each participant may, but is not required to, check the
Nonprocurement List (of excluded parties).
H. Nothing contained in the foregoing shall be construed to require estiiblishment o[a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is
not required to exceed that which is normally possessed by a prudent person in the ordinary course ofbusiness
dealings.
I. Except for transactions authorized under paragraph 6. ofthese instructions, ifa participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or
voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal
Government, DOH may terminate this transaction for cause or default.
7. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS - PRIMARY COVERED TRANSACTIONS
A. The prospective contractor certifies to the best of its knowledge and belief, that it and its principals:
l) Are not presently debaned, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal department or agency;
2) Have not within a three-year period preceding this contract been convicted of or had a civil judgment rendered
against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State or local) with commission of any of the offenses enumerated in paragraph l. B. of this certification; and
4) Have not within a three-year period preceding this contract had one or more public transactions (Federal,
State or local) terminated for cause or default.
201 8-2Ag 2 02 I Consolidated Contract Page 14 of17
DOH CONTRACT #: CLHI8249
B. Where the prospective contractor is unable to certify to any of the statements in this certification, such prospective
contractor shall attach an explanation to this contract.
AUTHORIZED SIGNATURE REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
PLEASE PRINT ORTYPE NAME:
ORGANIZATION NAME: (if applicable)DATE
2A 1 84AAA 2021 Consolidated Contract Page l5 of17
DOH CONTRACT #: CLH18249
Federal Assurances - Non-Construction Programs
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork
Reduction Proj ect (03 48-0040), Washington, DC 20 503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact
the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional
assurances. If such is the case, you will be notified.
As the duly authorized representative ofthe contractor, I certify that the contractor:
l. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share ofproject cost) to ensure proper planning, management, and
completion of the project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any
authorized representative, access to and the right to examine all records, books, papers, or documents related to the
award; and will establish a proper accounting system in accordance with generally accepted accounting standards or
agency directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the
appearance ofpersonal or organizational conflict ofinterest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. al j4728-4'163) relating to prescribed
standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of
OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of
the Civil Rights Act of 1964 (P.L.88-352) which prohibits discrimination on the basis of race, color or national origin;
(b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. r I t- 1681-1683, and 1685-1686), which
prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 7973, as amended (29 U.S.C.
1i794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended
(42 U.S.C. il tl 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment
Act of 1972 (P.L.92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive
Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended,
relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) ,lLt 523 and 521 of the Public Health
Service Act of 1912 (42 U.S.C. Lli I 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug
abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. rr 3601 et seq.), as amended, relating to
nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific
statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other
nondiscrimination statute(s) which may apply to the application.
7 . Will comply, or has already complied, with the requirements of Titles tl and III of the uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of
persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements
apply to all interests in real property acquired for project purposes regardless ofFederal participation in purchases.
2018-2429 2 0 2 I Consolidated Contract Page l6 of 17
DOH CONTRACT #: CLH18249
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. - ! 1501-1508 and7324-7328) which limit
the political activities of employees whose principal employment activities are funded in whole or in part with Federal
funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. Jl276ato 276a-7), the Copeland
Act (40 U.S.C. N276c and 18 U.S.C. Ll i 1874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. rLl
327-333), regarding labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.
1 l. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO I 1738; (c) protection of wetlands
pursuant to EO 1 1990; (d) evaluation of flood hazards in floodplains in accordance with EO 1 1988; (e) assurance of
project consistency with the approved State management program developed under the Coastal Zone Management Act
of 1972 (16 U.S.C. Llll1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under
Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. L).7401et seq.); (g) protection of underground
sources of drinking water under the Safe Drinking Water Act of 7974, as amended, (P.L.93-523); and (h) protection
of endangered species under the Endangered Species Act of 1973 , as amended, (P.L. 93 -205).
1 2. Will comply with the Wild and Scenic Rivers Act of 1 968 ( 1 6 U.S.C. Jt )1721 et seq.) related to protecting components
or potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of
1966, as amended (16 U.S.C. 1470), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C. l)469a-1 et seq.).
14. WillcomplywithP.L.93-34Sregardingtheprotectionofhumansubjectsinvolvedinresearch,development,andrelated
activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. lt-2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities
supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. - 14801 et seq.) which prohibits the use
oflead-based paint in construction or rehabilitation ofresidence structures.
17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Uniform Guidance at 2 CFR 200, Subpart F.
18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies
governing this program.
AUTHORIZED SIGNATURE REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
PLEASE PRINT OR TYPE NAME
ORGANIZATION NAME (if applicable)DATE
2018-2929 2 02 I Consolidated Contract Page 17 of l7
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT2OI8-202I CONSOLIDATED CONTRACT #CLIJI8249EXHIBIT A - STATEMENTS OF WORKTABLE OF CONTENTSDivision of Emergency Preparedness & Response PHEP - Effective July r,2020AMENDMENT # I72DOH Program Name or Title:DOH Program Name or Title:DOH Program Name or Title:DOH Program Name or Title:DOH Program Name or Title:DOH Program Name or Title:LSPAN-Local Strategies for Physical Activity & Nutrition - Effective February 19,2019 .................... 11OICP CARES Enhanced Influenza Coverage Project - Effective July l, 2020 ........... ........25OlCP-Promotion of Immunizations to Improve Vaccination Rates - Effective July 1,202027Supplemental Nutrition Assistance Program-Education - Effective october 1,202029Exhibit A, Statements of WorkRevised as of September 15,2020Page 1 of 42Contract N umber CLHI 8249 - 17
DoH Program Name or Title: Division of Emergency preparedness & ResponsePHEP - Effective Julv l. 2020SOW Type: Revision Revision # (for this SOW) IPeriod of Performance: July 1. 2020 throughJune 30. 2021AMENDMENT #I7Local Health Jurisdiction Name: Kittitas countv public Health DepartmentContract Number: CLHI8249Exhibit AStatement of WorkContract T erm: 2018-2021Type of PaymentX Reimbursementn Fixed PriceFederal Compliance(check if applicable)X ffefa (Transparency Act)I Research & DevelopmentFunding SourceI Federal Subrecipient! stateE otherStatement of Work Purpose: The purpose of this statement of work is to establish funding and tasks to support and sustain LHJ public health emergency preparedness as part ofstatewide public health emergency preparedness and response.Revision Purpose: The purpose ofthis revision is to extend the period ofperformance, add the remainder ofthe annual allocation, add an end-of-year report, revise the budgetdue date, add a training and exercise task, and remove activities no longer required.Exhibit A, Statements of WorkRevised as ofSeptember 15,2020TotalConsideration49,13349,133ChangeIncrease (+)19.65319.653CurrentConsideration29.48029,480Funding Period(LHJ Use Only)Start Date End Date06130/21TOTALS0710U20MasterIndexCode31102280BARSRevenueCode333.93.06CFDA #93.069Chart of Accounts Program Name or TitleFFY2O PHEP BP2 LHJPaymentInformation and/orAmountReimbursement foractual costs not toexceed total fundingconsideration amount.Due Date/TimeFrameDecember 31,2020June 30,2021Upon request.Deliverables/OutcomesMid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.Additional reporting may berequired if federal requirementschange.DOH will maintain documentationof evaluation participation.*May Support PHABStandards/lVleasuresTask/Activity/DescriptionAcross Domains and CapabilitiesComplete reporting templates as requested byDOH to comply with program and federal grantrequirements, including mid-year and end-of-yearreports.Across Domains and CapabilitiesParticipate in an evaluation of LHJ responsecapabilities, upon request from DOH.TaskNumberI)Page 2 of 42Contract Number CLHI 8249 -1 7
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #17PaymentInformation and/orAmountDue Date/TimeFrameWUpon requestfromDOH.December 31,2020June 30,2021December 31,2020June 30,2021December 31,2020June 30,2021Deliverables/OutcomesBudget, using template providedby DOH.Mid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.Input provided to DOH uponrequest from DOH.Mid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.Documentation of trainingavailable upon request.Mid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.*May Support PHABStandards/MeasuresTask/Activity/DescriptionAcross Domains and CapabilitiesDevelop a budget demonstrating how the LHJplans to spend funds during this period ofperformance, using a budget template provided byDOH.Note: 20olo of the LHJ's annual allocation will bewithheld until this requirement is met. Failure tomeet this requirement may result in DOHredirecting funds from the LHJ.Across Domains and CapabilitiesReview and provide input to DOH on public healthemergency preparedness plans developed by DOH,upon request from DOH.Domain I Community ResilienceCapabilify I Community PreparednessParticipate in emergency preparedness events (forexample, trainings, meetings, conference calls, andconferences) to advance LHJ, regional, orstatewide public health preparedness.Domain 2 Incident ManagementCapability 3 Emergency Operations Coordination -Training & ExerciseBased on availability of training, participate in atleast one Foundational Public Health EmergencyPreparedness Training provided by region, DOH,DOH-contracted partner, or DOH-approved trainerin person or via webinar.Notes:r For some LHJs this training won't be availableuntil the next Statement of Work period,January I - June 30,2021 . DOH will workTaskNumber3456Page 3 of 42Contract Number CLHI 8249 -17
PaymentInformation and/orAmountDue Date/TimeFrameOctober 30,2020December 31 ,2020June 30,20218.2 As requested byRERCS.8.3 As requested byDOH.Deliverables/OutcomesLHJ performance measure data(PM 2)LERCs & RERCs -Mid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.8.2 Input into Regional Training &Exercise Plan and Training &Exercise Planning WorkshopGuide provided to RERCs.*May Support PHABStandards/MeasuresTas k/Activity/Descriptionawith regions and LHJs to customize andschedule training(s).This is one or more specific trainingscoordinated by DOH. DOH will work withLHJ to implement.Participation in an activation, exercise or real-world event may be considered additionaltraining, but does not take the place oftherequirement to participate in at least onetraining as described above.aDomain 2 Incident ManagementCapability 3 Emergency Operations Coordination -Training & ExerciseGather and submit data for LHJ performancemeasure (PM) 2: Percent of public health andmedical responders who are trained on their roleduring a public health response.Note: DOH will provide additional guidance aboutsubmitting performance measure data.Domain 2 Incident ManagementCapability 3 Emergency Operations Coordination -Training & Exercise8.1 Review LHJ public health preparedness andresponse capabilities and identify gaps, priorities,and training needs.8.2 Provide input to Regional EmergencyResponse Coordinators (RERCs) for RegionalTraining & Exercise Plan and Training & ExercisePlanning Workshop Guide.8.3 Participate in Integrated PreparednessP lanning l{orkshop unless cancelled.Note: LHJ may opt to develop, update andmaintain a local Training & Exercise Plan. Theystill need to participate in regional processdescribed above.TaskNumber78AMENDMENT #I7Exhibit A, Statements of WorkRevised as ofSeptember 15,2020Page 4 of 42Contract Number CLHI 8249 - 17
AMENDMENT #I7Exhibit A, Statements of WorkRevised as ofSeptember 15,2020PaymentInformation and/orAmountDue Date/TimeFrameOctober 30,2020October 30,2020December 31,2020June 30,2021Deliverables/OutcomesLHJ performance measure data(PM 3)LHJ performance measure data(PM l)Mid-year report on templateprovided by DOH. Indicate thatthis was done or that no responseincident occurred.End-of-year report on templateprovided by DOH. Indicate thatthis was done or that no responseincident occurred.*May Support PHABStandards/MeasuresTas k/Activity/DescriptionDomain 2 Incident ManagementCapability 3 Emergency Operations CoordinationGather and submit data for LHJ performancemeasure 3: Percent of Corrective Action Plan itemscompleted by due date.NotesaDevelop corrective action plans following theHomeland Security Exercise and EvaluationProgram (HSEEP).DOH will provide additional guidance aboutsubmitting performance measure data.Domain 2 Incident ManagementCapability 3 Emergency Operations CoordinationGather and submit data for LHJ performancemeasure l: Amount of time (in minutes) tomobilize a public health and medical response.Notes:r "Mobilize a response" is defined as the firstverbal briefing ofthe response team from theinitial notification to the public healthresponders in the area.r The target is to mobilize a response within 45minutes.r DOH will provide additional guidance aboutsubmitting performance measure data.Domain 2 Incident ManagementCapability 3 Emergency Operations Coordination11.1 Provide immediate notification to DOH DutyOffi cer at 360-88 8-0 83 8 or hanalert@doh.wa. govfor all response incidents involving use ofemergency response plans and/or incidentcommand structures.TaskNumber91011Page 5 of 42Contract Number CLHI 8249 - l7
