HomeMy WebLinkAboutConCon Amendment 1 SOWsExhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Climate & Health Wildfire Smoke Indoor Air Quality
Project - Effective January 1. 2022
SOW Type: Ori�alal Revision # (for this SOW)
Period of Performance: January 1 202 through August 31, 2022
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
❑ State 0 FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work is two -fold and is being done as part of the Center of Disease Contol and Prevention's (CDC's) original and
supplementa I grant "Strengthening environmental health capacity (EHC) to detect, prevent, and control environmental health hazards in through data -driven, evidence -based
approaches" initially awarded to DOH on September 1, 2020.
1) The first is to respond to declared wildfire disasters in Washington state by identifying the most vulnerable populations, assessing ambient wildfire smoke infiltration into
indoor air in places where vulnerable populations reside, and providing resources to protect those populations in areas where indoor air quality needs improvement. This statement
of work provides KCPHD $21,00 to continue this work of the original grant.
2) The second is to increase readiness to apply ventilation practices that reduce wildfire smoke exposure and transmission of airborne COVID-19 and, while considering extreme
heat, in residences or facilities used by vulnerable populations. This work will include distributing wildfire smoke interventions to vulnerable individuals and repeating the
residential cleaner air room project from the original grant with improvements and incorporation of heat. This statement of work provides KCPHD $83,000 to perform these
activities of the supplemental grant that was awarded to DOH on September 1, 2021.
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
g
Increase (+)
Total
Allocation
FFY20 ENVIRO HEALTH CAPACITY -C (CDC) NCE
25440100
93.070
333.93.07
01/01/22 08/31/22
0
21,000
21,000
FFY22 CDC EHC EHR SUPPLEMENTAL
25450222
93.070
333.93.07 1
01/01/22 08/31/22
0
83,000
83,000
Code 25440100.
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
0
1 104,000
1 104,000
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1
Collaborate with DOH to identify larger facilities for indoor air
LHJ presents selected long-term care
August 31, 2022
Reimbursement for actual
quality consultation pilot within the selected target vulnerable
facility (2) and school (2)
costs not to exceed
population to include:
A written protocol for conducting
$21,000 on Master Index
consultation in larger facilities
Code 25440100.
Exhibit A, Statement of Work Page 1 of 5 Contract NumberCLH31015
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
#
and/or Amount
• Identify and secure commitment of two (2) long-term care
facilities and two (2) schools for consultation (consultation
consists of identifying current practices, assessing barriers
to improve and training best practices)
• Help develop protocol for consultation of cleaner indoor
air in larger facilities
2
Collaborate with DOH to provide indoor air quality
# of consultation sessions provided to
August 31, 2022
consultation pilot to include:
long-term care facilities on best practices
• Conduct consultation in two (2) long -tern care facilities
for indoor air quality
• Conduct consultation in two (2) schools
# of consultation sessions provided to
schools on best practices forindoor air
quality
3
Collaborate with DOH to assess the ability to achieve cleaner
# of residences assessed by DOH and LHJ,
August 31, 2022
indoor air during wildfire smoke events by serving as the main
and summary of airquality measurements
contact with residences using the protocol established by DOH
collected
to include:
• Collect air quality measurements to evaluate intervention
# of scores of current practices in long -
strategy
term care facilities
• Assess ten (10) residences
# of scores of current practices in schools
Collaborate with DOH to assess cleanerindoor air in larger
facilities to include:
# of long-term care facilities with
• Assess current practices in two (2) long-term care facilities
obstacles to indoor air quality
and two (2) schools
improvements characterized
• Assess barriers to improving indoor air quality practices in
two (2) long-term care facilities and two (2) schools
# of schools with obstacles to indoor air
quality improvements characterized
4
Collaborate with DOH as lead of qualitative assessment to
# of vulnerable people in residences
August 31, 2022
estimate the effectiveness and efficacy of the intervention to
impacted by the intervention
reduce exposures through access to cleanerindoor air spaces to
in residences include:
# of people completing qualitative
• Quantifying the number of people impacted by the
assessment
intervention
5
Adapt intervention and local communication resources forlocal
Submit a copy of revised local
August 31, 2022
use based on information from evaluation to include:
communication resources based on
• Developing a plan for revising local communication
information from the evaluation
resources
• Incorporating revisions in local communication resources
Exhibit A, Statement of Work Page 2 of 5 Contract NumberCLH31015
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
#
and/or Amount
6
Identify vulnerable individuals for distribution of wildfire
LHJ presents to DOH selection of priority
August 31, 2022
Reimbursement for actual
smoke intervention (NEPA portable air cleaner) to include:
at -risk target population and criteria for
costs not to exceed
• Establishing selection criteria for recipients
recipients
$58,000 on Master Index
• Developing method to collect demographics of
Code 25450222.
recipients
LHJ presents to DOH method to collect
demographics of recipients
7
Distribute wildfire smoke intervention (NEPA portable air
A copy of distribution plan
August 31, 2022
cleaner) to vulnerable individual to include:
• Establishing a plan for distribution
# of HEPA portable air cleaners purchased
• Purchasing HEPA portable air cleaners
• Distributing HEPA portable air cleaners (target 100)
# of vulnerable individuals receiving
• Collect demographics of recipients with developed
intervention
method
• Developing summary report of intervention
# of recipients with reported demographics
distribution
LHJ presents to DOH summary report and
presentation
8
Collaborate with DOH to identify residences for participation
LHJ presents to DOH selection of priority
August 31, 2022
Reimbursement for actual
in a repetition of residential cleaner air room project to include:
at -risk target population and criteria for
costs not to exceed
• Identifying vulnerable population based on health risk
participation
$25,000 on Master Index
and county need
Code 25450222.
• Establishing selection criteria for participation
A recruitment plan for participation in
• Identifying individuals for intervention and enrolling
residential cleaner air room project
participants in project
• Project staff takinghuman subjects research training
LHJ presents a list of selected households
• Summarizing recruitment process
for residential cleaner air room project
# of people providing informed consent
for participation in residential cleaner air
room project
Certification of completion forhuman
subjects research training
A copy of recruitment summary
9
Collaborate with DOH to develop training andprotocolfor
A copy of updated communication
August 31, 2022
repetition of residential cleaner air room project to include:
resource
• Updating communication resource to train residences on
creating cleaner air rooms
An updated protocol for applying
• Updating protocol for applying intervention and
interventions in residences
implementing ro'ect in residences
Exhibit A, Statement of Work Page 3 of 5 Contract NumberCLH31015
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
#
and/or Amount
• Incorporating heat intervention into protocol
10
Collaborate with DOH to implement intervention strategy for
# of HEPA portable air cleaners
August 31, 2022
repetition of residential cleaner air room project by serving as
purchased
main point of contact forparticipants to include:
• Implementing intervention strategy in ten residences, such
# of residences receiving intervention
as establishing the intervention in homes and notifying
participants when to implement it
Summary of implementation of
• Purchasing HEPA portable air cleaners for participants
intervention
• Managing and communicating with residences throughout
project, including addressing technical difficulties,
coordinating visits, etc., as needed
• Summarizing implementation of intervention
11
Collaborate with DOH as lead of qualitative assessment for
Copy of qualitative assessment tool
August 31, 2022
repetition of residential cleaner air room project to include:
• Updating qualitative intervention assessment tool
# of residences completing qualitative
• Leading dissemination of qualitative assessment to
a ssessment
residences
• Analyzing qualitative assessment data
Summary of qualitative assessment results
12
Continue collaboration with DOH to pilot test implementation
Intervention equipment purchased (i.e.
August 31, 2022
TBD on MasterIndex
of the intervention strategy for creating cleaner indoor air in
portable air cleaners)
Code 25440100.
residences by serving as main point of contact forparticipants
to include:
# of residences receiving interventions
• Implementing intervention strategy in ten 10 residences
from DOH and LHJ
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance(a-doh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal subrecipient funding.)
This statement of work is supported by federalfunds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federalfunds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Univers al Numbering System (DUNS®) number.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH a s required by P.L. 109-282.
Program Specific Requirements
Restrictions on Funds (i.e., disallowed expenses or activities, indirect costs, etc.):
The funds can be used to complete the activities outlined above to conduct community engagement and implement and evaluate th e pilot study. Restrictions on funds imposed by
the CDC include:
Exhibit A, Statement of Work Page 4 of 5 Contract NumberCLH31015
• Sub -recipients may not use funds for research.
• Sub -recipients may not use funds for clinical care except as allowed by law.
• Sub -recipients may use funds only for reasonable program purposes, including personnel, travel, supplies, and services.
• Generally, sub -recipients may not use funds to purchase furniture or equipment. Any such proposed spending must be clearly identified in the budget.
• Reimbursement of pre -award costs generally is not allowed, unless the CDC provides written approval to the sub -recipient.
• Other than for normal and recognized executive -legislative relationships, no fundsmaybeused for:
o publicity or propaganda purposes, forthe preparation, distribution, or use of any material designed to support or defeat the enactment of legislation before any
legislative body
o the salary or expenses of any grant or contract sub -recipient related to any activity designed to influence the enactment of legislation, appropriations, regulation,
administrative action, or Executive order proposed or pending before any legislative body
• In accordance with the United States Protecting Life in G1oba I Health Assistance policy, all non-governmental organization (NGO) applicants acknowledge that foreign
NGOs that receive funds provided through this award, either as a prime recipient or sub recipient, are strictly prohibited, regardless of the source of funds, from
performing abortions as a method of family planning or engaging in any activity that promotes abortion as a method of family planning, or to provide financial support to
anyotherforeign non-governmental organization that conducts such activities. See Additional Requirement (AR) 35 forapplicability
(https://www.cdc.gov/grants/additionalrequirements/ar-35.html).
Monitoring Visits (i.e., frequency, type, etc.):
Project staff from Kittitas County Public Health and DOH will have, at a minimum, monthly phone or video calls to check-in on the progress of the grant for the duration of the
project period. These maybe substituted for in-person meetings in the event that COVID restrictions are lifted during the project period.
Exhibit A, Statement of Work Page 5 of 5 Contract NumberCLH31015
DOH Program Name or Title: COVID-19 Mass Vaccination -FEMA -
Effective January 1, 2022
SOW Type: Orip-ina Revision # (for this SOW)
Period of Performance: January 1,2022 through April 1. 2022
Exhibit A
Statement of Work
Contract Term: 2022-2024
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
® Federal Contractor (check if applicable) ® Reimbursement
❑ State ® FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Develo ment
Statement of Work Purpose: The purpose of this statement of work is to establish the task activities, fundingperiod, andbilling details for cost reimbursement ofFEMA-funded
mass vaccination clinics in Washington state.
Revision Purpose: N/A
Master
Index
DOH Chart of Accounts Master Index Title Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Fund ing Period
Start Date End Date
Current
Allocation
Allocation
Change
g
None
Total
Allocation
*MASS VACCINATION FEMA 100% 934VO200
97.036
333.97.03
01/01/22 04/01/22
0
0
eligible costs.
0
SUBRECIPIENT but are as a CONTRACTOR of DOH.
0
0
0
MASS VACCINATION
DOH reimbursement provided for local mass vaccination
0
0
0
(MI 934V0200)
0
0
0
the Regional Incident Management Team (IMT) to
0
0
administer the vaccine efficiently, quickly, equitably, and
0
Requirements below)
safely in all regions of Washington State. State Supported,
0
0
0
TOTALS
0
0
0
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1.
*NOTE: Task activities for Mass Vaccination Clinics in this
*Reimbursement of
statement of work are NOT CONSIDERED
eligible costs.
SUBRECIPIENT but are as a CONTRACTOR of DOH.
MASS VACCINATION
DOH reimbursement provided for local mass vaccination
FEMA 100% Funding
clinic (see definition below) planning, implementation and
(MI 934V0200)
operations in coordination between Unified Command and
the Regional Incident Management Team (IMT) to
(See Program Specific
administer the vaccine efficiently, quickly, equitably, and
Requirements below)
safely in all regions of Washington State. State Supported,
Regionally Coordinated, Locally Implemented.
Definition: Mass vaccination clinics defined as those outside of
the usualhealthcare delivery. method such as pop-up clinics,
mobile clinics, non -clinical facility (fairgrounds, arenas, etc.).
Exhibit A, Statement of Work Page 1 of 4 Contract NumberCLH31015
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Guidance on vaccination protocols must be followed as
provided by DOH and CDC.
1 A
Local health jurisdiction (LHJ) will coordinate planning and
Submit to DOH amass vaccination plan
Within 30 days of
implementation of mass vaccination clinics/sites provided
including:
contract amendment
within the county(s) with a regional incident management
, e of site
si'p
execution.
team/organization as approved by DOH.
• site locations,
Request for regional IMT should be submitted through the
• throughput,
normalprocess through WebEOC.
• considerations made to ensure
equity to historically
LHJ is the coordinating agency for the mass vaccination plan
marginalized populations,
within the county.
• and tothe extent possible a
regional map of sites/locations.
