HomeMy WebLinkAboutRes-2021-176 InterlocalBOARD OF COUNTY COMMISSIONERS
COUNTY OF KITTITAS
STATE OF WASHINGTON
RESOL
NO.2021
UTION-lZJz
BOARD OF COLiNTY
RESOLUTION TO AUTHORIZE EXECUTION OF AN INTERLOCAL AGREEMENT
BETWEEN THE KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT AND THE
WASHINGTON STATE DEPARTMENT OF' HEALTH
WHEREAS, RCW 39.34, the Interlocal Cooperation Act, provides the capability for public
agencies to cooperate for mutual advantage; and
WHEREAS' Kittitas County, through the Kittitas County Public Health Department (KCPHD),
is charged with the preservation, promotion, and improvement of health in the
County;and
WHEREAS, one of the many ways KCPHD preserves and promotes health improvements is by
aiding in the COVID-19 response; and
WHEREAS, the Washington State Department of Health (DOH) is committed to accomplish
the National Initiative to Address COVID-19 Health Disparities Among
Populations at High-Risk and Underserved, Including Racial and Ethnic Minority
Populations and Rural Communities; and
WHEREAS' DOH desires to delegate certain COVID-19 activities to KCPHD as detailed in the
attached Interagency Agreement that is attached hereto, and hereby incorporated
by this reference; and
WHEREAS' KCPHD desires to participate in the COVID-I9 response at detailed in the attached
Interagency Agreement.
NOW THEREFORE' BE IT RESOLVED that the Board of County Commissioners of Kittitas
County, Washington, authorizes execution of an Interagency Agreement with the Washington
State Department of Health.
DATEDthis lu1r.duv or lJ ov&Wl>LY ,202l,atEllensburg, washington.
of
W nshingt on St nt e D ep ar tment of
Health
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- I 9 related health
disparities at the community level as described in Centers for Disease Control and Prevention (CDC) Grant
National Initiative to Address COVID-LI 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 incidinial 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 Transp*.n"y
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
Uriversal Numbering System (DLINS@) 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 iharge
by contacting Dun and Bradstreet at www.dnb.com.
Information about your organization and this Agreement will be made available on
www.USASpendine.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 musi
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 in-orporated herein.
DOH Contract GVL26649 -0
Revision October 2021
CONTRACT NUMBER:
GVL26649-0
SUBRECIPIENT *
Xves nNo
FFATA FORIU REQUIRED
Xvps nNo
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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 5200.22 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
Govemor, 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 l)
3. Primary document (document that includes the signature page)
4. Statement of Work (Exhibit A)
5. Contractor Vaccination Certification (Exhibit D)
INDEPENIDENT 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 ofthe 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:
DOH Contract GYL26649-0
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DOH Contract GV L26649 -0
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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; andD. 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 hogram against
all information stored locally and off-site. Information must be encrypted both in-transit and a-t rest
and applied in such away 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 (oclo) policy 141, Securing Information Technologr Assets, available at:
https ://ocio.wa. gov/po licy/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 Offrcer.
DOH may at arry 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 reshict, 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 Technolory (NIST) Cryptographic Algorithm Validation
Program (CMVP);
o Documented patch management practices that asswe 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 I 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
Confi dential 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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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, diwlge, 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 notiff 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 altemative acceptable date. If an altemative 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.
DOH Contract GVL26649-0
Revision October 2021
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EXHIBIT A, DOH CONTRACT GVL26649-0
Sub-recipient Statement of Work
KITTITAS COUNTY HEALTH DEPARTMENT
Period of Performance: March i,5, 2021 through May 31, 2023
PURPOSE: The purpose of this Contract is to lead and coordinate efforts to reduce Covid-l9 related
health disparities at the community level as described in Centers for Disease Control and Prevention
(CDC) Grant National Initiative to Address COVID-|? 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-l9 related health disparities, improve and increase testing and
contract tracing for rural populations, and improve local capacity and services to prevent and control
Covid-l9 infection and transmission among populations who are rural and underserved. See Exhibit C
for further detail.