AMENDMENT #17Exhibit A, Statements of WorkRevised as ofSeptember 15,2020PaymentInformation and/orAmountDue Date/TimeFrameDecember 31,2020June 30, 2021Deliverables/Outcomes1 1.I Notification to DOH DutyOfficer within 60 minutes ofactivation.1 1.2 Sitreps submitted to DOHDuE OfficerMid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.1,2.3 and, 12.4 Hotwash or AfterAction Review (AAR) ORsum m ary of c ommu ni c at ionactivities and one sample.*May Support PHABStandards/lVleasuresTask/Activity/DescriptionI 1.2 Produce and provide situation reports (sitreps)documenting LHJ activity during all incidents.Sitrep may be developed by the LHJ or anotherjurisdiction that includes input from LHJ.Domain 3 Information ManagementCapability 4 Emergency Public Information andWarning - Communication'12.1 Participate in Monthly Public HealthCommunicator Call/Webinar by joiningcall/webinar and/or following information onBasecamp.12.2 P articipate in at-least-ene-risk communicationdrillofferedbyDOH @nne4&r2e2+. Drill will occur via webinar, phoneand email. DOH will offer ene-in-July-lDeeenber4;:g2e-and one drill between January3 I - June 30,2021 .12.3 Conduct a hot wash evaluating LHJparticipation in the drill.12.4 Identifuing and implementing communicationstrategies in real world incident will satisfu need toparticipate in drill. Conduct a hot wash or AfterAction Review (AAR) evaluating LHJparticipation in communication strategies duringthe incident. If, the real world event response isongoing, LHJ may opt to conduct a hot wash orAAR evaluating communication strategies to date,OR include a summary of communication activitiesin mid-year and/or end-ofyear reports and ones amp le of c ommunic ati on.Note: Participation in a real world event may meetthe requirement for 12.2, 12.2 and 12.4.TaskNumbert2Page 6 of 42Contract Number CLHI 8249 - 1 7
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #I7PaymentInformation and/orAmountDue DatelTimeFrameOctober 30,2020December 31,2020June 30,2021Deliverables/OutcomesLHJ performance measure data(PM 7)Mid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.*May Support PHABStandards/MeasuresTasVActivity/DescriptionDomain 3 Information ManagementCapability 4 Emergency Public Information andWarningGather and submit data for LHJ performancemeasure 7: Amount of time to identifu andimplement communication strategies during aresponse or exercise.Notes:o The target is within the first six hours.r DOH will provide additional guidance aboutsubmitting performance measure data.Domain 3 Information ManagementCapability 6 Information Sharing14.1 Maintain Washington Secure ElectronicCommunications, Urgent Response and ExchangeSystem (WASECURES) as primary notificationsystem.Notes:r Registered users must log in quarterly at aminimum.r DOH will provide technical assistance to LHJson using WASECURES.o LHJ may choose to use another notificationsystem in addition to WASECURES to alertstaffduring incidents.ieUeasare g: PereewTaskNumberl3t4PageT of42Contract Number CLHI 8249 -17
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #17PaymentInformation and/orAmountDue Date/TimeFrameUpon request.December 31,2020June 30,2021December 31,2020June 30,2021Deliverables/OutcomesProvide EEIs upon request.Note in the mid-year and end-of-year reports that EEIs wereprovided or none were requested.Report progress and/or plans inmid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.Ifthere is a regional plan, provideinput to the RERC upon request.Updated MCM plans +r11J4e dueJune 30, 2021.*May Support PIIABStandards/MeasuresTask/Activity/Descriptionin@Domain 3 Information ManagementCapability 6 Information SharingProvide Essential Elements of Information (EEIs)during incident response upon request from DOHNote: DOH will request specific data elementsfrom the LHJ during an incident response, asneeded to inform decision making by DOH andstate leaders, as well as federal partners whenrequested.Domain 4 Countermeasures and MitigationCapability 8 Medical Countermeasures DispensingCapability 9 Medical CountermeasuresManagement and DistributionUpdate and maintain Medical Countermeasure(MCM) Plans for LHJ and/or Region.Notes:r MCM plans include number of localdistribution sites and number for which adetailed point-to-point distribution plan fromRSS to distribution site has been jointlyconfirmed by LHJ and DOH. (LHJ PM 4)r MCM plans include number of local points ofdispensing (PODs) and number for which adetailed point-to-point distribution plan fiomlocal distribution site to dispensing site has beenjointly confirmed by LHJ and POD operator(nursing home, local agency, public POD, andindependent pharmacy). (LHJ PM 5)r LHJs are not required to maintain a hub. LHJsmay partner with other organizations tocentralize distribution. If LHJs opt to maintain ahub, this should be included in the MCM plan.r DOH will provide technical assistance to LHJson core elements of an MCM planTaskNumber15l6Page 8 of 42Contract Number CLHI 8249-17
AMENDMENT #I7Exhibit A, Statements of WorkRevised as ofSeptember 15,2020PaymentInformation and/orAmountDue Date/TimeFrameDecember 31,2020June 30,2021October 30,2020Deliverables/OutcomesMid-year report on templateprovided by DOH.End-of-year report on templateprovided by DOH.LHJ performance measure data(PM 8)*May Support PIIABStandards/MeasuresTask/Activity/DescriptionaLHJ Performance Measure data will be dueOctober 30,2020. DOH will gather data forPMs 4 and 5.Domain 5 Surge ManagementCapability l0 Medical SurgeEngagement with regional Health Care Coalition(HCC)Participate in:- At least one regional HCC meeting, inperson or vitually.- The information sharing process duringincidents.- At least one planning process or exerciseconducted to inform on the roles andresponsibilities of public health.- Reviewing HCC plans for alignment withlocal ESF8 plans.Note: This task doesn't need to be completed untilJune 30, 2021. LHIs may begin work in thisStatement of Work period, or may opt to do all thework in the next Statement of Work period.Domain 5 Surge ManagementCapability l0 Medical SurgeGather and submit data for LHJ performancemeasure 8: Percent of Critical Healthcare Facilitieswhose functional status can be assessed by thelocal health jurisdiction in an emergency.Notes:r "Critical Healthcare Facilities" are hospitals,skilled nursing facilities, blood centers, anddialysis centers.r DOH will provide additional guidance aboutsubmitting performance measure data.TaskNumberl718Page 9 of 42Contract Number CLHI 8249 -1 7
AMENDMENT #17*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 aStandard/Measure. More detail on these and./or other Public Health Accreditation Board (PHAB) Standards/Measures tha-t miy apply can be found at:http://www.phaboard.orq/wp-content/uploads/PHAB-Standards-and-Measures-Version-l .0.pdfProgram Specifi c Req uirements/NarrativeAny subcontract/s must be approved by DOH prior to executing the contract/s.Deliverables are to be submitted to the ConCon deliverables mailbox at concondeliverables@doh.wa.sov. unless otherwise specified.Special RequirementsFederal Fundins Accountability 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 USASpendine.gov by DOH as required by p.L. l0g-282.Restrictions on Funds (what funds can be used for which activities, not direct payments, etc)Please reference the Code ofFederal Regulations:https://!vww.ecfi.sov/cgi-biniretrieveEcFR?sp:l&SID:58ffddb5363a27f26e9dl2ccec462549&r.v:HTML&h:L&mc:true&r=pART&n:pt2.1.200#se2.1.200 1439DOH Program ContactTory Henderson, Contracts and Finance SpecialistDivision of Emergency Preparedness and ResponseDepartment of HealthP O Box 47960, Olympia, WA 98504-7960Desk 360-236 -4596 I Mobile 360-789-7262tory.henderson@doh.wa. sovExhibit A, Statements of WorkRevised as ofSeptember 15,2020Page 70 of 42Contract N umber CLHI 8249 - 1 7
DOH Program Name or Title: LSPAN-Local Strateeies for physical Activify &Nutrition - Effective February 19. 2019AMENDMENT #I7Exhibit AStatement of WorkContract Term: 2018-2021Local Health Jurisdiction Name: Kittitas countv Public Health DepartmentContract Number: CLH18249SOW Type: Revision Revision # (for this SOW) 3Type of PaymentE Reimbursement! Fixed PriceFederal Compliance(check if applicable)XnFFATA (Transparency Act)Research & DevelopmentFunding SourceFederal SubrecipientStateE otherPeriod ofPerformance: February 19.2019 through September 29.2021Statement of Work Purpose: The purpose of this statement of work is to establish funding for Local Strategies for Physical Activity and Nutrition (LSpAN), a project of theState Physical Activity and Nutrition Program (SPAN).Revision Purpose: The purpose of this revision is to extend the period of performance from September 29,2020 to September 29,2021and add funding and due dates forYear 3-FFY20 activities.Exhibit A, Statements of WorkRevised as ofSeptember 15,2020TotalConsideration60,00060,00060,000t80,000ChangeIncrease (+)0060.00060.000CurrentConsideration60.00060,0000120,000Funding Period(LHJ Use Only)Start Date End Date0912912009129/2009129121TOTALS021191190913011909/30120MasterIndexCode774402487744023977440240BARSRevenueCode333.93.43333.93.43333.93.43CFDA#93.43993.43993.439Chart of Accounts Program Name or TitleFFYl8 PHYS ACTVTY &NUTRITION PROGFFYI9 PHYS ACTVTY & NUTRITION PROGFFY2O PHYS ACTVTY &NUTRITION PROGPaymentInformationand/or AmountReimbursementfor actual costs,not to exceedtotal contractfunding. SeeProgram SpecificRequirementsReimbursementfor actual costs,not to exceedtotal contractfundins. SeeDue Date/Time FrameFebruary 1 9, 20 I 9-September 29,1e24202 rFebruary I 9, 20 19-September 29, 2e24202 IDeliverables/OutcomesDesignated KCPHD staffwill participate in contractmanagement calls.Designated KCPHD staffwill participate in calls,webinars, and meetings.*May Support PHABStandards/MeasuresTask/Activity/DescriptionPROGRAM ADMINISTRATION:Participate in calls, at a minimum of onceevery month, with DOH contract manager.Dates and time for calls are mutually agreedupon between DOH and Kittitas CountyPublic Health Department (KCPHD).PROGRAM ADMINISTRATION:Participate in DOH-sponsored LSPANrelated quarterly conference calls and/orwebinars, including up to one (1) in-personmeeting.TaskNumber1albPage ll of 42Contract Number CLHI 8249 - 1 7
AMENDMENT #17Exhibit A, Statements of WorkRevised as ofSeptember 15,2020Paymentlnformationand/or AmountProgram SpecificRequirementsReimbursementfor actual costs,not to exceedtotal contractfunding. SeeProgram SpecificRequirementsDue Date/Time FrameYear l-FFYI8:April 15, 2019 (coveringFebruary 19, 2019-March 30, 201 9)July 15,2019 (coveringMarch 3 l, 201 9-June 29, 2019)October 15, 2019 (coveringJune 30, 2019-September 29,2019)Year 2-FFY19:January 1 5, 2020 (coveringSeptember 30, 201 9 -December 30,2019)April 15, 2020 (coveringDecember 3 l, 2019-March 30, 2020)July 15,2020 (coveringMarch 3 l, 2020-June 29, 2020)October 15, 2020 (coveringJune 30, 2020- September 29,2020)Year 3-FFY20:January 1 5, 202 1 (coveringSeptember 30, 2}2}-December 30,2020)April I 5, 202 I (coveringDecember 3 1, 2020-March 30, 202 1)July 15,2021 (coveringMarch 3 I, 202 I -June 29, 2021)October I 5, 202 I (coveringJune 30,2021- September 29, 2021)Deliverables/OutcomesQuarterly progress reports toDOH via SharePoint site oremail*May Support PHABStandards/MeasuresTask /Activity/DescriptionPROGRAM ADMINISTRATION:Perform administrative duties related toLSPAN.TaskNumber1cPage 12 of 42Contract Number CLHI 8249 -17
AMENDMENT #I7Exhibit A, Statements of WorkRevised as ofSeptember 15,2020PaymentInformationand/or AmountReimbursementfor actual costs,not to exceedtotal contractfunding. SeeProgram SpecificRequirementsReimbursementfor actual costs,not to exceedtotal contractfunding. SeeProgram SpecificRequirementsDue Date/Time FrameDraft due:Year I-FFYI8: March 15,2019Year 2-FFYI9:. July 3,2020Year 3-FFY20: March 26,2021Final due:Year 1-FFYI8: March 29,2019Year 2-FFY19: July 10, 2020Year 3 - FFY20: July 9,2021Year 1-FFYI8:April 15, 2019 (coveringFebruary 19, 2019-March 30, 201 9)October 15, 2019 (coveringJune 30, 2019-September 29,2019)Year 2-FFY19:January 1 5, 2020 (coveringSeptember 30, 2019-December 30,20te)April 15, 2020 (coveringDecember 3 l, 201 9-March 30, 2020)July 15,2020 (coveringMarch 3 l, 2020-June 29, 2020)October 75, 2020 (coveringJune 30, 2020- September 29,2020)Year 3-FFY20:January 1 5, 202 1 (coveringSeptember 30, 2020-December 30,2020)April I 5, 202 I (coveringDecember 31, 2020-March 30,2021)July 15,2021 (coveringMarch 3 1, 202 1-June 29, 202 1 )Deliverables/OutcomesSubmit Work Plan to DOHcontract manager via emailQuarterly progress reports toDOH via SharePoint site oremail*May Support PHABStandards/lVleasuresTas k/Activity/DescriptionPROGRAM IMPLEMENTATION:Finalize Work Plan and Budget Workbookusing DOH-provided templates.PROGRAM IMPLEMENTATION:Implement finalized community work planfocused on LSPAN that include:- Addressing at least two (2) statestrategies required by this grant funding.- Achieving policy, systems, orenvironmental changes consistent withthe strategies.- Identiling and reaching populations withhealth disparities.TaskNumber2a2bPage 13 of 42Contract Number CLHI 8249 - 1 7
Exhibit A, Statements of WorkRevised as ofSeptember 75,2020AMENDMENT #I7PaymentInformationand/or AmountReimbursementfor actual costs,not to exceedtotal contractfunding. SeeProgram SpecificRequirementsDue Date/Time FrameOctober 1 5, 2021 (coveringJune 30,2021- September 29,2021)Year 1-FFYI8:April 15, 2019 (coveringFebruary 79, 2019-March 30, 201 9)July 15,2019 (coveringMarch 3 1, 2019-June 29, 2019)October | 5, 2019 (coveringJune 30, 2019-September 29,2019)Year 2-FFY19:January 15, 2020 (coveringSeptember 30, 2019-December 30,20te)April 15, 2020 (coveringDecember 31, 2019 -March 30, 2020)July 15,2020 (coveringMarch 3 1, 2020-June 29, 2020)October 7 5, 2020 (coveringJune 30, 2020- September 29,2020)Year 3-FFY20:January 1 5, 202 1 (coveringSeptember 30, 2020-December 30,2020)April I 5, 202 I (coveringDecember 31, 2020-March 30, 2021)July 15,2021 (coveringMarch 3 1, 202 1 -June 29, 202 1 )October 1 5, 202 1 (coveringJune 30,2021- September 29,2021)Deliverables/OutcomesReport quarterly expendituresusing DOH-providedtemplate.*May Support PHABStandards/MeasuresTask/Activity/DescriptionPROGRAM IMPLEMENTATION :Report quarterly expenditures usingDOH-provided template.TaskNumber2cPage 74 of 42Contract N umber CLHI 8249 - 17