Regional IMT will be under the delegation authority of DOH
and they are to provide support and coordination forall efforts
around vaccine planning, resource support and general
guidance and information sharing in order to regionally
coordinate efforts. Local jurisdictions will maintain all
decisional authority around vaccination planningand execution
within their jurisdiction/district.
Provide any information as requested by the regional IMT.
1 B
Funding for eligible Mass Vaccination activities are reimbursed
Submit estimated budget for the mass
Within 30 days of contract
on actualcosts as outlined in the DOH guidance to provide the
vaccination plan.
amendment execution.
services and to carry out the mission. Funding will be
dependent on full participation in the LHJ and IMT processes
Monthly Cost Summary Spreadsheet to
Monthly
and all documentation will be required to be provided to fully
the IMT/IMOby the fifth of the following
close out funding requests by the end of the mission period of
month.
performance.
Allowable costs include expenses such as facility rentals, staff
to conduct planning, management, support and operation of the
site, medical personnel for vaccinations, site security personnel,
wrap around services for staff (meals, travel, lodging),
equipment (which must be pre -approved by IMT/DOH if it
exceeds $5,000 each), supplies for vaccinations and site
operation. LHJs should provide narratives to help assist IMT
and DOH finance know what expenditures were necessary to
cant' out the mission.
1C
Vaccination data—will be maintained according to current state
Submission of vaccine use into WA IIS
Daily
and federal requirements.
database within 24hrs of use.
Exhibit A, Statement of Work Page 2 of 4 Contract NumberCLH31015
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Vaccine Registration Systems— If a local jurisdiction or region
Jurisdiction/Regions will ensure a fair and
does not have a registration system(s) the include internet
equitable process forregistration of
based, phone option and other methods to ensure equitable
eligible Washingtonians across all
registration, the state PrepMod system and tools will be
available modalities.
available foruse.
1 D
Regularly report on vaccinations sites and operational activities
Provide monthly situation report to
Monthly
(number of vaccinations, personnel to operate the site,
IMT/IMO on status of implementation of
challenges, successes to share for learning across the public
ma ss vaccination plan, or more frequently
health system).
if that is the LHJ procedure. Sites
operating for the time period, vaccines
administered by site for the time period,
estimated costs for the time period, any
challenges/successes of note, including
assistance requested.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to financendoh.wa.gov.
DOH General Mass Vaccination Program and Fiscal Contact
Patrick Plumb
COVID FEMA Project Management Analyst
Washington State Department of Health
Office of Financial Services
111 Israel Road SE, Tumwater, WA 98501
patrick.plumb@doh.wa.gov / (360) 236-4291
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federalfunds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federalfunds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Univers al Numbering System (DUNS(g) number.
Information about the LHJ and this statement of work will be made available onUSASpending_.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual, Handbook, Policy References
Emergency Response Plan (or equivalent)
Medical Countermeasure/Mass Vaccination Plan
Billing Requirements:
Monthly invoices must be submitted timely to the regional IMT/Organization for review/approvalprior to submission to DOH for reimbursement.
Contract Master Index (MI) Code: 934VO200 General Mass Vaccination
BARS Revenue Code: 333.97.03 Mass Vaccination Reimbursement
Exhibit A, Statement of Work Page 3 of 4 Contract NumberCLH31015
Special Instructions:
The LHJ is considered a CONTRACTOR of DOH not a subrecipient forthis portion of the statement of work. An allocation of funds is not provided as these FEMA funds are only
available as reimbursement of costs associated with implementation of the mass vaccination plan.
Detailed documentation must be maintained as directed by the regional IMT/Organization and DOH to substantiate costs associated with these activities for submission to FEMA
upon request by DOH.
Eligible costs from the timeframe of January 1, 2022 through April 1, 2022 include facility rentals, medicaland support staff forplanning, management, support, and operations; as
well as wrap-around services for staff (i.e., meals, travel, lodging). Regular and overtime pay associated with this project is allowable for all staff working underthis project and
must be billed as a direct charge; timesheets are required documentation and must be available upon request by DOH. Indirect rates are not applicable to these funds. Eligible
equipment includes facility infection control measures, persona I protective equipment (PPE), storage equipment, coolers, freezers, temperature monitoring devices, portable
vaccine units for transportation, supplies such as emergency medical supplies (for emergency medicalcare needs that may arise in the administration of the vaccine), containers for
medical waste, as well as proper storage as needed for canisters of liquid nitrogen or dry ice. Eligible equipment purchase costs should not exceed $5,000 per piece. Equipment
over $5,000 apiece must be preapproved by the IMT and should be leased rather than purchased. Any diversion from the list of pre -approved expenses will require a narrative on
the purchase rationale and will be subject to IMT approvalprior to reimbursement. Timesheets are required documentation for all activities related to this project. Stafftime-in /
time-out mustbe recorded, as well as a brief description of their activities. A general description of activities is acceptable forthose working at the vaccine site; more
detailed/specific description is required for those not working at the vaccine site.
Exhibit A, Statement of Work Page 4 of 4 Contract NumberCLH31015
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Foundational Public Health Services (,FPHS) -
Effective January I , 2022
SOW Type: Origina Revision # (for this SOW)
Period of Performance: January 1.2022 through June 30.2023
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
❑ Federal <Select One> (check if applicable) ❑ Reimbursement
® State ❑ FFATA (Transparency Act) ® Periodic Distribution
❑ Other ❑ Research & Develo ment
Statement of Work Purpose: The purpose of this statement of work (SOW) is to specify how state funds for Foundational Public Health Services (FPHS) will be used for the
period of performance. Per RCW 43.70.512, these funds are for the governmentalpublic health system to deliver FPHS services statewide in the most effective, efficient and
equitable mannerpossible with the funds available.
The FPHS Steering Committee with input from FPHS Subject Matter Expert(SME) Workgroups and the Tribal Technical Workgroup is the decision makingbody for FPHS. For
the 2021-2023 biennium, the Steering Committee is using an iterative approach to decision making. Determining investments first for SFY22 (July 1, 2021— June 30, 2022),
then for SFY23 (July 1, 2022— June 30, 2023). This means that additionaltasks and/or funds maybe added to an LHJ's FPHS SOW as these decisions are made.
These funds are to be used as directed and allocated by the FPHS Steering Committee. As the global COVID-19 pandemic and the public health response to it continues and
begins to abate,theseFPHS funds can be braided with andusedto supplement other short-term pandemic response fundingas neededforFPHS activities during this period of
performance through 06/30/22. Respondingto pandemics, epidemics andpublic health emergencies are foundational services of the governmentalpublic health system.
Note:
The totalbiennial funding allocation is for the period of July 1, 2021 through June 30, 2023. The 2021 — 2023 biennial funding allocations will be divided into four six-month
lump sum amounts that will be disbursed at the beginning of each six month period as follows: July 1, 2021; January 1, 2022; July 1, 2022; January 1, 2023. Each year, the July
payment will be disbursed upon completion of the FPH S Annual Report.
The SFY22 July 1, 2021 disbursement of funds was completed in the 2018-2021 consolidated contract and is included in this statement of work for informationa I purposes only.
FPHS funds must be spent in the state fiscal year (SFY) in which they are appropriated by the legislature, allocated, and disbursed. Legislative appropriations lapse at the end of
each state fiscal year. (RCW 43.88.140)
Spending and spending projections must be reported as required by the FPHS Steering Committee. Funds that are projected to b e unspent by the close of the state fiscal year must
be reallocated per the process developed by the FPHS Steering Committee to assure that all funds appropriated by the legislat ure can be spent by the governmentalpublic health
system to deliver FPHS within the yearthat the funds are appropriated. Unspent funds revert to the state treasury and must be returned to DOH by July 15 th of each yearfor
return to the Office of Financial Management.
2021— 2023 Biennium
• SFY22 (July 1, 2021 — June 30, 2022)
• SFY23 (July 1, 2022 — June 30, 2023)
Revision Purpose: N/A
Exhibit A, Statement of Work Page 1 of 5 Contract NumberCLH31015
Master
Assistance
BARS
LHJ Fund ing Period
Allocation
Index
Listing
Revenue
Current
Change
Total
DOH Chart of Accounts Master Index Title
Code
Number
Code
Start Date End Date
Allocation
Allocation
Exhibit A, Statement of Work Page 1 of 5 Contract NumberCLH31015
BARS
Activity
Increase(+)
Funds to provide FPHS in:
FPHS-LHJ-PROVISO (YR1) 99202111 N/A 336.04.25 01/01/22 06/30/22
Note: TotalYRI allocation is for SFY22 07/01/21-06/30/22
0
605,000
605,000
FPHS-LHJ-PROVISO (YR2) 99202112 N/A 336.04.25 07/01/22 06/30/23
0
605,000
605,000
Tasks / Activities / Short Description
0
0
0
SFY23
0
0
0
0
0
0
0
0
0
TOTALS
0
1,210,000
1,210,000
BARS
Activity
Deliverables/Outcomes
Funds to provide FPHS in:
Payment Information
#
21-23
and/or Amount
Expenditure.
FPHS
Tasks / Activities / Short Description
Your
Other
SFY22
SFY23
BIENNIUM
Code 562.xx
increase delivery of FPHS services statewide asmeasured
jurisdictions
10-17,
All — CD,
_jurisdiction
data compiled and analyzed by contractors, DOH and Subject
20, 21, 23-29
EPH, CCC,
Reinforcing Capacity (Assessment, CD, EPH, CCC)
X
For SFY22 (07/01/21—
213,000
213,000
426,000
40-53,93
Assessment
payment will be disbursed
available here.
DOH)
upon completion of the
10
Assessment
CHA/CHIP
X
FPHS Annual Report.
30,000
30,000
60,000
20, 21,23-29,
93
CD
Communicable Disease (CD)
X
152,000
152,000
304,000
40-53,93
EPH
Environmental PublicHeahh(EPH)
X
210,000
210,000
420,000
TOTAL
j $605,000
j $605,000
j $1,210,000
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
#
and/or Amount
Incoordination with FPHS Steering Committee and Subject
Routine reporting of spending and
TBD
Matter Expert (SME) workgroups FPHS funds are to be used to
spending projections. Process and
increase delivery of FPHS services statewide asmeasured
reporting template TBD and provided by
through FPHS annua I reporting, indicators, metrics and other
the FPHS Steering Committee via DOH.
data compiled and analyzed by contractors, DOH and Subject
Matter Expert (SME) Workgroups. Resuts are published in the
FPHS annualreporting (template provided
For SFY22 (07/01/21—
Each year, the July
annualFPHS Investment Report. FPHS indicator metrics
by the FPHS Steering Committee via
06/30/22) due by 08/15/22
payment will be disbursed
available here.
DOH)
upon completion of the
For SFY23 (07/01/22—
FPHS Annual Report.
06/30/23) due by 08/15/23
1
Reinforcing Capacity — These funds are to each LHJ to deliver FPHS in their own jurisdiction — In coordination with the FPHS Steering Committee and Subject
Matter Expert (SME) Workgroups, provide FPHS Communicable Disease (CD), Environmental Public Health (EPH), Assessment (Surveillance & Epidemiology) and/
or any or all of the other FPHS Cross -cutting Capabilities (CCC) as defined in the most current version of the FPHS definitions.
Suggested BARS expenditure codes: 652.xx - 10-17, 20, 21, 23-29,40-53.
2
Assessment — CHA/CHIP (FPHS definitions G.3) — These funds are to each LHJ to deliver FPHS in their own jurisdiction — In coordination with the FPHS Steering
Committee and Subject Matter Expert (SME) Workgroups, conduct and complete a comprehensive community health assessment and identify health priorities arising
from that assessment, including analysis of health disparities and the social determinants of health as defined in the most current version of the FPHS definitions.
Exhibit A, Statement of Work Page 2 of 5 Contract NumberCLH31015
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
• Conduct a local and/orregional comprehensive community health assessment (CHA) every three to five years in conjunction with community partners.
• Develop a local and/orregional community health improvement plan (CHIP) in conjunction with community partners.
These funds can be used for any CHA/CHIP activity or service (e.g., data analysis, focus groups, report writing, process facilitation) and may be used to contract with
other LHJs for staff time or services. Coordinate with the Spokane Regional Health District to participate in County Health Insi ts.
Suggested BARS expenditure codes: 562.11.
3
Communicable Disease (CD) (FPHS definitions C.1, 2, 3, 4, 6) — These funds are to each LHJ to deliver FPHS in their own jurisdiction — In coordination with the
FPHS Steering Committee and Subject Matter Expert (SME) Workgroups, provide FPHS CD services as defined in the most current version of the FPHS definitions.
