HomeMy WebLinkAboutExecuted CON CON 2022-2024 Amendment 1Kittitas County
Review Form
Grants & Contract Agreement
Contr rant lnformation
Recommendation for Board of Health Review on
verification the contracting Agency is not suspended/Disbarred:
Today's Date
72/L5/2O2L PA Camas Request #: 53519
Fund/Department
116-Public Health AeendaDate: ;If5/Af
contract /Grant Agency: consolidated contract zo22-2o24 Amendment 1
Period Begin Date: January t,2O22 Period End Date: December 3\,ZOZ4
Total Grant/Contract Amou nt: S 1,805,945.00
Grant/Contract N umber: C1H31015
' Climate & Health Wildfire Smoke lndoor Air Quality Project - Effective January L,2OZ2
r COVID-19 Mass Vaccination-FEMA - Effective January t,2022
r Foundational Public Health Services (FpHS) - Effective January I, ZOZ}
r LSPAN-Local strategies for Physical Activity & Nutrition - Effective January t, zo22r Maternal & Child Health Block Grant - Effective January L,2022. Office of Drinking Water Group A program - Effective January L, ZO2Z. Office of Drinking Water Group B program - Effective January I, ZOZ2. Office of lmmunization COVID-19 Vaccine - Effective January I,2OZ2
lemental Nutrition Assistance p am-Education - Effective Januaa 2022
Contract/Grant Summary:
Adds Statements of Work for the following programs
Department H ignature:7Director Date
Board of Health Review and Comment:
7z-.
tor's Office Date
(
ce Dnatureof Auditor's
Signature of
Kittitas County Prosecutor, Auditor, an
PP FORM
E Agency is not suspended/disbarred I Not Checked (reason)
Grant/Contract Review Page 1
Financial lnformation
Bu lnformation
Pass Through lnformation
Prosecutor Review
Total Amou nt s1,805,845.00 state Fund s st,244,077 .OO Federal Funds S561,768.00
Percentage County Funds Matching Funds S CFDA#
ln-Kind 5
Explain
ls Equipment being purchased?Who owns equipment?
New Personnel being hired?Contact HR hiri -re rti re uirements
Budget Amendment Needed?
New Division Created?
Yes I attach budget form No E Why not
Already Bud
Revenue Code
6LL3360425 - $605,000
61294333LO56 - $30,818.00
6150804333 9307 - S2 1,000.00
67239243339326 - S 3s9,803.00
612313339343 - S34,000
6L222r03339399 - S 33, 147.00
6L2O233 40490 - 525,877.00
6750223 462664 - S 3, 600.00
6L5O223462665 - 54, 600.00
01-43116033393070 - S83,000.00
reimbursement of costs on lv)
Agency to Pass Through
Amount to Pass Through Expense Code:
Sub-Contract Approved Date
Has the Prosecutor reviewed this agreement?Yes No
Co
BOCC
De rtments I
I Needed?
ment of Tra lnformation
Auditor Facilities Maintenance
lnformation Services Human Resource
Prosecutor Treasurer
Yes !No[]
Staff Member Presenting:
Auditor's Office
Human Resource
Prosecutor's Office (42 a"'l
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2
I
KITTITAS COUNTY PUBLIC HEALTII DEPARTMENT
2022.2024 CONSOLIDATED CONTRACT
CONTRACT NUMBERT CLH31015 AMENDMENT NUMBER: I
PITRPOSE oF CHANGE: To amend this contract between the DEPARTMENT oF HEALTH hereinafter refened to as ,,DoH,,, andKITTITAS coUNTY PUBLIC HEALTH DEPARTMENT, a Local Health Jurisdiction, hereinafter refened to as ..LHJ,,, pursuant tothe ModificationsAVaivers clause, and to make neccssary changes withiu the scope of this contract and any subsequent amendmentsthereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as folrows:
1' Exhibit A Statements of work, looated on the Dol-l F'inance SlrirrePoinr site in the upload center, and incorporated by thisreference, are amended as follows:
X Adds Statements of Work for the following programs:
o Climate & Health Wildfire Smoke Indoor Air Quality Project - Effective January l,za2z. COVID-I9 Mass Vaccination-FEMA - Effective January-l,2022r Foundational public Hearth services (FPHS) - Effective January r,2022I LSPAN-Local Strategies for Physical Activify & Nutrition - nfisciivs January 1,2022r Matemal & Child Health Block Grant - Effective January l,Z02Zr lffice of Drinking water Group A program - Effective junuury I , 2022. Offrce of Drinking Water Group B program _ Effe+tive January l',2A22
' office of Immunization covlD-I9 vacoine - Effective January l,,zozzr Supplemental Nutrition Assistance program-Education - Effeciive Janu ary r,2022
Amends Statemsnts of Work for the following programs:
Deletes Statements of Work for the following programs:
2' Exhibit B-l Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-0 Alloeations as follows:X Increase of $1.805.845 for a revised maximum consideration of $1.g05.g45.
n Decrease of _ for a revised maximum consideration of _.
n Io. ?.h:ng" in rhe maximum consideration of _^ .H Exhibit B Afiocations are attached only for in6Eitionar purposes.
unless designated otherwise herein, the effective date of this amendment is the date of execution. ,
ALL orHER TERMS AND coNDITIoNS of the original contract and any subsequent amendments remain in fulr force and effect.
