HomeMy WebLinkAboutREVISED_GVL26649-0 KCHD - unsignedDOH Contract GVL26649-0 Page 1 of 27
Revision October 2021
CONTRACT NUMBER:
GVL26649-0
SUBRECIPIENT *
YES NO
FFATA FORM REQUIRED
YES NO
INTERAGENCY AGREEMENT
Between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
And
KITTITAS COUNTY HEALTH DEPARTMENT
THIS AGREEMENT is made by and between the State of Washington Department of Health, hereinafter
referred to as DOH, and KITTITAS COUNTY HEALTH DEPARTMENT, hereinafter referred to as
Contractor pursuant to the authority granted by Chapter 39.34 RCW.
PURPOSE: The purpose of this Contract is to lead and coordinate efforts to reduce Covid -19 related health
disparities at the community level as described in Centers for Disease Control and Prevention (CDC) Grant
National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and
Underserved, Including Racial and Ethnic Minority Populations and Rural Communities (CDC-RFA-
OT21-2103).
THEREFORE, IT IS MUTUALLY AGREED THAT:
STATEMENT OF WORK AND BUDGET: The Contractor 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 set forth in Exhibit A, attached hereto and incorporated herein.
PERIOD OF PERFORMANCE: Subject to its other provisions, the period of performance of this
Agreement shall commence on March 15, 2021 and be completed on May 31, 2023, unless terminated
sooner as provided herein. Any work done outside of the period of performance shall be provided at no cost
to DOH.
FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA): If checked
above, this Agreement 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 federal funds are spent.
To comply with the act and be eligible to enter into this Agreement, your organization must have a Data
Universal Numbering System (DUNS®) number. A DUNS® number provides a method to verify data
about your organization. If you do not already have one, you may receive a DUNS® number free of charge
by contacting Dun and Bradstreet at www.dnb.com.
Information about your organization and this Agreement will be made available on
www.USASpending.gov by DOH as required by P.L. 109-282. DOH’s form, Federal Funding
Accountability and Transparency Act Data Collection Form, is considered part of this Agreement and must
be completed and returned along with the Agreement.
PAYMENT: Compensation for the work provided in accordance with this Agreement has been established
under the terms of RCW 39.34.130. The parties have estimated that the cost of accomplishing the work
herein will not exceed $300,000.00 in accordance with Exhibit A, attached hereto and incorporated herein.
DOH Contract GVL26649-0 Page 2 of 27
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Consideration includes but is not limited to all taxes, fees, surcharges, etc. Payment will not exceed this
amount without a prior written amendment. 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.
Source of Funds:
Federal: $300,000.00 State: $0.00 Other: $0.00 TOTAL: $300,000.00
Contractor agrees to comply with applicable rules and regulations associated with these funds.
BILLING PROCEDURE: Payment to the Contractor for approved and completed work will be made by
warrant or account transfer by DOH within 30 days of receipt of the invoice. Upon expiration of the
Agreement, any claim for payment not already made shall be submitted per the Statement of Work, Exhibit
A (if applicable) or within 60 days after the contract expiration date, whichever is earlier.
AGREEMENT ALTERATIONS AND AMENDMENTS: This Agreement may be amended by mutual
agreement of the parties. Such amendments shall not be binding unless they are in writing and signed by
personnel authorized to bind each of the parties.
ALLOWABLE COST: Shall mean an expenditure which meets the test of the Uniform Guidance (2CFR
200) (see “I. Federal Compliance”). The most significant factors affecting allowability of cost are; 1) they
must be necessary and reasonable, 2) they must be allocable, 3) they must be authorized or not prohibited
under State or local laws and regulations, and 4) they must be adequately documented. For more specifics
see Selected Items of Cost 2 CFR 200.420).
ASSIGNMENT: The work to be provided under this Agreement, and any claim arising thereunder, is not
assignable or delegable by either party in whole or in part, without the express prior written consent of the
other party, which consent shall not be unreasonably withheld.
CONFIDENTIALITY/SAFEGUARDING OF INFORMATION: The use or disclosure by any party of
any information concerning a client obtained in providing service under this Agreement shall be subject to
Chapter 42.56 RCW and Chapter 70.02 RCW, as well as any other applicable Federal and State statutes
and regulations.
Any unauthorized access or use of confidential information must be reported to the DOH Chief Information
Security Officer at security@doh.wa.gov. The notification must be made in the most expedient time
possible (usually within one business day of discovery) and without unreasonable delay, consistent with
the legitimate needs of law enforcement, or any measures necessary to determine the scope of the breach
and restore the reasonable integrity of the data system.
CONTRACT MANAGEMENT: The contract manager for each of the parties shall be responsible for and
shall be the contact person for all communications and billings regarding the performance of this agreement.
The Contract Manager for DOH is: The Contract Manager for the Contractor is:
Name: Eileen Kazura, HSC4 Name: Tristen Lamb
Office: Community Health Systems Title: Public Health Director
Agency: Department of Health Company: Kittitas County Health Department
Address: PO Box 47853 Address: 507 N Nanum St Ste 102
City,
State, Zip: Olympia, WA 98504-7853
City,
State, Zip: Ellensburg, WA 98926
Phone: (360) 584-6106 Phone: (509) 962-7003
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CONTRACT: Shall mean the purpose of obtaining goods and services for the non-Federal entity's own
use and creates a procurement relationship with the Contractor. See §200.22 Contract. Characteristics
indicative of a procurement relationship between the non-Federal entity and a Contractor are when the non-
Federal entity receiving the Federal funds:
A. Provides the goods and services within normal business operations;
B. Provides similar goods or services to many different purchasers;
C. Normally operates in a competitive environment;
D. Provides goods or services that are ancillary to the operation of the Federal program; and
E. Is not subject to compliance requirements of the Federal program as a result of the agreement, though
similar requirements may apply for other reasons.
CONTRACTOR: Shall mean that agency, firm, provider, organization, individual or other entity
performing services under this contract. It shall include any subcontractor retained by the prime contractor
as permitted under the terms of this contract.
DISPUTES: In the event that a dispute arises under this Agreement, it shall be determined by a Dispute
Board in the following manner: Each party to this agreement shall appoint one member to the Dispute
Board. The members so appointed shall jointly appoint an additional member to the Dispute Board. The
Dispute Board shall review the facts, Agreement terms and applicable statutes and rules and make a
determination of the dispute. The determination of the Dispute Board shall be final and binding on the
parties hereto. As an alternative to this process, either of the parties may request intervention by the
Governor, as provided by RCW 43.17.330, in which event the Governor's process will control.