These funds can (and actually are intended to) be braided with temporary pandemic emergency funding such that when those fund s run out, FPHS funds can be used to
retain staff there were hired with pandemic emergency funds if the jurisdictions desires to retain them and/orto hire additional staff if needed and/or contract with other
LHJs for staff time or services for delivering FPHS CD. As the pandemic response wains, staff funded with FPHS funds are to shift focus to providing some or all or the
FPHS CD services. This includes maintainingaccess to and use of data systems created during the pandemic and others underdevelopment and case investigation and
contact tracing for sexually transmitted disease and other communicable and notifiable conditions within the mandated timeframes. Emphasis should be placed on
addressing syphilis and gonorrhea cases.
1. Provide timely, statewide, locally relevant and accurate information statewide and to communities on prevention and control of communicable disease and other
notifiable conditions.
2. Identify statewide and local community assets for the control of communicable diseases and othernotifiable conditions, develop and implement a prioritized
control plan addressing communicable diseases and othernotifiable conditions and seek resources and advocate forhigh priority prevention and control policies
and initiatives regarding communicable diseases and othernotifiable conditions.
3. Promote immunization through evidence -based strategies and collaboration with schools, health care providers and other community partners to increase
immunization rates.
4. Ensure disease surveillance, investigation and control for communicable disease and notifiable conditions in accordance with local, state and federa I mandates and
guidelines.
Suggested BARS expenditure codes: 562.xx — 20, 21, 23-29.
4
Environmental Public Health (EPH) (FPHS definitions B.3 & 4) — These funds are to each LHJ to deliver services in their own jurisdiction. In coordination with the
FPHS Steering Committee and Subject Matter Expert (SME) Workgroups, these funds are for each LHJ to deliver FPHS EPH services in their jurisdiction as defined in
the most current version of the FPHS definitions and supplement existing funding specifically for:
• Develop, implement and enforce laws, rules, policies and procedures for maintainingthe health and safety of retail food sery ice inspections and shellfish
monitoring, that address environmentalpublic health concerns. (B.3.b)
• Develop, implement and enforce laws, rules, policies and procedures for ensuring the health and safety of wastewaterand facilities, including onsite septic
design and inspections, wastewater treatment and reclaimed water,that address environmental public health concerns. (B.3.e)
• Develop, implement and enforce laws, rules, policies and procedures for ensuring the health and safety of solid waste and fac ilities, including hazardous waste
streams (e.g. animalwaste, solid waste permitting and solid waste inspections), that address environmentalpublic health concerns. (B.3.f)
• Develop, implement and enforce laws, rules, policies and procedures for ensuring the health and safety of schools, including through education and plan review
that address environmentalpublic health concerns. (B.3.g)
These funds can be used to retain, hire and/orcontract with other LHJs forstaff time or services and for staff training as needed to provide the following FPHS EPH
services that are not appropriately funded with fees. Each LHJ will be responsible to report on their progress on FPHS deliverables even if contracted with otherLHJs
(FPHS funds are intended to build capacity and not intended to justify the reduction of existing fee revenue):
Exhibit A, Statement of Work Page 3 of 5 Contract NumberCLH31015
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
• Food Safety (FPHS definitions B.3.b.) — Respond to food safety concerns that are not appropriately funded such as foodborne illness threats, requests for
technical assistance and addressing new and emerging business models. Every local jurisdiction in Washington is expected to respond to foodborne illness
outbreaks, food safety inquiries and provide preventative education forthe general public and technical assistance.
• Sewage Safety (FPHS definitions B.3.e-f) — Respond to sewage concerns and public health threats and provide technical assistance that are not appropriately
funded to ensure that sewage is handled appropriately to limit potentialexposureto sewage. Every local jurisdiction in Washington is expected to ensure
sewage is properly managed. On -Site Septic (OSS) permitting, enforcement andprovidingtechnical assistance and educationto OSS owners are fee funded
activities and should be funded through fees or local government who sets the fees. These FPHS funds provide resources to support activities for which a fee
cannot be charged such as: responding to OSS failures, surfacing sewage, OSS safety concerns, and similar issues. These funds can also be used for concerns
related to large on-site sewage systems, other OSS -related concerns that do not involve locally permittable systems, and othersewage-related issues, regardless
of whether they are related to a fee-for-service activity. Examples of activities FPHS funds can be used for:
o Work with partners to educate and inform public on OSS monitoring and maintenance
o Work with the public, policy makers and partners to assess needs and develop plans and solutions for wastewatermanagement in their communities.
o Respond to complaints, act as needed, and assure that failing OSS are identified and promptly repaired.
o Conduct Pollution Identification and Correction (PIC) investigations where water quality is impaired to identify failing septic systems and othe rpollution
sources.
o Ensure that sewage from both OSS and other sources is adequately handled to create barriers to potentialexpo sure to sewage.
o Adequate qualified staff to evaluate proposals, inspect new installations and repairs, assess cause of OSS failure, and comply with requirements in state
law.
• Schools Safety (FPHS definition B.3.g) — Assure safe and effective learning environments for children attendingK-12 schools — public, private and parochial.
Every local jurisdiction in Washington is expected to work collaboratively with DOH, ESDs and loc al school districts and use the modelprogram to assure
consistency to regularly evaluate each K-12 for health and safety concerns and provide mandated services per WAC 246-366. Initial priorities include:
o Build partnerships with school officia Is, local boards of education, parent teacher associations, education service districts, and other school focused entities.
o Participate with statewide public health groups to standardize schoolprogram implementation.
o Focus on schools that have notpreviously been inspected to assess current conditions
o Focus on existing elementary schools for first phase of inspections program
■ IndoorAir Quality
■ Classroom
■ Healthy cleaning and indoor environments
■ Playground
■ Drinking water(lead)
Suggested BARS expenditure codes: 5 62.xx — 40-5 3.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance c&doh.wa.gov.
Program Specific Requirements
Program Manual, Handbook, Policy References:
All FPHS Resources — www.doh.wa.¢ov/fphs or FPHS I Powered by Box
Exhibit A, Statement of Work Page 4 of 5 Contract NumberCLH31015
Special References (i.e., RCWs, WACs, etc.):
Link to RCW 43.70.512 — RCW 43.70.512: Public health system—Foundational public health services—Intent. (wa. og_v)
Link to RCW 43.70.515 — RCW 43.70.515: Foundational public health services—Funding._(wa. og_v)
Definitions:
FPHS Definitions—https://wsal2ho.box.com/s/gb6sslOmxbrajxOfla742lw6zcfxzohk
Special Instructions:
There are two different BARS Revenue Codes for"state flexible funds" to be tracked separately and reported separately on yourannualBARS report. These two BARS Revenue
Codes and definitions from the State Auditor's Office (SAO'S) are listed below along with a link to the BARS Manual. 336.04.25 is the new BARS Revenue Code to use forthe
FoundationalPublic Health Services (FPHS) funds included in this statement of work.
336.04.24 — County Public Health Assistance
Use this account forthe state distribution authorized by the 2013 2ESSB 5034, section 710. The local health jurisdictions are required to provide reports regarding expenditures
to the legislature from this revenue source.
336.04.25 —Foundational Public Health Services
Use this account forthe funding designated for the local health jurisdictions to provide a set of core services that govemm ent is responsible for in all communities in the WA
state. This set of core services provides the foundation to support the work of the broaderpublic health system and community partners. At this time the funding from this
account is for delivering ANY or all of the FPHS communicable disease services (listed above) and can also be used for the FPHS capabilities that support FPHS communicable
disease services as defined in the most current version of FPHS Definitions.
Public Health Budgeting, Accounting and Reporting System (BARS) Resources: www.doh.wa. og v/lhjfunding
DOH Program Contact
Marie Flake, Special Projects, Foundational Public Health Services, Washington State Department of Health
Mobile Phone 360-951-7566 /marie.flakendoh.wa. og_v
Exhibit A, Statement of Work Page 5 of 5 Contract NumberCLH31015
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: LSPAN-Local Strategies for Physical Activity &
Nutrition - Effective January 1, 2022
SOW Type: Ori�alal Revision # (for this SOW)
Period of Performance: January 1 202 through September29, 2022
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
❑ State 0 FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work is to establish funding for Local Strategies for Physical Activity and Nutrition (LSPAN), a project of the
State Physical Activity and Nutrition Program (SPAN).
Revision Purpose: N/A
Master
Index
DOH Chart of Accounts Master Index Title Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Current
Start Date End Date Allocation
Allocation
Chan e
g
Increase (+)
Total
Allocation
FFY21 PHYS ACTVTY & NUTRITION PROG 77440241
93.439
333.93.43
01/01/22 09/29/22 0
34,000
34,000
staff will participate in
actualcosts, not to
0
0
0
exceed total contract
0
0
0
funding. See Program
mutually agreed upon between DOH
0
0
0
and Kittitas County Public Health
0
0
0
Department (KCPHD).
0
0
0
TOTALS
January 1, 2022 — September 29, 2022
Reimbursement for
0
1 34,000
1 34,000
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1 a
PROGRAM ADMINISTRATION:
Designated KCPHD
January 1, 2022 — September 29, 2022
Reimbursement for
Participate in calls, ata minimum of
staff will participate in
actualcosts, not to
once every month, with DOH contract
contract management
exceed total contract
manager. Dates and time for calls are
calls.
funding. See Program
mutually agreed upon between DOH
Specific Requirements
and Kittitas County Public Health
Department (KCPHD).
lb
PROGRAM ADMINISTRATION:
Designated KCPHD
January 1, 2022 — September 29, 2022
Reimbursement for
Participate in DOH -sponsored LSPAN
staff will participate in
actual costs, not to
related quarterly conference calls
calls, webinars, and
exceed totalcontract
and/orwebinars, including up to one
meetings.
funding. See Program
1 in-person meeting.
Specific Requirements
Exhibit A, Statement of Work Page 1 of 3 Contract NumberCLH31015
Template Created September 2021
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
#
and/or Amount
1 c
PROGRAM ADMINISTRATION:
Quarterly progress
Year 4-FFY21:
Reimbursement for
Perform administrative duties related to
reports to DOH via
• January 17, 2022 (covering September 30,2021 -December30, 2021)
actualcosts, not to
LSPAN
SharePoint site or email
• April 15, 2022 (covering December 31, 2021 March 30, 2022)
exceed total contract
• July 15, 2022 (covering March 31, 2022 June 29, 2022)
funding. See Program
• October 17, 2022(covering June 30, 2022 -Se tember29, 2022
Specific Requirements
2a
PROGRAM IMPLEMENTATION:
Submit Work Plan to
Draft due: Year 4-FFY21: March 25, 2022
Reimbursement for
Finalize Work Plan and Budget
DOH contractmanager
actualcosts, not to
Workbook using DOH -provided
via email
Final due: Year 4 - FFY21: July 15, 2022
exceed total contract
templates.
funding. See Program
Specific Requirements
2b
PROGRAM IMPLEMENTATION:
Quarterly progress
Year 4-FFY21:
Reimbursement for
Implement finalized community work
reports to DOH via
• January 17, 2022 (covering September 30, 2021 -December 30, 202 1)
actualcosts, not to
plan focused on LSPAN that include:
SharePoint site or email
• April 15, 2022 (covering December 31, 2021 March 30, 2022)
exceed totalcontract
• Addressing at least two (2) state
• July 15, 2022 (covering March 31, 2022 June 29, 2022)
funding. See Program
strategies required by this grant
• October 17, 2022 (covering June 30, 2022-September29, 2022)
Specific Requirements
funding.
• Achieving policy, systems, or
environmental changes consistent
with the strategies.
• Identifying and reaching
populations with health dis arities.
2c
PROGRAM IMPLEMENTATION:
Report quarterly
Year 4-FFY21:
Reimbursement for
Report quarterly expenditures using
expenditures using
• January 17, 2022 (covering September 30, 2021 -December 30, 202 1)
actualcosts, not to
DOH provided template.
DOH -provided
• April 15, 2022 (covering December 31, 2021 March 30, 2022)
exceed totalcontract
template.
• July 15, 2022 (covering March 31, 2022 June 29, 2022)
funding. See Program
• October 17, 2022(covering June 30, 2022 -Se tember29, 2022
Specific Requirements
3
PROGRAM EVALUATION:
Quarterly progress
Year 4-FFY21:
Reimbursement for
Participate in performance measure
reports to DOH via
• January 17, 2022 (covering September 30,2021 -December30, 2021)
actualcosts, not to
data collection and program evaluation
SharePoint site or email
• April 15, 2022 (covering December 31, 2021 March 30, 2022)
exceed totalcontract
activities in collaboration with DOH.
• July 15, 2022 (covering March 31, 2022 June 29, 2022)
funding. See Program
• October 17, 2022 (covering June 30, 2022-September29, 2022)
Specific Requirements
4
PROGRAM COMMUNICATION:
Provide copies of any
Year 4-FFY21:
Reimbursement for
Inform partners and public about
relevant communication
• January 17, 2022 (covering September 30, 2021 -December 30, 202 1)
actualcosts, not to
program successes and related best
products with quarterly
• April 15, 2022 (covering December 31, 2021 March 30, 2022)
exceed totalcontract
practices, including social media posts
progress reports to
• July 15, 2022 (covering March 31, 2022 June 29, 2022)
funding. See Program
andpublication.
