HomeMy WebLinkAboutPSA Amend 1This Agreement is-made by and between Kittitas county (hereinafter,,the county")and Community Health of centraiwashington fn"i"in"no "contractor,,). The coung andContractor agree as follows:
General conditions; Exhibit A Qcope of work); Exhibit B (compensation);Exhibit C (Proof of lnsurance); Exni'Oit D (Consotidated Contract cLH3101sbetween Kittitas County and lhe Washington State o"p"rtr"nt of Health);Exhibit E (CYSHCN eu-arterty MCHBG Reporting Form); Exhibit F (CYSHCNAnnualReporting Form)
::iiffL:,T;j are attached hereto and incorporated herein by this reference as tuly as if
"nn
n#irfollowing
documents and/or laws are incorporated by reference as fully as if set
o HRSA - Title V Matemal and Child Health Services Block Grant program
o Sociatsecurity Act Tifle V liws:
The term of this Agreement shall commence on octobe r 1st,2021, and continue untilseptember 30, 2022. Any party' r"1,t"-i1id ili{ nJreement by giving thirty (30) daysnotice in writing either.personitty oltivereoZ;;;ir#'postage-prepaid by certified mail,retum receipt requested, to the drty's last known aooieis for the purposes of giving noticeunder this panagraph.
contractor acknowtedges and by signing this Agreement agrees that thelndemnification provisions set-fortn n FaiigfpiiT gniepenoent contraitor), 9 (Taxes),15 (Defense and lndemnity Agreement),- 2i patenvcopyright lnfringement) and 24(confidentiality), are.totally andrutty part of ffris Alreement-and hav6 been mutua'ynegotiated by the parties.
$Yt*=ss vvl-lEREoF, the parties have executed this Agreement this l€&ay ot Wh . ,
Pofessional Services Agreement
Page 1 of21
Signature of Signatory
(Date
APPROVED:
BOARD OF COUNTY COMMTSSIONERS
cou WASHINGTON
Com
Print Name of Signatory
Contractor DUNS:
86-798-2324
Project Contact:
Angela Gonzalez
Executive Director
Contractor Address:
Community Health of Central Washington
501 S 5th Ave.
Yakima, WA 98902
of Board
to Form
County Address:
Kittitas County
205 West Sth Avenue, Suite 108
Ellensburg, WA 98926
County DUNS:
01-020-2il7
Project Contact:
Chelsey Loeffers
Health Promotion Supervisor
D
,lilllt
By I 7v
AttomeyDeputy
Prcfessional Services Agreement
Page2of 21
AIi,IENDMENT 1
This Agreement is-made by and between Kittitas County (hereinafter,,the County,,)and.Community Health of CentraiWashington (hereinafter "contracto/j. ihe county andContractor agree as follows:
General Conditions; Exhibit A (Scope of Work); Exhibit B (Compensation);
Exhibit C (Proof of lnsurance); Exhibit D (Consolidated Contract CLH3101Sbetween Kittitas County gn9 !!"_Washington State Department of Heatth);Exhibit E (CYSHCN Quarterly MCHBG Reiorting Form);'exniOit F (CySHCN
Annual Reporting Form)
copies of which are attached hereto and incorporated herein by this reference as fully as ifset forth herein.
The following documents and/or laws are incorporated by reference as fully as if setforth herein:
o HRSA - Title V Maternal and Child Health Services Block Grant program
r Social Security Act Tiile V Laws:
The term of this Agreement shall commence on Octobe r 1st,2021, and continue untilSeptember 30,2Q22.Any party may,terminate this Agreement by giving thirty (30) daysnotice in writing either.personally delivered or mailed-postage-pieiaiO-Oy certified mail,return receipt requested, to the party's last known address tor[ne'purposei"of giving noticeunder this paragraph.
Contractor acknowledges and by signing this Agreement agrees that thelndemnification provisions set-forth in Pariglap:hs T llnoepenoent Gontraitor;, 9 (Taxes),15 (Defense and lndemnity Agreement),- 2a (Patdnucbpyright tnfrintement) and 24(Confidentiality), are.totally and fully part of this Agreement-and hav6 been mutuallynegotiated by the parties.
lN WTNESS WHEREoF, the parties have executed this Agreement tnisffo ay ofkb .
,2022. \
Professional Services Agreement
Page 1 ol21
QEO
Gar^,n llearw "rUff#iu
Signature natory
(Date
>Ic:-
Print Name of Signatory
APPROVED:
BOARD OF COUNTY COMMISSIONERS
INGTON
rman
Attest:
of Board
to Form:
By:I
Deputy P Attorney
County Address:
Kittitas County
205 West Sth Avenue, Suite 108
Ellensburg, WA 98926
Gounty DUNS:
o1-020-2547
Project Gontact:
Chelsey Loeffers
Health Promotion Supervisor
2L
Tv
Gontractor Address:
Community Health of Central Washington
501 S Sth Ave.
Yakima, WA 98902
Gontractor DUNS:
86-798-2324
Project Contact:
Angela Gonzalez
Executive Director
Professional Services Agreement
Page2of 21
trm
GENERAL CONDITIONS
1. Scope of Contractor's Services:
Contractor agrees to provide to the Coun$ services and any materials set forth in the project
narrative identified in Exhibit'4" during the Agreement period. No material, labor, orfaciliiies
will be furnished by the County, unless otherwise provided for in the Agreement.
2. Performance of Work:
C_ontractor shall perform work in accordance with, and shall comply with, all of the provisions
of this Agreement. Allwork shall comply with applicable codes anb ordinances.
3. Schedule of Performance:
Unless directed othenruise by the County, Contractor shall perform the work in accordance
with any schedules made a part of this Agreement.
4. Definitions:
4'1 "Additional lnsureds" means the County, its successors and assigns, and
the respective directors, officers, employees, agents and representatives of
the County and its successors and assigns.4.2 "Support" means the following: Contractods directors, officers, employees,
agents and representatives; and sub-Contractors of any tier; the respective
directors, officers, employees, agents and representatives of these sub-
Contractors of any tier; and any other person or entity acting under the
direction or control of, or on behalf of, Contractor or any Contractor's sub-
Contractors of any tier in connection with or incident to theperformance of the
Work or this Agreement.4.3 The "Work" means all of the duties listed in Exhibit A and the performance of
all other obligations, under this Agreement by Contractor or its Support.
5. Accountinq and Pavment for Contractor Services:
Payment to the Contractor for services rendered under this Agreement shall be as set forth
in Exhibit "B". Wlere Exhibit "8" requires payments by the County, payment shall be based
upon billings, supported unless otherwise provided in Exhibit "8",
-by
documentation of units
of work actually performed and amounts eamed, including where appropriate, the actualnumberof days worked each month, total numberof hours forthe month, and the totaldollarpayment requested. Unless specifically stated in Exhibit "B" or approved in writing in
advance by the Kittitas County Board of Commissioners, the County witt not reimburse the
Contractor for any costs or expenses incurred by the Contractor
-in
performance of this
Agreement.
\tVhere required, the County shall, upon receipt of appropriate documentation, compensate
the Contractor, no more often than monthly, through ttre County voucher system, for thecontractor's service pursuant to the fee schedute sJt forth in Exhlbit "8".
Professional Services Agreement
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6. Assiqnment and Subcontractinq:
No portion of this Agreement may be assigned or subcontracted to any other individual, firm
or entity without the express and prior written approval of the County.
7. lndependent Contractor:
The Contractor's services shall be furnished by the Contractoras an independent Contractor
and nothing herein contained shall be construed to create a relationship of employer-
employee or master-servant, but all payments made hereunder and all services performed
shall be made and performed pursuant to this Agreement by the Contractor as an
independent Contractor.
The Contractor acknowledges that the entire compensation for this Agreement is specified
in Exhibit "B" and the Contractor is not entitled to any County benefits including, but not
limited to: vacation pay, holiday pay, sick leave pay, medical, dental, or other insurance
benefits, or any other rights or privileges afforded to Kittitas County employees.
Contractor will defend, indemnifiT and hold harmless the County, its Additional lnsureds,
officers, agents or employees from any loss or expense, including but not limited to
settlements, judgments, setoffs, attomeys' fees or costs incurred by reason of claims or
demands because of breach of the provisions of this paragraph.
8. No Guarantee of Emplovment:
The performance of all or part of this Agreement by the Contractor shall not operate to vest
any employment rights whatsoever and shall not be deemed to guarantee any employment
of the Contractor or any employee of the Contractor or any sub-Contractor or any employee
of any sub-Contractor by the Coung at the present time or in the future.
9. Taxes:
The Contractor understands and acknowledges that the County will not withhold Federal or
State income taxes. Where required by State or Federal law, the Contractor authorizes the
County to make withholding for any taxes other than income taxes (i.e. Medicare). All
compensation received by the Contractor will be reported to the lnternal Revenue Service
at the end of the calendar year in accordance with the applicable IRS regulations. lt is the
responsibility of the Contractor to make the necessary estimated tax payments throughout
the year, if any, and the Contractor is solely liable for any tax obligation arising from the
Contractor's performance of this Agreement. The Contractor hereby agrees to indemniff
the County against any demand to pay taxes arising from the Contractor's failure to pay
taxes on compensation earned pursuant to this Agreement.
The County will pay sales and use taxes imposed on goods or services acquired hereunder
as required by law. The Contractor must pay all other taxes including, but not limited to:
Business and Occupation Tax, taxes based on the Contractor's gross or net income, or
personal property to which the County does not hold title. The County is exempt from
Federal Excise Tax.
Professional Services Agreement
Page4o121
10. Requlations and Requirement:
This Agreement shall be subject to all laws, rules and regulations of the United States of
America, and State of Washington, and political subdivisions of the State of Washington,
and to any other provisions set forth herein or in the attached exhibits.
11. Riqht to Review:
This contract is subject to review by any Federal or State auditor. The County or its designee
shall have the right to review and monitor the financial and service components of this
program by whatever means are deemed expedient by the County. Such review may occur
with or without notice, and may include, but is not limited to, on-site inspection by Coung
agents or employees, inspection of all records or other materials which the County deems
pertinent to the Agreement and its performance, and any and all communications with or
evaluation by service recipients under this Agreement. The Contractor shall preserve and
maintain all financial records and records relating to the performance of work under this
Agreement for 6 years after contract termination, and shall make them available for such
review, within Kittitas County, State of Washington, upon request.
12. Modifications:
12.1 Either party may request changes in the Agreement. Any and all agreed
modifications shallbe in writing, signed by each of the parties.
12.2 TheCountymay, atanytime, bywritten noticethereof toContractor("Change
Notice") makes changes in the Work within the general scope of this
Agreement, including, but not limited to: (a) changes in, revisions to,
substitutions for, additions to or deletions of any Work; (b) changes in
schedule; and (c) acceleration, deceleration or suspension of performance of
any Work.
12.3 lf any change in the Work causes an increase or decrease on Contractor's
cost of, or the time required for, performance of the work, an equitable
adjustment in the compensation to Contractor and in the schedule for the
performance of the Work shall be made to reflect such an increase or
decrease.
12.4 Notwithstanding any dispute or delay in arriving at a mutually acceptable
equitable adjustment, Contractor shall proceed in accordance with all Change
Notices. Contractor must, within thirty (30) days after receipt of any Change
Notice that does not set forth any acceptable adjustment, submit to the County
a written statement setting forth any adjustment claimed.
12.5 lf any change results in a decrease in the Work performed, Contractor shall
be entitled to compensation associated with changing the Work, such as
Professional Services Agreement
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revising. design already completed, revising calculations already performed,
and revising documents.
13. Termination for Default:
lf the Contractor defaults by failing to perform any of the obligations of the Agreement orbecomes insolvent or is declared bankrupt or commits any aciof bankruptcy oi insolvency
or makes an assignment for the benefit of creditors, the Cbunty may, by depositing written
notice to the Contractor in the U.S. mail, postage prepaid, terminate-theAgreement, and atthe County's option, obtain performance of ihe work elsewhere. lf th; Agreement isterminated for default, the Contractor shall not be entitled to receive any further payments
under the Agreement until all work called for has been fully performed. Any extra cost ordamage to the County_ resulting from such default(s) shall be deducted trom any money due
or coming due to the Contractor. The Contractor shall bear any extra e*pens"i incurred by
the County in completing the work, and all damage sustained, or whiclr may be sustained
by the County by reason of such default.
lf a notice of termination for default has been issued and it is later determined for any reason
that the Contractor was not in default, the rights and obligations of the parties shall be thesame as if the notice of termination had been issued pursuant to the Termination for public
Convenience paragraph hereof.
