HomeMy WebLinkAboutGrants and Contract Agreement KVHKittitas County
Review Form
Grants & Contract Agreement
Contract/G rant I nformation
Recommendation for Board of Health Review on
Department Head Signature Director outu, l?4 zr I zz
verification the contracting Agency is not suspended/Disbarred:
Today's Date
ro/10/2022 P A camas Request #: f)\ qhfr
Fund/Department
116-Public Health Agenda Date
Grant Agency: lnterlocal Agreement between Kittitas County Public Health Department andContract /
Kittitas Val Hospital
Period Begin Date: Date of Execution Period End Date: 2 years from Date of
Execution
Total Grant/Contract Amount: None
Grant/Contract Number
The lnterlocal Agreement between KCPHD and KVH is established to promote efficiency in providing
health services to the citizens of Kittitas County, The agreement allows KCPHD emergency storage of
vaccine should the need arise at the health department because of power outage or storage failure.
Contract/G rant Su m mary:
Kittitas county Prosecutor, Auditor, and Board of Health Review and Comment
APPR VED AS TO FORM
J a'L +?('t ,,( (r-
Signature of Prose r's Office Date
Signature of Audi s Office Date
! Agency is not suspended/disbarred ! Not Checked (reason)
Grant/Contract Review Page L
Financial lnformation
Budget lnformation
Pass Throu gh lnformation
Prosecutor Review
TotalAmount State Funds S Federal Funds S
Percentage County Funds Matching Funds S CFDA#
ln-Kind S
tn
ls Equipment being purchased?Who owns equipment?
New Personnel bein hired?Contact HR hirin requ irements-re orti
Future impacts or liability to Kittitas County
Bud Amendment Needed?
New Division Created?
Yes I attach budget form No fl why not
Revenue Code
Expense Code
Agency to Pass Through
Amount to Pass Through Expense Code:
Sub-Contract Approved Date
e Prosecutor reviewed this agreement?Has th Yes No
County De artments lmpacted
BOCC Ap roval Needed?
Assignment of Tracki ng lnformation
Auditor Facilities Maintenance
lnformation Services Human Resource
Prosecutor Treasurer
Yes I Non
Staff Mem ber Presenting:
Auditor's Office
Human Resource
Prosecutor's Office + .tLE t+k L1*
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2