Project Period: 3ll5l202l - 513112023
Budgqt: $300,000
Task
#
Tash/Activity Deliverable/Outcome Due Date
1 Form and facilitate a local Rural Equity
Advisory Team (REAT) to inform project
implementation and identiff strategies that
align with the CDC grant expectations.
Advisory team will use data sources
including, but not limited to:. Local population demographicse Covid-l9 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
progrcm 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
o DOH Program Manager will provide
a budget template.
Workplan document
Completed budget template
5/31/2023
-t Subrecipients will identiff, award, and
manage subcontractors or subrecipients as
needed to implement project activities in
alignment with grant expectations.
r 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 progam manager.
Duration of
project
DOH Contract GVL266 49 -0
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EXIIIBIT A, DOH CONTRACT GVL26649-0Sub-recipient Statement of WorkKITTITAS COUNTY HEALTH DEPARTMENTPeriod of Performance: March 15, 2021 through May 3/,, 2023This table includes only active funding sources.Certifications and Assurances - all requirements imposed on the subrecipient by the federal awarding agencyThe 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 I If applicable, this isidentified 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 Mairrtenance" section of the contract.Closeout Requirements:(l) Submit all final billings within 60 days ofthe 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 properfy purchased with subaward funds and dispose of or return govemment-fumished property no longer used for subaward related activities (If applicable DOHmust be contacted for disposal requirements.)(4) Additional DOH program specific contract closeout requirements (If applicable, see statement of work for additional closeout requirements.)DoH Contract GVL26649-ORevision October 2021Federal Grant Information SheetSubrecipient/Contractor:Contract Number:DUNS Number:Period of Performance:Project Description:Kittitas County Health DepartmentGVL26649010202547DOH Contract Manager:Eileen KazuraApproved Indirect Rate: yesContact Information:dohcon.msmt@doh.wa.govResearch andLimiting Indirect Cosf Rate: Development?Start Date: End Date: (rf yES, check box) trIuly 1,2021 May 31,2023National Initiative to Address COVID-I9 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and EthnicMinority Populations and Rural Communities.Totd Amount ofFederal FundsObligated for ThisFundins Source$300,000Amount ofFederalFunds Obligatedby This Action$300,000Name ofPass-ThroughAgencyWashington StateDepartment of HealthCFDA Program TitleCOVID-19 HealthDisparitiesCFDA#93.391Total Amount oftheFederal Award toDOH$29,015,581Federal Agency NamecDcFederalAward Date05/27t2021Federal AwardIdentification Number1NHT5OT000042-01Page 17 of27
EXHIBIT C, DOH CONTRACT GVL26649-0
SPECIAL TERMS & CONDITIONS
KITTITAS COUNTY HEALTH DEPARTMENT
2. Baild,leverage, and expand infrastructure supportfor COWD-L9 prevention and
control omong 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-I9 testing and contact tracing, as
well as PPE, quarantine and isolation, vaccination, and other wrap-around and supportive
services.
Activities under Strategt 2 may include but are not limited to:I Hieh Prioritv: 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;
o 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
o 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 communitieso Update jurisdictions' COVID-l9 plans and health equity plans to support
communities most at risk for COVID-I9 with the intention of seffing 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- I 9
3. Mobilize partners and collaborators to advance health equity and address social
determinants of health as they relate to COWD-L9 health disparities among
populations at higher risk and that are anderserved: Identifying and addressing current
gaps and factors that influence COVID-19-related health disparities requires a
collaborative approach.
Activities under Strategt J may include but are not limited to:o 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;
DOH Contract GVL26649 -0
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EXHIBIT C, DOH CONTRACT GVL26649.0
SPECIAL TERMS & CONDITIONS
KITTITAS COUNTY HEALTH DEPARTMENT
. 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.
o Increasing behavioral health access in rural communities.
r 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.
o Recovery from the COVID-19 impacts on healthcare, behavioral health, and public
health workforce.
r Recovery from the COVID-I9 impacts on key community assets integral to the health of
the community.
o 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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ATTACHMENT 1
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 Coion Health Program (BCCHP), Special Supplemental Nutrition
Program for Women, Infants, and Children (!UC), WIC Farmers Market Program, Immunization
Programs, and Ryan White CARE Act programs and other communicable disease treatment and
diagnostic programs.