DOH via SharePoint
• October 17, 2022 (covering June 30, 2022-September29, 2022)
Specific Requirements
site or email
Year 4-FFY21:
Write a success story related to LSPAN
Draft due: July 1, 2022
projects.
One success story using
Final due: July 29, 2022
DOH -provided template
Exhibit A, Statement of Work Page 2 of 3 Contract NumberCLH31015
Template Created September 2021
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance&doh.wa. og_v.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal subrecipient funding.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number.
Information about the LHJ and this statement of work will be made available on USASpendin,ggov by DOH as required by P.L. 109-282.
Program Specific Requirements
The Local Strategies for Physical Activity and Nutrition (LSPAN) project is providing funds to Kittitas County Public Health Department to implement policy, systems and
environmental changes at the community level to enact healthy nutrition guidelines and support breastfeeding -friendly environments. These changes must support the health of
priority populations who experience health disparities. LSPAN is partofDOH's State Physical Activity and Nutrition -Washington (SPANWA) Program. Funding for SPANWA
is through a cooperative agreement awarded to DOH from the Centers for Disease Control and Prevention's (CDC) DP18-1807: State Physical Activity and Nutrition Program
Required Disclosures for Federal Awardee Performance and Integrity Information System (FAPIISI:
Consistent with 45 CFR 75.113, applicants and recipients must disclose in a timely manner, in writing to the Centers for Disease Control and Prevention (CDC), with a copy to the
Health and Human Services (HHS) Office of InspectorGeneraI (OIG), all information related to violations of federa I criminal law involving fraud, bribery, or gratuity violations
potentially affectingthe federalaward. Subrecipients must disclose, in a timely mannerin writing to the prime recipient (pass through entity) and the HHS OIG, all information
related to violations of federalcriminal law involving fraud, bribery, or gratuity violations potentially affectingthe federalaward. Disclosures mustbe sent in writing to the CDC
and to the HHS OIG at the following addresses:
CDC, Office of Grants Services, Romero Stokes, Grants Management Officer/Specialist, Centers for Disease Control and Prevention Chronic Disease and Birth Defects Services
Branch, 2920 Brandywine Road, Mailstop E-09, Atlanta, Georgia 30341, Email: 1ni0na,cdc. og_v (Include "Mandatory Grant Disclosures" in subject line)
AND
U.S. Department of Health and Human Services, Office of the Inspector General, ATTN: Mandatory Grant Disclosures, Intake Coordinator, 330 Independence Avenue SW, Cohen
Building, Room 5527, Washington, DC 20201, Fax: (202) 205-0604 (Include "Mandatory Grant Disclosures" in subject line) or
Email: MandatoryGranteeDisclosures oig hhs. og_v
Restrictions on Funds:
• Only DOH -approved budget expenditures will be reimbursed.
• Subrecipients may not use funds to purchase furniture or equipment.
• Funds cannotbespenton capitalprojectsto supportbuilt environment changes.
• Reimbursement ofpre-award costs generally is not allowed, unless DOH provides written approvalto the subrecipient.
• The direct and primary recipient in a cooperative agreement program must perform a substantialrole in carrying out project outcomes and not merely serve as a conduit for an
award to anotherparty orprovider who is ineligible.
Monitoring Visits: In-person site visits at least once a year
Billing Requirements: Must use the budget workbook supplied by the program
Exhibit A, Statement of Work Page 3 of 3 Contract NumberCLH31015
Template Created September 2021
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Maternal and Child Health Block Grant -
Effective January 1. 2022
SOW Type: Orip-ina Revision # (for this SOW)
Period of Performance: January 1.2022 through September30.2022
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
❑ State ER FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Develo ment
Statement of Work Purpose: The purpose ofthis statement of work (SOW) is to support local interventions that impactthe target population ofthe MaternaIand Child Health
Block Grant.
Revision Purpose: N/A
Master
Index
DOH Chart of Accounts Master Index Title Code
Assistance
Listing
Number
BARS
Revenue LHJ Funding Period
Code Start Date End Date
Current
Allocation
Allocation
Change
g
Increase (+)
Total
Allocation
FFY22 MCHBG LHJ CONTRACTS 78101221
93.994
333.93.99 01/01/22 09/30/22
0
33,147
33,147
October 1, 2021 through March 31, 2022
MCHBG Budget Workbook to DOH
0
0
0
contractmana er
consideration. Action Plan and
Progress Reports must only reflect
0
0
0
September9, 2022
October 1, 2022 through September 30, 2023 using DOH
0
0
0
provided template.
0
0
0
0
0
0
TOTALS
See Program Specific
0
33,147
33,147
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information and/or
Amount
Maternal and Child Health Block Grant (MCHBG) Administration
la
Report actual expenditures forthe six-month period
Submit actual expenditures using the
May 27, 2022
Reimbursement for actual costs,
October 1, 2021 through March 31, 2022
MCHBG Budget Workbook to DOH
not to exceed total funding
contractmana er
consideration. Action Plan and
Progress Reports must only reflect
lb
Develop 2022-2023 MCHBG Budget Workbook for
Submit MCHBG Budget Workbook to
September9, 2022
October 1, 2022 through September 30, 2023 using DOH
DOH contract manager
activities paid for with funds
provided template.
provided in this statement of work
for the specified funding period.
See Program Specific
Requirements and Special Billing
Requirements.
Implementation
Exhibit A, Statement of Work Page 1 of 3 Contract NumberCLH31015
Template Created September 2021
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information and/or
#
Amount
2a
Report activities and outcomes of 2022 MCHBG Action
Submit quarterly Action Plan reports to
January 15, 2022
Reimbursement for actual costs,
Plan using DOH- provided template.
DOH Contract manager
April 15, 2022
not to exceed total funding
July 15, 2022
consideration. Action Plan and
Progress Reports must only reflect
2b
Develop 2022-2023 MCHBG Action Plan for October 1,
Submit MCHBG Action Plan to DOH
Draft August 19, 2022
2022 through September 30, 2023 using DOH -provided
contract manager
Final- September 9,
activities paid for with funds
template.
2022
provided in this statement of work
for the specified funding period.
See Program Specific
Requirements and Special Billing
Requirements.
Children and Youth with Special Health Care Needs(CYSHCN)
3a
Complete Child Health Intake Form (CHIF) using the
Submit CHIF data into Secure Access
January 15, 2022
Reimbursement for actual costs,
CHIF Automated System on all infants and children served
Washington website:
April 15, 2022
not to exceed total funding
by the CYSHCN Program as referenced in CYSHCN
https://secureaccess.wa.2ov
July 15, 2022
consideration. Action Plan and
Pro am avidance.
Progress Reports must only reflect
activities paid for with funds
3b
Identify unmet needs for CYSHCN on Medicaid and refer
Submit completed Health Services
30 days afterforms are
to DOH CYSHCN Program for approvalto access
Authorization forms and Central
completed.
provided in this statement of work
Diagnostic and Treatment funds to meet the need.
Treatment Fund requests directly to the
for the specified funding period.
CYSHCN Program asneeded.
See Program Specific
3c
Work with partnersto share updated local CYSHCN
Review resources for yourlocal area on
September30, 2022
resources with Within Reach / Help Me Grow (HMG).
ParentHelp 123.org annually for accuracy
Requirements and Special Billing
and submit any updates to Within Reach.
Requirements.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance c&doh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal subrecipient funding.)
This statement of work is supported by federa I funds that require compliance with the Federal Funding Accountability and Trans parency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Univers al Numbering System (DUNS®) number.
Information about the LHJ and this statement of work will be made available onUSASpendinggov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual, Handbook, Policy References:
Children and Youth with Special Health Care Needs Manual -
https: //www.doh.wa.gov/ForPublicHea lthandHealthcareProviders/PublicHea lthSystemResourcesandServices/Loca 1HealthResourcesandTools/MatemalandChildHealthBlockGrant/
ChildrenandYouthWithSpecialHealthCareNeeds
Health Services Authorization (HSA) Form
http: //www.doh.wa. gov/Porta ls/ 1 /Documents/Pubs/910-002-Api2rovedHSA.docx
Exhibit A, Statement of Work Page 2 of 3 Contract NumberCLH31015
Template Created September 2021
Restrictions on Funds (i.e., disallowed expenses or activities, indirect costs, etc.):
1. At least 30% of federalTitle V funds must be used for preventive and primary care services for children and at least 30% must be used services for children with
special healthcare needs. [Social Security Law, Sec. 505(a)(3)].
2. Funds may not be used for:
a. Inpatient services, other than inpatient services for children with special health care needs or high risk pregnant women and infants, and otherpatient services approved by
Health Resources and Services Administration (HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land, the purchase, construction, or permanent improvement of any building or other facility, or the purchase of majormedical
equipment.
d. Meeting other federa I matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. Payment for any services furnished by a provider or entity who has been excluded under Title XVIII (Medicare), Title XIX (Medicaid), or Title XX (social services block
grant).[Social Security Law, Sec 504(b)].
3. If any charges are imposed for the provision of health services using Title V (MCH Block Grant) funds, such charges will be p ursuant to a public schedule of charges; will not
be imposed with respect to services provided to low income mothers or children; and will be adjusted to reflect the income, resources, and family size of t he individual
provided the services. [Social Security Law, Sec. 505 (1) (D)].
Monitoring Visits: Telephone calls with DOH contract manager as needed.
Billing Requirements: Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable Al -IA invoice voucher. Payment to completely expend the
"Total Consideration" fora specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted quarterly by the
30th of each month following the quarter in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a monthly fraction
of the "Total Consideration" will notbe accepted orapproved.
Special Instructions: Contact DOH contract manager below for approval of expenses not reflected in approved budget workbook.
MCHBG funds may be expended on COVID-19 response activities that align with maternal and child health priorities. Examples may include:
• Providing support in educatingthe MCH population about COVID- 19 through partnerships with other local agencies, medical providers, and health care organizations.
• Working closely with state and local emergency preparedness staff to assure that the needs of the MCH population are represented.
• Funding infrastructure that supports the response to COVID-19. For example, Public Health Nurses who are routinely supported through the Title V program maybe able
to be mobilized, using Title V funds or separate emergency funding, to support a call center or deliver health services.
• Partnering with parent networks and health care providers to provide accura to and reliable information to all families.
• Engaging community leaders, including faith -based leaders, to educate community members about strategies forpreventing illness
Restrictions listed above continue to apply.
Exhibit A, Statement of Work Page 3 of 3 Contract NumberCLH31015
Template Created September 2021
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Drinking Water Group A Program - Effective
January 1, 2022.
SOW Type: Origina Revision # (for this SOW)
Period of Performance: January 1,2022 through December 31.2022
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
® Federal Contractor (check if applicable) ❑ Reimbursement
® State ER FFATA (Transparency Act) ® Fixed Price
❑ Other ❑ Research & Develo ment
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non -community Group A water systems
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
g
Increase (+)
Total
Allocation
SANITARY SURVEY FEES (FO -E) SS -STATE
24242522
N/A
346.26.65
01/01/22 12/31/22
0
3,600
3,600
YR 24 SRF -LOCAL ASST 15%) (FO -E) SS
24249224
N/A
346.26.64
01/01/22 12/31/22
0
3,600
3,600
YR 24 SRF -LOCAL ASST 15%) (FO -E) TA
24249224
N/A
346.26.66
01/01/22 12/31/22
0
1,000
1,000
significant deficiencies,
conducting the sanitary
Upon ODW acceptance of the Final Sanitary Survey
See Special Instructions fortask activity.
0
0
0
recommendations, and referrals
survey of a non -community system with four or more
0
0
0
connections and each community system.
The purpose of this statement of work is to
2. Completed Small Water System
0
0
0
TOTALS
checklist.
Payment is inclusive of all associated costs such as
0
8,200
8,200
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information and/or Amount
1
Trained LHJ staff will conduct sanitary
Provide Final* Sanitary Survey
Final Sanitary Survey
Upon ODW acceptance of the Final Sanitary Survey
surveys of small community and non-
Reports to ODW Regional Office.
Reports must be
Report, the LHJ shall be paid $400 for each sanitary
community Group A water systems
Complete Sanitary Survey Reports
received by the ODW
survey of a non -community system with three or
identified by the DOH Office of Drinking
shall include:
Regional Office within
fewer connections.
Water (ODW) Regional Office.
1. Cover letter identifying
30 calendar days of
significant deficiencies,
conducting the sanitary
Upon ODW acceptance of the Final Sanitary Survey
See Special Instructions fortask activity.
significant findings, observations,
survey.
Report, the LHJ shall be paid $800 for each sanitary
recommendations, and referrals
survey of a non -community system with four or more
for further ODW follow-up.
connections and each community system.
The purpose of this statement of work is to
2. Completed Small Water System
provide funding to the LHJ for conducting
checklist.
Payment is inclusive of all associated costs such as
sanitary surveys and providing technical
3. Updated Water Facilities
travel, lodging, per diem.
assistance to small community and non-
Inventory (WFI).
community Group A waters stems.