AMENDMENT #17Exhibit A, Statements of WorkRevised as ofSeptember 15,2020PaymentInformationand/or AmountReimbursementfor actual costs,not to exceedtotal contractfunding.Due Date/Time FrameYear 1-FFYI8:April 15, 2019 (coveringFebruary 19, 2019-March 30, 201 9)July 15,2019 (coveringMarch 3 1, 2019-June 29, 2019)October 15, 2019 (coveringJune 30, 2019-September 29,2019)Year 2-FFY19:January 15, 2020 (coveringSeptember 30, 2019-December 30,201e)April 15, 2020 (coveringDecember 3 1, 201 9-March 30, 2020)July 15,2020 (coveringMarch 3 l, 2020-June 29, 2020)October 1 5, 2020 (coveringJune 30, 2020- September 29,2020)Year 3-FFY20:January 1 5, 202 1 (coveringSeptember 30, 2120-December 30,2020)April I 5, 202 I (coveringDecember 3 l, 2020-March 30, 2021)July 15,2021 (coveringMarch 31, 2021-June 29,2021)October I 5, 202 I (coveringJune 30, 2021- September 29,2021)Deliverables/OutcomesQuarterly progress reports toDOH via SharePoint site oremail*May Support PHABStandards/MeasuresTask/Activity/DescriptionPROGRAM EVALUATION:Participate in performance measure datacollection and program evaluation activitiesin collaboration with DOH.TaskNumber3Page 15 of 42Contract Number CLHI 8249 - 1 7
AMENDMENT #17Exhibit A, Statements of WorkRevised as ofSeptember 15,2020PaymentInformationand/or AmountReimbursementfor actual costs,not to exceedtotal contractfunding.Due Date/Time FrameYear 2-FFYI9:January 1 5, 2020 (coveringSeptember 30, 2019-December 30,2019)April 15, 2020 (coveringDecember 3 1, 201 9-March 30, 2020)July 15,2020 (coveringMarch 3 1, 2020-Iune 29, 2020)October 15, 2020 (coveringJune 30, 2020- September 29,2020)Year 3-FFY20:January 1 5, 202 1 (coveringSeptember 30, 202}-December 30,2020)April I 5, 202 I (coveringDecember 3 l, 2020-March 30, 202 I)July 15, 2021 (coveringMarch 3 I, 202 I -June 29, 202 I)October I 5, 202 I (coveringJune 30, 2021- September 29,2021)Year 2-FFYI9:Draft due by August 30,2020Final due by October 15,2020Year 3-FFY20:Draft due: June 30, 2021Final due: July 30, 2021Deliverables/OutcomesProvide copies ofanyrelevant communicationproducts with quarterlyprogress reports to DOH viaSharePoint site or emailOne success story usingDOH-provided template*May Support PHABStandards/MeasuresTask/Activity/DescriptionPROGRAM COMML]NICATION:Inform partners and public about programsuccesses and related best practices,including social media posts and publication.Write a success story related to LSPANprojects.TaskNumber4Page 16 of 42Contract Number CLHI 8249 - 1 7
AMENDMENT #I7*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 aStandard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that miy apply can be found at:http://wlvw.phaboard.ore/$'p-content/uploads/PHAB-Standards-and-Measures-Version.l .0.pdfProgram Specifi c Requirements/NarrativeThe Local Strategies for Physical Activity and Nutrition (LSPAN) project is providing funds to Kittitas County Public Health Department to implement policy, systems andpriority populations who experience health disparities. LSPAN is part of DOH's State Physical Activity and Nutrition-Washington (SPANWA) i.og.uln. nunding for SpANWAis through a cooperative agreement awarded to DOH from the Centers for Disease Control and Prevention's (CDC) DPl8-1807: State Physical Activitv and Nutrition proeramSpecial RequirementsFederal 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 ofthe 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 (DLfNS@) 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.Required Disclosures for Federal Awardee Performance and Integritv Information Svstem (FAPIIS):Consistent with 45 CFR 75.1 13, applicants and recipients must disclose in a timely manner, in writing to the Centers for Disease Control and Prevention (CDC), with a copy to theand to the HHS OIG at the following addresses:CDC, Office of Grants Services, Romero Stokes, Grants Management Officer/Specialist, Centers for Disease Control and Prevention Chronic Disease and Birth Defects ServicesBranch,2920 Brandywine Road, Mailstop E-09, Atlanta, Georgia 30341, Email: lnjO@cdc.gov (lnclude "Mandatory Grant Disclosures" in subject line)ANDU.S. Department of Health and Human Services, Office of the Inspector General, ATTN: Mandatory Grant Disclosures, Intake Coordinator, 330 Independence Avenue SW, CohenBuilding, Room 5527, Washington, DC 20201,Fax: (202) 205-0604 (lnclude "Mandatory Grant Disclosures" in subject line) orEmail : MandatoryGranteeDisclosures@oi g.hhs. eovRestrictions on Funds (what funds can be used for which activities, not direct payments, etc)1 Only DOH-approved budget expenditures will be reimbursed.o Subrecipients may not use funds to purchase furniture or equipment.o Funds cannot be spent on capital projects to support built environment changes.o Reimbursement of pre-award costs generally is not allowed, unless DOH provides written approval to the subrecipient.r The direct and primary recipient in a cooperative agreement program must perform a substantial role in canying out project outcomes and not merely serye as a conduit for anaward to another party or provider who is ineligible.Exhibit A, Statements of WorkRevised as ofSeptember 15,2020Page77 of42Contract Number CLHI 8249 - 1 7
Monitoring Visits (frequency, type)o In-person site visits at least once ayearSpecial Billing Requirements. Must use the budget workbook supplied by the programDOH Program ContactChris Zipperer, Physical Activity CoordinatorWashington State Department of HealthPO Box 47848Olympia, WA 98504360-236-3614 (desk) / chris.zipperer@doh.wa.eovExhibit A, Statements of WorkRevised as ofSeptember 75,2020AMENDMENT #17Page 18 of 42Contract Number CLHI 8249 - 1 7
AMENDMENT #17Exhibit AStatement of WorkContract Term: 2018-2021DOH Program Name or Title: Matemal & Child Health Block Grant -Effective January l. 2018Local Health Jurisdiction Name: Kittitas county Public Health DepartmentContract Number: CLH18249SOW Type: Revision Revision # (for this SOW) 5Type of PaymentI Reimbursement! Fixed PriceFederal Compliance(check if applicable)X fnern (Transparency Act)n Research & DevelopmentFunding SourceI Federal SubrecipientE stateflottrerStatement 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 BlockGrant.Revision Purpose: The purpose ofthis revision is to provide additional fnding, add activities and deliverable due dates, and extend the period ofperformance and funding fromSeptember 30,2020 to September 30,2021 for continuation of MCHBG-related activities.Period of Performance: Januar.v 1.2018 through September 30.2021Exhibit A, Statements of WorkRevised as ofSeptember 75,2020TotalConsideration34.04044.19644,19644,196166,628ChangeIncrease (+)00044.19644.196CurrentConsideration34.04044.19644.1960122,432Funding Period(LHJ Use Only)Start Date End Date09130t180913011909/30t2009130t21TOTALS0 l/0 l/l 8r0l01/181010111910101/20MasterIndexCode78120281781202917812029278120293BARSRevenueCode333.93.99333.93.99333.93.99333.93.99CFDA #93.99493.99493.99493.994Chart of Accounts Program Name or TitleFFYl8 MCHBG LHJ CONTRACTSFFY19 MCHBG LHJ CONTRACTSFFY2O MCHBG LHJ CONTRACTSFFY2I MCHBG LHJ CONTRACTSPaymentInformation and/orAmountMaternal and Child Health Block Grant (MCHBG) AdministrationReimbursement foractual costs, not toexceed total fundingconsideration.Action Plan andProgress Reportsmust only reflectDue Date/Time FrameSeptember 30,2018September 30,2019September 30,2020May 26,2018Deliverables/OutcomesDesignated LHJ staff will participatein contract management calls.Submit actual expenditures using theMCHBG Budget Workbook to DOHcontract manager*May Support PHABStandards/lVleasur€sTask/Activity/DescriptionParticipate in calls, at a minimum of everyquarter, with DOH contract manager. Dates andtime for calls are mutually agreed upon betweenDOH and LHJReport actual expenditures for October 1,2017through March 31,2018TaskNumberla1bPage 79 of 42Contract Number CLHI 8249 - 17
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #I7PaymentInformation and/orAmountactivities paid forwith funds providedin this statement ofwork for thespecified fundingperiod.See ProgramSpecificRequirements andSpecial BillingRequirements.Due Date/Time FrameSeptember 5,2018May 24,2019September 5,2019November 30,2018September 30,2020December 6,2019September 6,2020May 22,2020Deliverables/OutcomesSubmit MCHBG Budget Workbookto DOH contract managerSubmit actual expenditures using theMCHBG Budget Workbook to DOHcontract manager.Submit MCHBG Budget Workbookto DOH contract managerSubmit actual expenditures using theMCHBG Budget Workbook to DOHcontract manager.Designated LHJ staff will attendregional meeting.Submit actual expenditures using theMCHBG Budget Workbook to DOHcontract manager.Submit MCHBG Budget Workbookto DOH contract managerSubmit actual expenditures using theMCHBG Budget Workbook to DOHcontract manager.*May Support PIIABStandards/MeasuresTas k/Activity/Desc riptionDevelop 2018-2019 MCHBG Budget Workbookfor October 1,2018 through September 30,2019using DOH provided template.Report actual expenditures for October 1, 2018through March 31,2019Develop 2019-2020 MCHBG Budget Workbookfor October 1,2019 through September 30,2020using DOH provided template.Report actual expenditures for October 1,2017through September 30, 201 8Participate in DOH sponsored MCHBG fallregional meeting.Report actual expenditures for October 1 , 20 I 8through September 30, 2019Develop 2020-2021 MCHBG Budget Workbookfor October 7,2020 through September 30,2021using DOH provided template.Report actual expenditures for the six monthperiod from October 1 , 2019 through March 3 I ,2020TaskNumberlcld1e1flgthli1jPage 20 of 42Contract Number CLHI 8249 -17
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #17PaymentInformation and/orAmountMCHBG Assessment and EvaluationReimbursement foractual costs, not toexceed total fundingconsideration.See ProgramSpecificRequirements andSpecial BillingRequirements.MCHBG ImplementationReimbursement foractual costs, not toexceed total fundingconsideration.Action Plan andProgress ReportsDue Date/Time FrameDecember 4, 2020May 2 I, 202 ISeptember 10,2021September 30, 2018September 30,2019September 30,2020September 30, 2021January 15,2018April 15,2018July 15,2018October 15,2018May 24,2019Draft August 16,2020Final September 6,2020Draft August 17,2018Final- September 5,201 8Monthly, on or beforethe l5'h ofthe followingmonthDeliverables/OutcomesSubmit actual expenditures using theMCHBG Budget Workbook to DOHcontract managerSubmit actual expenditures using theMCHBG Budget l4/orkbook to DOHcontract manager.Submit MCHBG Budget Workbookto DOH contract managerDocumentation using reporttemplate provided by DOHDocumentation using reporttemplate provided by DOHSubmit Needs Assessmentdocumentation to DOH contractmanager using templates providedby DOHInclude health equity planin2020-2021 MCHBG Action Plan usingDOH- provided template.Submit MCHBG Action Plan toDOH contract managerSubmit Action Plan monthly reportsto DOH contract manager*May Support PIIABStandards/IVIeasuresTas k/Activity/DescriptionReport actual expendituresfor October 1,2019through September 30, 2020Report actual expendituresfor the six monthperiodfrom October 1,2020 through March 31,202 IDevelop 2021-2022 MCHBG Budget Workbookfor October I, 2021 through September 30, 2022using DOH provided template.Participate in project evaluation activitiesdeveloped and coordinated by DOH, asrequested.Report program level strategy measure data(CSHCN, UDS, ACEs).Conduct a Maternal and Child Health (MCH)Needs Assessment.Explore health equity approaches to maternal andchild health and develop implementation planDevelop 2018-2019 MCHBG Action Plan forOctober 1,2018 through September 30,2019using DOH-provided template.Report activities and outcomes of 2017-2018MCHBG Action Plan using DOH- providedtemplate.TaskNumberIkilIm2a2b2c2d3a3bPage21 of 42Contract Number CLHI 8249 - | 7
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #17PaymentInformation and/orAmountmust only reflectactivities paid forwith funds providedin this statement ofwork for thespecified fundingperiod.See ProgramSpecificRequirements andSpecial BillingRequirements.Children and Youth with Special Health Care Needs (CYSHCN)Reimbursement foractual costs, not toexceed total fundingconsideration.Action Plan andProgress Reportsmust only reflectactivities paid forwith funds providedin this statement ofwork for thespecified fundingperiod.See ProgramSpecificRequirements andSpecial BillingRequirements.Due Date/Time FrameDraft August 17,2019Final- September 5,2019Monthly, on or beforethe 15th ofthe followingmonthDraft August 16,2020Final September 6,2020Monthly, on or beforethe 15th ofthe followingmonthOctober 15,2020January 15,2021April 15,2021Julv 15, 2021Draft August 20, 2021Final September 10,202 IJanuary 15,2018April 15,2018July 15,2018October 15,2018January 15,2019April 15,2019July 15,2019October 15,2019January 15,2020April 15,2020July 15,2020October 15,2020January 15,2021April 15,2021Julv 15,202130 days after forms arecompleted.Deliverables/OutcomesSubmit MCHBG Action Plan toDOH contract managerSubmit Action Plan monthly reportsto DOH contract managerSubmit MCHBG Action Plan toDOH contract managerSubmit Action Plan monthly reportsto DOH contract managerSubmit Action Plan reports to DOHcontracl managerSubmit MCHBG Action Plan toDOH contract managerSubmit CHIF data into Secure 4k@ Access Lf/ashingtonwebsite: l*#4ftt+a=se+https : //se c ure ac c es s.w a. g ovSubmit completed Health ServicesAuthorization forms and CentralTreatment Fund requests directly tothe CYSHCN Program as needed.*May Support PHABStandards/MeasuresTask/Activity/DescriptionDevelop 2019-2020 MCHBG Action Plan forOctober 1,2019 through September 30,2020using DOH-provided template.Report activities and outcomes of 2018-2019MCHBG Action Plan using DOH- providedtemplate.Develop 2020-2021 MCHBG Action Plan forOctober 7,2020 through September 30,2021using DOH-provided template.Report activities and outcomes of 2019-2020MCHBG Action Plan using DOH- providedtemplate.Report activities and outcomes of 2020-2 IMCHBG Action Plan using DOH-Providedtemplate.Develop 202 l-2022 MCHBG Action PlanforOctober I, 2021 through September 30, 2022us i ng D O H - Pr ovide d te mp I at e.Complete Child Health Intake Form (CHIF)using the CHIF Automated System on all infantsand children served by the CYSHCN Program asreferenced in CYSHCN Program MMguidance.Ensure client data is collected on all childrenserved by CYSHCN contractors,lnelud:.rngegionalmaxillofacial coordinators, and the DOHNewbom Screening Program.eYSHeN Pregrarn tr{atual vhenfunds are ased,Identifu unmet needsfor CYSHCN on Medicaid,and refer to DOH CYSHCN Prosram forTaskNumber3c3d3e3f3g3h4a4bPage 22 of 42Contract Number CLHI 8249 - 17