14. Termi for Public Co nlence:
The County may terminate the Agreement in whole or in part whenever the County
determines, in its sole discretion that such termination is in the best interests of the County
Vt/henever the Agreement is terminated in accordance with this paragraph, the Contractor
shall be entitled to payment for actualwork perfo rmed at unit contract prices for completed
items of work. ln the event of such term ination,an equitable adjustment shall be made inthe compensation payable to Contractor
An equitable adjustment in the contract price for partially completed items of work will bemade, but such adjustment shall not include provision for lbss of anticipated profit on deletedor uncompleted work. Termination of this Agreement by the County'at any time during theterm, whether for default or convenience, shall not constitute a breach oi contract Oy tne
County.
15. Defense & lndemnity Aqreement:
fh.g.Contrqctor agrees to and shall defend, indemniff and hold harmless the County, itsAdditional lnsureds, appointed and elective officers, agents and employees, from'and
against all loss or expense-, including but not limited to judgments, setl'emlnts, attorney's
fees and costs by reason of any and all claims and demahdJupon the county, its Additional
lnsureds, its elected or appointed officials, agents, or employees for camages because ofpersonal or bodily injury, including dea.th at any time resulting therefrom, srlstained by anyperson or persons and on account of damage to property including loss of use thereoiwhether such injury to persons or damage to property ii Oue to i-he negligence of the
Professional Services Agreement
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Contractor, its sub-Contractors, its elected officers, employees or their agents, except only
such injury or damage as shall have been occasioned by the sole negligence of the County,
its Additional lnsureds, appointed or elected officials, agents, or employees. lt is further
provided that no liability shall attach to the County by reason of entering into this contract,
except as expressly provided herein.
16. lndustrial lnsurance Waiver:
\Mth respect to the performance of this Agreement and as to claims against the County, its
Additional lnsureds, officers, agents and employees, the Contractor expressly waives its
immunity under Title 51 of the Revised Code of Washington, the lndustrial lnsurance Act,
for injuries to its employees and agrees that the obligations to indemnifiT, defend and hold
harmless provided in this agreement extend to any claim brought by or on behalf of any
employee of the Contractor. This waiver is mutually negotiated by the parties to thii
Agreement.
17. Venue and Choice of Law:
ln the event that any litigation should arise concerning the construction or interpretation of
any of the terms of this Agreement, the venue of such action of litigation shall be in the
SuperiorCourtof theStateof Washington inandfortheCountyof Kittitas. ThisAgreement
shall be governed by the law of the State of Washington.
18. Withholdinq Pavment:
ln the event the Contractor has failed to perform any obligation to be performed by the
Contractor under this Agreement within the time set forth in this Agreement, then the County
may, upon written notice, withhold all monies due and payable to Contractor, without
penalty, until such failure to perform is cured or otherwise adjudicated.
19. Future Non-Allocation of Funds:
lf sufficient funds are not appropriated or allocated for payment under this Agreement for
any future fiscal period, the County will not be obligated to make payments for services or
amounts incurred after the end of the current fiscal period. No penalty or expense shall
accrue to the County in the event this provision applies.
20. Contractor Com m itments. Warra nties and Representations:
The contractor represents and warrants to the county as foilows:20.1 The Contractor is duly incorporated, validly existing and in good standing
underthe laws of the State of Washington, and has all requisite corporate
power and authority to enter into and to perform its obligations under this
Agreement.
20.2 The Contractor has the authority to execute this Agreement, to make the
representations and warranties set forth in it and to perform the
obligations of the Contractor under this Agreement in accordance with its
terms.
Professional Services Agreement
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20.3 This Agreement has been validly executed by an authorizedrepresentative of the Contractor and constituies a valid and legallybinding and enforceabre obrigation of contractor.20'4 The Contractor has or will obtain prior to the commencement date suchlicenses, permits and other authorizations from teCerat,state ano othergovernmental authorities, as are necessary for the performance of itsobligations under this Agreement.2o'5 The Contractor is not in violation of any applicable law, ordinance orregu.lation the consequence of which will or may materially affectContracto/s ability to perform its obligations unier this Ag'reement. TheContractor is not subject !o any ordeior judgment of any"court, tribunal orgovernmental agency which materially and idversely afiects itsoperations or assets in the State of Washington, or ils ability to performits obligations under this Agreement.20'6 None of the representationi or warranties in this Agreement, and none ofthe documents, statements, certificates or schedul6s furnished or to befurnished by Contractor pursuant hereto or in connection with theperformance of the obligations contemplated under this Ajreement,contains or will contain any untrue statement of a materiaifact or omits orwill omit to state a material fact necessary to make the statements of factcontained therein not misleading.
21. PatenUCopvriqht lnfrinqement:
contractor will defend ano inoenrniff the county from any claimed action, cause or demandbrought against the county; to the extent such iction is based on the claim that informationsupplied by the contra.ctor infringes any patent or copyrght. The contractor will pay thosegosts.and damages attributablsto any such claimd inai are finally awarded against theCounty in any action. Such defense
"nd
payments are conoitioned upon the following:21'1 Contractorshallbe notified promptly in writing by County otanv notice of suchclaim.
21'2 Contractor shall have the right, hereunder, at its option and expense, to obtainfor the goYnty the right to tontinue using the information, in'inl event suchclaim of infringement is made, provided io reduction in perfonnance or lossresults to the County.
22. Disputes:
22.1 General
Differences between the contractor and. the county, arising under and byvirtue. of the Agreement Documents shall be brought to tnelttention of theCounty at the earliest possible time in order that suih matters may be setledor other appropriate action prompfly taken. Except for such objections as aremade of record in the manner hereinafter specified and witnin the time limits
ltated, the records, orders, instructions, and decisions of the Kittitas d;;tCommissioners shall be final and conclusive.
Professional Services Agreement
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22.2 Notice of PotentialClaims
The Contractor shall not be entitled to additional compensation which
otherwise may be payable, or to extension of time for (1) any act or failure to
act by the County, or (2) the happening of any event or occurrence, unless
the Contractor has given the Coun$ a written Notice of Potential Claim within
ten (10) days of the commencement of the act, failure, or event giving rise to
the claim, and before final payment by the County. The written Notice of
Potential Claim shall set forth the reasons for which the Contractor believes
additional compensation or extension of time is due, the nature of the cost
involved, and insofaras possible, the amount of the potential claim. Contractor
shall keep full and complete daily records of the work performed, labor and
material used, and all costs and additionaltime claimed to be additional.
22.3. Detailed Claim
The Contractor shall not be entitled to claim any such additional
compensation, or extension of time, unless within thirty (30) days of the
completion of the portion of the work from which the claim arose, and before
final payment by the County, the Contractor has given the County a detailed
written statement of each element of cost or other compensation requested
and of all elements of additional time required, and copies of any supporting
documents evidencing the amount or extension of time claimed to be due.
23. Ownershio of ltems Produced:
All writings, programs, data, public records or other materials prepared by the Contractor
and/or its consultants or sub-Contractors, in connection with performance of this Agreement
shall be the sole and absolute property of the County.
24. Confidentiality:
The Contractor, its employees, sub-Contractors, and their employees shall maintain the
confidentiality of all information provided by the County or acquired by the Contractor in
performance of this Agreement, except upon the prior written consent of the Kittitas County
Prosecuting Attorney or an order entered by a court after having acquired jurisdiction over
the County. Contractor shall immediately give to the County notice of any judicial
proceedings seeking disclosure of such information. Contractor shall indemniff and hold
harmless the Coun$, its Additional lnsureds, officials, agents or employees from all loss or
expense, including, but not limited to settlements, judgments, setoffs, attorneys'fees and
costs resulting from Contractor's breach of this provision.
To the extent that any information obtained by the Contractor is required to be shared with
or provided to others by the terms of the Statement of the Work, this provision is not
breached by such acts.
25. Notice:
Professional Services Agreement
Page 9 of21
Except as set forth elsewhere in the Agreement, for all purposes under this Agreement,
except service of process, notice shall be given by the Contractor to the department headof the department for whom services are rendered, and to the Kittitas County
Commissioners, 205 W sth Ave, Suite 108, Ellensburg, WA 98926. Notice to the Contractor
for all purposes under this Agreement shall be given to the address reflected on the
signature page. Notice may be given by delivery or by depositing in the U.S. Mail, first class,
postage prepaid.
26. Severability:
lf any term or condition of this Agreement or the application thereof to any person(s) or
circumstances is held invalid, such invalidity shall not affect other terms, conditions or
applications which can be given effect without the invalid term, condition or application. To
this end, the terms and conditions of this Agreement are declared severable.
27. Miscellaneous:
27.1 The County's failure or delay to insist upon strict performance of any of the
provisions of this Agreement or to exercise any rights or remedies under this
Agreement shall not be construed as a waiver or relinquishment to any extent
of its right to assert or rely upon any such provisions, rights or remedies in that
or any other instance; rather the same shall be and remain in full force and
effect.
27.2 This Agreement embodies the entire Agreement between the County and
Contractor, and supersedes any and all prior agreements, regarding the
Work. No change, amendment or modification of any provisions of this
Agreement shall be valid unless set forth in a written instrument signed by the
party to be bound thereby.
27.3 The rights and remedies of the County set forth in any provision of this
Agreement are in addition to and do not in any way limit any other rights of
remedies afforded to the County by any other provisions of this Agreement,
by any of Contractor's Support or by law.
27.4 The headings of sections and paragraphs of this Agreement are for
convenience of reference only and are not intended to restrict, affect or be
of any weight in the interpretation or construction of the provisions of such
sections or paragraphs.
28. Waiver:
Waiver of any breach or condition of this Agreement shall not be deemed a waiver of any
prior or subsequent breach. No terms or conditions of this Agreement shall be held to be
waived, modified ordeleted except by an instrument, in writing, signed by the parties hereto.
29. Survival:
The provisions of paragraphs 7, g, 1 1, 19, 14, 15, 16, 17, 1 8, 1 g, 20, 21, 22, 22, 24, 2g, gO,
31, and 32 shall survive, notwithstanding the termination or invalidity of this Agreement for
any reason.
Professional Services Agreement
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30. Nondiscrimination:
30.1
30.2
30.3
30.4
The Coung is an equal opportunity employer.
Nondiscrimination in Emplovment
ln the performance of this Agreement, the contractor will not
discriminate against any employee or applicant for emproyment on the
grounds of race, creed, color, national origin, sex, sexual orientation,
maritalstatus, age or the presence of any sensory, mental or
physical handicap; provided that the prohibition against discrimination
in employment because of handicap shall not appty if the particular
disability prevents the proper performance of the particular worker
involved. The contractor shall ensure that appricants are employed,
and that employees are treated during employment without
discrimination because of their race, creed, color, nationalorigin, sex,
sexual orientation, marital status, age or the presence of any sensory,
mental or physical handicap. such action shall include, but not be
limited to: employment, upgrading, demotion or transfers, recruitment or
recruitment advertising, layoff or termination, rates of pay or other
forms of compensation, and programs for training including
apprenticeships. The Contractor shall take such action with respect to
this Agreement as may be required to ensure fuil compliance with
local, state and federal laws prohibiting discrimination in employment.
Nondiscrimination in Services
The Contractor will not discriminate against any recipient of any services
or benefits provided for in this Agreement on the grounds of race,
creed, color, national origin, sex, sexualorientation, marital status, age or
the presence of any sensory, mental or physical handicap.
lf any assignment and/or subcontracting has been authorized by the
county, said assignment or subcontract shall include appropriate
safeguards against discrimination. The contractor shall take such
action as may be required to ensure full compliance with the
provisions in the immediately preceding paragraphs herein.
31. Prevailinq Waqe:
Contractor shall pay the prevailing rate of wages to all workers, laborers, or mechanics
employed in the performance of any part of the Work in accordance with RCW 39.12
and the rules and regulations of the Department of Labor and lndustries. The schedule
of prevailing wages rates for the locality or localities of the Work is determined by the
Professional Services Agreement
Page 11 of21
lndustrial Statistician of the Department of Labor and lndustries. lt is the Contractor's
responsibility to veriff the applicable prevailing wage rate. lt is understood that the
Contractor is responsible for obtaining and completing all required government forms
and submitting same to the proper authorities.
Disputes regarding prevailing wage rates shall be referred for arbitration to the Director
of the Department of Labor and lndustries. The arbitration decision shall be final and
conclusive and binding on all parties involved in the dispute as provided for by RCW
39.12.060.