I
I
I Payment is authorized upon receipt and acceptance of
Exhibit A, Statement of Work Page 1 of 4 Contract NumberCLH31015
Template September2021
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information and/or Amount
4. Photos of water system with text
the Final Sanitary Survey Report within the 30 -day
identifying features
deadline.
5. Any other supporting documents.
Late or incomplete reports may not be accepted for
*Final Reports reviewed and accepted
payment.
by the ODW Regional Office.
2
Trained LHJ staff will conduct Special
Provide completed SPI Report and
Completed SPI Reports
Upon acceptance of the completed SPI Report, the
Purpose Investigations (SPI) of small
any supporting documents and photos
must be received by the
LHJ shall be paid $800 for each SPI.
community and non -community Group A
to ODW Regional Office.
ODW Regional Office
water systems identified by the ODW
within 2 working days
Payment is inclusive of all associated costs such as
Regional Office.
of the service request.
travel, lodging, per diem.
See Special Instructions fortask activity.
Payment is authorized upon receipt and acceptance of
completed SPI Report within the 2 -working day
deadline.
Late or incomplete reports may not be accepted for
payment.
3
Trained LHJ staff will provide direct
Provide completed TA Report and any
Completed TA Report
Upon acceptance of the completed TA Report, the
technical a ssistance(TA) to small
supporting documents and photos to
must be received by the
LHJ shall be paid for each technical assistance
community and non -community Group A
ODW Regional Office.
ODW Regional Office
activity as follows:
water systems identified by the ODW
within 30 calendar
• Up to 3 hours of work: $250
Regional Office.
days of providing
. 3-6 hours of work: $500
technical assistance.
. More than 6 hours of work: $750
See Special Instructions fortask activity.
Payment is inclusive of all associated costs such as
consulting fee, travel, lodging, per diem.
Payment is authorized upon receipt and acceptance of
completed TA Report within the 30 -day deadline.
Late or incomplete reports may not be accepted for
payment.
4
LHJ staff performing the activities under
For training attended in person, prior
Annually
For training attended in person, LHJ shall be paid
tasks 1, 2 and attend periodic required
to attendingthe training, submit an
mileage, per diem, lodging, and registration costs as
survey training as directed by DOH.
"Authorization for Travel (Non-
approved on the pre -authorization form in accordance
Employee)" DOH Form 710-013 to
with the current rates listed on the OFM Website
See Special Instructions fortask activity.
the ODW Program Contact for
http://www.ofm.wa.,2ov/resources/travel.aW
approval (to ensure enough funds are
available).
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to financendoh.wa.gov.
Exhibit A, Statement of Work Page 2 of 4 Contract NumberCLH31015
Template September2021
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federalfunds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Univers al Numbering System (DUNS®) number.
Information about the LHJ and this statement of work will be made available on USASpendinggov by DOH as required by P.L. 109-282.
Program Manual, Handbook, Policy References: Field Guide (DOH Publication 331-486).
Special References:
Chapter246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work, ODW contracts with the LHJ to conduct sanitary surveys (and SPIs and
provide technical assistance) for small community and non -community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys (and
SPIs and provide technical assistance) for small community and non -community water systems with surface water sources, large water systems, and systems with complex
treatment.
LHJ staff assigned to perform activities under tasks 1, 2, and 3 must be trained and approved by ODW prior to performing work. See special instructions underTask 4, below.
Special Billing Requirements
The LHJ shall submit quarterly invoices within 30 days following the end of the quarterin which work was completed, noting on the invoice the quarter and yearbeing billed for.
Payment cannot exceed a maximum accumulative fee of $7,200 for Task 1, and $1,000 for Task 2, Task 3 and Task 4 combined during the contracting period, to be paid at the
rates specified in the Payment Method/Amount section above. When invoicing for sanitary surveys, bill half to BARS Revenue Code 346.26.64 and half to BARS Revenue Code
346.26.65.
When invoicing for Task 1, submit the list of WS Name, ID #, Amount Billed, Survey Date and Letter Date for which you are requesting payment.
When invoicing for Task 2-3, submit the list of WS Name, ID #, TA Date and description of TA work performed, and Amount Billed.
When invoicing for Task 4, submit receipts and the signed pre -authorization form fornon-employee travel to the ODW Program Contact below and a signed Al9-1A Invoice
Voucher to DOH Grants Management, billing to BARS Revenue Code 346.26.66 under Technical Assistance (TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW. Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose investigations and Technical Assistance (Field Guide). The sanitary survey will include an
evaluation of the following eight elements: source; treatment; distribution system; finished water storage; pumps, pump facilities and controls; monitoring, reporting and data
verification; system management and operation; and certified operator compliance. If a system is more complex than anticipat ed or other significant issues arise, the LHJ may
request ODW assistance.
• No more than 2 surveys of non -community systems with three of fewer connection be completed between January 1, 2022 and December 31, 2022.
• No more than 8 surveys of non -community systems with four or more connections and all community systems to be completed between January 1, 202 2 and
December 31, 2022.
The process for assignment of surveys to the LHJ, notification of the water system, and ODW follow-up with unresponsive water systems; and otherroles and responsibilities of
the LHJ are described in the Field Guide.
Task 2
Exhibit A, Statement of Work Page 3 of 4 Contract NumberCLH31015
Template September2021
Trained LHJ staff will perform Special Purpose Investigations (SPIs) as assigned by ODW. SPIs are inspections to determine the can se of positive coliform samples or the cause of
other emergency conditions. SPIs may also include sanitary surveys of newly discovered Group A water systems. Additional detail about conducting SPIs is described in the Field
Guide. The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staff will conduct Technical Assistance as assigned by ODW. Technical Assistance includes assisting water system personnel in completing work or verifying work
has been addressed as required, requested, or advised by the ODW to meet applicable drinking water regulations. Examples of technical assistance activities are described in the
Field Guide. The ODW Regional Office must authorize in advance any technical assistance provided by the LHJ to a water system.
Task 4
LHJ staff assigned to perform activities under tasks 1, 2, and 3 mustbe trained and approvedby ODW prior to performing work.
If required trainings, workshops or meetings are not available, not scheduled, or if the LHJ staff person is unable to attend these activities prior to conducting assigned tasks, the
LHJ staff personmay,with ODW approval, substitute other training activities to be determinedby ODW. Such substitute activities may include one-on-one training with ODW
staff, co -surveys with ODW staff, or otheractivities as arranged and pre -approved by ODW. LHJ staff may not perform the activities undertasks 1, 2, and 3 without completing
the training that has been arranged and approved by ODW.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH31015
Template September2021
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Drinking Water Group B Programs - Effective
January 1, 2022
SOW Type: Ori�alal Revision # (for this SOW)
Period of Performance: January 1 202 through June 30, 2023
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
❑ Federal <Select One> (check if applicable) ❑ Reimbursement
® State ❑ FFATA (Transparency Act) ® Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide financial support to LHJs implementing local Group B water systems programs.
Revision Purpose: N/A
Master
Index
DOH Chart of Accounts Master Index Title Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Current
Start Date End Date Allocation
Allocation
Chan e
g
Increase (+)
Total
Allocation
GFS Group B (FO -E) 24240103
N/A
334.04.90
01/01/22 06/30/22 0
25,877
25,877
An executed Memorandum of Agreement (MOA) with
January 1, 2022
Lump sum payment (See
0
0
0
thru June 30, 2022
Special Billing
0
0
0
Requirements)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
0
25,877
25,877
Task
Activity
Deliverables/Outcomes
Due Date/Time
Payment Information
#
Frame
and/or Amount
1
Implement a Group B water system program through a
An executed Memorandum of Agreement (MOA) with
January 1, 2022
Lump sum payment (See
Local Ordinance. Reference DOH MOA #CLH23577
DOH identifying responsibilities of a full Group B
thru June 30, 2022
Special Billing
program through a LocalOrdinance.
Requirements)
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to financendoh.wa.gov.
*For Information Only: Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might
contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
http: //www.phaboard.org/MM -content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf
Special Billing Requirements: For January 1, 2022 —June 30, 2022, the LHJ shall submit one invoice not later than June 30, 2022 and payment cannot exceed a maximum
cumulative fee of $25,877.
Exhibit A, Statement of Work Page 1 of 1 Contract NumberCLH31014
Template September2021
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of ImmunizationCOVID-19 Vaccine -
Effective January 1, 2022
SOW Type: Orip-ina Revision # (for this SOW)
Period of Performance: January 1,2022 through June 30, 2024
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
❑ State ® FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Develo ment
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide funding to conduct COVID-19 vaccine activities.
Revision Purpose: N/A
Master
Index
DOH Chart of Accounts Master Index Title Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Fund ing Period Current
Start Date End Date Allocation
Allocation
Change
g
Increase (+)
Total
Allocation
COVID19 Vaccines R4 74310230
93.268
333.93.26
01/01/22 06/30/24 0
359,803
359,803
be used with health care providers and
costs incurred, not to
0
0
0
exceed total funding
0
0
0
consideration amount.
with health care providers, community, and/orotherpartners to
0
0
0
help build vaccine confidence broadly and amonggroups
0
0
0
anticipated to receive early vaccination, as well as dispel
0
0
0
TOTALS
1 0
359,803
359,803
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
3.A
Identify activity/activities to support COVID vaccine response
Summary of the engagement strategies to
January 31, Annually
Reimbursement for actual
in your community, using the examples below as a guideline.
be used with health care providers and
costs incurred, not to
other partners, and the locally identified
exceed total funding
Example 1: Develop and implement communication strategies
population to be reached.
consideration amount.
with health care providers, community, and/orotherpartners to
help build vaccine confidence broadly and amonggroups
anticipated to receive early vaccination, as well as dispel
vaccine misinformation. Document and provide a plan that
shows the communication strategies used with health care
providers and otherpartners and the locally identified
population anticipated to reach.
Example 2: Engage in other vaccination planning activities
such as partnership development, provider education,
vaccination point of dispensing OD planning, tabletop
Exhibit A, Statement of Work Page 1 of 3 Contract NumberCLH31015
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
exercises, engagement with communities, leaders, non-
traditionalprovider, or vulnerable populations to develop
strategies to ensure equitable access to vaccination services
3.13
Implement the communication strategies or other activities,
Mid-term written report describing
June 30, Annually
Reimbursement for actual
working with health care providers and otherpartners to reach
activity/activities and progress made to-
costs incurred, not to
the locally identified population, support providers in
date and strategies used (template to be
exceed total funding
vaccination plans, and support equitable access to vaccination
provided)
consideration amount.
services.
3.0
Catalog activities and conduct an evaluation of the strategies
Final written report, showing the strategies
December 31, Annually
Reimbursement for actual
used
used and the final progress of the reach
costs incurred, not to
(template to be provided)
exceed total funding
consideration amount.
3.1)
As needed to meet community needs, expand operations to
Quarterly reports summarizing quantity,
March 31, Annually
Reimbursement for actual
increase vaccine throughput (i.e., providing vaccinations during
type, and frequency of activities
June 30, Annually
costs incurred, not to
evenings, overnight, and on weekends). Activities may include
exceed total funding
vaccine strike teams, mobile vaccine clinics, satellite clinics,
consideration amount.
temporary, or off-site clinics to travel and provide vaccination
services in non-traditional settings, or to supplement the work
of local health departments in underserved communities, and
may include administration costs for other vaccines co -
administered at the events. These activities may be done by the
local health department orin collaboration with community
partners. (see Restriction on Funds below
3.E
At the LHJ discretion, provide incentives to persons receiving
a. LHJ Incentive Plan Proposal
a. Prior to implementing
Reimbursement for actual
COVID vaccine, adhering to LHJ Guidancefor COVID
b. Quarterly report that summarizes
b. March 31, Annually
costs incurred, not to
Initiatives Application requirements and allowable/unallowable
quantity of incentives purchased and
June 30, Annually
exceed total funding
use of federal funds.
distributed
consideration amount.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance&doh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federalfunds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number.
Information about the LHJ and this statement of work will be made available on USASpendinggov by DOH as required by P.L. 109-282.
Program Specific Requirements
Restrictions on Funds (i.e., disallowed expenses or activities, indirect costs, etc.):
Exhibit A, Statement of Work Page 2 of 3 Contract NumberCLH31015
Coverage of co -administration costs for other vaccines administered at vaccination events does NOT apply to the FEMA Mass Vaccination funding. Coverage of co -
administration costs only applies to the vaccine funding (COVIDI9 Vaccine R4, MI 74310230) allocated for Task 3 of the consolidated contract. FEMA Mass Vaccination
funding is only available to cover the costs for COVID vaccine administration and cannot be used for co -administration costs of other vaccines.