AMENDMENT #17*For 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 aStandard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:http://wlvw.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version-l.0.pdfProgram Specifi c Requirements/NarrativeSpecial RequirementsFederal Funding Accountabilitv and Transnarencv 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 (DLJNS@) 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 ReferencesChildren and Youth with Special Health Care Needs Manual -Chi ldrenandYouthW ithSpecialHealthCareNeedsHealth Services Authorization (HSA) Formhttp://www.doh.wa.gov/Portals/l/Documents/Pubs/910-002-ApprovedHSA.docxRestrictions on Funds (what funds can be used for which activities, not direct payments, etc.)1. At least 307o of federal Title V funds must be used for preventive and primary care services for children and at least 30olo must be used services for children withspecial health care needs. [Social Security Law, Sec.505(a)(3)].2. Funds may not be used for:Health Resources and Services Administration (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 medicalequipment.d. Meeting other federal matching funds requirements.e. Providing funds for research or training 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 blockgrant).[Social Security Law, Sec 504(b)].Exhibit A, Statements of WorkRevised as ofSeptember 75,2020PaymentInformation and/orAmountDue Date/Time FrameDeliverables/Outcomes*May Support PHABStandards/MeasuresTas k/Activity/Descriptionapproval to access Diagnostic and Treatmentfunds to meet the need.TaskNumberPage23 of42Contract Number CLH18249 -17
JAMENDMENT #17If 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 notbe imposed with respect to services provided to low income mothers or children; and will be adjusted to reflect the income, resou.ces, and iamily size of the individualprovided the services. [Social Security Law, Sec. 505 (l) (D)].Monitoring Visits (frequency, type)Telephone calls with contract manager at least ene every q as needed.Special Billing RequirementsPayment is contingent upon DOH receipt and approval of all deliverables and an acceptable A19-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 *""thty quarterly by the 30th of eachmonth following the fenth quarter 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.Special InstructionsContact DOH contract manager below for approval ofexpenses not reflected in approved budget workbook.MCHBG funds may be expended on COVID-19 response activities that align'with maternal and child health priorities. Examples may include:c Providing support in educating the MCH population about COVID-19 through partnerships with other local agencies, medical providers, and health care organizations.e Working closely with state and local emergency preparedness staf to assure that the needs of the MCH population are represented.t Funding infrastructure that supports the response to COVID-19. For example, Public Health Nurses who are routinely supported through the Title V program may beable to be mobilized, using Title Vfunds or separate emergencyfunding, to support a call center or deliver health services.o Partnering with parent networks and health care providers to provide accurate and reliable information to all families.. Engaging community leaders, includingfaith-based leaders, to educate community members about strategiesfor preventing illnessRestrictions listed above continue to apply.DOH Program ContactMary Dussol, Community ConsultantOffice of Family and Community Health ImprovementWashington State Department of HealthStreet Address: 310 Israel Rd SE, Tumwater, WA 98501Mailing Address: PO Box 47848, Olympia, WA 98504Telephone: 360-236-3781 I Fax: 360-236-3646Email: Mary.Dussol@doh.wa.govExhibit A, Statements of WorkRevised as ofSeptember 15,2020Page 24 of 42Contract Number CLHI 8249 - 1 7
DoH Program Name or Title: olcP GARES Enhanced Influenza coverase proiect -Eflective July 1.2020SOW Type: Revision Revision # (for this SOW) tPeriod ofPerformance: July 1.2020 through June 30.2021Exhibit A, Statements of WorkRevised as of September 15,2020Type of PaymentX Reimbursement! Fixed PriceFederal Compliance(check if applicable)X ffnfa (Transparency Act)! Research & DevelopmentFunding SourceI Federal Subrecipientfl stut"! ottrerAMENDMENT # 17Local Health Jurisdiction Name: Kittitas countv public Health DepartmentContract Number: CLHI8Z49Exhibit AStatement of WorkContract Term: 2018-2021Statement of Work Purpose: The purpose of this statement of work is to contract with local health to conduct activities to improve influenza immunization coverage rates.Revision Purpose: The purpose of this revision is to extend the period of performance and funding from l2l3ll20 to 06/30121and add funds.ChangeIncrease (+)CurrentConsideration80006130/21End DateFunding Period(LHJ Use Only)0710U20MasterIndexCode74310219BARSRevenueCode333.93.26CFDA #93.268Chart of Accounts Program Name or TitleFFY2l Enhanced InfluenzaCARESTOTALSPaymentInformation and/orAmountReimbursement foractual costs incurred,not to exceed totalfunding considerationamount.*See Restrictions onFunds below.Due Date/TimeFrameJuly 28,2020December 31,2020Deliverables/OutcomesWritten proposal, to include a line-item, object-based budget(template will be provided) and areport that shows startingimmunization rates for the targetpopulationWritten report describing theprogress made on reachingmilestones for activities identifi edin the plan (template will beprovided)*May Support PHABStandards/NleasuresTask/Activity/DescriptionDevelop a proposal to work with partners onactivities that implement evidence-based strategiesto increase influenza immunization coverage ratesfor adult population, increase immunization andpromotion activities targeted at populations athigher risk for COVID-l9 and those that supportthem, uninsured and underinsured populations, andimprove collaboration with communifypartners. The proposal must include a line-item,object-based budget and must meet the goals andobjectives outlined inthe Local Health JurisdictionEnhanc e d I nflue nza C ov e rage Fundi ngO pp ortunity Guidelines.Upon approval of proposal, implement the plan toincrease immunization coverage rates with thetarget population identifi ed.TaskNumberI2Page25 of 42Contract Number CLH| 8249 -17
AMENDMENT #I7*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 aStandard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:htto://www.phaboard.ors/wp-content/uploads/PHAB-Standards-and-Measures-Version-l.0.pdfProgram Specific Req uirements/NarrativeTasks in this statement of work may not be subcontracted without prior written approval from DOH OICPSpecial RequirementsFederal Funding Accountability 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 ofthe 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 (DLTNS@) number.Information about the LHJ and this statement of work will be made available on USASpendins.sov 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 1212012017) is posted on the DOH Consolidated Contract website at this link. These federal funds may not be usedfor expenses related to travel or attendance at any non-DOH sponsored conference, training, or event without prior written approval from the DOH Office of Immunization andChild Profile.DOH Program ContactsTawney Harper, MPADeputy Director I Operations ManagerOffice of Immunization and Child ProfileDepartment of HealthPO Box 47843, Olympia WA 98504-7843tawney.harper@doh.wa. gov, 3 60 -23 6-3 525Exhibit A, Statements of WorkRevised as ofSeptember 75,2020DOH Program ContactMisty Ellis, Project ManagerCDC Public Health AdvisorOffice of Immunization and Child ProfileDepartment of HealthPO Box 47843, Olympia WA 98504-7843misty.ellis@doh.wa.gov, 360-236-367 5PaymentInformation and/orAmountDue Date/TimeFrameMarch 31, 2021Deliverables/OutcomesFinal written report, including areport showing ending influenzaimmunization rates for the targetpopulation (template will beprovided)*May Support PHABStandards/MeasuresTask/Activity/DescriptionConduct an evaluation of the interventionsimplementedTaskNumberJPage 26 of 42Contract Number CLHI 8249 - 17
DOH Program Name or Title: OlCP-Promotion of Immunizations to ImproveVaccination Rates - Effective July 1. 2020AMENDMENT #I7Exhibit AStatement of WorkContract Term: 2018-2021Local Health Jurisdiction Name: Kittitas County Public Health DepartmentContract Number: CLH18249SOW Type: Revision Revision # (for this SOW) IType of Paymentffi Reimbursement! Fixed PriceFederal Compliance(check if applicable)FFATA (Transparency Act)Research & DevelopmentFunding SourceFederal SubrecipientState! otherPeriod ofPerformance: July 1.2020 through June 30.2021Statement 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 extend the period of performance and funding from 12131/20 to 06130121, add funds, and modifu the statement of work.Exhibit A, Statements of WorkRevised as ofSeptember 15,2020TotalConsideration5,600s.600ChangeIncrease (+)2,8002,800CurrentConsideration2,8002.800Funding Period(LHJ Use Only)Start Date End Date06/30t21TOTALS0710U20MasterIndexCode74310202BARSRevenueCode333.93.26CFDA#93.268Chart of Accounts Program Name or TitleFFY21 VFC OpsPaymentInformation and/orAmountReimbursement foractual costs incurred,not to exceed totalfunding considerationamount.*See Restrictions onFunds below.Due Date/TimeFrameAugust 1,2020November 30,2020March 31, 202IJune 15,2021Deliverables/OutcomesWritten proposal and a report thatshows starting immunization ratesfor the target populationWritten report describing theprogress made on reachingmilestones for activities identifi edin the plan (template will beprovided)Final written report, including areport showing endingimmuni:alion ratesfor the targetpopulation (template will beprovided)*May Support PHABStandards/lvleasuresTask/Activity/DescriptionDevelop a proposal to improve immunizationcoverage rates for a target population by increasingpromotion activities and collaborating withcommunity partners. The proposal must meetguidelines outlined in the Local Health JurisdictionFunding Opportuni8. Promotion of Immunizationsto Increase Vaccination Rates announcement.Upon approval of proposal, implement the plan toincrease immunization coverage rates with thetarget population identifi ed.Perform data collection necessary to enable acomparison of immunization rates from the start ofthe project.TaskNumberI23Page27 of42Contract N umber CLHI 8249 - | 7
AMENDMENT #17*For 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 aStandard/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.ordwp-content/uploads/PHAB-Standards-and-Measures-Version-l.0.pdfProgram Specific Req uirements/NarrativeTasks in this statement of work may not be subcontracted without prior written approval from DOH OICPSpecial RequirementsFederal Fundins Accountabilitv and Transnarencv 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 ofthe 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 (DLINS@) number.Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. l0g-282.Restrictions on Funds (what funds can be used for which activities, not direct payments, etc.)Allowable Uses of Federal Operations Funds document (dated 12120/2017) is posted on the DOH Consolidated Contract website at this link. These federal funds may not be usedfor expenses related to travel or attendance at any non-DOH sponsored conference, training, or event without prior written approval from the DOH Office of Immunization andChild Profile.DOH Program ContactsTawney Harper, MPADeputy Director I Operations ManagerOffice of Immunization and Child ProfileDepartment of HealthPO Box 47843, Olympia WA 98504-7843tawney.hamer@doh.wa. sov, 3 60-23 6-3 525Exhibit A, Statements of WorkRevised as ofSeptember 15,2020DOH Program ContactMisty Ellis, Project ManagerCDC Public Health AdvisorOffice of Immunization and Child ProfileDepartment of HealthPO Box 47843, Olympia WA 98504-7843misty.elf is@doh.wa.eov, 360-236-367 5Page28 of 42Contract Number CLHI 8249 -17
DOH Program Name or Title: Supplemental Nutrition Assistance program-Education - Effective October l. 2020Period ofPerformance: October l. 2020 through September 30.2021AMENDMENT #I7Exhibit AStatement of WorkContract T erm: 2018-2021Local Health Jurisdiction Name: Kittitas coun8 public Health DepartmentContract Number: CLHI8249SOW Type: Orisinal Revision # (for this SOW)Type of PaymentX Reimbursement! Fixed PriceFederal Compliance(check if applicable)[l ffefa (Transparency Act)n Research & DevelopmentFunding SourceI Federal Subrecipientn stateI ottrerStatement of Work Purpose: The purpose of this statement of work is to provide Supplemental Nutrition Assistance Program-Education (SNAp-Ed) to improve the likelihoodthat persons eligible for SNAP (Basic Food, Food Stamps) will make healthy food choices within a limited budget and choose active lifestyies consistent with the current USDAdietary guidelines.Revision Purpose: N/AExhibit A, Statements of WorkRevised as ofSeptember 15,2020TotalConsideration26,04626,046ChangeIncrease (+)26,04626,046CurrentConsideration00Funding Period(LIIJ Use Only)Start Date End Date09130t21TOTALS10101/20MasterIndexCode76701912BARSRevenueCode330.10.56CFDA #10.561Chart of Accounts Program Name or TitleFFY21 IAR SNAP ED PROG MGNT-REGION 2Payment Informationand/or AmountReimbursement uponon-time receipt andapproval ofacceptabledeliverables/ outcomesfor the funding periodwill not exceed$26,046. KittitasCounty Public HealthDepartment will bepaid the allowable costsincurred based on theirapproved budget andprogram allowability.See special billingrequirements section.FFY2IDue Date/Time FrameFor the Period:10101120 to 09130121Due: per the approved workplan and per the requireddue dates during the federalfiscal year, and no later than09130/21.Measure (whereapplicable)Sites and audiencesincluded in Project bySubrecipient documentedas approved eligible sitesor audiences.Documented completereporting by Subrecipientof the delivery,implementation, andevaluation ofapprovedProject activities in therequired PEARS onlinereporting modules, whererelevant to Project(Program Activities, PSEDeliverables/OutcomesProject provides 100% ofSNAP-Ed activities at eligiblesites and/or with eligibleaudiences.On-time delivery,implementation, andevaluation of Proj ect activitiesas scheduled in approved stateplan and project work plan.Satisfactory progress towardsState SNAP-Ed project goal(s)selected by Subrecipient isdemonstrated and reported.Satisfactory progress towardsproject objective(s) andadditional proiect eoal(s)aaaaTask/Activity/DescriptionProject Planning, Implementation,and PerformanceFor SNAP-Ed, the Subrecipient willdevelop, implement, and evaluate aSNAP-Ed project included in theWashington SNAP-Ed State Planapproved by Department of Social andHealth Services (DSHS) and UnitedStates Department of Agriculture(USDA); and, as described in theSubrecipient's project work planapproved by Department of Health(DOH).TaskNumber1.0Page 29 of 42Contract Number CLHI 8249 - 1 7
