HomeMy WebLinkAboutGrants and Contract FormKittitas County
Review Form
Grants & Contract Agreement
Contract/G rant I nformation
Recommendation for Board of Health Review on
Department Head Signature Director Date t"lw I
t L\
verification the contracting Agency is not suspended/Disbarred:
Today's Date
05.1.6.2023 PA Camas Request #)-'Fund/Depa rtment
L16-Public Health Lr\2ulzzAgenda Date
ntCo ra ct G ar tn raRu Hn ea ht UAge G nra tcyEq with aW hs nity n State De a mrt ntegto Hof ae hItp
Period Begin Date Period End Date: 05.3L2024
Total Grant/Contract Amount: $300 ,000
Gra nt/Contract N umber: GV126649
No cost extension through May 3L, 2024, for Rural Health Equity Grant to lead and coordinate efforts toreduce covidLg related health disparities at the community level as described in centers for Diseasecontrol and Prevention (cDC) Grant National lnitiative to Address covlD-19 Health Disparities AmongPopulations at High-Risk and underserved, lncluding Racial and Ethnic Minority populations and Rural
Co m m u n ities (CDC- R F A-OT 21,-2j"03).
Contract/G rant Su m mary:
Kittitas County Prosecutor, Aud itor, and Board of Health Review and Comment:
PROV TOF
{?-L8+*z
Signature of utor's Office Date
Signature of Auditor's Office e
Agency is not suspended/disbarred f litpt Checked (reason)
Grant/Contract Review Page 1-
Financial lnformation
Budget lnformation
Pass Through lnformation
Prosecutor Review
TotalAmount State Funds $Federal Funds S 0 roo@
Percentage County Funds Matching Funds $CFDA#q
ln-l(ind $
tnEx
ls Equipment being purchased?Who owns equipment?
New Personnel bei ng hired?-reContact HR hir rti n uirementsre
F uture impacts or liability to Kittitas County:
Budget Amendment Needed?
New Division Created?
Revenue Code
Yes ! attach budget form
1,1"6.612.39. 26, 333, 93. 39 1 ( Covrdtq Yut,"at l.l@tU4 0rtp4^.lrS)
No ! Why not
Expense Code 116.612.39.26.s1001 / s2oor/ so098 Covi4lq tOC Qu-,n)
Agency to Pass Through
Amount to Pass Through Expense Code
Sub-Contract Approved Date:
e Prosecutor reviewed this agreement?Has th Yes No
Cou Departments lm cted
BOCC A proval Needed?
Assi ment of Tracking lnformation
Auditor Facilities Ma intenance
lnformation Services Human Resource
Prosecutor Treasurer
Yes I Nol
Staff Member Presenting:
Auditor's Office
Human Resource
Prosecutor's Office {tarb* c- t)4* ({,"
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2