32. Debarment Certification:
The Contractor certifies that it:32J ls not presently debarred, suspended, proposed for debarment, declared
ineligible or voluntarily excluded from covered transactions by any Federal
department or agency.
32.2 Has not within a three-year period preceding the execution of this contract
with Kittitas County, been convicted of or had a civiljudgment rendered
against them for commission of fraud or a criminal offense in connection
with obtaining, attempting to obtain, or performing a public or private
agreement or transaction, violation of Federal or State antitrust statutes or
commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, tax evasion, receiving
stolen property, making false claims, or obstruction of justice.
32.3 ls not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State, or local) with commission of any of
the offenses enumerated in paragraph j2.2 of this section.32.4 Has not within a three-year period preceding the preceding the execution
of this contract with Kittitas County had one or more public transactions
(Federal, State, or local) terminated for cause of default.
33. Backqround Checks: Contractor shall ensure that all employees and or volunteers
meet background check requirements pursuant to RCW43.43.g30-940.
34: Vehicles. Licenses. and lnsurance: County will not provide vehicles for Contractor's
use. Contractor shall ensure that all driver's performing any services under this contract
hold a valid Washington State Driver's License and ensure that insurance requirements
found in Exhibit C are met.
Professional Services Agreement
Page 12 of 21
EXHIBIT'A"
SCOPE OF WORK
In addition to providing all material and labor, the Contractor shall perform the following
services as detailed below:
Employ a registered nurse, fully licensed within the State of Washington to perform the work
described below within the Children with Special Health Care Needs Program, hereinafter
"CYSHCN".
This work shall include quarterly reporting (Exhibit E) due January 10, 2022, annual
reporting (Exhibit F) due October 10,2022, and the following:
Professional Services Agreement
Page 13 of21
Task/Activity/Descri ptio n De I ive rab les/O utcom es Due Date/Time
Frame
Complete Child Health lntake Form
(CHIF) using the CHIF Automated
System on all infants and children
served by the CYSHCN Program as
referenced in CYSHCN Program
Manual. Ensure client data is
collected on allchildren served by
CYSHCN contractors, including
neu rodevelopmental centers,
regional maxillofacial coord inators,
and the DOH Newborn Screening
Program.
Submit CHIF data into Secure
File Transport (S FT)website:
https://sft.wa.gov
1t15t22
4t15t22
7t15t22
10t15t22
Administer requested DOH
Diagnostic and Treatment funds for
infants and children per CYSHCN
Program Manualwhen funds are
used.
Submit completed Health
Services Authorization forms
and Central Treatment Fund
requests directly to the
CYSHCN Program as needed
30 days after
forms are
completed.
EXHIBIT ''B''
COMPENSATION
As full compensation for satisfactory performance of the work, the County shall pay
Contractor compensation as follows.
Monthly payments totaling no more than $13,258.00 for the length of the contract for the
delivery of CYSHCN care coordination program services. This amount is based on
projected funding from the Washington State Department of Health MaternalChild Health
Block Grant, which is contingent on the final award from the Washington State
Department of Health. ln the event of a reduction of funding, Contractor agrees to an
amendment of this section consistent with the reduction in funding.
Restrictions on Funds: Contractor agrees that payments received from the County under
this Agreement shall not be used for:
1 . lnpatient services, other than inpatient services for children with special health care
needs or high-risk pregnant women and infants, and other patient services
approved by Health Resources and services Administration (HRSA).2. Cash payments to intended recipients of health services.3. The purchase or improvement of land, the purchase, construction, or permanent
improvement of any building or other facility, or the purchase of major medical
equipment.
4. Meeting other federal matching funds requirements.5. Providing funds for research or training to any entity other than a public or nonprofit
private entity.
6. Payment for any services furnished by a provider or entity who has been excluded
under Title XVlll (Medicare), Title XIX (Medicaid), or Title XX (social services block
grant).[Social Security Law, Sec 504(b)].
l! any charges are imposed for the provision of health services using Tifle V (Maternal
Child Health Block Grant) funds, such charges will be pursuant 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 the
individual provided the services. [social security Law, sec. sos (1XD)l
The Contractor may use an approved federally recognized indirect costs rate negotiated
between the subrecipient and the federal government or, if no such rate exists, a rate
negotiated between the pass-through entity and the subrecipient or a de minimis indirect
costs rate. A de minimis indirect cost rate is defined in the Federal Office of Management
and Budget Uniform Grant Guidance 5200.414 as 1Oo/o of modified totaldirect cos1s. The
Contractor will inform the County as to which indirect cost rate will be used on invoices
Professional Services Agreement
Page 14 of 21
sent to the County during the period of this agreement before the first invoice of this
agreement is paid.
Reimbursement Procedures
a. Contractor shall submit invoices for services due quarterlv, which may be
emailed to Katie odiaga, Kittitas county Public Health Department,
katie.odiaqa@co. kittitas.wa. us
b. All invoices must be submitted thirty (30) days following the last day of each
calendar month in which services were delivered.
c. All invoices must include the Contract Number.
d. A tracking spreadsheet for expenditure breakdown and supporting
documentation for all non-payroll charges. Payroll charges must reflect actual
time worked on the program in order to comply with the Uniform Grant
Guidance 5200.430 section I Standards for Documentation of Personnel
Expenses. Supporting documentation for these charges includes copies of
receipts, invoices, purchase orders, and/or mileage logs.
e. All invoice corrections must be submitted no later than sixty (60) days after
the last day of the month in which those operating expenses occurred, except
at the end of the fiscal year, when all invoices and corrections must be
submitted by the fifth (5th) working day of the month following the end of the
fiscalyear.
f. The County agrees to make payment for eligible expenses as approved by
the Auditor of Kittitas County with County warrants within thirty (30) working
days following receipt of Contractor's claim for reimbursement; provided that
no payment shall be made in the month during which expenses occurred
unless otherwise approved by the County.
g. Kittitas County is not liable for services provided unless the invoice is
received on time or prior arrangement are agreed to in a writing signed by the
Kittitas County.
h. ln no event will payments total more than $13,258.00 under this agreement.
Professional Services Agreement
Page 15 of21
EXHIBIT "C"
PROOF OF INSURANCE
The Contractor shall secure and maintain in effect at all times during performance of the
Work such insurance as will protect Contractor, its Support and the Additional lnsureds
from all claims, losses, harm, costs, liabilities, damages and expenses arising out of
personal injury (including death) or property damage that may result from performance of
the work or this Agreement, whether such performance is by Contractor or any of its
Support.
All insurance shall be issued by companies admitted to do business in the State of
Washington and have a rating of A-, Class Vll or better in the most recently published
edition of Best's Reports unless otherwise approved by the County. lf an insurer is not
admitted, all insurance policies and procedures for issuing the insurance policies must
comply with Chapter48.15 RCW and284-15 WAC.
The Contractor shall provide proof of insurance for:
I Commercial General Liabilitv lnsurance
Coverage limits not less than:. $1,000,000 per occurrence/$2M aggregate. Certificate Holder - Kittitas Countyo The Certificate must name the County as additional insured. Sixty (60) days written notice to the County of cancellation of the insurance
policy
I CommercialAutomobile Liabilitv lnsurance (if ANY use of vehicle in performance)
Automobile Liability for owned, non-owned, hired, and leased vehicles (MCS gO
endorsement and a CA 9946 endorsement must be aftached if 'poltutants' are to be
transpofted). Coverage limits not less than:. $1,000,000 combined single limit
' Thirty (30) days written notice to the County of cancellation
of the insurance policy.
X Workers' Compensation
Workers'Compensation in amounts required by law
[l Stop Gap/Employers Liabilitv
Professional Services Agreement
Page 16 of21
Coverage limits not less than:. $1,000,000 each accident. $1,000,000 disease - policy limit. $1,000,000 disease - each employee
' Thirty (30) days written notice to the County of cancellation
of the insurance policy.
I Professional Liability
The Contractor and/or its Subcontractor and/or its consultant providing
professional services shall provide evidence of Professional Liability lnsurance
covering professionalerrors and omissions. Such policy must provide the following
minimum limits:. $1,000,000 per claim. $2,000,000 annual aggregate
' lf insurance is on a claims-made form, its retroactive date, and that of all
subsequent renewals, shall be no later than the effective date of this
Agreement.
I Poltution Liabitity
The Contractor shall provide a Pollution Liability policy, providing coverage for
claims involving bodily injury, property damage (including loss of use of tangible
property that has not been physically injured), cleanup costs, remediation, disposal
or other handling of pollutants, including costs and expenses incurred in the
investigation, defense, or settlement of claims arising out of:. Contractor's operations related to this project; and/oro Remediation, abatement, repair, maintenance or other work with lead-based
paint or materials containing asbestos; and/oro TransPortation of hazardous materials away from any site related to this project
Such Pollution Liability policy shall provide the following minimum coverage:r $ per claimr $ annual aggregate
f Property Damaqe
The Contractor shall provide a policy that covers damage to Kittitas County
facilities, including buildings, equipment, grounds, etc. Such policy shall provide
the following minimum coverage:o $ per occurrence
I Umbrella Coveraqe
Umbrella policies shall provide coverage at least as broad as specified for
underlying coverages (CGL, Auto, Employer's Liability) and cover those insured in
the underlying policies, including additional insured.o Amount required for this Agreement: $5,000,000
Professional Services Agreement
Page 17 ot 21
Contractor shall furnish the County a Certificate of lnsurance to include the policy
Endorsements/Exclusions as evidence that policies providing insurance required by thii
Agreement are in full force and effect. Contractor hereby wlives all rights of recourse,
including any right to which another may be subrogated, against fittitas County foipersonal injury, including death, and property damage. Contractor's insurance policies
required above shall be primary insurance and shall be non-contributing with any
other insurance maintained by Kittitas County.
The Contractor shall assume full responsibility for all loss or damage from any cause
whatsoever to any tools, Contractor's employee-owned tools, machinery, equipment, or
motor vehicles owned or rented by the Contractor, or the Contractor's agenis,.suppliers
or Contractors as well as to any temporary structures, scaffolding and protective fences.
The Contractor shall have sole responsibility for ensuring the insurance coverage and
limits required are obtained by subcontractors.
NOTE: No contract shall form until and unless a copy of the Certificate of
lnsurance with Endorsements/Exclusions, properly completed and in the amount
required, is attached hereto.
Failure of the Contractor to fully comply with the above insurance requirements during
the term of the Agreement shall be considered a material breach of contract and cauJe
for immediate termination of the Agreement at the County's discretion. Alternatively, the
County may procure and maintain, at the Contractor's soie expense, insurance to the
elJent deemed proper up to the amount of the required coverage(s)- The County may
offset the cost of such insurance against payment due to the Conirictor under this
Agreement.
Professional Services Agreement
Page 18 of21
EXHIBIT "D"
See attached: Consolidated Contract CLH31015 between Kittitas County and the
Washington State Department of Health.
Professional Seruices Agreement
Page 19 of21
EXHIBIT "E"
Contract will submit quarterly reports using the attached template to: Chelsey Loeffers,Kittitas County Public Health Department, .
Quarterly reports are due by 1t1et22, 4l1ol22, Tt1ot22, and 1011ot22.
See attached: Children with Special Health Care Needs Program euarterly MaternalChild Health Block Grant Reporting Form.
Professional Services Agreement
Page2o ol21
EXHIBIT "F"
Contract will submit a final annual reports using the attached template to: Chelsey
Loeffers, Kittitas County Public Health Department, chelsey.loeffers@co.kittitas.wa.us.
Annual report is due by October 10,2O22.
See attached: Children with Special Health Care Needs Annual Reporting Form.
Professional Services Agreement
Page21 of21
I
l(ittitas County
Public Health
D€psrtmsnt
507 N. Nanum Street, Suite 102 Ellensburg,WA9g926
T: 509.962.7515 F : 509.962.7581
www.co.kittitas.wa. us/health/
Facilityreporting: CHCW-E
Name of reporter:
Exhibit "E"
Quarterly Reporting Form
(CYSHCN Quarterly MCHBG Reporting Form)
Email report to: chelsey'loeffers@co.kittitas.wa.us or fax: g33-g2 46 bythe 5th of the monthfollowing the end of the quarter.
Quarter period:
Date CHIF entry completed:
What would you like to share
challenges, etc.
with regional/statewide CySH CN partners? Highlights, questions,
What's new?