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #I7Payment Informationand/or Amount**NOTE: The DOHSNAP-Ed program willdeny payment for anycosts not submitted bythe required due dateswithout prior DOHapproval in writing.See paymentinformation asreferenced in tasknumber 1.0FFY2IDue Date/Time FrameFor the Period:r0l0ll20 to 0913012rDue: Progress reviews.Occur at minimum quarterlywithin the fiscal year, andno later than 30 businessdays after the end ofthefederal fiscal quarter, exceptfor the last quarter whichmust be completed by09 /30 121. Progress reviewscan be scheduled morefrequently if deemednecessary by DOH, or ifagreed upon by both parties.Federal quarters listedbelow:Ql: Oct 1 - Dec 3lQ2: Jan 1 - Mar 31Q3: Apr I - June 30Q4: July I - Sep 30Due: Project monitoring.Occurs at minimum onceMeasure (whereapplicable)Site Activities, IndirectActivities, Coalitions,Partnerships, and SuccessStories).Documented completereviews of SubrecipientProject activities throughrequired reporting andproject and fiscalmonitoring reviews andreports.Cost per reach reported bySubrecipient in approvedform/system provided byDOH.Progress reviews -documentation of one-on-one meeting(s) with DOHSNAP-Ed staffperson(s)and Subrecipientcompleted in person, webconference, phone, or viaemail as needed.Documentation of progressreview notes.Project monitoring -documentation of one-on-one meeting(s) with DOHSNAP-Ed staff person(s),Subrecipient, other SNAP-Ed funded staff, andcommunity partners and/orparticipants completed inperson, web conference,phone, or via email asneeded. Completion of on-site program observationswhere applicable.Completion of proiectDeliverables/Outcomesadetermined by Subrecipient isdemonstrated and reported.Project maintains cost-effectiveness per currentapproved cost-effectivemeasure provided by DOH orDSHS.1. On-time delivery ofproposedlist ofProject site(s) oraudience(s) to DOH.2. All sites and,/or audiences aredetermined to be eligible percurrent SNAP-Ed eligibilityguidance before programmingbegins with site(s) oraudience(s).3. Demographic data of classparticipants collected andreported for all directeducation strategies.4. On-time reporting of actualpanicipant reach to DOH inapproved method/form.5. Intervention strategiesimplemented as planned, orusing approved alternatestrategies.6. Approved evaluation plansand methods implemented forthe project (e.g. pre and postsurveys for direct education;PSE assessments).Task/Activity/DescriptionProject Progress: Monitoring andComplianceFor SNAP-Ed, the Subrecipient willdemonstrate satisfactory progress ofthe approved Project as documented inDOH SNAP-Ed progress reports,progress reviews, and project andfi scal monitoring reports.Monitoring of Subrecipient Proj ectprogress includes but is not limited tothe following activities:i. one-on-one progress reviews withDOH,ii. progress reports submitted toDOH,iii. project monitoring completedwith DOH or DSHS or USDA,andiv. project monitoring site visitscompleted by SNAP-Ed statewideinitiative teams.TaskNumber1.1Page 30 of 42Contract Number CLHI 8249 - 17
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #17Payment Informationand/or AmountFFY2lDue Date/Time Framewithin the fiscal year. Ifproject monitoringdocuments majordeficiencies or correctiveaction, the Subrecipient willbe monitored again withinthe fiscal year. Projectmonitoring can bescheduled more frequentlyif deemed necessary byDOH, or if agreed upon byboth parties.Due: Fiscal monitoring.Each Subrecipient receivesone (1) annual fiscalmonitoring visit every otheryear, unless Subrecipientmonitoring results incorrective action or finding,in which case Subrecipientwill be monitored again thefollowing year. Fiscalmonitoring can bescheduled more frequentlyifdeemed necessary byDOH, or if agreed upon byboth parties.Measure ('1_vliereappticab!e)monitoring report forms,with monitoring resultsdocumented and providedto Subrecipient.Fiscal monitoring -documentation ofcompleted fi scal reviewsscheduled by SNAP-Edfiscal analyst or DOHfiscal monitoring unit, withcorresponding reportswhere applicable. Fiscalmonitoring completed inperson, web conference,phone, or via email asneeded.Deliverables/Outcomes7. Evaluation results used toreport progress and outcomesofproject, and to adapt theproject as needed.8. Evidence ofpositive changeor improvement in SNAP-Edeligible site(s) or audience(s)based on project activities isdemonstrated and reported.9. If positive change orimprovement in SNAP-Edeligible site(s) or audience(s)not apparent, project mustdemonstrate acceptableimplementation of approvedinterventions and strategiesand use results of processevaluation to improve projectplan so that positive change inSNAP-Ed eligible site(s) oraudience(s) can occur.10. Strategy for working with oneor more CSOs implementedand demonstrated to increaseknowledge, awareness, orparticipation in SNAP-Edeligible audience.I l. Strategy for promotingavailable Federal, state, orlocal fruit and vegetableincentive program(s)implemented anddemonstrated to increaseknowledge, awareness, orparticipation of program(s) inSNAP-Ed eligible audience.12. Direct education strategiesonly: Statewide SNAP-EdCurriculum team or DOHmonitoring reviews showeducation delivered withfidelitv. with no maiorTask/Activity/DescriptionSatisfactory progress of theSubrecipient's Proj ect includesprogress shown in the following areasand documented in reporting and/ormonitoring completed:l Progress demonstrated inachieving goal(s) outlined in theproject.2. Progress demonstrated inachieving objective(s) outlined inthe proj ect's interventions.3. Progress demonstrated in creatinga sustainable project.4. Progress demonstrated inengaging or involving thecommunity in project planning,implementation, and/orevaluation.5. Progress demonstrated in workingwith DSHS community servicesoffices (CSOs).6. Progress demonstrated inpromoting available Federal,state, or local fruit and vegetableincentive programs to SNAPclients.7. Progress demonstrated in usingstrategies that are evidence-basedand delivered with fidelity, whereapplicable.8. Compliance with current SNAP-Ed financial and cost policyguidance and 2 CFR 200 federalUniform AdministrativeRequirements (OMB guidance).TaskNumberPage 37 of 42Contract Number CLHI 8249 - 1 7
AMENDMENT #17Exhibit A, Statements of WorkRevised as ofSeptember 75,2020Payment Informationand/or AmountSee paymentinformation asreferenced in tasknumber 1.0FFY2IDue Date/Time FrameFor the Period:10101/20 to 09130121Progress Reports: Due atminimum quarterly, and nolater than I 0 calendar daysafter the end ofthe quarter,except for the last month ofthe FFY which is due by91 1 5 121. If the I Oth calendarday falls on a weekend day,the report is due the nextbusiness day.r lst Progress report due01111t21c 2nd Progress report due04112/21. 3rd Progress report due07112121. Final Progress reportdue 09115121, or followclose-out procedures.PEARS: Project evaluationand reporting requiredbetween 10101120 lo09lrsl21.Direct educationstratesies onlv:lVleasurg (whereapplicable)Documentation showingcompletion of progressreport and submission toDOH on or before therequired due dates, or byapproved extension date.Completion of requiredevaluation data in progressreports and PEARSelectronically, or usingapproved reportingmethod,/form, on or beforethe required due dates, orby approved extensiondate.Direct educationstrategies only:1. Submission ofrequired SNAP-Edparticipant surveys toDOH using approvedsubmission method,on or before therequired due dates forsubmission, or byapproved extensiondate.Deliverables/O utcomesdeficiencies. If majordefi ciencies documented,corrected properly withintimeline required.13. Compliance maintained withcurrent SNAP-Ed fi nancialand cost policy guidance, 2CFR 200 federal UniformAdministrative Requirements(OMB guidance), and relatedDOH SNAP-Ed fiscal policyand procedures.On-time and correct submission ofreporting, data, and materials forall SNAP-Ed funded activitiesimplemented, including:1. Progress for all interventionstrategies reported forapproved project plan.2. All evaluation results reportedfor approved project plan(formative, process, outcome,qualitative, PSE).3. All qualitative evaluationresults (success stories,pictures, etc.) reported forapproved project plandescribing progress or successofproject activities, or positivechange or improvement inSNAP-Ed eligible site(s) oraudience(s).4. Required release form(s) forall photos submitted.5. Direct education strategiesonly: All required informationfor scheduled direct educationlessons submitted to StatewideSNAP-Ed Curriculum team,using approved form/system,by dates required.Task/Activity/DescriptionEvaluation Data and ReportsFor SNAP-Ed, the Subrecipient willreport progress ofthe approvedproject and work plan, includingongoing evaluation ofthe project andoutcomes, using an approvedform/system on a regular basis thatwill at a minimum include:1. Progress reports2. Reporting in PEARS onlinereporting system ofallSNAP-Ed activitiesSNAP-Ed activities implemented andevaluation ofthe project and outcomesare reported in an online programevaluation and reporting system(PEARS) through the followingrequired modules as appropriate forthe approved project: ProgramActivity (direct education), IndirectActivity (health promotion, indirecteducation channels), PSE SiteActivities, Partnerships, Coalitions,Success Stories, and Social Marketing.The following evaluation activitiesand information are required based onTaskNumber2.0Page 32 of 42Contract N umber CLHI 8249 - 1 7
AMENDMENT #17Exhibit A, Statements of WorkRevised as ofSeptember 15,2020Payment Informationand/or AmountFFY2lDue Date/Time FramePEARS ProgramActivities moduleupdated with completedactivities no later thantwo (2) weeks afterservices are provided.aDue: PEARS IndirectActivities, PSE SiteActivities, Partnerships,Coalitions, SuccessStories, and SocialMarketing modulescompleted no later thanthe last business day ofthe month followingwhen the activity tookplace, except for thelast month ofthe FFYwhich is due by09115t21.Activities completed inOct 2020 due inPEARS by 11/30120Nov 2019 by 12131120Dec 2019 by 01129121Jan2020by 02126121Feb2020by 03/31121Mar 2020by 04130121Apr 2020by 05/31/21May 2020by 06130121Jun2020by 07130121Jul2020by 08l3tl2tAug2020 by 09115121Final data entry for allactivities not alreadyreported, due by09/15121, or followclose-out schedule.aaaaaMeasure (whereapplicable)2. When survey data isentered by theSubrecipient,completion ofrequired evaluationdata into PEARSelectronically, orusing approvedreporting method, onor before the requireddue dates for dataentry, or by approvedextension date.Deliverables/OutcomesOn-time and correct submission ofrequired evaluation data for directeducation strategies into PEARSelectronically, or using approvedreporting method, according totime frame provided, including:6. Direct education strategiesonly: Pre-test surveys for eachproject class series received byDOH, or data entered intoPEARS by Subrecipient, nolater than two weeks after.completion of the pre-testsurvey.7. Direct education strategiesonly: Post-test surveys foreach project class seriesreceived by DOH, or dataentered into PEARS bySubrecipient, no later than twoweeks after completion of thepost-test survey.8. Direct education strategiesonly: Demographic cards foreach class series received byDOH, or data entered intoPEARS by Subrecipient, nolater than two weeks aftercollection of the demographiccards.Task/Activity/Descriptionthe Subrecipient's approved projectand work plan.r Formative evaluationr Process evaluationr Outcome evaluationr Qualitativeevaluationo Evaluation ofPSE strategiesPlease Note: the deliverables maychange based on state SNAP-EdEvaluation guidance, DSHS, or USDArequirements.Please Note: Topics included inProgress Report subject to changebased on Department of Health(DOH), Department of Social andHealth Services (DSHS), WashingtonSNAP-Ed (WA SNAP-Ed), or UnitedStates Department of Agriculture(USDA) Food and Nutrition Services(USDA) requirements.TaskNumberPage 33 of 42Contract Number CLH18249-17
Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #17Payment Informationand/or AmountSee paymentinformation asreferenced in tasknumber 1.0See paymentinformation asreferenced in tasknumber 1.0.FFY2lDue Date/Time FrameSNAP-Ed Direct educationconducted between l0l 1 120and 09115121.e Direct educationstrategies only:Completed Pre- andpost-test surveysreceived by DOH, ordata entered intoPEARS database bySubrecipient, no laterthan two weeks aftercompletion of thesurvey. All completedpre- and post-testsurveys must bereceived, or dataentered bySubrecipient, no laterthan COB 09ll5l2l, orfollow close-outschedule.For the Period:l0l0ll20 to 09130121Due:12131/20 for allSNAP-Ed funded staff. Newhires to complete within 30days ofhire.For the Period:10/01120 to 09/30/21Fiscal: Annually, and nolater than March 3l ,2021Measure (whereapplicable)Submission ofdocumentation showingcompleted Civil Rightstraining for all SNAP-Edfunded staffon or beforethe required due date.Documentation showingrequired person(s) anddate(s) ofattendance for allweb-based and in-personrequired meetings.Deliverables/OutcomesOn-time completion of anapproved Civil Rights training forall SNAP-Ed funded staff.On-time completion of all requiredtrainings by required SNAP-Edstaff.Tas k/Activity/Descriptio nCivil Rights TrainingAll SNAP-Ed funded staff mustcomplete training each fiscal year incivil rights.*See special requirements section-Civil RightsDocumentation must include:. Training and sourcer Who attended. Date completedOther Required Training andMeetingsThe following trainings or meetingsare required for all Subrecipientswhen provided bv DOH or WATaskNumber3.03.1Page.34 of 42Contract Number CLHI 8249 - 17