IN wITNEss WHEREOF, the undersigned has affixed his/her signature in execution thereof.
KITTITAS COUNTY PTJBLIC TDALTH DEPARTMENT STATE OF WASHINGTON
DEPARTMENT OF HEALTH
u'?f*\
Date
APPROVED AS TO FORM ONLY
Assistant Attomey General
Page I ofl
Date
)l
Kittitas County public IIeaIth Departmelt
Indirect Raie as of Jaluary \2a222 2;,2lvoPublic Eealth D ept & L2.4ilo/ocounty ceatral svcs
EXHIBIT B-I
ALLOCATIONS
Contuact Term: 2022-2024
BARs stat€'enrorwork .3ffi:I"3TI"
Chsrt ofAccounts fitle Federal Award
fdenffietion #
FFY22 IAR SNA} Ed prog Mgnt-Regiou 2 Z07WAWA5e3903
FFY22 CDC EHC EHR Supplemenhi NGANotReceived
FFY20 EnvirHeaith Capacity-C (CDC) NCE NUEIEH001445
COVIDI9 Vaccines R4 NID 30I/ZZ6tg
FFY2I PhysAcwty&Nukitionprog NU5SDP006504
FFY22 MCI{BG IJ{J Contracts 80445251
GFSCroupB (FGE)
FPHS-LHJ-Proviso flfR2)
FPHS-LHl-Proviso (yRl )
YR24 SRF - tncal Asst (l 5%,) (FO_E) SS
Sanitary Survey Fees (FO-E) SS-State
YR24 SRF - Local Assr (15%) (FO_E) TA
TOTAI.
Total consideratiol:
S0
'RAND
TorAL $l't05,845
$1,805s45
*Caalog of Federal Domestic Assisrance
ttFederal revenue codes begin with "333 ". State revenue codes begin with ,,334.,.
Amend#
Amd I
Amd I
Amd I
Amd I
tund I
Amd I
Axnd I
AEd I
Amd 1
Amd I
AEd I
Amd I
Assist
List #t
10.561
93.0'.70
93.070
93.268
93.439
93.994
N/A
N/A
N/A
N/A
N/A
N/A
Revenuc
Code*r
333.10.56
113.93.07
333.93.07
333.93.26
133.93.43
333,93.99
334.U.90
336.04.2s
336.04.25
346.26.64
346.26.65
346-26.6s
0U0t/22
0tn1n2
0L/au22
0t/0r/22
0U01/22
0l/01/22
01/01/22
07/01/22
0t/01/22
at/01/22
01/0r/22
01/01t22
09/30n2
08/31n2
08/3t/22
06/30/24
09/29/22
09/30t22
06/30t22
06/30t23
06/30t22
1.2/31/22
12/3y22
tu37/22
r0t01/21
09t0r/20
09t01120
01/01/20
09/30t21
l0lav21
oTtauzl
07/otn1
07/0r/21
07/0u21
o7lotm
07/ot/2t
09/30/22
08Btn2
08Blt22
06R0/24
09t29m
09t30/22
06/30/22
06/30D3
06/30/23
06/30t23
06130n3
06/30/23
LEJFuudingperiod Fundingperiod
Start Date ErdDatcStertDate End Date Amourt
$30,818 $0,818
$83,000 $83,000
$21,000 $21,000
$359,803 $359,803
$34"000 s34,000
$33,1.47 {33,147
$2s,E77 $2s,877
$605,000 $605,000$605,000 $60s,000
$3,600 $3,600
$3,600 $3,600
st,000 s1,000
s1,t0s,t{5 $I,m5,g45
GRANDTOTAL
Totrl Fed
Total State
ContrtctNmber:
Datei
Fuoding
Period
SubTotal
cl,Iltl0l5
trutu,aryl,2022
Ctart of
Accounts
Total
$30,818
$83,000
$2r,000
$3s9,803
$34,000
s33,t47
s25,877
$1,210,000
$3,600
$3,600
$1,000
$I,E05,t4s
$s61,76t
$1,244,071
Page I of I
I
C1H31015 Kittitas Amend #1
FinalAudit Report 2022-02-22
"CLH31015 Kittitas Amend #1', History
fr Document created by Brenda Henrikson, contracts specialist (Brenda.Henrikson@DoH.wA.Gov)
2022-01-24 - 7:30:13 pM cMT- tp address: 97.126.72.15
trl Document emailed to Tristen Lamb (candi.btackford@co.kittitas.wa.us) for signature
2022-01-24 - 7:40:90 pM GMT
Et Email sent to lina.rowan.ph@co.kiftitas-wa.us bounced and coutd not be delivered
2022-01-24- 7;40;01 pM GMT
fl Email viewed by Tristen Lamb (candi.bracKord@co.kittitas.wa.us)
2022-01-24 - e:54:OT pM GMT_ tp address; 66.24g.254..t8
fi emair viewed by Tristen Lamb (candi.brackford@co. kittitas.wa.us)