Factors to success or barriers
HP Version: I Supersedes: 0 I 9 :\pproval By: T Lamb
S]
Kittitas Couniy
Public Health
S*p*rtrrsirl.
507 N. Nanum Street, Suite 102 Ellensburg,WA9g926
T: 509.962.7515 F: 509.962.7581
www. co. kittitas. wa. us/health/
Exhibit "F"
Annual Reporting Form
Unduplicated Count of lndividuals Served Under Title V by Class of lndividuals and percent of
Health Coverage
Email report to: chelsey.loeffers@co.kittitas.wa.us or fax: 933-g246 by November 3orh 2022
Facilityreporting: CHCW-E Date:
Report the unduolicated number served for each population category served if a direct or
enablins service (the top two levels of the MCH Pyramid) was fully or partially supported withyour total MCH allocation. Estimate the percent with Title Xlx, Title XXl, other, or No/Unknown
Health Coverage.
Population
Category
A.
Total f
Served
with Title V
(partially
or fully
funded
with MCH
al
B.
Estimated
%with
Title xtx
coverage
c.
Estimated
% with
Title xxt
coverage
D.
Estimated %
with
Private/Other
coverage
E.
Estimated %
with No
health
coverage
F.
Estimated
%
Unknown
health
coverage
Total %
(should
be 100%)
Pregnant
Women
0.00%
lnfants<1
yr. of age
0.00%
Children 1
to22yr.0.00%
CYSHCN 0.00%
Others 0.00o/o
TOTAL 0
HP Version: 1 Supersedes: 0 -pate Adopted:9/29/21 Modified/Created By: Chelsey Loeffers Approval By: T Lamb
t
Kittitas County
Public Health
Depailtmenl
507 N. Nanum Sheet, Suite 102 Ellensburg, WA 9g926
T: 509.962.7 515 F: 509.962.7581
www.co.kittitas.wa. us/health/
lnstructions for Completing Report:
Enter the unduplicated number of individuals in each population category who received a
direct or enabling service (in person, by phone) that was fully or partially supported with
Title V (MCH Block Grant)funds. These services would generally be included in direct and
enabling services, and would not include those individuals encountered in public Health
Services and Systems work. NOTE: There will be overlap between the figures listed for
Column (A) and the remaining columns.
1. Column
A:
2. Columns
B-F:
Estimate for each population category the proportion with Title XlX, Title xxl,
Private/Other, No or Unknown health coverage.
HP Version: I Supersedes: 0 Date Adopted:9129/21 Modified/Created By: Chelsev Loeffers Approval By: T Lamb
Exhibit AStatement of WorkContract T erm: 2022-2024DOH ProgramName or Title:Effective Januarv 1. 2022SOW Type: Original Revision # (for this SOW)Period of Performance: January 1.2022 through September30. 2022Statement of work Purpose: The purpose of this statement of work (Sow)Block Grant.Revision Purpose: N/AExhibit A, Statement of WorkTemplate Created Septemb er202lLocal Health Jurisdiction Name: Kittitas countv public Health DeoartmentConfract Number: CLH3 l0t5Type of PavmentEl ReimbunementE rixed PriceFederal Compliance(check if applicable)El rFnrn (Transparency Act)IJ Research & DeveloomentFunding SourceEl f"aJrt SubrecipientE stut.E oth"tis to support local interyentions that impact the target population of the Matemaland Child HealthTotalAllocation14730007ChangeIncrease (+)14700CurrentAllocation0009t3LHJ Funding PeriodStart Date End DateBARSRevenueCode93.99AssistanceListingNumber93.994MasterIndexCodeDOH Chart of Accounb Master Index TifleFFY22Information and/orPaymentAmountReimbursement for actual costs,not to exceed totalfundingconsideration. Action PIan andProgress Reports must only reflectactivities paid for with fundsprovided in this statement of workfor the specified funding period.See Program SpecificRequirements and Special BillingDue Date/Time tr'rameMay27,2022September9,2022Deliverables/Outco mesSubmit actua I expenditures using theMCHBGBudget Workbook to DOHcontractMCHBG Budget Workbook toDOH contractmanagerSubmitActivityReport actualOctober l, 20expenditures forthe six-month period2 I through March 3 l, 20222022 -2023 MCHB G Budger Workbook forOctober 1,2022 through September 30, 2023 using DOHprovided template.DevelopTask#AdminishationGrantBlockHealthchitdandternalMalalbImplementationPage I of3Contract NumberCLH3 I 0 I 5
Payment Information analoFAmount2aReport activities andoutcomes of 2022 MCHBG ActionSubmit qua rterly ActionDOH ContractmanagerPIan using DOH- provided template.Plan reports toJanuary 15,2022Apnl 15,2022Reimbursement for a ctua I costs,not to exceed total fundingconsideration, Action Plan andProgress Reports must only reflectactivities paid for with fundsprovided in this statement of workfor the specified funding period.See Program Specific2bDevelop2022-2023MCHBGt5ActionPlanfbrOctoberISubmit MCHBGcontractmanagerAction Plan to DOHDraflAugust 19,2022Final- Septemberg,20222022throughSeptemberJ0,2023usmgDOH-providedtemplate.Requirements and Special Bilingand Youth withHealth Care NeedsdataAccess75,2CHIF Automated System on all infants and children servedWashington website:https: //secureaccess.wa.sovApnl 15,2O22July 15,2022by the CYSHCN Program as referenced in CYSHCNnot to exceed total fundingconsideration. Action Plan andProgress Reports must only reflectactivities paid for with fundsprovided in this statement ofworkfor the specified funding period.unmeton Medicaid acompHeaforms areto DOH CYSHCN Progam forapprovaltoaccessDiagnostic and Treatment funds to meet the need.Authorization fomrs and Centralcompleted.TreatmentFundrequestsdirectlytotheCYSHCNasneeded.3cWork withpartners to share updated local CYSHCNReview resources for your local area onSeptember30, 2022See Program SpecificRequirements and Special B illingresources with Within Reach/ Help Me Grow (HMG).llvforaccuracyandtestoReach.Due Date/Time FrameDeliverables/Outco mesActivityTask#Dorr Program and tr'iscal contact rnformation for all concon Sows can be found on the DoH Finance sharepoint site. euestions related to this sow, or any otherfinance-related inquiry, may be sent to finance@doh.wa.govEglblEundins Accountabilitv and Transparency Act (FFATA'I (Applies to federal subrecipient funding.)This statement of work is supported by federalfundt tnat tequite co-pliance with the Federal Funding Alcouliliiity and rransparency Act (FFATA or the Transparency Act).The purpose of the Transparency Act is to make information available online so the pubticcan r". fro* tft. federalfulds ar" ,p"nt.To comply with this act and be eligible to perform the activities in this statement ofwork, the LHJ must have a Data Univers al Numbering System (DuNS@) number.InformationabouttheLHJandthisstatementofworkwillbemadeavailableonuSASoending.eovbyDoHasrequiredbyp.L. log-2g2.Pro gram Specific ReouirementsProgram Manual, Handbook, Policy References:Children and Youth with Special Health Care Needs Manual -ChildrenandYouthWith Sp ecia lHea lthC a reNeedsHealth Services Authorization (IISA) Formhttp://rvrvw.doh.ua.eov/Portals/1/Documents/pubs/910{02-AoprovedHSA.docxExhibit A, Statement of WorkTemplate Created Septemb er202lPage 2 of 3Contract NumberCLH3 I 0 I 5
Restrictions on tr'unds (ie_1$a1t9yed expenses or activities, indirect costs, etc.):I ' At least 3 0% of federal ritle v funds must be used for preventive and primary care seryices for children and at least 3 0olo must be used services for children withspecial health care needs. [Social Security Law, Sec. StiStaXl jt. - - -'2. Funds maynotbe used for:a' Ii#ftr*".T[::'Jil"s."tlij#l1t*il1]"Jf#,ffl'JlT*"withspecialheahhcareneedsorhighriskpresnantwomenandinrants,andotherpatientservicesapprovedbyb. Cash payments to intended recipients ofhealth services.c' The purchase or improvement of land, the purchase, construction, or pennanent improvement of any building or other faciJity, or the purchase of majormedicalequipment.d. Meeting other federalmatchingfunds requirements.e' Providing funds for research ortraining to any entity other than a public or nonprofit private entity.f' Payment forany services fumished uy a-provider oientity who hai been exchdled unierTitle xvttl ltrl"ai.are), Title )trX (Medicaid), or Title )o( (social services blockgrant).[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 notbe imposed with respect to services provided to low income motheis or children; and will be adjusted to reflect the-income, resources, and family size of t he individualprovided the services. [Social Security Law, Sec. 505 (l) (D)].Monitoring visib: Telephone cails with DoH contractmanagerasneeded.BillingRequiremenb: PaymentiscontingentuponDoHY"tptandapprovalofalldeliverablesandanacceptableAlg-lAinvoicevoucher. paymenttocompletelyexpendtheof the "TotalConsideration" will notbe accepted orapproved.special rnstructions: contact DoH contract managerbelow for approvalofexpenses not reflected in approved budget workbook.MCHBGfundsmaybeexpendedoncovlD-l9r€sponseactivitiesthatalignwithmatemalandchildhealthpriorities. Examplesmayinclude:o Providing support in educatingthe MCH population about covlD--l 9 through partnerships with otherlocal agencies, medical providers, and health care organizations.' working close ly with state and local emergency preparedness staff to assu.rihut th. n".ds of the MCH population are represen ted.o Funding infrastructure that supports the response to coMD-t 9. For example, Fublic HealthNurses who are routinely supported through the Title v program may be ableto be mobilized, using Title V funds or separate emergency funding to support a call center or deliver health services.r Partnering with parent networks and health care providers to provide accura te and retiable information to all families.o Engagrng community leaders, including faith-based leaders, io educate community members about strategies forpreventing illnessRestrictions listed above continue to apply.Exhibit A, Statement of WorkTemplate Created Septemb et202lPage 3 of3Contract Number CLH3 I 0 I 5
DOH CONTRACT #: CLH3l0l5
January 1,2022 - December 31, 2024
CONSOLIDATED CONTRACT
Between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
Kittitas County Public Health Department
And
Page I ofl6
DOH CONTRACT #: CLH3t0t5
Table of Contents
l.
2.
J.
4.
5.
6.
7.
8.
9.
10.
I l.
t2.
13.
14.
15.
t6.
17.
18.
19.
20.
2t.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Purpose.
Statements of Work
Exhibits........
3
4
..3
....3
Definitions
Funding and Billing
Contract Management....
Access to Records.
All Writings Contained Herein.......
Assignment
Assurances
Confidential Information ..
Ethics
Debarment Certifi cation ...............
Disputes
Equipment Purchases..
Governing Law and Venue
Independent Capacity
Insurance.......
Licensing, Accreditation, and
Maintenance of Records .......,
Registration.........
Modifications and Waivers.....
No Third-Party Rights Created......
Nondiscrimination
Order of Precedence...............
Ownership of Material/Rights in Data......
...5
5
........5
........5
........5
5
........6
6
6
6
7
7
7
7
7
7
8
8
I
.......7
..7
Publications.
Responsibility for Actions .8Loss or Reduction of Funding
Severability
Subcontracts.............
8
8
8
9
9
9
Subrecipient ........................
Survivability........................
Term....
Termination for Convenience
Termination for Default.........
Termination Procedure
9
9
9Standard Federal Certifications and Assurances
Federal Assurances - Non-Construction 1l
l5
2022-2024 Consolidated Contract
Programs
Page2 of 16
DOH CONTRACT #: CLH31015
CONSOLIDATED CONTRACT
between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
(Referred to as..DOH")
and
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
(Referred to as,,LHJ")
for
THE DELIVERY OF PUBLIC HEALTH SERVICES
FOR THE PERIOD OF
1.
January 1,2022 through December 31,2024
Purpose
This Contract is entered into in accordance with RCW 43.70.512,RCW 43.70.515, the general statutory powers of the
SecretaryoftheDepartmentofHealth(DOH),includingatRCW43.70.020and.43.7\.040,thegeneralriuioto.ypowers
of local health jurisdictions (LHJs), including at RCW 70.05.060, RCW 70.05.070, hCW 70.08.02b, and
RCW 70.46.060, the authority for joint or cooperative action provided for under chapter 39.34 RCW, and the LHJ,s
home rule charter authority. The purpose of this Contract is to define the parties' joint and cooperative relationship.
The contract and all statements of work adopted under its provisions are intended to facilitate tfie delivery of public
health services to the people in Washington State. This Contract is the result of cooperative planning efforts beiween
the LHJ and DOH.