GOVERNANCE: This Agreement is entered into pursuant to and under the authority granted by the laws
of the State of Washington and any applicable federal laws. The provisions of this Agreement shall be
construed to conform to those laws.
In the event of an inconsistency in the terms of this Agreement, or between its terms and any applicable
statute or rule, the inconsistency shall be resolved by giving precedence in the following order:
A. Federal statutes and regulations
B. State statutes and regulations
C. Agreement amendments
D. The Agreement (in this order)
1. Special Terms and Conditions (Exhibit C)
2. Federal compliance and Standard Federal Certifications and Assurances
(Attachment 1)
3. Primary document (document that includes the signature page)
4. Statement of Work (Exhibit A)
5. Contractor Vaccination Certification (Exhibit D)
INDEPENDENT CAPACITY: The employees or agents of each party who are engaged in the
performance of this Agreement shall continue to be employees or agents of that party and shall not be
considered for any purpose to be employees or agents of the other party.
NONCOMPLIANCE: Shall mean if a non-Federal entity fails to comply with Federal statutes, regulations
or the terms and conditions of a Federal award, the Federal awarding agency or pass-through entity may
impose additional conditions, as described in §200.207 Specific conditions. If the Federal awarding agency
or pass-through entity determines that noncompliance cannot be remedied by imposing additional
conditions, the Federal awarding agency or pass-through entity may take one or more of the following
actions, as appropriate in the circumstances:
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A. Temporarily withhold cash payments pending correction of the deficiency by the non-Federal entity or
more severe enforcement action by the Federal awarding agency or pass-through entity.
B. Disallow (that is, deny both use of funds and any applicable matching credit for) all or part of the cost
of the activity or action not in compliance.
C. Wholly or partly suspend or terminate the Federal award.
D. Initiate suspension or debarment proceedings as authorized under 2 CFR part 180 and Federal awarding
agency regulations (or in the case of a pass-through entity, recommend such a proceeding be initiated
by a Federal awarding agency).
E. Withhold further Federal awards for the project or program.
F. Take other remedies that may be legally available.
PRIVACY: Personal information collected, used or acquired in connection with this Agreement shall be
used solely for the purposes of this Agreement. Contractor and its subcontractors agree not to release,
divulge, publish, transfer, sell or otherwise make known to unauthorized persons personal information
without the express written consent of the agency or as provided by law. Contractor agrees to implement
physical, electronic and managerial safeguards to prevent unauthorized access to personal information.
DOH reserves the right to monitor, audit or investigate the use of personal information collected, used or
acquired by the Contractor through this Agreement. The monitoring, auditing, or investigating may include
but is not limited to "salting" by DOH. Contractor shall certify the return or destruction of all personal
information upon expiration of this Agreement. Salting is the act of placing a record containing unique but
false information in a database that can be used later to identify inappropriate disclosure of data contained
in the database.
Any breach of this provision may result in termination of the Agreement and the demand for return of all
personal information. The contractor agrees to indemnify and hold harmless DOH for any damages related
to the Contractor's unauthorized use of personal information.
RECORDS MAINTENANCE: The parties to this Agreement shall each maintain books, records,
documents and other evidence which sufficiently and properly reflect all direct and indirect costs expended
by either party in the performance of the ser vices described herein. These records shall be subject to
inspection, review or audit by personnel of both parties, other personnel duly authorized by either party,
the Office of the State Auditor, and federal officials so authorized by law. All books, records, documents,
and other material relevant to this Agreement will be retained for six years after expiration and the Office
of the State Auditor, federal auditors, and any persons duly authorized by the parties shall have full access
and the right to examine any of these materials during this period.
Records and other documents, in any medium, furnished by one party to this Agreement to the other party,
will remain the property of the furnishing party, unless otherwise agreed. The receiving party will not
disclose or make available this material to any third parties without first giving notice to the furnishing
party and giving it a reasonable opportunity to respond. Each party will utilize reasonable security
procedures and protections to assure that records and documents provided by the other party are not
erroneously disclosed to third parties.
RIGHTS IN DATA: Unless otherwise provided, data, which originates from this Agreement shall be
"works for hire" as defined by the U.S. Copyright Act of 1976 and shall be owned by DOH. Data shall
include, but not be limited to, reports, documents, pamphlets, advertisements, books magazines, surveys,
studies, computer programs, films, tapes, and/or sound reproductions. Ownership includes the right to
copyright, patent, register, and the ability to transfer these rights.
RISK ASSESSMENT: Shall mean (2 CFR 200.331(b)) DOH is required to evaluate each subrecipient's
risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for
purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this
section, which may include consideration of such factors as:
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A. The subrecipient's prior experience with the same or similar subawards;
B. The results of previous audits including whether or not the subrecipient receives a Single Audit in
accordance with Subpart F—Audit Requirements of this part, and the extent to which the same or
similar subaward has been audited as a major program;
C. Whether the subrecipient has new personnel or new or substantially changed systems; and
D. The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives
Federal awards directly from a Federal awarding agency).
SECURITY OF INFORMATION – Unless otherwise specifically authorized by the DOH Chief
Information Security Officer, Contractor receiving confidential information under this contract assures that:
encryption is selected and applied using industry standard algorithms validated by the National
Institute of Standards and Technology (NIST) Cryptographic Algorithm Validation Program against
all information stored locally and off-site. Information must be encrypted both in-transit and at rest
and applied in such a way that it renders data unusable to anyone but authorized personnel, and the
confidential process, encryption key or other means to decipher the information is protected from
unauthorized access.
It is compliant with the applicable provisions of the Washington State Office of the Chief Information
Officer (OCIO) policy 141, Securing Information Technology Assets, available at:
https://ocio.wa.gov/policy/securing-information-technology-assets.
It will provide DOH copies of its IT security policies, practices and procedures upon the request of the
DOH Chief Information Security Officer.
DOH may at any time conduct an audit of the Contractor’s security practices and/or infrastructure to
assure compliance with the security requirements of this contract.