Exhibit A, Statement of Work Page 3 of 3 Contract NumberCLH31015
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: SupplementalNutrition Assistance Program -Education -
Effective January 1, 2022
SOW Type: Ori�alal Revision # (for this SOW)
Period of Performance: January 1 202 through December 31, 2024
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH31015
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
❑ State 0 FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work is to provide SupplementalNutrition Assistance Program -Education (SNAP -Ed) to improve the likelihood
that persons eligible for SNAP (Basic Food, Food Stamps)will make healthy food choices within a limited budget and choose active lifestyles consistent with the current USDA
dietary guidelines.
Revision Purpose: N/A
Master
Index
DOH Chart of Accounts Master Index Title Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Current
Start Date End Date Allocation
Allocation
Chan e
g
Increase (+)
Total
Allocation
FFY22 IAR SNAP ED PROG MGNT-REGION 2 76701937
10.561
333.10.56
01/01/22 09/30/22 0
30,818
30,818
eligible sites and/orwith eligible audiences.
01/01/22 to 09/30/23
on-time receipt and
0
0
0
10/01/23 to 12/31/24 TBD
approvalof acceptable
0
0
0
deliverables/out-
included in the Washington SNAP -Ed State Plan
0
0
0
approved by Department of Social and Health
3. Project plan supports at least one State SNAP-
0
0
0
Services (DSHS) and United States Department of
Ed goal as selected by Subrecipient.
dates during the federal fiscal
0
0
0
TOTALS
year, and no later than
County Public
0
30,818
30,818
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1.0
Project Planning, Implementation, and
1. Project provides 100% of SNAP -Ed activities at
For the Period:
Reimbursement upon
Performance
eligible sites and/orwith eligible audiences.
01/01/22 to 09/30/23
on-time receipt and
For SNAP -Ed, the Subrecipient will develop,
2. On-time delivery, implementation, and
10/01/23 to 12/31/24 TBD
approvalof acceptable
implement, and evaluate a SNAP -Ed project
evaluation of Project activities as scheduled in
deliverables/out-
included in the Washington SNAP -Ed State Plan
approved state plan and project work plan.
Due: per the approved work
comes for the funding
approved by Department of Social and Health
3. Project plan supports at least one State SNAP-
plan and per the required due
period will not exceed
Services (DSHS) and United States Department of
Ed goal as selected by Subrecipient.
dates during the federal fiscal
$30,818. Kittitas
Agriculture (USDA); and, as described in the
4. Demonstrates progress towards project
year, and no later than
County Public
Subrecipient's project work plan approved by
objective(s), and additionalprojectgoal(s)
09/30/23.10/01/23 to 12/31/24
Health Department
Department of Health (DOH).
determined by Subrecipient are demonstrated
TBD.
will be paid the
and reported.
I
I allowable costs
Exhibit A, Statement of Work Page 1 of 12 Contract NumberCLH31015
Template September2021
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
5. Project maintains cost-effectiveness per current
incurred based on their
approved cost-effective measure provided by
approved budget and
DOH or DSHS.
program allowability.
See special billing
MEASURE
requirements section.
Sites and audiences included in Project by
Subrecipient documented as approved eligible sites
"NOTE: The DOH
or audiences.
SNAP -Ed program
will deny payment for
Documented required reporting by Subrecipient of
any costs not
the delivery, implementation, and evaluation of
submitted by the
approved Project activities in the required PEARS
required due dates
online reporting modules, where relevant to Project
without prior DOH
(Program Activities, PSE Site Activities, Indirect
approval in writing.
Activities, Coalitions, Partnerships, and Success
Stories), and in a progress report form/system
approved by DOH.
Documented reviews of Subrecipient Project
activities through required reporting and project and
fiscal monitoring reviews and reports.
Cost per reach meets current cost-effective measure
when reviewed by DOH.
1.1
Project Progress: Monitoring and Compliance
1. On-time delivery of proposed list of Project
For the Period:
See payment
For SNAP -Ed, the Subrecipient will demonstrate
site(s) or audience(s) to DOH.
0 1/0 1/22 to 09/30/23
information as
satisfactory progress of the approved Project as
2. All sites and/oraudiences are determined to be
10/01/23 to 12/31/24 TBD
referenced in task
documented in DOH SNAP -Ed progress reports,
eligible per current SNAP -Ed eligibility
number 1.0
progress reviews, and project and fiscal monitoring
guidance and DOH process before programming
Due: Progress reviews. Occur
reports.
begins with site(s) or audience(s).
at minimum once a fiscal year,
3. Demographic data of class participants is
and no later than 09/30/23.
Monitoring of Subrecipient Project progress includes
collected and reported for all direct education
10/01/23 to 12/31/24 TBD.
but is not limited to the following activities:
strategies.
i. one-on-one progress reviews with DOH,
4. On-time reporting of actualparticipant reach to
Due: Project monitoring.
ii. progress reports submitted to DOH,
DOH in approved method/form.
Occurs at minimum once
iii. project monitoring completed with DOH or
5. Intervention strategies implemented as planned
within every other fiscal year.
DSHS or USDA, and
or using approved alternate strategies.
If project monitoring
iv. project monitoring site visits completed by
6. Approved evaluation plans and methods
documents major deficiencies
SNAP -Ed statewide initiative teams.
implemented for the project (e.g. pre and post
or corrective action, the
surveys for direct education; PSE assessments).
Subrecipient will be monitored
Satisfactory progress of the Subrecipient's Project
again within the fiscal year.
includes progress shown in the following areas and
Project monitoring can be
Exhibit A, Statement of Work Page 2 of 12 Contract NumberCLH31015
Template September2021
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
documented in reporting and/or monitoring
7. Evaluation results are used to report progress
scheduled more frequently if
completed:
and outcomes of project, and to adapt the project
deemed necessary by DOH, or
1. Progress demonstrated in achieving goal(s)
as needed.
if agreed upon by both parties.
outlined in the project.
8. Strategy as feasible for working with one or
2. Progress demonstrated in achieving objective(s)
more CSOs implemented and demonstrated to
Due: Fiscal monitoring. Each
outlined in the project's interventions.
increase knowledge, awareness, or participation
Subrecipient receives one (1)
3. Progress demonstrated in creating a sustainable
of SNAP -Ed eligible audience.
annua I fisca I monitoring visit
project.
9. Strategy for promoting available Federal, state,
every other year, unless
4. Progress demonstrated in engaging or involving
or local fruit and vegetable incentive program(s)
Subrecipient monitoring results
the community in project planning,
is implemented and demonstrated to increase
in corrective action or finding,
implementation, and/or evaluation.
knowledge, awareness, or participation of
in which case Subrecip ient will
5. Progress demonstrated in working with DSHS
program(s) in SNAP -Ed eligible audience.
be monitored again the
community services offices (CSOs).
10. Direct education strategies only: Statewide
following year. Fiscal
6. Progress demonstrated in promoting available
SNAP -Ed Curriculum team orDOH monitoring
monitoring can be scheduled
Federal, state, or local fruit and vegetable
reviews show education delivered with fidelity,
more frequently if deemed
incentive programs to SNAP clients.
with no major deficiencies. If major deficiencies
necessary by DOH, or if agreed
7. Progress demonstrated in using strategies that
documented, corrected properly within timeline
upon by both parties.
are evidence -based and delivered with fidelity,
required.
where applicable.
11. Compliance maintained with current SNAP -Ed
8. Compliance with current SNAP -Ed financial
financial and cost policy guidance, 2 CFR 200
and costpolicy guidance and 2 CFR 200 federal
federalUniform Administrative Requirements
Uniform Administrative Requirements (OMB
(OMB guidance), and related DOH SNAP -Ed
guidance).
fiscalpolicy andprocedures.
MEASURE
Progress reviews — documentation of one-on-one
meeting(s) with DOH SNAP -Ed staffperson(s) and
Subrecipient completed in person, web conference,
phone, or via email as needed. Documentation of
progress review notes.
Project monitoring — completed in person, web
conference, phone, or via email as needed.
Completion of on-site program observations where
applicable. Completion of project monitoring report
forms, with monitoring results documented and
provided to Subrecipient.
Fiscal monitoring — documentation of completed
fiscal reviews scheduled by SNAP -Ed fiscal analyst
or DOH fiscal monitoring unit, with corresponding
reports where applicable. Fiscal monitoring
completed in person, web conference, phone, or via
email asneeded.
Exhibit A, Statement of Work Page 3 of 12 Contract NumberCLH31015
Template September2021
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
2.0
Evaluation Data and Reports
On-time and correct submission of reporting, data,
For the Period:
See payment
For SNAP -Ed, the Subrecipient will report progress
and materials for all SNAP -Ed funded activities
0 1/0 1/22 to 09/30/23
information as
of the approvedproject and work plan, including
implemented, including:
10/01/23 to 12/31/24 TBD
referenced in task
ongoing evaluation of the project and outcomes,
1. Progress for all intervention strategies reported
number 1.0
using an approved form/system on a regular basis
for approved project plan.
Progress Reports: Due at
that will at a minimum include:
2. All evaluation results reported for approved
minimum quarterly, and no
1. Progress reports
project plan (formative, process, outcome,
later than 10 calendardays after
2. Reporting in PEARS online reporting
qualitative, PSE).
the end of the quarter, except
system of all SNAP -Ed activities
3. Success stories reported for approved project
for the last month of the FFY
plan describing progress or success of project
which is due by 9/15/22. If the
SNAP -Ed activities implemented and evaluation of
activities, or positive change or improvement in
10th calendarday falls on a
the project and outcomes are reported in an online
SNAP -Ed eligible site(s) or audience(s).
weekend day, the report is due
program evaluation and reporting system (PEARS)
4. Required release form(s) for all photos
the next business day.
through the following required modules as
submitted.
• 1 st Progress report due
appropriate forthe approved project: Program
5. Direct education strategies only: All required
1/11/22
Activity (direct education), Indirect Activity (health
information for scheduled direct education
• 2nd Progress report due
promotion, indirect education channels), PSE Site
lessons submitted to Statewide SNAP -Ed
4/12/22
Activities, Partnerships, Coalitions, Success Stories,
Curriculum team, using approved form/system,
• 3rd Progress report due
and Social Marketing.
by dates required.
7/12/22
• Final Progress report due
The following evaluation activities and information
On-time and correct submission of required
9/15/22 or follow close-out
are required based on the Subrecipient's approved
evaluation data fordirect education strategies into
procedures.
project and work plan.
PEARS electronically, or using approved reporting
• FFY 23-24 TBD
• Formative evaluation
method, according to time frame provided,
• Process evaluation
including:
PEARS: Project evaluationand
• Outcome evaluation
6. Direct education strategies only: Pre-test
reporting required between
• Qualitative evaluation
surveys for each project class series are entered
10/1/21 to 9/15/22.
• Evaluation of PSE strategies
into PEARS by Subrecipient no later than two
weeks aftercompletion of the pre-test survey.
. Direct education
Please Note: the deliverables may change based on
7. Direct education strategies only: Post-test
strategies only: PEARS
state SNAP -Ed Evaluation guidance, DSHS, or
surveys for each project class series are entered
Program Activities module
USDA requirements.
into PEARS by Subrecipient no later than two
updated with completed
weeks after completion of the post-test survey.
activities no later than two
Please Note: Topics included in Progress Report
8• Direct education strategies only: Demographic
(2) weeks afterservices are
subject to change based on Department of Health
cards for each class series are entered into
provided.
(DOH), Department of Social and Health Services
PEARS by Subrecipient no later than two weeks
• Due: PEARS Indirect
(DSHS), Washington SNAP -Ed (WA SNAP -Ed), or
after collection of the demographic cards.
Activities, PSE Site
United States Department of Agriculture (USDA)
Activities, Partnerships,
Food and Nutrition Services (USDA) requirements.
MEASURE
Coalitions, Success Stories,
Documentation showing completion of progress
and Social Marketing
report and submission to DOH on or before the
modules completed
required due dates, or by approved extension date.
later than the last business
Exhibit A, Statement of Work Page 4 of 12 ContractNumberCLH31015
Template September2021
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
day of the month following
Completion of required evaluation data in progress
when the activity took
reports and PEARS electronically, or using approved
place, except for the last
reporting method/form, on or before the required due
month of the FFY which is
dates, or by approved extension date.
due by 9/15/22.
• Jan 2022 by
Direct education strategies only:
• 2/26/22
1. Entry of required SNAP -Ed participant surveys
• Feb 2022 by 3/31/22
into PEARS using DOH approved method, on
• Mar 2022 by 4/30/22
or before the required due dates or by approved
. Apr 2022 by 5/31/22
extension date.
0 May 2022 by 6/30/22
2. Completion of required evaluation data into
• Jun 2022 by
PEARS electronically, or using approved
. 7/30/22
reporting method, on or before the required due
• Jul 2022 by
dates for data entry, or by approved extension
date.
• 8/31/22
• Aug 2022 by 9/15/22
• Final data entry forall
activities not already
reported, due by 9/15/22,
or follow close-out
schedule.