2. Statements of Work
The individual program activities, requirements, and outcomes/deliverables to be achieved by the parties under this
Contract shall be mutually agreed to and issued as Exhibit A, Statements of Work, subsequent to the execution of this
Contract. The LHJ shall fumish the necessary personnel, equipment, material and/or services and otherwise do all things
necessary for or incidental to the performance of the work as set forth.
3. Exhibits
This Contract shall incorporate mufually agreed to and issued amendments throughout the Contract term, as the
following Exhibits:
o Exhibit A - Statements of Worko ExhibitB -Allocations
4. Definitions
As used throughout this Contract and unless amended for a particular Statement of Work, the following terms shall have
the meanings set forth below:
"Assistance Listing Number":
identifies the awarding agency.
The unique identiffing code assigned to a federal assistance program which
"Budget, Accounting, and Reporting System (BARS)": The system designed by the State Auditor's office for
collecting, consolidating, and reporting financial budgeting and accounting informaiion from all local govemmental
units.
"Client": An agency, firm, organization, individual or other entity applying for or receiving services provided by
the LHJ under this Contract.
"Confidential Information": Information protected from disclosure under federal or state law.
"Contract Coordinator": Each party's designated contact for all notices required or permitted under this Contract.
2022-2024 Consolidated Contract page 3 of 16
DOH CONTRACT #: CLH3l0l5
"Contracting Of;ficer": The DOH Contracts and Procurement Office Director and hisftrer delegates within that
office authorized to execute this agreement on behalf of DOH.
"Conhactor": An entity that provides goods or services to DOH and others. A contractor normally operates its
business in a competitive environment, provides its goods and/or services to many different purrlur.., during
normal business hours, and is not subject to the compliance requirements of the fedeial progrur.
"Equipment": When used in this Contract is defined as an article of non-expendable, tangible properly other than
land, buildings, or fixtures which is used in operations and having a useful life of moie than on. y.* and an
acquisition cost of $5,000 or more, or as otherwise stated.
"Federal Assistance": Assistance provided by a federal agency in the form of grants, contracts, loans, loan
guarantees, property, cooperative agreements, interest subsidies, insurance, or direct appropriations, but does not
include direct federal cash assistance to individuals.
"Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act)": A federal act to make
information available online so the public can see how federal funds are speni.
"Fixed Assets": Fixed assets are property and/or equipment obtained through donation, gift, purchase, capital lease,
or construction with a service life of more than one year.
"Program Contact": Each party's designated contact for those purposes identified in the Exhibit A, Statements of
Work.
"Subcontractor": Any individual or group contracted with the LHJ to perform all or part of the services included
in this Contract. This term will also apply to situations where an LHJ's subcontractor contracts with another
individual or group to perform all or part of the services included in its agreement with the LHJ.
"Subrecipient" or "subgrantee": A non-federal entity that receives a subaward offederal grant money or goods
directly or indirectly from DOH and makes decisions regarding who can receive what federal assistance; has its
performance measured against the objectives contained inthe DbH agreement with the federal government; makes
decisions on howto operate the program to accomplish the program goals; has the obligation to Jomply with federal
subrecipient requirements; andlor use federal funds to carry out a program for the pu1ti. purpose ipecified in the
authorizing statute.
5. Funding and Billing
A. DOH shall pay the LHJ for services as set forth in Exhibit A, Statements of Work, not to exceed funding amounts
as detailed in Exhibit B, Allocations (as executed).
The LHJ will advise the Program Contact identified in the applicable Statement of Work in writing 90 calendar
days prior to the end of the funded period, or as soon as practiiable thereafter, if the LHJ anticipates not using all
Contract funding.
B. If the Exhibit A, Statement of Work, is supported by federal funds that require compliance with FFATA (the
Transparency Act), the corresponding checkbox on the statement of work willbe checked.
C. Total consideration for this Contract shall be modified by mutually agreed to amendments issued on a periodic
basis.
The LHJ will submit accurate and timely billings which, for clarity and consistency, will be prepared using the form
provided and following the instructions located on the DOH website, www.doh.wa.sov-. bOH will-authorize
payment only upon satisfactory completion and acceptance of deliverables and for allowable costs as outlined in
the statement of work and/or budget.
2022-2024 Consolidated Contract Page 4 of 16
DOH CONTRACT #: CLH31015
D. The LHJ will submit a DOH BARS Financial Report on a DOH-provided template by April l5th for the prior
calendar year
6. Contract Management
Unless otherwise specified in the Contract, the following individuals are the contacts ("Contract Coordinators',) for all
notices required or permitted under this Contract:
LHJ Contract Coordinator:DOH Contract Coordinator:
Name: Candi Blackford Name: Brenda Henrikson
Title: Contracts Manager Title: Contracts Specialist
Mailing Address:Address:
507 N. Nanum Street, Suite 102
Ellensburg, WA 98926-2886
PO Box 47905
wA 98s04-7905
Physical Address:Address:
Same as above.101 Israel Rd SE
Tum wA 98s01-5s70
Phone: 509-962-7515 Fax: 509-962-7581 Phone: 360 -236-3933
Email Add ress: candi. blackford@co.kittitas.wa. us Email Address: brenda.henrikson@doh.wa.sov
A party may change its Contract Coordinator or its Program Contact by providing written notice to the other party.DoH Program contacts can be found in the Exhibit A, Statements of wor[.
7. Access to Records
To the extent authorizedby applicable federal and state law, the parties shall provide access to records relevant to thisContract to each other, the Joint Legislative Audit and Review Committee, ttr" Sat. Auditor, and auttrorized federal
officials, at no additional cost. Inspections shall occur at reasonable times and upon reasonable notice.
8. All Writings Contained Herein
This Confract contains all the terms and conditions agreed upon by the parties. No other understandings, oral or otherwise,
regarding the subject matter of this Contract shall be deemed to exist oi to bind any of the parties hereto. The individuals
signing this Contract and subsequent amendments certify by their signatures that ihey are authorized to sign this Contract
on behalf of their respective entity.
9. Assignment
Except for subcontracting as authorized in this Contract, the LHJ shall not assign or delegate, in whole or in part, thisContract or any of its rights, duties, obligations, or responsibilities, without thr prioi written consent of DOH'scontracting officer, which consent shall not be unreasonably withheld.
10. Assurances
The parties agree that all activity pursuant to this Contract shall be in accordance with all applicable current federal,
state and local laws, rules, and regulations.
The LHJ acknowledges its agreement to comply with federal certifications and assurances by signing and returning thefollowing:
1. Standard Federal Certifications and Assurances (page I l)
2. Federal Assurances for Non-Construction programs (page 15)
I 1. Confidential Information
The parties agree to comply with all state and federal statutes and regulations relating to Confrdential Information. DOH
and LHJ will limit access to the Confidential Information to the fewest number Jf people necessary to complete the
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DOH CONTRACT #: CLH3l0l5
work. Everyone having access to Confidential Information covered by this Contract must agree to protect theconfi dentiality of the information.
Either party to this Contract may designate certain Confidential Information as "Confidential InformationArlotice
Requested." The designation shall be made by clearly stamping, watermarking, or otherwise marking each page of theConfidential Information. If a third-party requestor i."ks informatioriihut hu, been marked ,,Confidential
InformationA'{otice Requested," notice shall be given to the marking party prior to release of the information. Suchnotice shall be provided to the program contact no less than five (5f business days prior to the date of disclosure, toallow the party objecting to disclosure to seek a protective order from the proper tribunal.
DOH and LHJ agree to establish, document and maintain security practices and safeguards consistent with state andfederal laws, regulations, standards, and guidelines to prevent unauihorized access, uJe, or disclosure ofConfidentialInformation in any form. In accordance with federal and state contracting requirements, DOH may monitor, audit, orinvestigate LHJ management of Confidential Information relating to thii Contract. Working together, the LHJ andDOH may use any and all tools available to track Contract related-Confidential Information.
If one of the parties becomes aware of an act'ral or suspected breach of confidentiality, that party will promptly notiffthe Contract Coordinator for the other party of the racti. The parties will work within iheir iespecti ve irganizations totake any steps necessary to determine the scope of the breac^h and to restore reasonable security to thJ ConfidentialInformation. Both parties agree to mitigate any known harmful effects of a breach in confidentiality, including notiffingaffected individuals to the extent required by law. The parties will also reasonably cooperate witir law enfoicement asappropriate.
12. Ethics
Both parties and their officers shall comply with all ethics laws applicable to their activities under this Contract,including Chapters 42.23 and 42-52F(CW. If a violation occurs and is not cured within a reasonable time after notice,the other party shall have the right to terminate this Contract. This section is expressly subject to the Disputes sectionof this Contract.
13. Debarment Certification
The LHJ, by signing this Contract, certifies that the LHJ is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participatingin this-Conhact tiv ^v federai depanment or agency.The LHJ also agrees to include the above requiremint in all sui'contracts into whicir it enters. fhe irtf wil notify DOHof any such events that may occur during the term of the contract.
14. Disputes
Except as otherwise prdvided in this contract, when a dispute arises between the parties and it cannot be resolved bydirect negotiation, the parties agree to participate in good faittr in non-binding mediation. The mediator shall be chosenby agreement of the parties' If the parties cannot agree on a mediator, ttre p"arties shall use a mediation service locatedin Washington Sta!9 that selects a qualified mediatoi for the parties. Each party shall bear its own costs for mediationand each party shall contribute equally to the mediator's fee, if any. The parties agree that mediation shall precede anyaction in a judicial tribunal.
Nothing in this contract shall be construed to limit the parties' choice of a mutually acceptable alternate disputeresolution method in addition to the dispute resolution p.ocidrre outlined above.
15. Equipment Purchases
Equipment purchased by the LHJ for use by the LHJ or its subcontractors during the term of this Conftact using federalfunds, in whole or in part, shall be the property of the LHJ. The use, managemint and disposal of the equipment mustcomply with federal requirements. These requirements are found in the Office of Management and Budget,s (OMB,s)Uniform Guidance, Title2 Code of Federal Regulations Part 200 QCFR 200) - Uniform Administrative ft.equirements,Cost Principles, and Audit Requirements for Federal Awards, or are included in the federal fundini agency,s
regulations.
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DOH CONTRACT #: CLH3l0l5
16. Governing Law and Venue
The laws of the state of washington govem this contract. In the event of a lawsuit by the LHJ against DoH arisingunder this contract,.venue.shall-be p.ip"t only in Thurston county,_warrringion.--in the event ola lawsuit by DoHagainst the LHJ arising under this cbntract, venue shall be properonly in the county in which the LHJ is located or ineither of the two nearest judicial districts *itttin fre meaniniof RCW 36.01.050.
17. Independent Capacity
The employees or ageltl of each puq
Y.ho are engaged in the performance of this contract shall continue to beemployees or agents of that pany and shall not b" .o;;il"r.d for any pu.por. to Le employees or agents of the otherpilty.
18. Insurance
The LHJ certifies that it is self-insured, is a member of a risk pool, or maintains insurance coverages sufficient to coverobligations under this contract' Each parfy shall pay ro. tors*'ro, which it i, r"*J ri"ure. The LHJ agrees to require all
ilr:rT:-l",frHffiffiffi'J:il:Lttvi,.. *iiirt'=ii'ii'-". mav be aete,mineo by the LHJ ana/oi its risk manaser,
19. Licensing, Accreditation, and Registration
The LHJ shall comply with all appiicable local, state, and federal licensing, accreditation and registration requirementsand standards, necessary for the pirfonnance ofthis Contract.
20. Maintenance of Records
Each party to this contract shall maintain books, records, documents and other evidence that sufficiently and properlyreflect all direct and. indir:ect costs expended by it- ett uoot<s, records, documents, and other material relevant to thiscontract will be retained for six (6) years afte. Jlniq*ion. ii-y ritigution, .rui,o oi-uuait is started before the expiration
ffJ:iffif$,|!ild, the records ttutt t" retained until ari riiiguttn, "iui.r, o. uro], findings invorving the records
Each party will use reasonable selurity procedures and protections to assure that records and documents provided bythe other party are not erroneously disclbsed t" thil ;;i". 'B-oth.parties
ugr.. io Lntinue protecting records untilsuch time as the information is destroyed in u"ro.da*J*itl.ppri.abre state ilo r.J.*r records retention laws.
21. Modifications and Waivers
This contract' or f{rY term or condition, may be modified only by a written amendment signed by the DoH contractingOffrcer and the authorized representativ" f* tfr" iHj. El,h;;;*b, may propose an amendment.