It has implemented physical, electronic and administrative safeguards that are consistent with OCIO
security standard 141.10 and ISB IT guidelines to prevent unauthorized access, use, modification or
disclosure of DOH Confidential Information in any form. This includes, but is not limited to, restricting
access to specifically authorized individuals and services through the use of:
o Documented access authorization and change control procedures;
o Card key systems that restrict, monitor and log access;
o Locked racks for the storage of servers that contain Confidential Information or use AES encryption
(key lengths of 256 bits or greater) to protect confidential data at rest, standard algorithms validated
by the National Institute of Standards and Technology (NIST) Cryptographic Algorithm Validation
Program (CMVP);
o Documented patch management practices that assure all network systems are running critical
security updates within 6 days of release when the exploit is in the wild, and within 30 days of
release for all others;
o Documented anti-virus strategies that assure all systems are running the most current anti-virus
signatures within 1 day of release;
o Complex passwords that are systematically enforced and password expiration not to exceed 120
days, dependent user authentication types as defined in OCIO security standards;
o Strong multi-factor authentication mechanisms that assure the identity of individuals who access
Confidential Information;
o Account lock-out after 5 failed authentication attempts for a minimum of 15 minutes, or for
Confidential Information, until administrator reset;
o AES encryption (using key lengths 128 bits or greater) session for all data transmissions, standard
algorithms validated by NIST CMVP;
o Firewall rules and network address translation that isolate database servers from web servers and
public networks;
o Regular review of firewall rules and configurations to assure compliance with authorization and
change control procedures;
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o Log management and intrusion detection/prevention systems;
o A documented and tested incident response plan
Any breach of this clause may result in termination of the contract and the demand for return of all personal
information.
SEVERABILITY: If any provision of this Agreement or any provision of any document incorporated by
reference shall be held invalid, such invalidity shall not affect the other provisions of this Agreement which
can be given effect without the invalid provision, if such remainder conforms to the requirements of
applicable law and the fundamental purpose of this Agreement, and to this end the provisions of this
Agreement are declared to be severable.
SPECIFIC CONDITIONS:
A. The Federal awarding agency or pass-through entity may impose additional specific award conditions
as needed, in accordance with (2 CFR 200.207) paragraphs (b) and (c) of this section, under the
following circumstances:
1. Based on the criteria set forth in §200.205 Federal awarding agency review of risk posed by
applicants;
2. When an applicant or recipient has a history of failure to comply with the general or specific terms
and conditions of a Federal award;
3. When an applicant or recipient fails to meet expected performance goals as described in §200.210
Information contained in a Federal award; or
4. When an applicant or recipient is not otherwise responsible.
B. These additional Federal award conditions may include items such as the following:
1. Requiring payments as reimbursements rather than advance payments;
2. Withholding authority to proceed to the next phase until receipt of evidence of acceptable
performance within a given period of performance;
3. Requiring additional, more detailed financial reports;
4. Requiring additional project monitoring;
5. Requiring the non-Federal entity to obtain technical or management assistance; or
6. Establishing additional prior approvals.
C. The Federal awarding agency or pass-through entity must notify the applicant or non-Federal entity as
to:
1. The nature of the additional requirements;
2. The reason why the additional requirements are being imposed;
3. The nature of the action needed to remove the additional requirement, if applicable;
4. The time allowed for completing the actions if applicable, and
5. The method for requesting reconsideration of the additional requirements imposed.
D. Any specific conditions must be promptly removed once the conditions that prompted them have been
corrected
SUBCONTRACTING: Neither the Contractor, nor any subcontractors, shall enter into subcontracts for
any of the work contemplated under this agreement without prior written approval of DOH. In no event
shall the existence of the sub operate to release or reduce the liability of the Contractor to DOH for any
breach in the performance of the contractor’s duties. This clause does not include contracts of employment
between the contractor and personnel assigned to work under this Agreement.
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Additionally, the Contractor is responsible for ensuring that all terms, conditions, assurances and
certifications set forth in this Agreement are carried forward to any subcontracts. Contractor and its
subcontractors agree not to release, divulge, publish, transfer, sell or otherwise make known to unauthorized
persons personal information without the express written consent of DOH or as provided by law.
If, at any time during the progress of the work, DOH determines in its sole judgment that any subcontractor
is incompetent, DOH shall notify the Contractor, and the Contractor shall take immediate steps to terminate
the subcontractor's involvement in the work. The rejection or approval by DOH of any subcontractor or
the termination of a subcontractor shall not relieve the Contractor of any of its responsibilities under the
Agreement, nor be the basis for additional charges to DOH.
SUBRECIPIENT: Shall mean a non-Federal entity that received a subaward from a pass-through entity to
carry out part of a Federal program; but does not include an individual that is a beneficiary of such program.
A subrecipient may also be a recipient of other Federal awards directly from a Federal awarding agency. (2
CFR 200.93)
Characteristics which support the classification of the non-Federal entity as a subrecipient include when the
non-Federal entity:
A. Determines who is eligible to receive what Federal assistance;
B. Has its performance measured in relation to whether objectives of a Federal program were met;
C. Has responsibility for programmatic decision making;
D. Is responsible for adherence to applicable Federal program requirements specified in the Federal award;
and
E. In accordance with its contract, uses the Federal funds to carry out a program for a public purpose
specified in authorizing statute, as opposed to providing goods or services for the benefit of a pass -
through entity.
SUSPENSION OF PERFORMANCE AND RESUMPTION OF PERFORMANCE: In the event
contract funding from State, Federal, or other sources is withdrawn, reduced, or limited in any way after
the effective date of this Agreement and prior to normal completion, DOH may give notice to Contractor
to suspend performance as an alternative to termination. DOH may elect to give written notice to Contractor
to suspend performance when DOH determines that there is a reasonable likelihood that the funding
insufficiency may be resolved in a timeframe that would allow performance to be resumed prior to the end
date of this Agreement. Notice may include notice by facsimile or email to Contractor’s representative.
Contractor shall suspend performance on the date stated in the written notice to suspend. During the period
of suspension of performance each party may inform the other of any conditions that may reasonably affect
the potential for resumption of performance.