Exhibit A, Statements of WorkRevised as of September 75,2020AMENDMENT #I7Payment Informationand/or AmountFFY2IDue Date/Time FrameSNAP-Ed Curriculum:New direct education stafftrained within 30 days forspecific curriculum to beused in direct educationstrategy, or before providingSNAP-Ed direct educationactivities to SNAP-Edaudience. Projectcoordinator or qualifieddesignated staff person tocomplete additional SNAP-Ed Curriculum trainingwhen new information isprovided for specificcurriculum to be used indirect education strategy.Data collection andreporting: Annually, ormore often as needed. Ifapproved data collectionsystem changes, everySNAP-Ed funded staffmember entering data willbe required to completetraining on any newexpectations or systemchanges on the day of, orwithin 30 days of when thetraining is provided.Annual Forum: Annually,when provided, and no laterthan09/30/21.Coordinator meetings:Completed on datesscheduled by DOH, whenprovided.Measure (whereapplicable)Documentation showingrequired person(s); date(s)ofattendance; and,completion of training forall web-based and in-person required trainings.Documentation ofsatisfactory understandinggained from requiredtrainings, and applicationof applicable knowledgeand skills in progressreviews and,/or monitoringreports.Deliverables/OutcomesAttendance of required orappropriate staffperson(s) at allrequired meetings.Demonstration of satisfactoryunderstanding of the informationand concepts included in requiredtrainings.SNAP-Ed Curriculum: On-timecompletion of required training forspecific curriculum to be used indirect education strategy by projectcoordinator or qualified designatedstaff person responsible fordelivering SNAP-Ed curricula toSNAP-Ed eligible audience.Food handler training:Completion of a Washington Stateauthorized food handler or foodworker training by all staffwhowill handle and serve food to thepublic.Coordinator meetings:Attendance of project coordinatoror qualified, designated staffperson to at least 75%o of allcoordinator meetings provided.Regional meetings: Attendance ofproject coordinator or qualified,designated staffperson to at least50o/o of all regional meetingsprovided.State Forum: Attendance ofproject coordinator or qualified,designated staffperson to all stateforums provided.Tas k/Activity/DescriptionSNAP-Ed for the staff listed. Unlessmore staff attendance is required,minimum of one (l) staff personrequired to attend to satisfrrequirements. Multiple staff mayattend ifcosts for attendance arecovered in Subrecipient's annualbudget.aFiscal training - fiscal agent orproject coordinator, whoever ismost responsible for creating andmonitoring budget, procurements,invoices, budget decisions, orbudget amendments for theSNAP-Ed program.aFood handler training - all staffwho will handle, prepare, cook,assemble, and/or serve food ordrink to participants or the public.Training on data collection andreporting - project coordinatoror any staffperson responsible forcollecting, reporting, or enteringSNAP-Ed related data.aaaRegional meeting(s), whenprovided - project coordinator orany qualified designated staffperson.Annual State SNAP-Ed forum,when provided - projectcoordinator or any qualifieddesignated staff person.SNAP-Ed Curriculum training(either in person or online)(only required for directeducation strategies) - proiectTaskNumberPage 35 of 42Contract N umber CLHI 8249 - 17
AMENDMENT #17Exhibit A, Statements of WorkRevised as ofSeptember 15,2020Payment Informationand/or AmountSee paymentinformation asreferenced in tasknumber 1.0.FFY2IDue Date/Time FrameRegional meetings:Completed on datesscheduled by DOH, whenprovided.SNAP-Ed systemsapproaches trainingonline: At least once withinthe three year period ofperformance, and no laterthan the end ofthe firstfiscal year within the threeyear period of performance.. Due: On or before09t30t21SNAP-Ed systemsapproaches training !4pgry!!: Once annually,when provided, on datesscheduled by WA SNAP-Ed.For the Period:10101120 to 09/30121Due: Inventory list isrequired to be updated nolater than 30 days after theend ofeach quarter. Finalinventory list updated by0911s120.At the time of a fiscal orproject monitoring review,or when requested, an up-to-date inventory list must bemade available.Measure (whereapplicable)Completed documentationshowing updated SNAP-Edinventory using approvedform,/system provided.Deliverables/OutcomesSNAP-Ed Systems Approachesfor Healthy Communities:Demonstrate satisfactoryunderstanding of the informationand concepts included in thetraining. Satisfactory application ofknowledge and skill learned fromtraining to SNAP-Ed project, asneeded.If required meeting or training isnot provided, Subrecipient is notrequired to make up requirementsfor attendance and will be incompliance. Attendance at requiredmeetings and completion ofrequired hainings required onlywhen provided.On-time updates to SNAP-Edinventory list.1. Inventory list updated per duedates required.2. Inventory list containscomplete list of all itemspurchased with SNAP-Edfunds in current fiscal year andprevious fiscal years still inuse and in possession oftheSubrecipient.TaslVActivity/Descriptioncoordinator or qualifieddesignated staffpersonresponsible for delivering SNAP-Ed curricula to SNAP-Ed eligibleaudience.SNAP-Ed Systems Approachesfor Healthy Communitiestraining (online, whenprovided) - project coordinatorand all staffinvolved in planning,implementing, and evaluatingSNAP-Ed proj ect activities.SNAP-Ed Systems Approachesfor Healthy Communitiestraining (in person, whenprovided) - project coordinator orqualifi ed designated staff person.Project coordinator meetin gs(conference calls or in person) -project coordinator or qualifieddesignated staff person.aaSNAP-Ed InventorySNAP-Ed Subrecipients are requiredby regulation to keep an up-to-dateinventory list that includes all non-capital equipment, approved capitalequipment, purchased curriculum, andother SNAP-Ed purchased items thatare not disposable. This list shouldinclude items purchased in prior fiscalyears still in use and in possession ofthe Subrecipient. This list should beupdated per the due dates required.Agencies are required to follow theDOH SNAP-Ed Inventory policy andprocedure.TaskNumber4.0Page 36 of 42Contract Number CLHI 8249 - | 7
AMENDMENT #17*For 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 aStandard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:Exhibit A, Statements of Work page 37 of 42 Contract Number CLHlg249_17Revised as ofSeptember 15,2020Payment lnformationand/or AmountSee paymentinformation asreferenced in tasknumber 1.0.FFY2IDue Date/Time FrameFor the Period:l0l0ll20 to 09130121Due: Monthly - Submitinvoices to DOH no laterthan 30 calendar days afterthe end ofthe precedingmonth. (E.g. October A19invoice submitted no laterthan November 30)o Oct. Invoice due:t'U30t20o November:12130120o December:01130121o January: 02128121o February:03130121o March: 04130121o April: 05130121o May: 06130/21o June: 07130/21o July: 08130121o August: 09130121Final invoice is dueOctober 30,2021, or followclose-out schedule.Or*Ifpre-approved inwriting by DOH, agenciescan submit invoices everytwo months. Upon approval,a list of submission dateswill be provided.Measure (whereapplicable)SNAP-Ed invoices (Al9)with all documented costsand any requiredaccompanying materialsreceived at DOH by duedates required, or byapproved extension date.Delivera bles/OutcomesOn-time delivery of correctcompletion of SNAP-Ed A19invoices, using the current form forthe fiscal year.On-time delivery of detailed ledgersupporting the costs to be reviewedby SNAP-Ed program via the mostcurrent submission procedurebefore approval of payment.Complete documentation of allactual costs incurred shall beaccompanied by the Subrecipient'sfinancial system report. IfSubrecipient does not have afinancial reporting system, theSubrecipient must check with theDOH SNAP-Ed program forfurther guidance.Task/Activity/Descriptio n*See special requirements section -MonitoringSNAP-Ed A19 InvoicesSubrecipients must use the A19invoice form specific to the DOHSNAP-Ed program. This documentwill be sent to all Subrecipients priorto October 31't ofthe current fiscalyear.TaskNumber5.0
AMENDMENT #I7httP://wlvw.nhaboard.orpy'wp-content/uploads/PHAB-Standards-and-Measures-Version- I .0.pdfSpecial RequirementsFederal Fundine Accountabilitv 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 Subrecipient must have a Data Universal Numbering System (DUNS@) number.Information about the Subrecipient and this statement of work will be made available on https://www.usaspending.gov by DOH as required by p.L. l0g-2g2.* Program Specific Requirements/NarrativeContract Noncomnliance and Corrective Action (see CFR Q 200.338 Remedies for noncomnliance)specified due dates will be determined by the DOH SNAP-Ed program and provided to the Subrecipient in writing. Based on contract performance (as documented in progre"ssSpecific conditions (see https://www.sovrees.com/regulations/2/200.207), DOH reserves the right to withhold up to l07o of funds from the nexi applicable payment toiheas such. After DOH SNAP-Ed provides documentation of the issue(s) and outlines the appropriate corrective action in writing, and with upp.ouuifro- the DOH SNAp-Edprogram manager, the first withholding of funds up to 10% would occur one time and allow 60 days for the appropriate correitive action io be completed by the Subrecipient. Ifafter the 60-day window, the initial 10% of funds withheld will not be provided as reimbursement to the Subrecipient as penalty. The subsequent monthly withholdings (of up toWashington Department of Health SNAP-Education, PO Box 47886, Olympia, WA 98504-7886, or in writing via email to snap-ed@.doh.wa.sov.All invoices must be approved by DOH prior to payment; approval will not be unreasonably withheld. DOH will authorize payment only upon satisfactory and on-time completionof acceptance deliverables/outcomes and for allowable costs as outlined in the SNAP-Ed federal guidance, statement of woik,-state ptan, anAlor budget. DOH will return alfincorrect or incomplete invoices and will not pay for services that occur outside the period ofperformance or that are deemed unallowable costs.Additional Details Regarding DeliverablesDOH for required training(s) if necessary and if funds are available.Monitoring ExpectationsThe Subrecipient's premises and records will be made available upon request to DOH, DSHS, and USDA staff for the purposes of observing project activities and reviewing forfunds should be tracked in an inventory list and available for review upon request. Based on fiscal and project monitoring results or fndings, additional monitoring during thefiscal year may be required at the discretion of the DOH SNAP-Ed program, DOH fiscal analyst, or DOH fiscal monitoring unit. Completed project and fiscal monitoring reportswith suggestions, observations, comments, feedback, findings, and/or corrective action will be kept on file at DOH and shared with Subrecipients regularly and by requeit. ^Exhibit A, Statements of WorkRevised as of September 15,2020Page 38 of 42Contract Number CLHI 8249 - 1 7
staff Requirements AMENDMENT #17Upon request by DOH, the Subrecipient must demonstrate 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.Project Coordinator requirementsThe Subrecipient must maintain a SNAP-Ed project coordinator. The project coordinator is the main contact between Department of Health SNAp-Ed team and the Subrecipient.DoH sNAP-Ed expectations for the project coordinator responsibilities include:r Ensure all contract deliverables are met.r Coordinate the planning, implementation, evaluation, and reporting of all parts of the approved project plan.. Comply with and remain knowledgeable about all WA SNAP-Ed and DOH SNAP-Ed policies and procedures.. Comply with and remain knowledgeable about the National SNAp-Ed Guidance.' Ensure staffand any sub-Subrecipients funded through this contract stay informed ofcurrent and new SNAP-Ed policies, and are held accountable to policies when needed.required by WA SNAP-Ed and DOH.' Attend, or designate and send qualified staffmember as proxy to, required DOH and State SNAP-Ed meetings and trainings.r Monitor or maintain knowledge of project budget status, including estimated spend out and total dollars spent to date.' Submit plan and budget amendments for approval as outlined in the current year's policy and procedures.r Coordinate the on-time completion of all data entry and reporting.' Ensure photo and media release forms are obtained for persons featured in SNAP-Ed programming photographs or videos.Communication RequirementsThe Subrecipient must maintain communication with DOH SNAP-Ed. Communication required between DOH SNAP-Ed and the Subrecipient will not be unreasonable orexcessive. DOH SNAP-Ed expectations for communication include:r Submit updates to DOH following any change in contact information for the project coordinator, fiscal agent, contract signatory, or any SNAP-Ed funded staffwithin l0business days ofthe change.o Be available for regular and intermittent meetings, both in person and phone, with DOH SNAP-Ed as agreed upon or as needed.r Respond to all DOH and SNAP-Ed Statewide initiative requests within the timeline requested.e Maintain or obtain an internet connection for communication with DOH, for access to DOH SharePoint webpages, to view updates and messages ffom Washington SNAp-Edthrough the WA SNAP-Ed Providers website, and for reliable reporting of SNAP-Ed activities. If reliable internet connection cannot be t""rr.d, the Subrecipient and DOHSNAP-Ed will agree on a plan for necessary communication, data entry, and reporting.. Obtain a Secure Access Washington (SAW) account to access DOH SNAP-Ed SharePoint webpages.SNAP-Ed Assurances:The following assurances must be followed (see program Guidance https://snaped.firs.usda.eov/program-administration/guidance-and-templates)r The Subrecipient is fiscally responsible for activities funded with Supplemental Nutrition Assistance Program Education funds and is liable for repayment of unallowablecosts.. Programming is provided to approved SNAP-Ed eligible audiences.' Only expanded or additional coverage of those activities funded under the Expanded Food and Nutrition Education Program (EFNEP) may be claimed under the SNAp-Edgrant. 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 mayactivities funded under the EFNEP grant be included in the budget for SNAp-Ed.r Contracts are procured through competitive bid procedures governed by State procurement regulations.r Program activities are conducted in compliance with all applicable Federal laws, rules, and regulations including Civil Rights and OMB regulations governing cost issues.Exhibit A, Statements of WorkRevised as ofSeptember 15,2020Page 39 of 42Contract Number CLH18249-17