3. C|l 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. $$ l68l-1683 and 1685-
1686), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. $ 794), the Age Discrimination Act
of 1975 (42 U.S.C. $$ 6101-6107),the Drug Abuse Office and Treatment Act of 1972 (PL92-255),
the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act
of 1970 (PL 9l-616), $$523 and 527 of Ihe Public Health Service Act of l9l2 (42 U.S.C. $$290dd-3 and290ee-3), Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 993601 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. STANIDARD 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.
CERTITICATIONS
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 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 ofFederal 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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A]]TACHMENT 1
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:
l) 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 ofsuch notices:
Compliance and Intemal 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 (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
DOH Contract GV L266 49 -0
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ATTACHMENT 1
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 disqualiff 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 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 was effoneous 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 debaned, 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 enoneous. 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 Non-procurement List (of
excluded parties).
DOH Contract GVL26649 -0
Revision October 2021
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ATTACHMENT 1
X'EDERAL ASSURANCES . NON.CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average l5 minutes per response'
including timelor reviewing instructions, searching existing data sources, gathering and maintaining the
data neeied, 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 Project (0348-0040)'
Washingfon, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFtr'ICE 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. Ifsuch is the case, you will be notified-
As the duly authorized representative ofthe contractor, I certiff 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 of project cost) to ensure proper
planning, management. and completion of the proiect 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 Intergovemmental Personnel Act of 1970 (42 U.S.C. 554728-4763) relating to
prescribed it*d*ds for merit systems for programs funded under one of the 19 statutes or regulations
ipecified 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) fiitJ Vf of the Civil Rights Act of 1964 (P.L. 83-352) 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. g$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. gg 6l0l-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office
and Treatment Act of 1972 eL . SZ-ZSS), 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. 9l-616), as amended, relating to nondiscrimination on the basis of
alcohol abuse or alcoholism; (g) gg 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
DOH Contract GVL26649 -0
Revision October 2021
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ATTACHMENT 1
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. gg480l 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
DOH Contract GV L26649 -0
Revision October 2021
SIGNATURE OF OFFICIAL TITLE
bew
C)^MfryAfr1
ORGANZATION NAME: (if applicable)
\{thttts C{vn+y
DATE
tr Ir lJ
Page25 of27
EXHIBTT D, DOH CONTRACT GVL26649-0
DEPARTMENT OF HEALTH
Contra ctor/Vendor Certifi cation
Proclamatio n 2l-14 - COVID-l9 Vaccination Certification
KITTITAS COT]NTY HEALTH DEPARTMENT
OR
CDNTRACTOR/VENDOR DOES NOT HAVE A COWD-lg CONTRACTOR/VENDOR
VACCINATION VnrunCnnOr,l PLAN. Contractor/Vendor does not have a current
COVID-l9 Contractor/Vendor Vaccination Verification Plan and, is not able to
develop and provide a COVID-I9 ContractorA/endor Vaccination Verification Plan
to ensure thai personnel meet the COVID-l9 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. fNote: Compliance with the
Proclamation is mandatory and failure to comply could result in termination of
contract/purchase order.]
I hereby certiff, under penalty of perjury under the laws of the State of Washington, that the certifications
herein are true and correct unA tnut I arnauthorized to make these certifications on behalf of the firm listed
herein.
DoH Contract GVL26649-0
Revision October 2021
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DOH Contract Number 26649
Contract Description (see instructions and example below)
Federal Funding Accountability and Transparency Act Data Collection Form
FOR DEPARTMENT OF HEALTH USE ONLY
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 eiisting addiction treatment programs,
Funds will also be used to assist centers in creating tobacco free treatment environments.
Page2 of2 i0.lr'?i.il9)