When DOH determines that the funding insufficiency is resolved, DOH may give Contractor written notice
to resume performance and a proposed date to resume performance. Upon receipt of written notice to
resume performance, Contractor will give written notice to DOH as to whether it can resume performance,
and, if so, the date upon which it agrees to resume performance. If Contractor gives notice to DOH that it
cannot resume performance, the parties agree that the Agreement will be terminated retroactive to the
original date of termination. If the date Contractor gives notice it can resume performance is not acceptable
to DOH, the parties agree to discuss an alternative acceptable date. If an alternative date is not acceptable
to DOH, the parties agree that the Agreement will be terminated retroactive to the original date of
termination.
TERMINATION: Either party may terminate this Agreement upon 30 days prior written notification to
the other party. If this Agreement is so terminated, the parties shall be liable only for performance rendered
or costs incurred in accordance with the terms of this Agreement prior to the effective date of termination.
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TERMINATION FOR CAUSE: If for any cause, either party does not fulfill in a timely and proper
manner its obligations under this Agreement, or if either party violates any of these terms and conditions,
the aggrieved party will give the other party written notice of such failure or violation. The responsible
party will be given the opportunity to correct the violation or failure within 15 working days. If the failure
or violation is not corrected, this Agreement may be terminated immediately by written notice of the
aggrieved party to the other.
WAIVER: A failure by either party to exercise its rights under this Agreement shall not preclude that party
from subsequent exercise of such rights and shall not constitute a waiver of any other rights under this
Agreement unless stated to be such in a writing signed by an authorized representative of the party and
attached to the original Agreement.
ALL WRITINGS CONTAINED HEREIN: This Agreement contains all the terms and conditions agreed
upon by the parties. No other understandings, oral or otherwise, regarding the subject matter of this
Agreement shall be deemed to exist or to bind any of the parties hereto.
IN WITNESS WHEREOF, the parties have executed this Agreement.
This document has been approved as to form only by the Assistant Attorney General.
NOTE: The Contractor’s signature is also required on Attachment 1,
Federal Certifications and Assurances (pages 22 and 25).
CONTRACTOR SIGNATURE
{{Sig_es_:signer1:signature}}
DATE
{{Dte_es_:signer1:date}}
PRINT OR TYPE NAME
TITLE
{{*Ttl_es_:signer1:title}}
DOH CONTRACTING OFFICER SIGNATURE
{{Sig_es_:signer2:signature}}
DATE
{{Dte_es_:signer2:date}}
EXHIBIT A, DOH CONTRACT GVL26649-0
Sub-recipient Statement of Work
KITTITAS COUNTY HEALTH DEPARTMENT
Period of Performance: March 15, 2021 through May 31, 2023
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PURPOSE: The purpose of this Contract is to lead and coordinate efforts to reduce Covid-19 related
health disparities at the community level as described in Centers for Disease Control and Prevention
(CDC) Grant National Initiative to Address COVID-19 Health Disparities Among Populations at High-
Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities
(CDC-RFA-OT21-2103). Implementation Leads will advance health equity in their communities and
collaboratively work to reduce Covid-19 related health disparities, improve and increase testing and
contract tracing for rural populations, and improve local capacity and services to prevent and control
Covid-19 infection and transmission among populations who are rural and underserved. Work will
focus in Kittitas County. See Exhibit C for further detail.
Project Period: 3/15/2021 – 5/31/2023
Budget: $300,000
Task
#
Task/Activity Deliverable/Outcome Due Date
1 Form and facilitate a local Rural Equity
Advisory Team (REAT) to inform project
implementation and identify strategies that
align with the CDC grant expectations.
Advisory team will use data sources
including, but not limited to:
Local population demographics
Covid-19 indicator data and social
vulnerability index
Stakeholder input
Documentation of formed
advisory team, such as
meeting schedule and
minutes, shared with DOH
program manager.
Documentation of local data
used to guide selections of
strategies shared with DOH
program manager.
Recommendations from
advisory team shared with
DOH program manager.
Within 90 days
after date of
execution
2 Upon selection of strategies a workplan and
budget will be developed.
Workplan to include objectives,
strategies, persons responsible and
target dates
DOH Program Manager will provide
a budget template.
Workplan document
Completed budget template
5/31/2023
3 Subrecipients will identify, award, and
manage subcontractors or subrecipients as
needed to implement project activities in
alignment with grant expectations.
Subcontracts should include key
partnerships with organizations who
have existing community or social
service delivery programs for
underserved populations
disproportionately impacted by
Covid-19 and health disparities
Subcontracts in place and
managed in accordance with
federal guidelines.
Copies of subcontracts shared
with DOH program manager.
Duration of
project
EXHIBIT A, DOH CONTRACT GVL26649-0
Sub-recipient Statement of Work
KITTITAS COUNTY HEALTH DEPARTMENT
Period of Performance: March 15, 2021 through May 31, 2023
DOH Contract GVL26649-0 Page 10 of 27
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4 Progress and Performance Reporting:
Subrecipient will submit a quarterly progress
report using a template provided by DOH
manager.
Progress and Performance
reports are submitted in
accordance with CDC grant
requirements
Quarterly
5 Develop a plan for sustainability.
Sustainability plan includes but is not
limited to:
Covid-19 community recovery
strategies
Emergency preparedness planning
Sustainability Plan in place
and shared DOH program
manager
5/31/2023
Special Requirements:
This is a federally funded contract. All expenditures incurred and reimbursements made for performance
under this contract shall be based on actual, allowable and allocable costs. See Exhibit C for further detail.
For activities that require the purchase of equipment: For purchases of pieces of equipment in which the
aggregate unit price of the equipment (including shipping, handling and associated costs) is $5,000 or more,
the contractor shall obtain written prior approval from the Washington State Department of Health, and
adhere to all federal requirements as referenced in;
2 CFR 200.313, Equipment at: https://www.gpo.gov/fdsys/granule/CFR-2014-title2-vol1/CFR-
2014-title2-vol1-sec200-313 , and
2 CFR 200.439, Equipment and other Capital Expenditures at:
https://www.gpo.gov/fdsys/granule/CFR-2014-title2-vol1/CFR-2014-title2-vol1-sec200-439
Invoicing must include backup documentation as described in the statement of work deliverables:
Billings/invoices shall include copies of backup documentation for all expenses. Backup documentation can
include, but is not limited to; receipts, invoices, billing records, work orders, positive time and attendance
records (timesheets), travel vouchers and accounting expense reports.
Additional backup documentation may be requested if needed.