• FFY23-24 TBD
SNAP -Ed Direct education
conducted between 01 /01 /22
and 9/15/22. FFY23-24 TBD
• Direct education
strategies only:
Completed Pre- and post-
test surveys are entered
into PEARS databaseby
Subrecipient no later than
two weeks after
completion of the survey.
All completedpre- and
post-test surveys mustbe
entered by Subrecipient, no
later than COB 9/15/22, or
follow close-out schedule.
3.0
Civil Rights Training
On-time completion of an approved Civil Rights
For the Period:
See payment
All SNAP -Ed funded staff must complete training
training for all SNAP -Ed funded staff.
0 1/0 1/22 to 09/30/23
information as
each fiscal year in civil rights.
10/01/23 to 12/31/24 TBD
Exhibit A, Statement of Work Page 5 of 12 Contract NumberCLH31015
Template September2021
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
*See special requirements section- Civil Rights
MEASURE
referenced in task
Submission of documentation showing completed
Due: 01/01/22 forall SNAP -Ed
number 1.0
Documentation must include:
Civil Rights training for all SNAP -Ed funded staff
funded staff. FFY23-24 TBD.
• Training and source
on or before the required due date.
New hires to complete within
• Who attended
30 days of hire.
• Date completed
3.1
Other Required Training and Meetings
On-time completion of all required trainings by
For the Period:
See payment
The following trainings or meetings are required for
required SNAP -Ed staff.
0 1/0 1/22 to 09/30/23
information as
all Subrecipients when provided by DOH or WA
10/01/23 to 12/31/24 TBD
referenced in task
SNAP -Ed for the staff listed. Unless more staff
Attendance of required or appropriate staff person(s)
number 1.0
attendance is required, minimum of one (1) staff
at all required meetings.
Fiscal: Annually, and no later
person required to attend to satisfy requirements.
than March 31, 2022. FFY23-
Multiple staff may attend if costs for attendance are
Demonstration of satisfactory understanding of the
24 TBD.
covered in Subrecipient's annualbudget.
information and concepts included in required
trainings.
SNAP -Ed Curriculum: New
• Fiscal training — fiscal agent or project
direct education staff trained
coordinator, whoever is mostresponsible for
SNAP -Ed Curriculum: On-time completionof
within 30 days for specific
creating and monitoring budget, procurements,
required training forspecific curriculum to be used
curriculum to be used in direct
invoices, budget decisions, or budget
in direct education strategy by project coordinator or
education strategy, or before
amendments forthe SNAP -Ed program.
qualified designated staff person responsible for
providing SNAP -Ed direct
• Food handler training — all staff who will
delivering SNAP -Ed curricula to SNAP -Ed eligible
education activities to SNAP -
handle, prepare, cook, assemble, and/or serve
audience.
Ed audience. Project
food or drink to participants or the public.
Food handler training: Completion of a
coordinator or qualified
• Training on data collection and reporting —
Washington State authorized food handler or food
designated staff person to
project coordinator or any staff person
worker training by all staff who will handle and
complete additional SNAP -Ed
responsible for collecting, reporting, or entering
serve food to the public.
Curriculum training when new
SNAP -Ed related data.
Coordinator meetings: Attendance of project
information is provided for
• Regional meeting(s), when provided —project
coordinator or qualified, designated staff person to at
specific curriculum to be used
coordinator or any qualified designated staff
least 50% of all coordinator meetings provided.
in direct education strategy.
person.
Regional meetings: Attendance of project
• Annual State SNAP -Ed forum, when
coordinatoror qualified, designated staff person to at
Data collection and reporting:
provided - project coordinatoror any qualified
least 50% of all regional meetings provided.
Annually, or more often as
designated staff person.
State Forum: Attendance of project coordinator or
needed. If approved data
• SNAP -Ed Curriculum training (either in
qualified, designated staff person to all state forums
collection system changes,
person or online) (only required for direct
provided.
every SNAP -Ed funded staff
education strategies) — project coordinator or
SNAP -Ed Systems Approaches for Healthy
memberentering data will be
qualified designated staffpersonresponsible for
Communities: Demonstrate satisfactory
required to complete training
delivering SNAP -Ed curricula to SNAP -Ed
understanding of the information and concepts
on any new expectations or
eligible audience.
included in the training. Satisfactory application of
system changes on the day of,
• SNAP -Ed Systems Approaches for Healthy
knowledge and skill learned from training to SNAP-
or within 30 days of when the
Communities training (online or in person,
Ed project, as needed.
training is provided.
whenprovided) - project coordinatorand all
Exhibit A, Statement of Work Page 6 of 12 Contract NumberCLH31015
Template September2021
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
#
and/or Amount
staff involved in planning, implementing, and
If required meeting or training is not provided,
Annual Forum: Annually,
evaluating SNAP -Ed project activities.
Subrecipient is not required to makeup requirements
when provided, and no later
• Project coordinator meetings (conference
for attendance and will be in compliance. Attendance
than 9/30/22. FFY23-24 TBD
calls or in person)—projectcoordinatoror
at required meetings and completion of required
qualified designated staff person.
trainings required only when provided.
Coordinator meetings:
Completed on dates scheduled
MEASURE
by DOH, when provided.
Documentation showing required person(s) and
date(s) of attendance forall web -based and in-person
Regional meetings: Completed
required meetings.
on dates scheduled by DOH,
when provided.
Documentation showing required person(s); date(s)
of attendance; and, completion of training for all
SNAP -Ed systems approaches
web -based and in-person required trainings.
training online: At least once
within the three yearperiod of
Documentation of satisfactory understanding gained
performance, and no laterthan
from required trainings, and application of applicable
the end of the first fiscal year
knowledge and skills in progress reviews and/or
within the three yearperiod of
monitoring reports.
performance.
• Due: On or before 9/30/22.
FFY23-24 TBD.
4.0
SNAP -Ed Inventory
On-time updates to SNAP -Ed inventory list.
For the Period:
See payment
SNAP -Ed Subrecipients are required by regulation to
1. Inventory list updated perdue dates required.
0 1/0 1/22 to 09/30/23
information as
keep an up-to-date inventory list that includes all
2. Inventory list contains complete list of all items
10/01/23 to 12/31/24 TBD
referenced in task
non -capital equipment, approved capital equipment,
purchased with SNAP -Ed funds in current fiscal
number 1.0
purchased curriculum, and other SNAP -Ed
yearand previous fiscal years still in use and in
Due: Inventory list is required
purchased items that are not disposable. This list
possession of the Subrecipient.
to be updated at minimum
should include items purchased in prior fiscal years
annually and no later than
still in use and in possession of the Subrecipient.
MEASURE
9/15/22. FFY23-24 TBD.
This list should be updated perthe due dates
Completed documentation showing updated SNAP -
required. Agencies are required to follow the DOH
Ed inventory using approved form/system provided.
At the time of a fiscal or project
SNAP -Ed Inventory policy and procedure.
monitoring review, or when
requested, an up-to-date
*See special requirements section - Monitoring
inventory list must be made
available.
5.0
SNAP -Ed A19 Invoices
On-time delivery of correct completion of SNAP -Ed
For the Period:
See payment
Subrecipients must use the Al invoice form
Al invoices, using the current form for the fiscal
01/0 1/22 to 09/30/23
information as
specific to the DOH SNAP -Ed program. This
year.
10/01/23 to 12/31/24 TBD
referenced in task
document will be sent to all Subrecipients prior to
number 1.0
October 31St of the current fiscal year.
On-time delivery of detailed ledger supporting the
Due: Monthly - Submit
costs to be reviewed by SNAP -Ed program via the
invoices to DOH no later than
Exhibit A, Statement of Work Page 7 of 12 Contract NumberCLH31015
Template September2021
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
most current submission procedure before approval
30 calendardays afterthe end
of payment.
of the preceding month. (E.g.
October Al invoice submitted
Complete documentation of all actualcosts incurred
no later than November 30)
shall be accompanied by the Subrecipient's financial
o January: 2/28/22
system report. If Subrecipient does not have a
o February: 3/30/22
financial reporting system, the Subrecipient must
o March: 4/30/22
checkwith the DOH SNAP -Ed program forfurther
o April: 5/30/22
guidance.
o May: 6/30/22
o June: 7/30/22
MEASURE
o July: 8/30/22
SNAP -Ed invoices (Al 9) with all documented costs
o August: 9/30/22
andanyrequired accompanying materials received at
DOH by due dates required, or by approved
Final invoice is due November
extension date.
30th, 2022 or follow close-out
schedule. FFY23-24 TBD.
Or
*If pre -approved in writing
by DOH, agencies can submit
invoices every two months.
Upon approval, a list of
submission dates will be
provided.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to financeadoh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federa I funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number.
Information about the LHJ and this statement of work will be made available on USASpending_gov by DOH as required by P.L. 109-282.
Program Specific Requirements/Narrative
• Contractorshall ensure, and shall require of its subcontractor, that services provided by the subcontractor are provided in accordance with the terms and co nditions of the
Contract; and Contractoris responsible for the acts and omissions of the subcontractor.
• Contractorshall ensure that the subcontractorand subcontractor's staff who will have unsupervised accessto children or vulnerable adults served unde r the Contract have
each completed and received a satisfactory background check before providing services to DSHS clients, as required under the Contract.
• Contractorshall ensure that the subcontractorhas and maintains insurance with the same types and limits of coverage as requ ired of the Contractor under the Contract.
Exhibit A, Statement of Work Page 8 of 12 Contract NumberCLH31015
Template September2021
• Contractor is responsible to ensure that allterms, conditions, assurances, and certifications set forth in this Contract are included in the subcontract, including all
confidentiality and data security requirements.
• All contract terms in the above -referenced contract remain in full force and effect and nothing in this Checklist shall be construed as waiver of terms in the above -
referenced Contract.
Contract Noncompliance and Corrective Action (see CFR § 200.338 Remedies for noncompliance)
The Subrecipient must meet the required set of acceptable deliverables/outcomes and adhere to contractual obligations. The co ntract's acceptable deliverables/outcomes alongwith
specified due dates will be determined by the DOH SNAP -Ed program and provided to the Subrecipient in writing. Based on contract performance (as documented in progress
reviews, progress reports, project monitoring reports, and fiscal monitoring reports) and after implementation of otherspecific conditions as appropriate listed in CFR § 200.207 -
Specific conditions (see htti2s://www.iovreizs.com/regulations/2/20Q..207), DOH reserves the right to withhold up to 10% of funds from the next applicable payment to the
Subrecipient for deliverables/outcomes that are documented as consistently incomplete; continually late (without approved extension by D OH in writing); found to be unacceptable
or unsatisfactory accordingto the standards of acceptable deliverables/outcomes outlined in the Statement of Work; or, not carred out sufficiently or consistently and documented
as such. After DOH SNAP -Ed provides documentation of the issue(s) and outlines the appropriate corrective action in writing, and with approval from t he DOH SNAP -Ed
program manager, the first withholding of funds up to 10% would occur one time and allow 60 days forthe appropriate corrective action to be completed by the Subrecipient. If
satisfactory corrective action is completed within 60 days, the funds withheld will be released to the Subrecipient. If satisfactory corrective action does not take place within 60
days, up to 5% of funds will be withheld from each subsequent monthly payment untilthe appropriate corrective action is comp leted.If satisfactory corrective action is completed
after the 60 -day window, the initial 10%of fundswithheld will notbeprovided as reimbursement to the Subrecipient aspenalty.The subsequent monthly withholdings (ofup to
5% per month) will be reimbursed to the Subrecipient upon satisfactory completion of the corrective action. The Subrecipient may request reconsideration by submitting a letter to
Washington Department of Health SNAP -Education, PO Box 47886, Olympia, WA 98504-7886, orin writing via email to snap-ed(&doh.wa.gov.
All invoices must be approved by DOH prior to payment; approval will not be unreasonably withheld. DOH will authorize payment only upon satisfactory and on-time completion
of acceptance deliverables/outcomes and for allowable costs as outlined in the SNAP -Ed federa I guidance, statement of work, state plan, and/or budget. DOH will return all
incorrect or incomplete invoices and will not pay for services that occur outside the period of performance orthat are deemed unallowable costs.
Additional Details Regarding Deliverables
Required deliverables for SNAP -Ed reporting will depend on approved SNAP -Ed plan activities for each Subrecipient, e.g. if direct education is not an approved plan activity fora
Subrecipient, submission of pre/post surveys is not a required deliverable forthat Subrecipient. To attend required trainings during fiscal year, the Subrecipient must use the travel
funds within their current allotted budget to send the minimum numberof one (1) staff person to the required training. The Subrecipient may request additional travel funds from
DOH for required training(s) if necessary and if funds are available.
Monitoring Expectations
The Subrecipient's premises and records will be made available upon request to DOH, DSHS, and USDA staff forthe purposes of observing project activities and reviewing for
project and fiscal compliance. All non -capital equipment, capital equipment, reusable educationalmaterialsandsupplies,andanynon-disposable items purchased using SNAP -Ed
funds should be tracked in an inventorylist and available forreview upon request. Based on fiscal and project monitoring results or findings, a dditiona I monitoring during the
fiscal year maybe required at the discretion of the DOH SNAP -Ed program, DOH fiscal analyst, or DOH fiscal monitoring unit. Completed project and fisca I monitoring reports
with suggestions, observations, comments, feedback, findings, and/or corrective action will be kept on file at DOH and shared with Subrecipients regularly and by request.