aAMENDMENT #17Program activities do not supplant existing nutrition education and obesity prevention programs, and where operating in conjunction with existing programs, enhance as wellas 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 with SNAP- Ed funds include the appropriate USDA non-discrimination statement and credit SNAP as a funding source in standard font that is easilyreadable.SNAP-Ed Statewide InitiativesSubrecipients are expected to communicate with, respond to, and comply with requests, guidance, requirements, and/or on-site visits from all contracted SNAp-Ed statewideinitiative entities.Any SNAP-Ed cuniculum modifications should be developed and executed based on the most current Guidance for Curriculum Modification, found under .,Guidauce andProcess" on WA SNAP-Ed Providers website. Subrecipients must consult DOH SNAP-Ed as directed.After notification to the DOH SNAP-Ed implementing agency, the Subrecipient may adjust or deny requests, requirements, and/or site visits from any contracted SNAp-Edand deliberation between the Subrecipient, DOH SNAP-Ed, and the contracted SNAP-Ed statewide initiative entity/entities; and, when n"..ssa.y, DSHS. Aftir appropriateconsideration and deliberation, the resulting decision about whether or not the Subrecipient must comply or can adjust or deny a specific will be providea in writing to ttreSubrecipient from DOH SNAP-Ed and/or DSHS.Health and SafetySNAP-Ed audience or community members in situations that could endanger their health, safety, or well-being. Participation in SNAP-Ed by the SNAp-Ed audience is voluntary.sufficient and acceptable technical assistance between Subrecipient and DOH SNAP-Ed and afer prior written notifcation to the Subrecipient. Any change in annual fundlng due'Contract Noncompliance and Corrective Action' section.AuditsThe Subrecipient must make State financial and program audits or reviews conducted by other entities available to the DOH, DSHS, USDA, or its designee.I ndirect Rate/Allocation PlanAll indirect ratelallocation plans must be submitted and preapproved by the DOH grants office and the DOH SNAP-Ed program. The Subrecipient is responsible for ensuring thatindirect costs included in the Subrecipient's SNAP-Ed plan and budget are supported by an indirect rate and/or cost allocation plan approved 6y the appropriate agency. The-Subrecipient cannot bill indirect costs that are determined to be unacceptable and will be disallowed.who supervise 'frontline staff must be provided civil rights training an annual basis."Records Maintenance - Record Retention and Management - State Agency and All Subrecipient s ICFR272.2DOH SNAP-Ed regulations require that all records related to the SNAP-Ed program be retained for six (6) years from fiscal closure. This requirement applies to fiscaldocumentation and procurement records, contract related documents and emails, progress reports, monitoring reports, and SNAP-Ed client information (pre/post surveys,aaExhibit A, Statements of WorkRevised as ofSeptember 15,2020Page 40 of 42Contract Number CLHI 8249 - 1 7
AMENDMENT #17demographic cards, etc.). Supporting documentation may be kept at the Subrecipient level, but shall be available for review within six years from the date of the last quarterlyclaim submittal. Any costs that cannot be substantiated by source documents will be disallowed as charges to SNAp-Ed.TravelThe Subrecipient is expected to comply with the Office of Financial Management's Travel Management Requirement and Restrictions as found in policy 10.10AmendmentsSubrecipients should check the current year's federal SNAP-Ed guidance, the current year's DOH SNAP-Ed budget amendment guidance, and/or with a DOH SNAp-Ed programconsultant to know what changes they can make on their own and what changes require an amendment and pre-approval in writing. Notify DOH staff prior to implementingamendments that significantly change the scope or direction ofthe approved project plan, including creatingnew-or completely .ndlng inierventions, or adding dlfferentwritten budget amendment request to DOH, and receive written approval from DOH, prior to making any changes within their p.oj..t or budget and prior to making any purchasesincluded within the amendment. Any requests needing USDA approval must be submitted to DOH no later than April 1st of eaih fiscal year,-or no later than date specineA UyUSDA, DSHS, or DOH. Following the current year's guidance when required, if Subrecipients submit plan or budget no cost amendments that do not require DSH-S or USDAapproval, DOH can review those and make approvals on a case by case basis during the federal fiscal year following the current year's guidance when required. All costamendments that do not require DSHS or USDA approval should be submitted to DOH no later than July 16s of eaih fiscal year.OvertimeStaff overtime is not billable in the DOH SNAP-Ed program unless it has been reviewed by the DOH SNAP-Ed program in advance and approved in writing.Special Funding RequirementsPayment for deliverables as specified herein is dependent on receipt offunding from the USDA funding sources. In the event funding is not received, DOH is under no obligationto 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, DOFi-mayterminate 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 thefunding. DOH will notiry the Subrecipient within 10 working days upon notice by the funding source of funding availability.Special Billing Requirementsl. All invoices, billing, and reimbursements must be in compliance with all applicable Federal laws, rules, regulations including the current year SNAp-Ed Guidance and OMBcirculars 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 A19-lA Invoice voucher.r A SNAP-Ed specific A19-lA must be submitted to the subrecipient's designated DOH SNAP-Ed staff member within 30 days of the last day of the month for which thework is being billed, ORo An Subrecipient may request pre-approval to bill every 2 months instead, in which case, that Subrecipient is required to adhere to the billing due dates provided by DOH.3. The SNAP-Ed program will deny payment for any costs not submitted by the due date without prior approval. If for ANY reason a Subrecipient is unable to submit the SNAp-Ed A- I 9- I A on the due date, the Subrecipient is required to submit a request for an exception to the DOH no later than 7 days prior to due date to the DOH SNAp-Edprogram. 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.Exhibit A, Statements of WorkRevised as ofSeptember 15,2020Page4l of42Contract Number CLHI 8249 - 1 7
5AMENDMENT #I74. Supporting documentation for each month must be submitted with each SNAP-Ed Al9-1A.r At the very least this means a copy ofa Subrecipient's financial expanded/detailed general ledger level report.o Additionally, all receipts, timecards and other supporting documentation, as noted by USDA, must be available upon request.If a Subrecipient 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 furthernotice by DOH.. All new SNAP-Ed Subrecipients within their l.t fiscal year.r Subrecipients with current fiscal findings.. Subrecipients who have not submitted adequate or accurate backup documentation within the last year.. Subrecipients who receive a rating of "High" from the DOH Federal Subrecipient Risk Assessment Tool.BUDGETAmount$26,046SourceUSDADOH Program ContactJamie Wells, SNAP-Ed Contract ManagerDepartment of HealthPO Box 47886, Olympia, WA 98504-7886Jamie.Wells@doh.wa. gov / 3 60 -23 6-3668Exhibit A, Statements of WorkRevised as ofSeptember 15,2020DOH Fiscal ContactKim Henderson, Fiscal AnalystDepartment of HealthPO Box 47886, Olympia, WA 98504-7886Kim.Henderson@doh.wa. gov I 3 60-23 6-3 49 IPage 42 of 42Contract N umber CLHI 8249 - | 7
Kittitas County Public Health DepartmentIndirectRateasofJanuary20l8:29.50ToPublicHealthDept&12.50o/ocountycentralsvcsIndirect Rate as of Janu ary 2019: 28.25o/o Ptblic Health Dept & l2.7so/o Cotnty central SvcsChart ofAccounts Program TitleFederal AwardIdentification #Amend #EXHIBIT B-I7ALLOCATIONSContract Term: 2018-2021BARSRevenueCFDA* 666"**DOH Use OnlyStatement of Work Chart of AccouotsFunding Period Funding PeriodStart Date End Date Start Date End DateContract Number:Date:cLHt8249September 15,2020FFYI9 CSS IAR SNAP Ed Program MgntFFYI9 CSS IAR SNAP Ed Program MgntFFYI8 CSS IAR SNAP Ed Program Mgnt CFFFYI8 CSS IAR SNAP Ed Program MgntFFYI8 CSS IAR SNAP ED Program MgntFFY18 CSS IAR SNAP ED Program MgntFFY I 7 CSS IAR SNAP ED Program Mgnt CFFFY2I L{R SNAP Ed Prog Mgnt-Region 2FFY20 IAR SNAP Ed Prog MgnrRegion 2BITV-COVID Ed LHJ Allocation-CARESCOVID LHJ OFM Allocation-CAREsFFYIT EPR PHEP BPI LHJ FundingFl"Yl7 EPR PHEP BPI LHJ FundingFFYI8 EPR PHEP BPI Supp LHJ FundingIrFYl8 EPR PHEP BPI Supp LHJ FundingFFY20 PHEP BP2 LHJ FundingFFY20 PHEP BP2 LHJ FundingFFYI9 PHEP BPI LHJ FundingFFY17 317 OpsFFYIT AFIXFFY2I Enhanced lnfluenza Coverage CARESFFY2l Enhanced Influenza Coverage CARESFFYI 7 Increasing Immunization RatesFFY2I \rFC OpsFF-Y2l VFC OpsFFY20 VFC OpsFFYIT VFC Opsl97WAWAsQ3903l97WAWA5Q3903l87WAWA5Q3903l87WAWA5Q3903l87WAWA5Q3903l87WAwAsQ3903l717WAWA5Q390NGA Not Received207WAWAsQ3903NGA Not ReceivedNGA Not ReceivedNU90TP92l889-01NU90TP92l889-01NU90TP92l 889-01NU90TP92l889-01NU90TP922043NU90TP922043NU90TP9220435NH23tP000762-05-005NH23rP000762-05-00NH23IP9226l9NH23tP9226 I 9NH23tP000762NH23rP9226r9NH23IP9226t9NH23[P9226195NH23tP000762-05-0010.56110.56110.56110 56r10.56110.56110 561333JJJ333JJJ333333JJJ10.5610.5610.5610 5610.5610.5610.56Amd 9Amd 4Amd 4Amd 4Amd 2N/AN/A10/01/1810/0 l/1 8l0/01/1 80l/01/180l /01/180 l /01/l 80l/01/1809/30/1909/3011909/30t1909/30/r 809/30t1809/30/1809/30/18l0/01/1 8l0/01/18l0/01 /l 8t0/01/1710/01/1710/olt17t0l0ll1709/30/1909/30/1909/30/1909/301't809/30/t 809/30/1809/30/1,8Amount$429$19,14s$8s8$3,000$l1,02s$8,830$r"412$26,046$20,603$s6s$1 9,833$885s48,249$ r 9,653$29,480$49,1 33s2,800$2,800$s,600s2,800$2,800s5,600$1.1 14FundingPeriodSub Totals20,1'14$858$22,8ss91,472$26,046$20,603$63,009$909,400$20,398s49,134s49,133$49,r 33$61 6$2,226$5,600$s,600$5,600$s$1Chart ofAccountsTotal$4s,359$46,649$63,009$909,400$20,398s49"134$98,266$616$2,226s5,600$s,600$12,314Amd l7Amd l0Amd 2N/AAmd 5Amd 4Amd 17Amd 16, 17Amd lOAmd 17Amd 16, 17Amd 3,4Amd 17Amd 15, 17Amd 9N/A10.56110.561333.10.s6 t0/0U20 09t30/21 10/01/20333.10 s6 10/0v19 09t30/20 tD/ot/t909/30/2t09/30n0Amd 16 21.019 33321.01 07/01120 12130/20 07/01/20 t2/30/20 $63.009Amd l6 2t.019 333.21.01 03/01120 12130/20 03/0t/20 t2/30/20 $909,40093.06993.069333.93.06 0l/01/18 06/30t18 W/AtA7333.93.06 0l/01/18 06/30^8 a7/01t17o7/o2/r801/02/1893.06993.069333 93 06 01t01/t8 06t30tt9 07t01/t8 06t30/19333 93.06 07/01/18 0;6t30/19 0'il01/r8 06t30/1993.06993.06993.069333.93.06 07/OU20333.93.06 01/0l/20333.93.06 07/Ol/1906/30/21 07/0t/20 06t30/2t06t30t2t 07/01/20 06/30/2t06/30120 07/0t/19 06/30/20N/A93.268 3339326 01/01/18 0:613Q/18 04/0t/17 06/30/18$616N/A93268 333.93.26 0l/01/18 06/30/18 04/01n7 06130/t8s2,22693.26893.069333.93.26 07/01/20 06t30t21 06/05/20 06/30/21333.93.06 01/01120 06t30/2r 06/05/20 06/30/2t93.268 333 93.26 07/01/18 06t30/19 07/01/18 06/30fi993.26893 26893 26893.268333.93.26333.93 26333.93 26333.93.2607/oU20 06t30/2t0710U20 06t30t2t07/0119 06/30/2001/01/18 06/3011807tjtD007/0U20ffi/01/t904/01/t706/30/2t06/3'0nt06/3012006/30/l 8,600.t t4Page I of3
Kittitas County Public Health Departmentlndirect Rate as ofJanuary 2018: 29.507. Public Health Dept & 12.507o County central SvcsIndirect Rate as of Janu ary 2ol9: 28.257o Public Health Dept & l2.lso/o County central svcsEXHIBIT B-I7ALLOCATIONSContract Term: 2018-2021BARSRevenueDOH Use OnlyStatement of Work Chart of AccountsFunding Period Funding PeriodStart Date End Date Start Date End DateContract Number:Date:cLHr8249September 15,2020Chart of Accounts Program TitleFFY20 Phys Actvty & Nutrition ProgFFYI9 Phys Act\ty & Nutrition ProgFFYI8 Phys ActW & Nutrition ProgFFY2I MCHBG LHJ ContractsFFY20 MCHBG LHJ ContractsFFYl9 MCHBG LHJ ContractsFFY18 MCHBG LHJ ContractsI.-FYl8 MCHBG LHJ ContractsFEMA-75 COVID LHJ AllocationcFS:croup B (FO-E)GFS-GroupB(FO-E)FY2 Group B Programs for DW (FO-E)Zoonotics-GFSZoonotics-GFSbY20/21 COVID-19 Disaster Response AcctSFY2 Lead Environments ofChildrenSFY2 Lead Environments ofChildrenSFYI Lead Environments of ChildrenFPHS Funding for LHJsFPIIS Funding for LHJsFPHS F'unding for LHJsFPHS Funding for LHJsFPHS Funding for LHJs DirYR 20 SRF - Local Asst (15%) (FS) SSYR 20 SRF - Local Asst (15%) (FS) SSFederal AwardIdentification #NGA Not ReceivedNU58DP006504NU58DP006s04NGA Not ReceivedB04MC32578804MC32578B04MC31524804MC31524NCA Not ReceivedAmd 17Amd l0Amd 8, 15Amd 17Amd l0Amd 4Amd 2NiAAmd 10N/AAmd 9Amd 9Amd 8Amd 4Amd I333.93.99333.93.99333.93 99333.93.99333.93.99FundingPeriodSub Total$60,000s60,000$60,000$44,196$44"196s44,t96$34,040$r 89,027$20,000$s,000$ l 0,000$4,029$971$71,478$0$2,000$ r 00,000$ l 00,000$42,000s0Chart ofAccountsTotal$61,177$18,s22$r 80,000$r 66,628$l 89,027$25,000$ l 0,000ss,000$71,478$2,000$242,000Amend # CFDA* 666.**09t29/2t09t29/2009/29/20Amount$60,000$60,000$60,000$44,196s44,196$44,196$893s33,147$20,000$s,00094,O29$971FFYI9 COVID CARESNU50CK0005 I 5FFY20 CDC COVID-19 Crisis Resp LHJ-Tribe NU90TP922069Amd 1593.323 333.93 32 06t0v20 12/3t/20 06/01n0 06t30/21 $61,177$61,177Amd 1393 3s4 333 93.3s 01/20/20 t2t31t2o Ot/ciln} 06/30i2t $.78,s22s78,52293.43993.43993.439s33.93.43 09/30t20 09/29/21 AgBjzO333.93.43 09/30t19 09/29/20 09/30/19333 93 43 02/19^9 09/29120 09/28/1893.99493.99493.99493.99493.994tol01/20t0101/19l 0/01/l 80l /01/1801/01/r 809130/2109130t2009/30/19.09130/1809130/t810/01/2010/01^910/01/1810l0lll7t0/01/1709/30Dt09/30t2009/30/1909/30/1809/30/18Amd 1697.036 333 97 03 07/0120 ,12t30/20 07/01/20 12/30120 $189,027N/AN/A334.04.90 0'7t01/20 t2/3U20 07t01/19 06t30/213340490 01/0r/18 06i30/18 07t01/t7 06t30/t9334.04.91 07/01t19 06t30120 07tot/t9 06/30/21334.04.91 06/0U19 06/30n9 07t\t/r7 06t30/t9334.0493 07t01/18 06/30/19 07/01/18 06t30/t9334.0493 o7tOU18 06t30/19 07/01/18 o6/30/tg334.04.93 0t/01/18 06t30/18 07/01/17 06/30/t8Amd 3N/A 334.04 90 07/01/18 06/30^9 07/011t7 06/30/19 $lo,o00N/AN/AAmd 13N/A 334.04 92 0U20t20 t2/3t/20 0l/01n0 06/30/2ts7r,4'18N/AN/AN/A(s l "s00)$ l,s00$2,000Amd 16Amd l0Amd 16Amd l0Amd 3N/AN/AN/AN/AN/A07/01t20070v200'7/01/190t /01/190t/01/18t2/3112012/3U2006/3012006/30t2006/30t1907 /0t/1907/01/1907101/1907/01/1907/01/1706/30/2106/30/2t06130t2106t30/2t06/30/19$s8,000$42,000$s8,000$42,000$42,000($2,400)$2,400336.04 25336 04.25336.04.25336.04 25336.04.25Amd 3N/AN/A346.26.64 0l/01/18 t2t3u18 07/O1/tS346.26.64 0l/01/18 t2t3vt8 07/01/t5t2/31/18tzRt/t8N/A, Amd 3Page 2 of3$0