Signed A-19 invoices must be received prior to approval and payment. A scanned copy of your A-19 with
signature is acceptable.
Please email the signed A-19s and backup documentation to:
Washington State Department of Health
ATTN: Eileen Kazura
Community Health Systems
PO Box 47850
Olympia, WA 98504-7850
Eileen.kazura@doh.wa.gov
EXHIBIT A, DOH CONTRACT GVL26649-0
Sub-recipient Statement of Work
KITTITAS COUNTY HEALTH DEPARTMENT
Period of Performance: March 15, 2021 through May 31, 2023
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This table includes only active funding sources.
Federal Grant Information Sheet
Subrecipient/Contractor: Kittitas County Health Department DOH Contract Manager: Contact Information:
Contract Number: GVL26649 Eileen Kazura dohcon.mgmt@doh.wa.gov
DUNS Number: 010202547 Approved Indirect Rate: yes
Period of Performance: Start Date: End Date:
Limiting Indirect Cost Rate:
Research and
Development?
(If YES, check box)
July 1, 2021 May 31, 2023
Project Description: National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic
Minority Populations and Rural Communities.
Federal Award
Identification Number
Federal
Award Date Federal Agency Name
Total Amount of the
Federal Award to
DOH
CFDA # CFDA Program Title Name of Pass-Through
Agency
Amount of Federal
Funds Obligated
by This Action
Total Amount of
Federal Funds
Obligated for This
Funding Source
1NHT5OT000042-01 05/27/2021 CDC $29,015,581 93.391 COVID-19 Health
Disparities
Washington State
Department of Health $300,000 $300,000
Certifications and Assurances – all requirements imposed on the subrecipient by the federal awarding agency:
The contract boilerplate covers all standard certifications and assurances.
Are there any additional requirements imposed by the pass-through entity (DOH) to meet its own responsibilities to the awarding agency? Yes No If applicable, this is
identified by the DOH program staff writing the contract. This can also be found in the “Statement of Work” section of the contract.
All subrecipients are required to make their accounting records available and accessible to the awarding agency:
This requirement can be found in the “Records Maintenance” section of the contract.
Closeout Requirements:
(1) Submit all final billings within 60 days of the end of the contract (This is required per standard contract language.)
(2) Submit all required program reports and deliverables within 60 days (This is required per standard contract language.)
(3) Dispose of property purchased with subaward funds and dispose of or return government -furnished property no longer used for subaward related activities (If applicable DOH
must be contacted for disposal requirements.)
(4) Additional DOH program specific contract closeout requirements (If applicable, see statement of work for additional close out requirements.)
EXHIBIT C, DOH CONTRACT GVL26649-0
SPECIAL TERMS & CONDITIONS
KITTITAS COUNTY HEALTH DEPARTMENT
DOH Contract GVL26649-0 Page 12 of 27
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For this scope of work (SOW), each awardee will complete activities that help to prevent and
control Covid-19 infection or transmission in populations at higher risk and that are underserved.
These activities will advance health equity in racial and ethnic minority groups and rural
populations.
STRATEGIES AND ALLOWABLE COSTS:
Your Rural Equity Advisory Team (REAT) will use data to identify high priority COVID-19
related health disparities and activities to address those disparities. The selected activities should
aim to build infrastructures that both address disparities in the current COVID-19 pandemic and
set the foundation to address future responses.
Work under this grant falls under the following three overarching strategies. CDC has indicated
high priority activities under each strategy.
Please note that this is not a complete list of possible activities. If you have questions about the
eligibility of activities not listed here, please reach out to your DOH program manager.
1. Expand existing and/or develop new mitigation and prevention resources and services
to reduce COVID-19 related disparities among populations at higher risk and that are
underserved: Ensuring equitable access to critical COVID-19 personal protective
equipment (PPE), testing, contact tracing, quarantine and isolation, vaccination, and other
wrap-around services require deploying focused strategies, resources, and activities to
meet the needs of individuals and mitigate the spread of COVID-19 among populations
disproportionately impacted.
Activities under Strategy 1 may include but are not limited to:
High Priority: Expand testing (including home test kits and mobile testing sites) and
contact tracing among populations at higher risk and that are underserved, including
racial and ethnic minority populations and people living in rural communities;
Vaccine coordination, quarantine and isolation options, and preventive care and
disease management among populations that are underserved and at higher risk for
COVID-19
Tailor and adapt evidence-based policies, systems, and environmental strategies to
mitigate social and health inequities related to COVID-19
Identify and establish collaborations with critical partners affiliated with populations
at higher risk and that are underserved, including racial and ethnic minority groups at
higher risk for COVID-19 to:
1) connect community members to programs, healthcare providers,
services and resources (e.g., transportation, housing support, food
assistance programs, mental health and substance abuse services,
substance abuse services) they might need and
2) lessen adverse effects of mitigation strategies.
EXHIBIT C, DOH CONTRACT GVL26649-0
SPECIAL TERMS & CONDITIONS
KITTITAS COUNTY HEALTH DEPARTMENT
DOH Contract GVL26649-0 Page 13 of 27
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2. Build, leverage, and expand infrastructure support for COVID-19 prevention and
control among populations that are at higher risk and underserved: Sufficient
workforce, infrastructure, and capacity are critical to providing equitable access to
disproportionately affected populations. Where feasible, this short-term program will
build, leverage, and expand the infrastructure and capacity within state, local, US
territorial and freely associated state health departments (or their bona fide agents) to
ensure and expand equitable access to critical COVID-19 testing and contact tracing, as
well as PPE, quarantine and isolation, vaccination, and other wrap-around and supportive
services.
Activities under Strategy 2 may include but are not limited to:
High Priority: Expand the infrastructure to improve testing and contact tracing
among populations at higher risk and that are underserved, including racial and
ethnic minority populations and rural communities;
Establish, enhance, or implement leadership-level health equity offices,
workgroups, task forces, or positions to guide addressing COVID-19 among
communities at higher risk and that are underserved
Convene and facilitate multi-sector coalitions or advisory groups that include
members of underserved communities and organizations that serve the
community. These groups may provide advice, guidance, and recommendations
for addressing COVID-19 and advancing health equity among their communities
Update jurisdictions’ COVID-19 plans and health equity plans to support
communities most at risk for COVID-19 with the intention of setting up systems
that put in place infrastructures and plans that can also support future emergency
responses
Build and expand an inclusive public health workforce, including hiring people
from the community (e.g., community health workers, social workers, other
trusted community members) who are equipped to assess and address the needs of
communities disproportionately affected by COVID-19
3. Mobilize partners and collaborators to advance health equity and address social
determinants of health as they relate to COVID-19 health disparities among
populations at higher risk and that are underserved: Identifying and addressing current
gaps and factors that influence COVID-19-related health disparities requires a
collaborative approach.