Failure or delay on the part of either p*v tg :T.Tise any righg power, privilege or remedy provided under this confactshall not constitute a waiver. No provisionof this contd;;t il *"il* uy .iTt.i purty except in a writing signed by theDoH contracting officer or the authorized representatiu" oid.iru.
22. No Third-party Rights Created
This contract' or any program hereunder, is entered into solely for the benefit of the two parties thereto and shall notbe construed as giving rise to any right, remedy or "*p".t*rylr*y kind or "ut"r"-"" trr. part of any third party.
23. Nondiscrimination
Dwing the performance ofthis confacf the LHJ and DoH shall comply with all federal and state nondiscrimination laws,regulations and policies' In the event of the LHJ's non*.pii*ce or renrsat to comply with any nondiscrimination law,regulation or policy, this contract may be rescinded, r-..i.d o.J.-inated in whole or in par! and the LHJ may be declaredineligible for fi*ther contacts with DoH. The LHJ shall, however, be given a reasonable time in which to cure thisnoncompliance' Any dispute may be resolved in accordanc. *itn tft" .Disputes,, procedure set forth herein.
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DOH CONTRACT #: CLH3l015
24. Oriler of Precedence
In the event of an-inconsistency in the terms ofthis Contract, or between its terms and any applicable statute or rule, theinconsistency shall be resolved by giving precedence in the following order:
' Applicable state and federal statutes, and local laws, rules and regulations.o Terms and conditions of this Contract.o Statements of Work.
o Any other provisions of this Contract, including other materials incorporated by reference.
25. Ownership of Material/Rights in Data
Records and other documents relevant to_this Contract, in any medium, furnished by one party to this Contract to theother parfy, will.remain the property of the fumishing party, unless otherwise agreed. Data which is delivered underthe contract shall be transfened to DoH with a non.*ilurirr", royalty-free, perietual, irrevocable license to publish,t3n1late, reproduceo modify, deliver, perform, dispose of, and to authorize others to do so; provided that such licenseshall be limited to the extent which the LHJ has a right to grant such a license. The LHJ shall exert all reasonable effortto advise DoH, at the time of delivery of data furnisheJunder this Contract, of all known or potential invasions ofprivacy contained. therein and of any portion of such document which was not produced in the performance of thisContract' DoH shall receive prompt written notice of each notice or claim or copyright infringement received by theLHJ with respect to any data delivered under this Contract. DoH shall have the rigrri to mooiff oi remove any restrictivemarkings placed upon the data by the LHJ, provided that if DoH modifies or..rn-ou., such markings without the LHJ,sapproval, it assumes all liability for doing so.
26. Publications
{ny program reports, articles, and publications that result from information gathered through use of state and federalfunds must acknowle'lge receiving support from DoH and/or the appropriate"federal agencies. Correspondingly, suchdocuments resulting from information gathered through use of loCal funds must ack}owledge receip of such localsupport.
27. Responsibility for Actions
Each party to this Contract shall be solely responsible for the acts and omissions of its own officers, employees, andaqents in the performance of this Contract. Neither party to this Contract will be responsible for the acts and omissionsof entities or individuals not party to this contract.
-odu
and the LHJ shall .oop.iui. in the defense of tort lawsuits,when possible.
28. Loss or Reduction of Funding
In the event funding from state. federal, or other sources is withdrawn, reduced, or limited in any way afterthe cffcctivedate of this contract and prior to normal completion, DoH may elect to suspend or terminate tire contract, in whole orin part, under the "Termination for Convenience" clause witir a ten (10) business day notice to LHJ, to the extentpossible, subject to renegotiation at DOH's discretion under those nr* fi.111ding limitations and conditions.
29. Severability
If any term or condition of this contract is held invalid, such invalidity shall not affect the validity of the other tenns orconditions of this Contract, provided, however, that the remaining terms and conditions can still iairly be given effect.
30. Subcontracts
unless specifically noted as not allowable within a Statement of work, the LHJ may subcontract any or all of theservices or other obligations specified in this Contract. The LHJ will require the subcontractor to comply with all theapplicable terms and conditions ofthis Contract, including all terms, conditions, certifications and assurances. The LHJagrees it is responsible for assuring adequate performanc- on the part ofthe su6contractor.
The parties agree that all subcontractors must be responsible for any liabilities created by their actions or omissions. Inthe event DOH, LHJ, and subcontractor are found by a jury or trier of fact to be jointly and severally liable for personalinjury damages arising from any act or omission, thln iac-h entity shall be responsibl! fb; ilp;"p"rt;;;;;*..
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DOH CONTRACT #: CLH31015
31. Subrecipient
For those activities designated as "subrecipient" in Exhibit A, Statements of Work, the LHJ must comply with applicablefederal requirements, including but not limited to oMB's tiniform Guidance at i cFR 200, subparts o ltost FederalAward Requirements), E (Cost Principles) and F (Audit Requirements), and program ,p""ifi. federal regulations. Ifthe LHJ expends $500,000 or more in federal awards from all sources, ii is respons-ible foi obtaining upprof,.iut. audits.If the LHJ expends $750,000 or more in federal grants or awards from all .ou.""r, it is responsible for obtaining therequired single audit.
32. Survivability
The terms and conditions contained in this Contract, which by their sense and context are intended to survive theexpiration ofthe Contract, shall survive. Surviving terms include, but are not limited to: Access to Records, ConfidentialInfbrmation, Disputes, Responsibility for Actioni, Maintenance of Records, ownership of Material/Rights in Data,Subcontracts, Termination for Convenience, Termination for Default, and Termination procedure.
33. Term
This Contract will be_in effect following execution by the parties from January 1,2022 through December 3l, ZOZ4,unless terminated earlier as provided herein.
34. Termination for Convenience
Except as otherwise provided in this Contract, either pany may terminate or suspend this Contract, or any programhereunder, for convenience by providing at least thirry t30i days' advance written notice to the other pzrty. '
If DOH elects to suspend the Contract, in whole or in part, LHJ shall stop work as of the effective date ofDoH,s writtennotice of suspensio-n. During suspension, each Party will reasonably notify the other of any conditions that may affectrezumption of performance. Upon DoH's written notice to r"rrrmi performance, LHJ shall resume work unless theLHJ provides notice to DOH that services cannot be resumed. If LilJ cannot resume performance, the Contract oraffected Exhibit A, Statement of Work, will be deemed terminated upon the date the LHJ received notice to suspendperformance.
35. Termination for Default
(a) In the event of a default by either party under this Contract, the nondefaulting party may give written notice to thedefaulting parfy that it intends to terminate this Contract, or any program trer"rinaer, ifthe default is not cured withinthirty (30) days of the date ofthe notice, or such longer period ofii.i as may be reasonable under the circumstances.If the default is not cured within that time, the nondefiulting party may then notiry the defaulting party in writingthat this Conhact is terminated. In the event of such termination, the nondefaulting party shall have all rights andremedies available to it under general law.
(b) A disputed termination for default is expressly subject to the Disputes section of this Contract.
36. Termination Procedure
Upon termination DoH may require the LHJ to deliver to DOH any non-LHJ-owned equipme nt, data,or other propertyspecifically produced or acquired for the performance of such part of this Contract as tras'uee' ie.riti"rrJ.
- -
DoH shall pay to t!.^LHl tle agreed upon price, if separately stated, for completed work and services accepted byDoH' In addition DoH shall pay the amount determinio by DoH's contracting oflicer for (a) completed work andservices for which no separate price is stated, (b)_ partially completed work and sErvices, (c) otirer proierty or servicesyhich are accepted by DoH, and (d) the protection and preservation of the property. Disagreement by ttt. LHJ withthe determination of DOH's Contracting Officer that reiates to the obligationr o.'u111ounts due to the LHJ shall beconsidered a dispute,within the meaning of the "Disputes" clause of this Contract. DOH may withhold from anyamounts due the LHJ for such completed work or lervices such sum as DoH's Contracting Officer reasonablydetermines to be necessary to protect DoH against potential loss or liability. The rights and remed]ies of DoH providedin this section shall not be exclusive and arein addition to any other rights ana rem"edies provided by law or under thisContract.
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DOH CONTRACT #: CLH3l0l5
After receipt of a written notice of termination, the LHJ sha[:
' Stop work under the Contract on the date and to the extent specified in the notice;o Place no further orders or subcontracts for materials, services, or facilities, except as necessary to complete suchportion of the work not terminated;I Assign to DoH, to the extent reasonably directed by DoH's contracting officer and to the extent that the LHJhas.the legal right to do so, all of the right, title, and inlerest of the LHJ under the orders and subcontracts inwhich case DoH has the right, at its reaionable discretion, to settle or pay any or all claims arising out of thetermination of such orders and subcontracts.r Settle all outstanding liabilities *l ilt claims_ arising out of orders or subcontracts, with the approval orratification of DoH's contracting officer to the extJrt he/she may ."uronulry require, which approval orratification shalr be final for all the purposes ofthis clause;o Transfer title to DoH and deliver, as reasonably directed by DoH s contracting officer, any property which, ifthe Contract had been completed, would have been t"qrir"o to be fumished to;oH;o complete performance of such part of the work not terminated by DoH,s contracting officer; and,r Take such action as may be necessary, or as DoH's contracting officer may reasonably direct, for the protectionand preservation of the property related to this Contract which is in the possession of the LHJ, or itssubcontractors, and in which DoH has or may acquire an interest.
IN wITNEss WHER-EOF, the parties have executed this contract.
KITTITAS COUNTY PUBLIC HEALTH
DEPARTMENT STATE OF WASHINGTON
DEPARTMENTOF HEALTH
Signature:
, r*Q-\
Signature:
Ereula lfuwtkron
Title:
Public Health Director
Title:
Contracts Specialist
Print Name:
Tristen Lamb
Print Name:
Brenda Henrikson
Date:
Jan20,2022
Date:
Jan20,2022
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DOH CONTRACT #: CLH3t0l5
Standard Federal Certifications and Assurances
Following are the Assurances, certifications, and special conditions lhat apply to all federally funded (in whole or in part)agreements administered by the washington State Departrnent of iealth.
CERTIFICATIONS
1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSIONThe undersigned (authorized official signing for the cont acting organization) certifies to the best of his or herknowledge and belief, that the contractor,lefined ur th";;;-uty purti.ilunt in accordance with 45 cFR paxt 76, and itsprincipals:
A' Are not presently debaned, suspended, proposed for debarment, declared ineligible, or voluntarily excluded fromcovered transactions by any Federal Department or agency;
B' Have not within a3'year period preceding this contract been convicted of or had a civil judgment rendered againstthem for commission of fraud or a criminal offense in .o*..iion with obtaining, attempting to obtain, or performinga public (Federal, State, or local) transaction or contract under a public transaction; violation ofFederal or Stateantitrust statutes or commission of embezzlement, itt"n, r"i".y, bribery, falsificaiion or destruction of records,making false statements, or receiving stolen property; ) ---1
c' Are not presently indicted or otherwise criminally or civilly charged by a govemmental entity (Federal, State, orlocal) with commission of any of the offens",
"nu*".ut o ii p*ugruph (b) of this certification; andD' Have not within a 3-year period preceding this contract had one or more public transactions (Federal, state, or local)terminated for cause or default.
should the contractor not be able to provide this certification, an explanation as to why should be placed after theassurances page in the contract.
The conhactor agrees by signing this contract-that it will include, without modification, the clause titled certificationRegarding Debarment, Suspension, Ineligibility, una vor*tu.y Exclusion-Lower Tier covered Transactions in alllower tier covered transactions (i.e., transitions with ."6- t*ntl.s and/or contractors) and in all solicitations for lowertier covered transactions in accordance with 45 CFR pffi72.