Staff Requirements
Upon request by DOH, the Subrecipient must demonstrate that SNAP -Ed staff meet requirements appropriate to their positions including but not limited to: background checks,
food handlers' permits, qualifications, and training required by DOH.
Project Coordinator Requirements
The Subrecipient must maintain a SNAP -Ed project coordinator. The project coordinator is the main contact between Department of Health SNAP -Ed team and the Subrecipient.
DOH SNAP -Ed expectations forthe project coordinator responsibilities include:
Exhibit A, Statement of Work Page 9 of 12 Contract NumberCLH31015
Template September2021
• Ensure all contract deliverables are met.
• Coordinate the planning, implementation, evaluation, and reporting of all parts of the approved project plan.
• Comply with and remain knowledgeable about all WA SNAP -Ed and DOH SNAP -Ed policies and procedures.
• Comply with and remain knowledgeable about the National SNAP -Ed Guidance.
• Ensure staff and any sub-Subrecipients funded through this contract stay informed of current and new SNAP -Ed policies, and are held accountable to policies when needed.
• Ensure staff and any sub-Subrecipients meet requirements appropriate to their positions, including but not limited to: background checks, food handler s' permits, and trainings
required by WA SNAP -Ed and DOH.
• Attend, or designate and send qualified staff inemberasproxy to, required DOH and State SNAP -Ed meetings and trainings.
• Monitor or maintain knowledge of project budget status, including estimated spend out and total dollars sp ent to date.
• Submit plan and budget amendments for approval a s outlined in the current year's policy and procedures.
• Coordinate the on-time completion of all data entry and reporting.
• Ensure photo and media release forms are obtained forpersons featured in SNAP -Ed programming photographs orvideos.
Communication Requirements
The Subrecipient must maintain communication with DOH SNAP -Ed. Communication required between DOH SNAP -Ed and the Subrecipient will not be unreasonable or
excessive. DOH SNAP -Ed expectations for communication include:
• Submit updates to DOH following any change in contact information forthe project coordinator, fiscal agent, contract signatory, or any SNAP -Ed funded staff within 10
business days of the change.
• Be available for regular and intermittent meetings, both in person and phone, with DOH SNAP -Ed as agreed upon or as needed.
• Respond to all DOH and SNAP -Ed Statewide initiative requests within the timeline requested.
• Maintain or obtain an intemet connection for communication with DOH, for access to DOH SharePoint webpages, to view updates and messages from Washington SNAP -Ed
through the WA SNAP -Ed Providers website, and forreliable reporting of SNAP -Ed activities. If reliable intemet connection c annot be secured, the Subrecipient and DOH
SNAP -Ed will agree on a plan for necessary communication, data entry, and reporting.
• Obtain a Secure Access Washington (SAW) account to access DOH SNAP -Ed SharePoint webpages.
SNAP -Ed Assurances:
The following assurances must be followed (see program Guidance https://snal2ed.fns.usda.2ov/program-administration/guidance-and-templates)
• The Subrecipient is fiscally responsible for activities funded with SupplementalNutrition Assistance Program Education funds and is liable for repayment of unallowable
costs.
• Programming is provided to approved SNAP -Ed eligible audiences.
• Only expanded or additional coverage of those activities fundedunder the Expanded Food andNutrition Education Program (EFNEP) may be claimed underthe SNAP -Ed
grant. Approved activities are those designed to expand the State's current EFNEP coverage in order to sery e additional SNAP -Ed targeted individuals. In no case may
activities funded under the EFNEP grant be included in the budget for SNAP -Ed.
• Contracts are procured through competitive bid procedures governed by State procurement regulations.
• Program activities are conducted in compliance with all applicable Federal laws, rules, and regulations including Civil Rights and OMB regulatio ns governing cost issues.
• Program activities do not supplant existing nutrition education and obesity prevention programs, and where operating in conjunction with existing programs, enhance as well
as supplement them. This applies to all activities and costs underthe Federal budget.
• Program activities are reasonable and necessary to accomplish SNAP -Ed objectives and goals.
• All materials developed with SNAP- Ed funds include the appropriate USDA non-discrimination statement and credit SNAP as a funding source in standard font that is easily
readable.
SNAP -Ed Statewide Initiatives
Subrecipients are expected to communicate with, respond to, and comply with requests, guidance, requirements, and/oron-site visits from all contracted SNAP -Ed statewide
initiative entities.
Exhibit A, Statement of Work Page 10 of 12 Contract NumberCLH31015
Template September2021
Any SNAP -Ed curriculum modifications should be developed and executed based on the most current Guidance for Curriculum Modification, found under "Guidance and
Process" on WA SNAP -Ed Providers website. Subrecipients must consult DOH SNAP -Ed as directed.
After notification to the DOH SNAP -Ed implementing agency, the Subrecipient may adjust or deny requests, requirements, and/or site visits from any contracted SNAP -Ed
statewide initiative entities if said request, requirement, and/orsite visit is deemed unreasonable, burdensome, unnecessarily costly, or inequitable after appropriate consideration
and deliberation between the Subrecipient, DOH SNAP -Ed, and the contracted SNAP -Ed statewide initiative entity/entities; and, when necessary, DSHS. After appropriate
consideration and deliberation, the resulting decision about whetheror not the Subrecipient must comply or can adjust or deny a specific will be provided in writ ing to the
Subrecipient from DOH SNAP -Ed and/orDSHS.
Health and Safety
Subrecipients are not required to work under conditions that could endangertheir health, safety, or well-being. Additionally, Subrecipients should ensure they are not putting any
SNAP -Ed audience or community members in situations that could endangertheir health, safety, or well-being. Participation in SNAP -Ed by the SNAP -Ed audience is voluntary.
If an activity is deemed unsafe, Subrecipients must adapt activities as needed to allowable and safe alternatives. For a give n situation, all Subrecipients and SNAP -Ed activities
should follow current health and safety laws, regulation and guidance from the designated authorities in the applicable city/town, county, state, and/orthe relate d federal authority,
e.g. CDC, USDA. If Subrecipient is unable to adapt activities as needed to safe, allowable alternatives within their allocation, funding forthe current fiscal year may change after
sufficient and acceptable technical assistance between Subrecipient and DOH SNAP -Ed and afterprior written notification to the Subrecipient. Any change in annual funding due
to inability to adapt project activities as needed to safe, allowable alternatives will not be a permanent change in annual funding, unless accompanied by actions outlined underthe
`Contract Noncompliance and Corrective Action' section.
Audits
The Subrecipient must make State financialand program audits or reviews conducted by other entities available to the DOH, DSHS, USDA, or its designee.
Indirect Rate/Allocation Plan
All indirect rate/allocation plans must be submitted and preapproved by the DOH grants office and the DOH SNAP -Ed program. The Subrecipient is responsible for ensuring that
indirect costs included in the Subrecipient's SNAP -Ed plan and budget are supported by an indirect rate and/orcost allocation plan approved by the appropriate agency. The
Subrecipient cannot bill indirect costs that are determined to be unacceptable and will be disallowed.
Annual Civil Rights Training Requirement (see USDA Instruction Number 113-1 ChapterXI)httl2://www.fns.usda.2ov/sites/default/files/I 13-1.12df "Training is required so
thatpeople involved in all levels of administration of programs that receive Federal financial assistance understand civilrights related laws, regulations, procedures, anddirectives.
Local agencies are responsible for training their sub recipients, including 'frontline staff.' `Frontline staff'who interactwith program applicants or participants, and those persons
who supervise `frontline staff'mustbeprovided civil rights training anannualbasis."
Records Maintenance - Record Retention and Management - State Agency and All Subrecipients 7CFR 272.2
DOH SNAP -Ed regulations require that all records related to the SNAP -Ed program be retained for six (6) years from fiscal closure. This requirement applies to fiscal
documentation and procurement records, contract related documents and emails, progress reports, monitoring reports, and SNAP -Ed client information (pre/post surveys,
demographic cards, etc.). Supporting documentation may be kept at the Subrecipient level, but shall be available forreview within six years from the date of the last quarterly
claim submittal. Any costs that cannot be substantiated by source documents will be disallowed as charges to SNAP -Ed.
Travel
The Subrecipient is expected to comply with the Office of Financial Management's Travel Management Requirement and Restrictio ns as found in policy 10.10
(httl2://www.ofm.wa.iaov/12oficy/I O.htm), with the travel requirements found in the current year's SNAP -Ed federal guidance, and with any travelrelated DOH SNAP -Ed policy
and procedures. If the Subrecipient organization's travel related policy and procedures are in conflict with any of the aforementioned t ravelrelated federal or state policies and
procedures, the Subrecipient organization will follow the stricter of the travel related policy and procedures unless otherwise approved and allowable by DOH or higher authority.
Exhibit A, Statement of Work Page 11 of 12 Contra ct Number CLH3 1015
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Amendments
Subrecipients should check the current year's federal SNAP -Ed guidance, the current year's DOH SNAP -Ed budget amendment guidance, and/orwith a DOH SNAP -Ed program
consultant to know what changes they can make on their own and what changes require an amendment and pre -approval in writing. Notify DOH staff prior to implementing
amendments that significantly change the scope or direction of the approved project plan, including creating new or completely ending interventions, or adding different
recruitment or delivery sites for reaching SNAP eligible population. Following the current year's guidance when required, sub recipients must submit a written plan amendment or
written budget amendment request to DOH, and receive written approval from DOH, prior to making any changes within their proj ector budget and prior to making any purchases
included within the amendment. Any requests needing USDA approvalmust be submitted to DOH no later than April 1 st of each fiscal year, or no later than date specified by
USDA, DSHS, or DOH. Following the current year's guidance when required, if Subrecipients submit plan or budget no cost amend ments that do not require DSHS or USDA
approval, DOH can review those and make approvals on a case by case basis during the federal fiscal year following the curren t year's guidance when required. All cost
amendments that do not require DSHS or USDA approval should be submitted to DOH no later than July 16th of each fiscal year.
Overtime
Staff overtime is not billable in the DOH SNAP -Ed program unless it has been reviewed by the DOH SNAP -Ed program in advance and approved in writing.
Special Funding Requirements
Payment fordeliverables as specified herein is dependent on receipt of funding from the USDA funding sources. In the event funding is not receiv ed, DOH is under no obligation
to make payments forthe deliverables as specified. If funding is reduced or limited in any way aft erthe effective date of this contract and priorto normal completion, DOH may
terminate task(s), remove funds, or reallocate funds at DOH's discretion under new funding limitations and conditions. DOH will make payments only upon the receipt of the
funding. DOH will notify the Subrecipient within 10 working days upon notice by the funding source of funding availability.
Special Billing Requirements
1. All invoices, billing, and reimbursements must be in compliance with all applicable Federal laws, rules, regulations including the current year SNAP -Ed Guidance and OMB
circulars governing cost issues.
2. Totalcosts billed will not exceed the USDA -approved budget amount listed in the box below.
• Bills must be for only SNAP -Ed specific activities, using a DOH Al9-1A Invoice voucher.
• A SNAP -Ed specific At9-1A must be submitted to the subrecipient's designated DOH SNAP -Ed staff inemberwithin 30 days of the last day of the month for which the
work is being billed, OR
• A Subrecipient may request pre-approvalto bill every 2 months instead, in which case, that Subrecipient is required to adhere to the billing due dates provided by DOH.
3. The SNAP -Ed program will deny payment forany costs not submitted by the due date without prior approval. If forANY reason a Subrecipient is unable to submit the SNAP -
Ed A-19-1 A on the due date, the Subrecipient is required to submit a request for an exception to the DOH no later than 7 days prior t o due date to the DOH SNAP -Ed
program. The SNAP -Ed program reserves the right and responsibility to either approve ordeny the request for an exception and will reply to the request.
4. Supporting documentation for each month must be submitted with each SNAP -Ed Al 9-1 A.
• At the very least this means a copy of a Subrecipient's financial expanded/detailed general ledger level report.
• Additionally, all receipts, timecards and other supporting documentation, as noted by USDA, mustbe available upon request.
5. If a Subrecipient meets one of the criteria below, they will need to submit all SNAP -Ed backup documentation with each bill and this requirement will continue until further
notice by DOH.
• All new SNAP -Ed Subrecipients within their 1 It fiscal year.
• Subrecipients with current fiscal findings.
• Subrecipients who have not submitted adequate oraccurate backup documentation within the last year.
• Subrecipients who receive a rating of "High" from the DOH Federal Subrecipient Risk Assessment Tool.
BUDGET
Source Amount
USDA $30,818
Exhibit A, Statement of Work Page 12 of 12 Contract NumberCLH31015
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