Activities under Strategy 3 may include but are not limited to:
High Priority: Build community capacity to reach disproportionately affected
populations with effective culturally and linguistically tailored programs and
practices for testing and contact tracing, and quarantine, including racial and
ethnic minority populations and rural communities;
EXHIBIT C, DOH CONTRACT GVL26649-0
SPECIAL TERMS & CONDITIONS
KITTITAS COUNTY HEALTH DEPARTMENT
DOH Contract GVL26649-0 Page 14 of 27
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Build and implement cross-sectoral partnerships to align public health, healthcare,
and non-health (e.g., housing, transportation, social service) interventions that
decrease risk for COVID-19
Develop mechanisms such as community advisory groups that include leaders
representing racial and ethnic minority groups and rural community leaders and
members representing underserved populations to inform COVID-19 and future
emergency response activities
Develop and disseminate culturally and linguistically responsive COVID-19
prevention communications through various channels (e.g., local media, local or
community newspapers, radio, TV, trusted communications agents) written in
plain language and in formats and languages suitable for diverse audiences—
including people with disabilities, limited English proficiency, etc.—addressing
and, as necessary, dispelling of misinformation and barriers to mitigation
practices due to mistrust.
Build community capacity that includes traditional organizations (e.g., public
health, healthcare) and non-traditional partners (e.g., community health workers,
churches, transportation providers, social workers) to reach disproportionately
affected populations with effective culturally and linguistically tailored programs
and practices for testing, contact tracing, isolating, vaccination, and healthcare
strategies
Identify and establish collaborations with critical partners affiliated with and who
provide services to populations that are underserved and at higher risk for
COVID-19 to disseminate scientifically accurate, culturally, and linguistically
responsive information and facilitate access to health-related services
Note on Strategy 3: Much or all of the work associated with formation/extension, coordination
and management of the Rural Equity Advisory Teams falls under this strategy.
Applicants are not required to implement all strategies, but rather they should select the
strategies and activities that best address their jurisdiction’s respective priorities and needs.
EXAMPLE ACTIVITIES:
Please note that this is not a complete list of possible activities. If you have questions about the
eligibility of activities not listed here, please reach out to your DOH program manager.
Increasing awareness and education on COVID-19 prevention, testing and vaccination
for rural populations
o Increasing testing in rural areas
o Increasing contract tracing and follow-up
o Improving emergency preparedness and response capacity in rural communities
EXHIBIT C, DOH CONTRACT GVL26649-0
SPECIAL TERMS & CONDITIONS
KITTITAS COUNTY HEALTH DEPARTMENT
DOH Contract GVL26649-0 Page 15 of 27
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Rural Paramedicine for COVID-19 testing and vaccination. This approach can build
community capacity to reach underserved groups such as home bound residents and other
adults 65+ years.
Increasing behavioral health access in rural communities.
Increasing supports and services for rural residents with long-haul COVID-19 symptoms.
Design improvements to address rural residents who already face barriers to care
exacerbated by COVID-19 such as transportation issues, childcare needs to make
healthcare visits, limited access to relevant specialists, or being uninsured or under-
insured, lack of technology to participate in telehealth interactions from home.
Recovery from the COVID-19 impacts on healthcare, behavioral health, and public
health workforce.
Recovery from the COVID-19 impacts on key community assets integral to the health of
the community.
Youth strategies, such as structured activities or opportunities meant to assist recovery
from the social isolation, depression and anxiety suffered during the pandemic.
PERFORMANCE REPORTING:
Performance reporting will be requested quarterly. Guidance will be provided with all
reporting requests.
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FEDERAL COMPLIANCE
AND STANDARD FEDERAL CERTIFICATIONS AND ASSURANCES
In the event federal funds are included in this agreement, added by future amendments(s), or redistributed
between fund sources resulting in the provision of federal funds, the following sections apply: “I. Federal
Compliance” and “II. Standard Federal Assurances and Certifications”. In the instance of inclusion of
federal funds as a result of an amendment, the contractor may be designated as a “Subrecipient” and the
effective date of the amendment shall also be the date at which these requirements go into effect.
I. FEDERAL COMPLIANCE - The use of federal funds requires additional compliance and control
mechanisms to be in place. The following represents the majority of compliance elements that may
apply to any federal funds provided under this contract. (Refer to Catalog of Domestic Assistance
number(s) cited in the “Payment” section of this contract for requirements specific to that fund source.)
For clarification regarding any of these elements or details specific to the federal funds in this contract,
contact:
Compliance and Internal Control Officer
Office of Financial Services
Department of Health
Post Office Box 47901
Olympia, Washington 98504-7901
1. UNIFORM ADMINISTRATIVE GUIDANCE – The Uniform Administrative Guidance
(Supercircular) became effective December 26, 2014 and combines numerous OMB Circulars into
one document. This document established requirements which govern expenditure of federal
funds. These requirements apply to the Department of Health, as the primary recipient of federal
funds, and then follow the funds to the subrecipient. The Uniform Administrative Guidance
provides the applicable administrative requirements, cost principles, and audit requirements are
identified by subrecipient organization type.
Compliance Matrix
OMB CIRCULAR
ENTITY TYPE ADMINISTRATIVE
REQUIREMENTS
COST PRINCIPLES AUDIT
REQUIREMENTS
State. Local and Indian
Tribal Governments &
Governmental Hospitals
2 CFR 200
Subpart D
2 CFR 200
Subpart E
2 CFR 200
Subpart F
Non-Profit Organizations 2 CFR 200
Subpart D
2 CFR 200
Subpart E
2 CFR 200
Subpart F
Hospitals 2 CFR 200
Subpart D
45 CFR 74
Appendix E
2 CFR 200
Subpart F
Colleges or Universities &
Affiliated Hospitals
2 CFR 200
Subpart D
2 CFR 200
Subpart E
2 CFR 200
Subpart F
2. CITIZENSHIP/ALIEN VERIFICATION/DETERMINATION - The Personal Responsibility
and Work Opportunity Reconciliation Act (PRWORA) of 1996 (PL 104-193) states that federal
public benefits should be made available only to U.S. citizens and qualified aliens. Entities that
offer a service defined as a “federal public benefit” must make a citizenship/qualified alien
determination/ verification of applicants at the time of application as part of the eligibility criteria.