Kittitas County Public Health DepartmentIndirect Rate as ofJanuary 2018: 29.507o Public Health Dept & l2.50yo county central svcsIndirect Rate as of January 2019: 28.25o/o Public Health Dept & l2.15oh counfy Central SvcsFederal AwardIdentification #DOH Use OnlyBARS Statement of Work Chart of AccountsRevenue Funding Period Funding PeriodCode** Start Date End Date Start Date End DateEXHIBIT B.I7ALLOCATIONSContract Term: 2018-2021Contract Number:Date:cLHt8249September 15,2020FundingPeriodSub TotalChart ofAccountsTotalChart ofAccountsTitleYR 2 I SRF - Local Asst ( 15%) (FS) SSYR 2l SRF - Local Asst (15%) (FS) SSYR 2l SRF - Local Asst (15%) (FS) SSYR 2l SRF - Local Asst ( I 5%) (FS) SSYR 22 SRF - Local Asst (15%) (FO-E) SSYR 22 SRF - Local Asst (15%) (FO-E) SSYR 22 SRF - Local Asst (15%) (FO-E) SSSanitary Survey Fees (FO-E) SS-StateSanitary Survey Fees (FO-E) SS-StateSanilary Survey Fees (FO-E) SS-StateSanitary Survey Fees (FO-E) SS-StateSanitary Survey Fees (FO-E) SS-StateYR 20 SRF - Local Asst (15%) (FS) TAYR 20 SRF - Local Asst (15%) (FS) TAYR 2l SRF - Local Asst (15%) (FS) TAYR 2l SRF - Local Asst (15%) (FS) TAYR 2l SRF - Local Asst ( I 5%) (FS) TAYR 22 SRF - Local Asst (15%) (FO-E) TAYR 22 SRF - Local Asst ( l5%) (FO-E) TAYR 22 SRF - Local Asst (1s%) (FO-E) TATOTALTotal consideration:GRAND TOTAL+Catalog of Federal Domestic Assistance+*Federal revenue codes begin with "333"Amend #CFDA*06/30/1906/30n9a6B0/t906/30/19Amount(s3,200)$400$2,800$2,400(s400)$3,800$3;200$2,400s6,600$9,00092,400$6,600$9,000$2,309,403s1,933,925$37s,478Amd l0Amd 9, l0Amd 7, 10Amd 3,7, l0Amd 14Amd 12Amd 10, 12Amd 14Amd 12Amd 9, 12Amd7,12N/A, Amd 3,7, 12Amd 3N/A, Amd 3Amd 10Amd 7, 10Amd 3,7, l0Amd 14Amd 12Amd 10" 12346.26.6434626 6434626.64346 26.64N/AN/AN/AN/A01i01/18 06t30/t9 07/01/t70l/01ir8 06/30t19 07/0t/170l/01/18 06/30119 07t01/170l/01i l8 06/30^9 07/0t/17N/AN/AN/A346.26.64 0t/0r/19346.26 64 0t/01t19346.26.64 01/0U19t2/3r/20 01/01/19 06/30/2112/31/20 01/01/19 06/30/2tt2/31/20 0v0l/19 06t30/21N/AN/AN/AN/AN/AN/AN/A0l/0 I /1 80l /01/180 l/0r /l 80r /01/1801/01 /l 8t2/3tD0t2/3l/20t2l3v20t2/3t/20t2/31/2007 /01/t707/0t/1707/01n707/01/1707/0vt706/30/2106t30t2106/30Dt06/3012106/30/21l2/Jt/1812/311r8($400)s3,800$400$2,800$2,400346.26.6s346.26 65346.26.6s346.26.65346.26 65346.26 66 01/01/18 12/31/'t8 07/01/15346.26.66 0l/01/18 t2/31/18 07/Olns($2,ooo)$2,000($4,ooo)$2,000$2,000($2.000)$2,000$2,000$2,309,403 $2,309,403CRAND TOTAITotal FedTotal State$0$0$0$0N/AN/AN/AN/AN/AN/A34626.66 0l/01iI8 06/30t1.9 07/01/17346.2666 0l/01/18 06t30t19 07t0ln734626.66 0l/01/18 06/30n9 07/01/t706/301t906/30/t906130/19346.26.66 01t}U19346.26.66 01/0U19346.26.66 0It0U19t2/3t/20 01t01/1912/31t20 0ltolt19t2/3v20 0l/01/t906/30/2106/30/21o6t30nl$2,000$2,000$2,153,908sl 55,495$2,309,403State revenue codes begin with "334"Page 3 of3
Exhibit C-14 Schedule of Federal AwardsKITTITAS COUNTY HEALTH DEPT-SVN'oo10475-07CONTRACT CLH1824g-Kittitas County pubtic Heatth DepartmentcONTRACT PERIODt 01 tO'U2O1a-12t31 t2O21Federal Amrdldentification NumberAMENDMENT #17Date: September 1 5, 2O2OFederal Grant Awrd Name2019 SUPPLEMENTAL NUTRITIONASSISTANCE PROGRAIVl.EDUCATION(SNAP.ED)Chart of Accounts Program TitleBARSFFY2O IAR SNAP ED PROG MGNT-REGION 2FFY2O IAR SNAP EO PROG MGNTfiEGION 2FFY19 CSS IAR SNAP-ED PROG IVIGNTFFY18 CSS IAR SNAP-ED PROGMM IVIGNT CF333.10.56FFY1E CSS IAR SNAP.ED PROGRAM MGNTFFY17 CSS IAR SMP-EO PROGRAM IVGNT CFCOVID LHJ OFNI ALLOCATION-CARES333.21.01BITV4OVID ED LHJ ALLOCATION4ARESFFY2O PHEP BP2 LHJ FUNDINGDalc333.10.5609/30/19 $5,300,00010to1t19 09t30t20ContractAmt CFDA CFDA Program TiileFedeml Agency NameDepartmeni of Agriculture Food andNutrition Seruice207WAWAsQ3903Department of Agriculture Food andNutrition SetuiceNGA Not ReceivedDepartment ofAgricullure Food andDOHFederalAward DateTotal AmtFederalAwardNGA NotReceivedNGA NotReceivedNGA NoiReceivedNGA NotReceivedNGA NotReceivedNGA NotReceivedAllocation PeriodStart End10t01t20 09t30t21$26,046 10.561State Administrative ivlatching$20,603 '10.561 crants forthe SupptementalNutdtion Assistan@ ProgcmState Administrative l\4atchingGrants forthe SupplementalNutrition Assistance ProgramNutrition SetuiceNGA Not Received1g7WAWA5Q3903SNAP 2YR NUTRITION ED OBESITY333.10 5609t28t18 $5,386,26810/01/18 09/30/1909/30/19 $5,300,00010/01/18 09/30/19333 10 5509t24t17 $5,300,00001/01/18 09/30/18333.10.5609/10/16 $5,739,85601/01/18 0S/30/18520,174 10.561 cranis forthe SupptementatNutrilion Assistane PrcgEm$858 10.561State Administrative [4atchingGranls forthe SupplementalNutrition Assistance ProgramState Administrative Matching522,455 10.561 Grants forthe SupplementatNutrition Assistane Prcg€mPublic Health EmergencyPreparednessDepartmenl of Agriculture Food andNutrition Setuice'iE7WAWAs03903Department of Agriculture Food and187WAWAso3903Nuirition SeNiceDepartment of Agriculture Food andNutrition Seryice1717WAWAsQ390NGA Not ReceivedNGA Not ReceivedDepartment of Health and HumanSetuices Cente6 for Disease Contrcl NU90TP922043and PreventionDepartment of Health and HumanSetuices Cente6 for Disease Control NU90Tp922043and PrevenlionDepartment of Health and HumanSefrices Cente6 for Disease Conlrol N1J90TP921889-01and Prevention20,1 8 SUPPLEI\4ENTAL NUTR'TIONASSISTANCE PROGRAM EDUCATION(SNAP-ED)2018 SUPPLEMENTAL NUTRITIONASSISTANCE PROGRANI EDUCATION(SNAP-ED)2018 SUPPLEMENTAL NUTRITIONASSISTANCE PROGRA[/] EDUCATION(sNAP-ED)$1,472 10.561 crants forthe SupplementatNutrition Assistance ProgramO3lO1l20 12130120 $909,400 21.019 Corcnavirus Retief FundDepartment of the Treasury07101t20 12130t20$63,009 21.019 Corcnavirus Relief FundDepartmenl of the TreasuryNGA Not ReceivedNGA Not ReceivedPUBLIC HEALTH EIV]ERGENCYPREPAREDNESS (PHEP)COOPERATIVE AGREEMENTPUELIC HEALTH EIIIERGENCYPREPAREDNESS (PHEP)COOPERATIVE AGREEI\4ENT333 21 01333.93.0606t12t20 $11,365,797 07tj1t20 06t30t21$49,133 93.069FFY19 PHEP BP1 LIIJ FI.JNDINGFFY18 EPR PHEP BP1 SUPP LHJ FUNDINGFFY17 EPR PHEP BPl L}I.J FUNDING333 93 0606129t19 $11,307,904 07t01t19 06t30t20$49,'133 93.069Public Health EmergencyPreparedness333.93.0608/01i18 511,062,7A2 07/01t18 06t30t19$49,134 93.069HOSPITAL PREPAREDNESSPROGRAM AND PUBLIC HEALTHEIVIERGENCY PREPAREDNESSCOOPERATIVE AGREEMENTDepariment of Health and HumanSeryices Cente6 for Disease Contrcl NU90TP921 E89-01and PreventionHPP AND PHEP COOPERATIVEAGREEMENTPublic Health EmeeencyPreparedness333.93.0607t1a117 $11,062,782 01t01t18 06t30t18$20,39E 93.069 Public Health Emergencytsrepareonesslmmunization CooperativeAgreemenisFFY21 VFC OPS333.93 2607t01119 $9,234,83507t01t20 06t30t21$5,600 93 26EFFY21 ENHANCED INFLUENZA COVERAGE CARES 333.93.2608113120 $12,548,955 07t01t20 06t30t21$5,600 93.268FFY2O VFC OPS333.93.2607101119 $9,234,83507t01t19 06t30t20$5,600 93.26803t03t17 $1,201,605 01t01t18 06/30t1E$1,1 14 93.268lmmunizatjon CooperativeAgreementsDepadmeni of Heallh and HumanSeruices Cenierc for Disease Contol NH231P922619and PreventionIMIVIUNIZATION GRANT ANDVACCINES FOR CHILDREN PROGRAIVllmmunization CooperativeAgreementsDepartment of Health and HumanSetuices Centers for Disease Controland PreventionDepartment of Health and HumanSeNices Cente6 for Disease Controland PaeventionNH23tP92261 INH23tP92261 IIMMUNIZATION GRANT ANDVACCINES FOR CHILDREN PROGRAIUIMMUNIZATION GRANT ANDVACCINES FOR CHILDREN PRocRAl\rllmmunization CooperativeAgreementsDepartment of Health and HumanServices Cente6 for Oisease Conlrcl 5NH231P000762-05-00and PreventionFFY17 VFC OPS333 93 26Page 1 of2IMMUNIZATION GRANT ANDVACCINES FOR CHILDREN'SPROGRAM
Exhibit C-14 Schedule of Federal AwardsKITTITAS COUNTY HEALTH DEPT-SWVOO1O47 5-O7CONTRACT CLH1824g-Kittitas County pubtic Heatth DepartmentCONTRACT PERIODi 01 lO1 12018-'1281 t2O21DOH Totat AmtFederal FederalAward Oate AwardEnd03t03t17 $1,672,28901/01/18 06/30/18Contract Amt CFDA CFDA Proqram TifleFederal Agency NameNU50CK00051 5Depadmenl of Health and HumanSeruices Centers for Disease Contrcl NU90TP922069and PEventionDepartment of Health and HumanSetuicesFederal Amrdldentification NumberAMENDMENT #17Date: September 1 5, 2O2OFederal Grant Amrd NameEPIDEI\4IOLOGY & LABORATORYCAPACIry FOR INFECTIOUSDISEASES (ELC)-BUILDING &STRENGTHENING EPIDEMIOLOGY,CDC COOPEMTIVE AGREEMENT FOREl\4ERGENCY RESPONSE: PUBLTCHEALTH CRISIS RESPONSE CDGRFA.TP'16-1802NGA Not ReceivedSTATE PHYSICAL ACTIVITY ANDNUTRITION-WASHINGTON (SPANWA)STATE PHYSICAL ACTIVITY ANDNUTRITION-WASHINGTON (SPANWA)NGA Not ReceivedAllocation PeriodChart of Accounts Program TitleFFY1 7 INCREASING IMIVIUNIZATION RATESFFY17 AFIXFFY17 317 oPSFFY19 COVID CARESFFY2O CDC COVID-'I9 CRISIS RESP LIIJ-TRIBEFFY2O PHYS ACTVTY & NUTRITION PROGFFY'I9 PHYS ACTVTY & NUTRITION PROGFFYIs PHYS ACTVTY & NUTRITION PROGFFY21 IV]CHBG LHJ CONTRACTSFFY2O MCHBG LI+J CONTPACTSFFYl9 MCHBG LHJ CONTRACTSFFY18 MCHBG LHJ CONTRACTSFEMA-75 COVID LHJ ALLOCATION333.93.2606t29t18 $1,722,44307/01/18 06/30/13$5,600 93.266333.93.26$2,226 93 268333 93 2603t03t17$575,969 01/0,t/18 06/30/1E$616 93.268333.93.3204t23t20 $22,581,799 06t01t20 12t31t20$61.177 93.32303116120 $13,230,799 0'U20t20 12t31t20$78,522 93.354333.93.43NGA NotReceivedNGA NotReceived9/30.t20 09t29t21$60,000 93.439333.93.4307t24t19 $1,846,000 09t30t19 09t29t20s60,000 93.439BARSStartDatelmmunization CooperativeAgreemenlsDepartment of Health and HumanSeruices Centers for Disease Contrct NH23lpOOO762and PreventionIMMUNIZATION GRANT ANDVACCINES FOR CHILDREN'SPROGRAMlmmunizaiion CooperaliveAgreementsDepartment of Heallh and HumanSetuices Centers for Disease Contrcl 5NH23lpOOO762-05-00and PreventionIMI\4UNIZATION GRANT ANDVACCINES FOR CHILDREN'SPROGRAMDepartment of Health and HumanSetuices Cente6 for Disease Controt 5NH23lP0OO762-05-OOand PrcventionIMMUNIZATION GRANT ANDVACCINES FOR CHILDREN'SPROGRAMDepa.tment of Health and HumanSeryices Centers for Disease Controland Prevention333.93.4309/01/1 8$923,000 02t19t19 09t29120$60,000 93.439lmmunization CooperativeAgreementseiiaeniiotogy ario La6oratoryCapacity for lnfectious Diseases(ELC)-Building andStrengthening Epjdemiology,Public Health EmergencyResponse: CoopeEliveAgreement for EmergencyResponse: Public Health CrisisState Physical Activity andNutrition (SPAN)State Physical Activily andNutdtion (SPAN)NGA Not ReceivedDepartment of Health and HumanSeryicesNU58DP006504Department of Health and HumanSeruicesN1J58DP006504Depariment of Health and HumanSeruices Health Resources andServices AdminiskationNGA Not ReceivedB04t\4C32578Department of Health and HumanSeNices Health Resour@s andSetuices AdministrationDepartment of Health and HumanSeryices Health Resour@s and804MC32578804MC31524Department of Homeland Security NGA Not ReceivedState Physi€l Activity andNutrition (SPAN)333.93.99333.97.03333.93.9911t14t18 $2,225,97710/01/18 oS/30/19333.93.9911114118 $2,225,97710t01t19 09t30t2j10120t17 $1,650,52801/01/18 09/30/18Malemal and Child Heaith$44,196 93.994 Seruices Block Grant to theStatesDepartment of Health and HumanSeryices Health Resources andSeruices AdministrationMatemal and Child Heatth$44,196 93.994 Seryices Block crant to theStaies[4atemal and Chitd Health$34,040 93.994 Setutces Block c€nt to theStatesNGA NotReceivedlGA.Nol rororizoNGA NolReceivedlGA.Nol oz,o,,ro09t30t21$44,196 93.99412t30t20 $189,02797.036TOTAL $1,933,925lMaternal and Child HealthSetuices Block c€nt to theSlaiesl\4ATERNAL AND CHILD HEALTHSERVICES ELOCK GRANTN]ATERNAL AND CHILD HEALTHSERVICES BLOCK GRANTIVIATERNAL AND CHILD HEALTHSERVICESDisaster GEnis-PublicAssistan@ (PresidentiallyDeclared Disaste6)NGA Not ReceivedPage 2 of 2
Signature:Email:8rez2* Henr/<satq. Canlra#r. St>ccrh/h+Brenda Henrikson, Contrdcts Specialist (Feb 9, 2021 08:12 pST)Brenda. Hen ri kson@ DOH.WA.GOV
Kittitas County
Review Form
Grants & Contract Agreement + Scrbil
Today'q Date
1.2/L4/2020
Agenda Date sl;c;t
Fund/Department
116-Public Health
Contract/G rant I nformation
Recommendation for Board of Health and Board of Health Review on
Contract /Grant Agency: Consolidated Contract Amendment 17
Period Begin Date: 01./OL/2O18 Period End Date: t2/37/202L
Total Grant/Contract Amount: lncrease of 5155,495.00
Grant/Contract Number: C1H18249
Contract/G ra nt Su m ma ry:
The Consolidated Contract Amendment L7
Exhibit A Statements of Work are amended as follows:
Adds Statements of Work for the following programs
. Supplemental Nutrition Assistance Program-Education - Effective October 7,2020o Division of Emergency Preparedness & Response PHEP - Effective July L,202Oo LSPAN-Local Strategies for PhysicalActivity & Nutrition - Effective February 19,2019o Maternal & Child Health Block Grant - Effective January t, ZOL8o OICP CARES Enhanced lnfluenza Coverage Project - Effective July L,2020
o OlCP-Promotion of lmmunizations to lmprove Vaccination Rates - Effective July 1.,2020
Exhibit B-1-7 Allocations amends and replaces Exhibit B-L6 Allocations as follows:
r lncrease of 5155,495.00 for a revised maximum consideration of 52,309,403.00
Dgpartment Head gnature o^t", t/tz1z"fAdministrator
rd of Health Review and Comment:
Signature
Signa itor's Office Date
te
7 L^a/-^
&
Signature of Board of Health member Date
rosecutor's Office
Kittitas County Prosecutor, Auditor,
APPROVED AS TO FORM:
Grant/Contract Review Page 1
TotalAmount S 155,495 State Funds $Federal Funds S i.55,495
Percentage County Funds Matching Funds 5 CFDA# 10.56L; 93.069; 93.439;
93.994 93.26893.268
ln-Kind S
ut ent bei urchased?ls Who owns uipment?
New Personnel being hired?Contact HR hiri - reportin uirements
Future impacts or liability to Kittitas County
Financial lnformation
Bu lnformation
Pass Through lnformation
Agency to Pass Through
Amount to Pass Through
Sub-Contract Approved Date:
Prosecutor Review
Budget Amendment Needed ?
New Division Created?
Yes ! attach budgetform No n why not
Revenue Code: LL6.612.94.333.10.561 52a,oqa Snap-Ed
LL6.672.88. 3. 3 33. 93. 069
716.6L2.3r.333.93.439
11"6.612.22. 10. 333. 93. 994
776.612.32. 1. 333. 93. 268
1,L6.612.32. 3. 3 33. 93. 268
S19,653
S6o,ooo
544,196
s 2,800
s 2,800
PHEP
LSPAN
MCHBG
lmmz Enhanced Flu
lmmz VFC Ops lm prove Rates
Has the Prosecutor reviewed this a ment?Yes No
County De rtments lmpacted
Submitted
Signature:Date:
De rtment
Assignment of Tracki ng lnformation
Grant/Contract Review page 2
Auditor Facilities Maintenance
lnformation Services Human Resource
Prosecutor Treasurer
Auditor's Office
Human Resource
Prosecutor's Office L\0/
Who Signed the grant application )
Reviewer Date