2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTSThe undersigned (authorized official signing for the_ ront *ffi organization) certifies that the contractor will, or willcontinuc to, provide a drug-free workplice in accordance with Zs cpn paftTebti- -
A' Publishing a stalemenl notifying employees that the unlawful manufacture, distribution, dispensing, possession oruse of a controlled substance is prohlbiied in the grantee's workplac" *a rp.ri$ing ttre actions that will be takenagainst employees for violation of such prohibitio"n;
B. Establishing an ongoing drug-free awareness program to inform emproyees about:
l) The Dangers of drug abuse in the workplace;
2) The contractor's poricy of maintaining a drug-free workplace;
3) Any available drug counseling, rehabilitation, and employee assistance programs; and
4) The penalties that may be imposed upon employees for drug abuse violations occuning in the workplace;c' Making it a requirement that each employee to be engaged in the performance of the contract be given a copy ofthe statement required by paragraph lj abbve;
D' Notifying the employee in the statement required by paragraph l), above, that, as a condition of employment underthe contract, the employee will:
l) Abide by the terms of the statement; and
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DOH CONTRACT #: CLH31015
2) Notiff the employer in writing of his or her conviction for a violation of a criminal drug statute occuning in theworkplace no later than five carendar days after such conviction;
E' Notifying the agency in writing within ten calendar days after receiving notice under paragraph D. 2) from anemployee or othenvise receiving actual notice of such conviction. Employ"ers oictnvicted employees must providenotice, including position title, to every contract officer or other designee on *rrl.. contract activity the convictedemployee was working, unless the Federal agency has des_ignated a central point for the receipt of such notices.Notice shall include the identification numbe(s) of each affited grant;
F' Taking one of the following actions,.within 30 calendar days of receiving notice under paragraph D. 2) with respectto any employee who is so convicted:
l) Taking appropriate personnel action against r-lq* employee, up to and including termination, consistent withthe requirements of the Rehabilitation Act of 1973, asamended; or
2) Requiring-such employee to participate satisfactorily in a drug abuse assistance or rehabilitation programapproved for such purposes by a Federal, state, or local health, taw enrorcement, or other appropriate agency;G' Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs(A), (B), (C), (D), (E), and (F).
For purposes of paragraph (E) regarding agency notification of criminal drug convictions, DoH has designated thefollowing central point for receipt of such notices:
Compliance and Intemal Control Officer
Department of Health _ Office of Financial Services
PO Box 47901
Olympia, WA 98504-7901
3. CERTIFICATIONREGARDINGLOBBYING
Title 3l ' united states code, section 1352, entitled "Limitation on use of appropriated funds to influence certain Federalcontracting and financial transactions," Eelerally prohibits recipients ofFederal grants and cooperative agreements fromusing Federal (appropriated) funds for lobbying ih" B*..utiui or Legislative Branches of the Federal Govemment inconnection with a SPECIFIC grant or coopeiatiie agreement. section"l352,ulr.o r;quit;r that each person who requestsor receives a Federal grant or cooperative agreement must disclose lobbying .inJ.rtut"n with non-Federal (non-appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in totalcosts (45 CFR part 93).
The undersigned (authorized official signing for the contracting organization) certifies. to the best of his or herknowledge and belief, that:
A' No Federal appropriated funds have been paid or will be paid, by or on behalf ofthe undersigned, to any person forinfluencing or attempting to influenc" * offi... or ".proy.. of any agency, a Member of congress, an officer oremployee of congress'-or an employee of a Membe. oicfngr"s in conn..iion with the awarding of any Federalcontract' the making of any Federal grant, the making of an] Federal loan, the entering into of any cooperativeagreement' and the extension' continuation, renewal, imendment, or modification of any Federal contract, grant,loan, or cooperative agreement.
B' If any funds other than Federally appropriated funds have been paid or will be paid to any person for influencing orattempting to influence an officer or employee of any aqency,-a Member of iongress, an officer or employee ofcongress, or an employee of a Member- or congr.ss fir connection with this F"ederal contract, grant, loan, orcooperative agreement, the undersigned shall "ornll"tr and submit standard Form-LLL, ,,Disclosuft of LobbyingActivities," in accordance with iis instructions. (If needed, standard ro*-ir1, ',Disclosure of LobbyingActivities," its instructions, and continuation sheet are included at the end of this application form.)C' The undersigned shall require that the language of this certification be included in the award documents for allsubcontracts at all tiers (including subconhacti, subcontracts, and contracts under grants, loans and cooperativeagreements) and that all subrecipients shall certiff and disclose accordingly. (
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DOH CONTRACT #: CLH3l0l5
This certification is a material representation of fact upon which reliance was placed when this transaction was made orentered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed bySection 1352, U.S. Code. Any person who failsto file the required certifiiation shallie subject to a civil penaity of not
less than $10,000 and not more than $100,000 for each such failure.
CERTIFICATION REGARDING PROGRAM FRAUD CIVI REMEDIES ACT (PFCRA)
The undersigned (authorized official signing for the contracting organization) certifies thut th" statements herein aretrue, complete, and accurate to the best of his or her knowledge, anO ttrat he oi she is aware that any false, fictitious, orfraudulent statements or claims may subject him or her to criminal, civil, or administrative penalties. The undersigned
agrees that the contracting organization will comply with the Public Health Service terms and conditions of awari'if acontract is awarded.
5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Public Law 103-227, also known as the Pro-Children Act of 1994 (Act),requires that smoking not be permitted in anyportion of any indoor facility owned or leased or contracted for by an-entity and used routiiely or regularly for theprovision ofhealth, day care, early childhood development services, education or library services to children under the
age of 18, if the services are funded by Federal programs either directly or through State or local governments, byFederal grant, contract, loan, or loan guarantee. The law also applies to children's sirvices that are provided in indoorfacilities that are constructed, operated, or maintained with ru"h F.d.rul funds. The law does not apply to children,sservices provided in private residence, portions of facilities used for inpatient drug or alcohol treatment, serviceproviders whose sole source of applicable Federal funds is Medicare or Medicaid, or ficilities where WIC coupons areredeemed.
Failure to comply with the provisions ofthe law may result in the imposition of a civil monetary penalty of up to S1,000for each violation and/or the imposition of an administrative compliance order on the responsibG entity.
By signing the certification, the undersigned certifies that the contracting organization will comply with therequirements of the Act and will not allow smoking within any portion of any inao- facility used for the irovision ofservices for children as defined by the Act.
The contracting organization agrees that it will require that the language of this certification be included in anysubcontracts which contain provisions for children's iervices and that a1l sibrecipients shall certify accordingly.
The Public Health Services strongly encourages all recipients to provide a smoke-free workplace and promote the non-use of tobacco products. This is consistent with the PHS missiorto protect and advance the physical and mental healthof the American people.
' DEBARMENT' SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - INSTRUCTIONS FORCERTIFICATION
By signing and submitting this certification, the prospective contractor is providing the certification set out below.
A' The inability of a person to provide the certification required below will not necessarily result in denial ofparticipation in this covered transaction. The prospective contractor shall submit an explanation of why it cannotprovide the certification set out below. The certification or explanation will be considered in connection with thedepartment or agency's determination whether to enter into this transaction. However, failure of the prospectivecontractor to fumish a certification or an explanation shall disqualift such person from participaiion in thistransaction.
B' The certification in this clause is a material representation of fact upon which reliance was placed when thedepartment or agency determined to enter into thiJtransaction. If it is latei determined that the prospective contractorknowingly rendered an eroneous certification, in addition to other remedies available to thJFederal Government,
the department or agency may terminate this transaction for cause of default.
C' The prospective contractor shall provide immediate written notice to the department or agency to whom this contractis submitted if at any time the prospective contractor learns that its certification was erroneous when submitted or
has become enoneous by reason of changed circumstances.
4
6
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DOH CONTRACT #: CLH310t5
D' The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person,primary covered transaction, principal, propoial, and voluritarily excluded, as used in this clause, have the meaningsset out in the Definitions and Coverage sections of the rules impiementing
-Executive
order 12549. you may contactthe person to whom this contract is submitted for assistance in obtaining-a copy "fih"* ;;;lut;;"
*-
E' The prospective contractor agrees by submitting this contract that, should the proposed covered transaction beentered into, it shall not knowingly enter into any lower tier covered transaction *itt u person who is Jebaned,suspended, declared ineligible, or voluntarily excluded from participation in this covlred transaction, unlessauthorized by DOH.
F' The prospective contractor further agrees by submitting this contract that it will include the clause titledCertification Regarding Debarment, Suspension, Ineligibility and voluntary Exclusion -- Lower Tier coveredTransaction, provided by HHS, without modification, in all lower tier.ou.."d transactions and in all solicitationsfor lower tier covered transactions.
G' A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tiercovered transaction that it is not debaned, suspended, ineligible, or .rrotrntu.ily excluded from the coveredtransaction, unless it knows that the certification ii erroneous. A participant may decide the method and frequencyby which it determines the eligibility.of its principals. Each participant nruy, but is not required to, check theNonprocurement List (of excluded parties).
H' Nothing contained in the foregoing shall be construed to require establishment of a system of records in order torender in good faith the certification required by this clause. ihe knowledge and information of a participant is notrequired to exceed that which is normally possessed by a prudent person irithe ordinary course of business dealings.
I' Except for transactions authorized under paragraph F. of these instructions, if a participant in a covered transactionknowingly enters into a lower tier covered tianiaction with a person who is suspended, debarred, inelilible, orvoluntarily excluded from participation in this transaction, in addition to other rernedies available to the FederalGovemment, DoH may terminate this transaction for cause or default.
7. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITYMATTERS - PRIMARY COVERED TRANSACTIONSA' The contractor certifies to the best of its knowledge and belief, that it and its principals:
1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excludedfrom covered transactions by any Federai department or agency;
2) Have not within a three{ear period preceding this contract been convicted of or had a civil judgment renderedagainst them for commission of fraud or a criminal offense in connection with obtaining, utL*"ptintto obtain,or performing a public (Federal, State or local) transaction or contract under a public tiansaction; iiolation ofFederal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, faisification ordestruction of records, making false statements, or receiving stolen property;
3) Are not presently indicted for or otherw-ise criminally or civilly charged by a govemmental entity (Federal,
State or local) with commission of any of the offenses enumeratld in plagraph A.z.of this certification; and
4\ Have not within a three-year period,preceding this contract had one or more public hansactions (Federal, Stateor local) terminated for cause or default.
B' Where the prospective contractor is unable.to certifi to any of the statements in this certification, such prospectivecontractor shall attach an explanation to this contract.
AUTFIORIZED SIGNA TURE IR.ED
SIGNATURE OFA UTHORIZED CERTIFYING
; 1n*u-17\.iJ
OFFICIAL TITLE
Public Health Director
PLEASE PRINT ORTYPE NAME:
Tristen Lamb
DATE
Jan20,2022
2022-2024 Consolidated Contract Page 14 ofl6
DOH CONTRACT #: CLH31015
Federal Assurances - Non-Construction programs
Public reporting burden for this collection of information is estimated to average l5 minutes per response, including timeforreviewing instructions, searching existing data sources, gathering and maintiining the data-needed, and completiig andreviewing the collection of information. Send comments regarding tie burden estimaL or any other aspect ofthis collectionof information, including suggestions for reducing this burden, to the Office of Management and Budget, paperwork
Reduction Project (0343-0040), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FOR]VI TO THE OFFICE OF MANAGEMENT ANDBUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contactthe awarding agency. Further, certain Federal awarding agencies may-require applicants to certify to additional
assurances. If such is the case, you will be notified.
As the duly authorized representative of the contractor, I certiff that the contractor:
l' Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability(including funds suffrcient to pay the nol-Federal share of project cost) to ensure propie. planning, management, andcompletion of the project described in this application.
2' Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through anyauthorized representative, access to and the right to examine all records, books, puprrr, or documents related to theaward; and will establish a proper accounting system in accordance with generally accepted accounting standards oragency directives.
3' Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the
appearance ofpersonal or organizational conflict ofinterest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovemmental Personnel Act of 1970 (42 U.S.C. S 47zL-4763)relating to prescribed standardsfor merit systems for programs funded under one of the 19 statutes or regulations specified ii Appendix A of OpM,s
Standards for a Merit System of Personnel Administration (5 C.F.R. 900,iubpart F).
6' Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of
the Civil Rights Act of 1964 (P.L.88-352) which prohibits discrimination on the basis of race, color or national origin;(b) Title IX of the Education Amendmentsof 1972, as amended (20 u.s.c. $ 16g1-16g3, and 16g5-16g6), whichprohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, asamended (29 U.S.C.
S 794)' which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended(42U.S.C.$ 610l-6107),whichprohibitsdiscriminationonthebasisofag-e;(e)theDrugAbuseOfficeandTreatment
Act of 1972 (P-L.92-255), as amended, relating to nondiscrimination on thi basis of drug abuse; (f) the ComprehensiveAlcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of f lZl p.f. 9l-616), as amended,relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) g 523 and 527 of the public Health ServiceAct of l9l2 (42 U.S.C. $ 290 dd-3 and.290 ee-3), as amended, relating'io confidentiality of alcohol and drug abusepatient records; (h) Title vIII of the civil Rights Act of lg6s (42 u.s.c. $ 3601 et seq.), as amended, rela=ting tonondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions inihe specificstatute(s) under which application for Federal assistance is being made; and (i) the requirements of any othernondiscrimination statute(s) which may apply to the application.