Non-US citizens and unqualified aliens are not eligible to receive the services. PL 104 -193 also
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includes specific reporting requirements. Exemptions from the determination/verification
requirement is afforded the following programs offered by the Department of Health: Family
Planning, Breast, Cervical and Colon Health Program (BCCHP), Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC), WIC Farmers Market Program, Immunization
Programs, and Ryan White CARE Act programs and other communicable disease treatment and
diagnostic programs.
3. CIVIL RIGHTS AND NONDISCRIMINATION - During the performance of this agreement,
the Contractor shall comply with all current and future federal statutes relating to
nondiscrimination. These include but are not limited to: Title VI of the Civil Rights Act of 1964
(PL 88-352), Title IX of the Education Amendments of 1972 (20 U.S.C. §§ 1681-1683 and 1685-
1686), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794), the Age Discrimination Act
of 1975 (42 U.S.C. §§ 6101-6107), the Drug Abuse Office and Treatment Act of 1972 (PL 92-255),
the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act
of 1970 (PL 91-616), §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290dd-
3 and 290ee-3), Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), and the
Americans with Disability Act (42 U.S.C., Section 12101 et seq.).
4. SINGLE AUDIT ACT - A subrecipient (including private, for-profit hospitals and non-profit
institutions) shall adhere to the federal Uniform Administrative Guidance (subpart F) as well as all
applicable Federal and State statutes and regulations. A subrecipient who expends $750,000 or
more in federal awards during a given fiscal year shall have a single or program-specific audit for
that year in accordance with the provisions of 2 CFR 200 Subpart F.
II. STANDARD FEDERAL 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 belief, that the contractor, defined as the primary participant in
accordance with 45 CFR Part 76, 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;
B. have not within a 3-year period preceding this contract been convicted of or had a civil
judgment rendered against them for commission of fraud or a crimina l 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;
C. 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
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D. 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 Part 76.
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 specifying 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 pe rformance of the contract
be given a copy of the statement required by paragraph 1) above;
D. Notifying the employee in the statement required by paragraph 1), 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;
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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 1973, 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 of such notices:
Compliance and Internal Control Officer
Office of Grants Management
WA State Department of Health
PO Box 47905
Olympia, WA 98504-7905
3. CERTIFICATION REGARDING LOBBYING
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 (non-appropriated) 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
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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 CIVIL 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 of any indoor facility owned or leased or contracted for by an entity
and used routinely or regularly for the provision of health, 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 of services for children as defined by the Act.
The contracting 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.
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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 DEBARMENT, 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.
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 transact ion. 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 was erroneous when submitted or has become erroneous 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 deter mines the eligibility of its
principals. Each participant may, but is not required to, check the Non-procurement List (of
excluded parties).
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H. Nothing contained in the foregoing shall be construed to require establishment of 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 of business dealings.
I. Except for transactions authorized under paragraph 6 of these instructions, if a 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:
1) Are not presently debarred, 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 1. 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.
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.
CONTRACTOR’S SIGNATURE IS REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
{{Sig_es_:signer1:signature}}
TITLE
{{*Ttl_es_:signer1:title}}
ORGANIZATION NAME: (if applicable)
{{Cmpy_es_:signer1:company}}
DATE
{{Dte_es_:signer1:date}}
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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 informati on, including suggestions for reducing
this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040),
Washington, DC 20503
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 of the contractor, I certify that the contractor:
1. Has the legal authority to apply for Federal assistance, and the institutional, manageria l and financial
capability (including funds sufficient to pay the non-Federal share of project 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 of personal or organizational conflict of interest, 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. §§4728-4763) 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 nondiscrimina tion. 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. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c)
Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42
U.S.C. §§ 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) §§ 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.
§§ 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse patient
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records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. § 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 II 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 of Federal participation in purchases.
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-
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. §§276a to 276a-7),
the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §§874) and the Contract Work Hours and Safety
Standards Act (40 U.S.C. §§ 327-333), regarding labor standards for federally assisted construction sub
agreements.
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.
11. 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 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State
management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§1451
et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans und er Section
176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of
underground sources of drinking water under the Safe Drinking Water Act of 1974, 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).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§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. §470), EO 11593 (identification and protection of
historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§469a-
1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research,
development, and related 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.
§§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.
ATTACHMENT 1
DOH Contract GVL26649-0 Page 25 of 27
Revision October 2021
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which
prohibits the use of lead- based paint in construction or rehabilitation of residence 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 Super circular 2CFR200, Subpart F.
18. Will comply with 2CFR200.216 - Prohibition on certain telecommunications and video surveillance
services or equipment - as amended effective August 13, 2020, and any amendments to this section
thereafter
19. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations
and policies governing this program.
CONTRACTOR’S SIGNATURE IS REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
{{Sig_es_:signer1:signature}}
TITLE
{{*Ttl_es_:signer1:title}}
ORGANIZATION NAME: (if applicable)
{{Cmpy_es_:signer1:company}}
DATE
{{Dte_es_:signer1:date}}
EXHIBIT D, DOH CONTRACT GVL26649-0
DEPARTMENT OF HEALTH
Contractor/Vendor Certification
Proclamation 21-14 - COVID-19 Vaccination Certification
KITTITAS COUNTY HEALTH DEPARTMENT
DOH Contract GVL26649-0 Page 26 of 27
Revision October 2021
To reduce the spread of COVID-19, Washington state Governor Jay Inslee, pursuant to emergency powers
authorized in RCW 43.06.220, issued Proclamation 21-14 – COVID-19 Vaccination Requirement (dated
August 9, 2021), as amended by Proclamation 21-14.2 – COVID-19 Vaccination Requirement (dated
September 27, 2021) and as may be amended thereafter. The Proclamation requires contractors/vendors
who have goods, services, or public works contracts with a Washington state agency to ensure that their
personnel (including subcontractors) who perform contract activities on-site comply with the COVID-19
vaccination requirements, unless exempted as prescribed by the Proclamation.
I hereby certify, on behalf of the firm identified below, as follows
CONTRACTOR/VENDOR {{*plan_es_:signer1:dropdown(options=”has, does not have”)}}
A COVID-19 CONTRACTOR VACCINATION VERIFICATION PLAN THAT COMPLIES WITH THE
VACCINATION PROCLAMATION.
Explanation/Information/Definition
CONTRACTOR/VENDOR HAS A COVID-19 CONTRACTOR VACCINATION VERIFICATION
PLAN THAT COMPLIES WITH THE VACCINATION PROCLAMATION. Contractor/Vendor:
1. Has reviewed and understands Contractor/Vendor’s obligations as
set forth in Proclamation 21-14 – COVID-19 Vaccination
Requirement (dated August 9, 2021), as amended by Proclamation
21-14.2 – COVID-19 Vaccination Requirement (dated September
27, 2021);
2. Has developed a COVID-19 Vaccination Verification Plan for
Contractor/Vendor’s personnel (including subcontractors) that
complies with the above-referenced Proclamation;
3. Has obtained a copy or visually observed proof of full vaccination
against COVID-19 for Contractor/Vendor personnel (including
subcontractors) who are subject to the vaccination requirement in
the above-referenced Proclamation;
4. Complies with the requirements for granting disability and religious
accommodations for Contractor/Vendor personnel (including
subcontractors) who are subject to the vaccination requirement in
the above-referenced Proclamation;
5. Has operational procedures in place to ensure that any contract
activities that occur in-person and on-site at Department of Health
premises that are performed by Contractor personnel (including
subcontractors) will be performed by personnel who are fully
vaccinated or properly exempted.
6. Has operational procedures in place to enable Contractor/Vendor
personnel (including subcontractors) who perform contract activities
on-site at Department of Health premises to provide compliance
documentation that such personnel are in compliance with the
above-referenced Proclamation;
7. Will provide to Agency, upon request, Contractor/Vendor’s
COVID-19 Vaccination Verification Plan and related records,
except as prohibited by law, and will cooperate with any
investigation or inquiry pertaining to the same.
EXHIBIT D, DOH CONTRACT GVL26649-0
DEPARTMENT OF HEALTH
Contractor/Vendor Certification
Proclamation 21-14 - COVID-19 Vaccination Certification
KITTITAS COUNTY HEALTH DEPARTMENT
DOH Contract GVL26649-0 Page 27 of 27
Revision October 2021
OR
CONTRACTOR/VENDOR DOES NOT HAVE A COVID-19 CONTRACTOR/VENDOR
VACCINATION VERIFICATION PLAN. Contractor/Vendor does not have a current
COVID-19 Contractor/Vendor Vaccination Verification Plan and, is not able to
develop and provide a COVID-19 Contractor/Vendor Vaccination Verification Plan
to ensure that personnel meet the COVID-19 vaccination requirements as set forth in
the above-referenced Proclamation, and provide the same to Department of Health
within twenty-four (24) hours of such request. [Note: Compliance with the
Proclamation is mandatory and failure to comply could result in termination of
contract/purchase order.]
I hereby certify, under penalty of perjury under the laws of the State of Washington, that the certifications
herein are true and correct and that I am authorized to make these certifications on behalf of the firm listed
herein.
Federal Funding Accountability and Transparency Act Data Collection Form
Page 1 of 2 (03/2019)
This contract is supported by federal funds that require compliance with the Federal Funding Accountability and
Transparency Act. The purpose of the Transparency Act is to make information available online so the public can see
how federal funds are spent. To comply with the act and be eligible to enter into this contract, your organization must
have a Data Universal Numbering System number (DUNS®). If you do not already have one, you may receive a DUNS®
number free of charge by contacting Dun and Bradstreet at www.dnb.com. The Department of Health (DOH) also
encourages registration with the System for Award Management (SAM) to reduce data entry by both DOH and your
organization. You may register with SAM free of charge at www.sam.gov. Information about your organization and this
contract will be reported by DOH to the federal government as required by P.L. 109-282. This information will then be
made available to the public by the federal government on USASpending.gov.
SUBRECIPIENT
1.Legal Name 2.DUNS Number
3.Principle Place of Performance
3a. City 3b. State
3c. Zip+4 3d. Country
NO 4.Are you registered in SAM? YES (skip to signature block. Sign, date and return)
5.In the preceding fiscal year did your organization:
a.Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans, subgrants, and/
or cooperative agreements; and
b.$25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans, subgrants, and/
or cooperative agreements; and
c.The public does not have access to this information about the compensation of the senior executives of your
organization through periodic reports filed under section 13(a) or 15(d) of the Securities and Exchange Act of
1934 (15 U.S.C. §§ 78m(a), 78o(d) or section 6104 of the Internal Revenue Code of 1986.
NO (skip to signature block. Sign, date and return)
YES (You must report the names and total compensation of the top 5 highly compensated officials of your
organization).
Name of Official Total Compensation
1.
2.
3.
4.
5.
Note: “Total compensation” for purposes of this requirement generally means the cash and non-cash value earned by the
executive during the past fiscal year and includes salary and bonus; awards of stock, stock options and stock appreciation
rights; and other compensation such as severance and termination payments, and value of life insurance paid on behalf of the
employee, and as otherwise provided by FFATA and applicable OMB guidance.
By signing this document, the Authorized Representative attests to the information.
Subrecipient’ s Authorized Representative Sign & Date
DOH will not endorse your subaward until this form is completed and returned.
Federal Funding Accountability and Transparency Act Data Collection Form
Page 2 of 2 (03/2019)
FOR DEPARTMENT OF HEALTH USE ONLY
DOH Contract Number
Contract Description (see instructions and example below)
Instructions for Contract Description:
In the first line of the description provide a title for the subrecipient contract that captures the main purpose of the work.
Then, indicate the name of the subrecipient and provide a brief description that captures the overall purpose of the work,
how the funds will be used, and what will be accomplished.
Example of a Contract Description:
Increase Healthy Behaviors: Educational Services District XYZ will provide training and technical assistance to chemical
dependency centers to assist the centers to integrate tobacco use into their existing addiction treatment programs.
Funds will also be used to assist centers in creating tobacco free treatment environments.