7 ' Will comply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance
and Real Properly Acquisition Policies Act of 1970 (P.L. 9l-646) which provide for fair and equitable treatment ofpersons displaced or whose property is acquired as aresult of Federal or fedeially assisted p.og.u*r. These requirementsapply to all interests in real property acquired for project purposes regardless of Federal iarti-cipation in purc'hases.
8. Will comply, as applicable, with the provisions of the Hatch Act (5 u.s.c. $ l50l-150g and,7324-732g) which limit
the political activities of employees whose principal employment activities are funded in whole or in part with Federal
funds.
2022-2024 Consolidated Contract page 15 of t6
DOH CONTRACT #: CLH3l0l5
9' Will comply, as applicablg'-Yilh the provisions of the Davis-Bacon Act (40 u.s.c. g276ato276a-7),the copeland Act(40 U'S'C' $ 276c and l8 U.S.C. 5 874) and the Contract Work Hours and Safety stanAarOs Act (40 U.S.C. S 327-333),regarding labor standards for federally assisted construction sub-agreements.
l0' Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood DisasterProtection Act of 1973 (P.L.93-234) *ll".h requiies recipients in a special flood hazard'areato participate in theprogram and to purchase flood insurance if the total cost ofinsurable construction and acquisition is $to,oob or more.
I l ' will comply with environmental standards -which may be prescribed pursuant to the following: (a) institution ofenvironmental qualrty control measures under the Naiional'Environmental Policy Act of 1969 (p.L. gl-lg0) andExecutive order (Eo) ll5l4; (b) notification of violating facilities pursuant to Eo lll3g;(c) protection of wetlandspursuant to Eo I1990; (d) evaluation offlood hazards in floodplains in accordance with eoiiqsg; (e) assurance ofproject consistency with the approved state management program developed under the coastal zone Management Actof 1972 (16 u's'c'-$ l45l et seq.); (D conformity of Fediraiactions to state (clear Air) Implementation pians underSection 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. g 7401 et seq.); (g) protection of undergroundsources of drinking water under the safe Drinking water Act of 1974, L *.na.J, 1i; .f.'riz-szz);and (h) protectionof endangered species under the Endangered Speiies Act of 1973, asamended, p.f . l:-201.
12' will comply with the wild and Scenic Rivers Act of l96s (16 u.s.c. S lTzl et seq.) related to protecting componentsor potential components of the national wild and scenic rivers system.
13' Will assist the awarding agency in assuring compliance with Section 106 of the National Historic preservation Act of1966' as amended (16 u.s.c. $ 470), Eo 11593 (identification and protection of historic properties), and theArchaeological and Historic preservation Act of 1974 (l6u.s.c. g 469a-l et seq.).
14' will comply with P-.L. 93'348 regarding the protection of human subjects involved in research, development, and relatedactivities supported by this award of assistance.
15' will comply with the Laboratory Animal welfare Act of 1966 (p.L. gg-544, as amended, 7 u.s.c. $ 2l3l et seq.)pertaining to the care, handling, and treatment of warm-blooded animals held for research, teaching, ortth., activitiessupported by this award of assistance.
16' Will comply with the Lead-Based Paint Poisoning Preventio n Act (42u.s.c. $ 4s0l et seq.) which prohibits the use oflead-based paint in construction or rehabilitation-of residence structures.
17' will cause to ue q9{on1e-a the required financial and compliance audits in accordance with the Single Audit ActAmendments of 1996 and oMB uniform Guidance at 2 cFR 200, Subpart F.
18' will comply with2 CFR 200.216 - Prohibition on certain telecommunications and video surveillance services orequipment - as amended effective August 13,2020, ancl any amendments to this section thereafter.
19' will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policiesgoveming this program.
AI.JTHOR TZE D STGNATUR.E R.EQUIRED
SIGNATURE OF AUTHORZED CERTIFYING OFFICIAL
,, u,:'-r|\
TITLE
Public Health Director
PLEASE PRINT
Tristen Lamb
ORTYPE NAME:DATE
Jan20,2022
2022-2024 Consolidated Contract Page 16 of16
Federal Funding Accountability and Transparency Act Data Col lection FormThiscontracttssupportedbyfederalfundsthatrequirecomplrancewiththeFederalFundingTransparencyAct.The purpose of the Transpa
Accountability andrencyActtstomakeinformationavatlableonlinesothepubliccan seehowfederafundsarespent.To comply with the act and be eligible to enter into th is contract,have a Data Universal Numbering
you orga nization m ustSystemnumber(DUNS@ ).If you do not al ready have one,you may receive a DUNS@numberfreeofchargebycontactingDunandBradstreetatwww.dnb.com.The Department of Hea Ithencouragesregistrationwiththe DOH )a lsoSystemforAwardManagement(sAM)to reduce data entry by both DOH and yourorganizationYoumayregisterwithSAMfreeofchargeat.sa m.gov Information aboutcontractwillbereportedbyDOHtothefederal
your organization and thi s
made lable
government as required by P .1.109-282 Th ts nformation wil then beavartothepublicbythefederalgovernmentonUSASpending.90vSUBRECIPIENT
4. Are you registered in SAM?ZlyES (skip to signature block. Sign, date and return)NO5. In the preceding fiscal year did your organization
a Receive 80o/o or more ofannual gross revenue from federal contracts, subcontracts, grants, loans, subgrants, and/o1 cooperative agreements; and
$25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans, subgrants, and/or cooperative agreements; and
b.
c,The public does not have access to this information about the compensation of the senior executives of yourorganization through periodic reports filed under section 13(a) or 15(d) of the securities and Exchange Act of1934 (15 U.S.c' 55 78m(a), 78o(d) or section 6104 ofthe Internal Revenue Code of 19g6.
NO (skip to signature block. Sign, date and return)
YES (You must report the names and total compensation of the top 5 highly compensated officials of your
organization).
Note: "Total compensation" for purposes of this requirement generally means the cash and non-cash value earned by theexecutive during the past fiscal year and includes sa.lary and 6onrr; awards of stock, stoii options and stock appreciationrights; and other compensation such as severance and termination pivruntr, and value of life insurance paid on behalf of theemployee, and as otherwise provided by FFATA and appricabre ortre griiu,i.".
By signing this document, the Authorized Representative attests to the information.
Subrecipient's Authorized Representative Sign & Date
(01t20t21
{0ji2ii t9)
1. Legal Name
Tristen Lamb
2. DUNS Number
01-020-25473. Principle Place of performance
Kittitas County
3a. City
Ellensburg
3b. State
WA
3c.Zip+4
98926-2886
3d. Country
USA
me of
1
2
3.
4.
5.
Page I of2
DoH will not endorce your subaward until this form is completed and returned.
FOR DEPARTM
Federal Funding Accountability and TransparencyAct Data collection Form
ENT OF HEATTH ONtY
c1H31015DOHContract Number
Contract Description (see i nstructions and example below)
fnstructions for Contract Description:
In the first line of the description prwide a title.for the subrecipient contract that captures the main purpose of the work.Then' indicate the name of the subrecipient and provide a brieiJescription that .upturu tnu overall purpose of the work,how the funds will be used, and what will be accomplished.
Example of a Contract Descriptiont
Increase Healthy Behaviors: Educational seruices District XYZ will provide training and technical assistance to chemicaldependency centers to assist the centers to integrate tobacco use into tneir eiisting addiction treatment programs.Funds will also be used to assist centers in creating-tobacco free treatment environments.
Page2 of2 ii).ir'l()19)
C1H31015 Kittita s 2022-2024 Consolidated
Contract
Final Audit Report
zo22-01-2o
"CLH31 01 5 Kittitas 2022-2024 Consolidated Contract,, History
fr Document created by Brenda Henrikson (Brenda.Henrikson@DoH.wA.Gov)
2021-11-19 - 10:97:44 pM cMT_ lp address: T5.,t72.120.46
El Document emailed to Tristen Lamb (candi.blacKord@co.kittitas.wa.us) for signature
202't-11-19 - 10:39:30 pM GMT
l& Email sent to tina.rowan.ph@co.kittitas.wa.us bounced and could not be delivered
2021-11-19- 10:39:41 pM GMT
fi Emait viewed by Tristen Lamb (candi.blacKord@co.kittitas.wa.us)
2021-11-22 - 4:30:26 pM GMT- lp address: 66.243.254.ia
lS Email sent to tina.rowan.ph@co.kittitas.wa.us bounced and could not be delivered
2O21-12-,t6 - 7:54:01 pM GMT
E& Email sent to tina.rowan.ph@co.kiftitas.wa.us bounced and could not be delivered
2022-01-10 - 4:31 :tS pM GMT
fi Emait viewed by Tristen Lamb (candi.blackford@co.kittitas.wa.us)
2022-01-'10 - 5:12:1O pM GMT- lp address: 66.24g.254.18
ds D ocument e-si gned by Tristen Lam b (candi. brac*ord@co. kittitas.wa. us)
signature Dare:2022-01-20 - 4:42:32 pM GMT - Time source: server_ rp address: 66.243.2s4..r8
B Document emailed to Brenda Henrikson (Brenda.Henrikson@DoH.wA.Gov) for signature
2022-01-20 - 4:42:35 pM GMT
fi Emait viewed by Brenda Henrikson (Brenda.Henrikson@DoH.wA.Gov)
2022-01-20 - 8:23:53 pM GMT_ lp address: 104.47.65.254
r{ort;m
I
lt!:;!nit 3l
,{dobe Srgn
Created:
By:
Status:
Transaction lD:
2021-11-19
Brenda Henrikson (Brenda.Henrikson@DOH.WA.GOV)
Signed
CBJCHBCMBMRntSTbxoE_wOSkSbTEmqmxVWuDVXRivD
ds Document e-signed by Brenda Henrikson (Brenda.Henrikson@DoH.wA.Gov)
signarure Date:2022-01-20 - g:24:45 pM GMT - Time source: server- lp address: 192.230.13.106
O Agreement completed.
2022-01-20 - 8:24:45 pM GMT
Pt r:t !it;! FyftuFyffini
I ,adobe$gn
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
70/07/202L PA Camas Request #:53539
Fund/Department
116-Public Health Agenda Date: ?/rs e)
Contract/G rant I nformation
Recommendation for Boa on
verification the contracting Agency is not suspended/Disbarred:
ncy:ntCo ctra rant/e mCom unAge ofHealth alCentrity sWa h CYSCH Nington(
Period Begin Date: LO/OL/2OZL Period End Date: 09/30/2022
Total G rant/Contract Amount: S 13,259.00
G rant/Contract N umber:
o The agreement is in place between Community Health of Central washington and the Kittitas
County Public Health Department. The contract provides a scope of work for Community Health
of Central Washington to be able to provide services for the Children with Special Health Care
Needs program which is a part of the Maternal Child Health Block Grant.o Amendment 1 extends the expiration dates and funding allowance based on the new
Consolidated Contract.
Contract/Grant Summary:
Department Head Signat Director Date:
Prosecutor's Office
re of Auditor's Office
I rL
Sign
t
Kittitas County Prosecutor, Auditor,and Board of Health Review and Comment:
Signatu
APPROVED AS TO FORM:
! Agency is not suspended/disbarred ! Not Checked (reason)
Grant/Contract Review Page 1
Financial lnformation
lnformation
Pass lnformation
Prosecutor Review
Total Amount s13,259.00 State Funds S13,258.00 Federal Funds $
Percentage County Funds Matching Funds S CFDA# 93.994
ln-Kind S
ls Equipment being purchased?Who owns equipment?
New Personnel be hired?Contact HR hiri uirements
Future impacts or liability to Kittitas County:
Budget Amendment Needed?
New Division Created?
Yes f] attach budget form No E why not
lncluded in 2022 budget
Revenue Code: LL6.GL2.Z2, 14.333.93.994
Agency to Pass Through
Amount to Pass Through s
Sub-Contract Approved Date
Has the Prosecutor reviewed this agreement?Yes No
BOCC
Departments lm
I Needed?
nt of Tracki lnformation
Auditor Facilities Maintenance
lnformation Services Human Resource
Prosecutor Treasurer
Yes !NoE
Staff Member Presenting:
Auditor's Office
Human Resource
Prosecutor's Office )
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2