2022-01-31 - 2:56:b0 FM cMT_ lp artdress: 66.24A.247.125
D Emair viewed by Tristen Lamb (candi.brackford@co.kittitas.wa.us)
2022-0%10 - 9:41:26 pM GfrrT- lp address: 66.24l,2il.18
dg Document e-signecr by friste n Lamb (ca nd i. brackford@co. kittitas.wa. us)
signatureDate:2022-0L1g-11:16;sTpMGMT-Timesource:server-rpaddress:66.24s.2s4.18
El Document emailed to Brenda Henrikson, contracls specialist (Brenda.Henrikson@DoH.wA.Gov) for signature2022-02-19 - 1t:16:59 pM GMT
@ Document e-signed by Brenda Henrikson, contracts specialist (Brenda.Henrikson@DoH.wA.Gov)
signature Dara: 2022-02-22 - 3:a4:27 pM GMT - Time source: server- rp address: 7s.172.118.66
0 Agreement completed.
2022-02-22 - 3:04:27 pM cMT
Created:
By:
Status:
Transaction ]D:
2022-01-24
Brenda Henrikson, Contracts Specialist {Brenda.Henrikeon@DOH.WA.cOV)
Signed
CBJCHBCAABAAPM2 UWDAeqTlXbMpjgxa bppFyXBKsse_v
{hWeanil
I Adobe Slgn
� ..
�.
ti�
DOH ProgramName or Title: Climate& HealthWildfire Smoke IndoorAir Ouality
Project - Effective January 1.2022
Period of Performance : J anuary | . 2022 through Au$st 3 l. 2022
Exhibit A
Statement of Work
Contract T erm: 2022-2024
Local rrealth Jurisdiction Name: Kittitas county public Health Department
Contract Number: CLH3 1015
SOW Type: Original Revision # (for rhis SOW)Type of Payment
El Reimbunement
I Fixed Price
Federal Compliance
(check if applicable)
El PPere (rransparency Act)
lJ Research & Development
Fundine Source
Elr"aJ*t Subrecipient
E stat"
I oth"t
Statement of Work Purpose: The pulpose of this statement
supplementa I grant "Strengthening environmentalhealth capa
approaches" initially awarded to DOH on September 1,2020.
of work provides KCPHD $21 ,00 to continue this work of the original grant.
residential cleaner air room project from the original grantwith improvements and incorporation of heat. This statement of work provides KCpHD $g3,000 to perform theseactivities of the supplementalgrantthatwasawardedtoDoH onsiptember 1,2021.
Revision Purpose: N/A
ofworkis two-fold andis being doneaspart ofthe Centerof Disease ContolandPrevention,s (CDC's) original andcity (EHC) to detect, prevent, and control environmentalhealth ha zards in through data-driven, evidence-based
Total
Allocation
0
0
0
0
0I
Allocation
Change
Increase (+)
21
0
0010
Current
Allocation
0
0
0
0
0
LIIJ Funding Period
Sfart Date End Date
t/0r/22
1/22
BARS
Revenue
Code
333.9
333.93
Assistance
Listing
Number
Master
Index
Code
100
0222
NCE
DOH Chart of Accounts Master Index Tifle
O ENIVIRO CAP
CDC EHC
TOTALS
Payment Information
and/or Amount
Reimbursement for actual
costs not to exceed
$21,000 on Master Index
Code 25440 I 00.
Due Date/Time Frame
August 31,2022
Deliverables/Outcomes
LHJ presents selected long-term care
facitty (2) and school (2)
A written protocol for conducting
consultation in larger facilities
Activity
Collaborate with DOH to identify larger facilities for indoor air
quality consultation pilot within the selected target vulnerable
population to include:
Task
#
I
Exhibit A, Statement of Work Page 1 of5 ContractNurfr berCLH3 I 0 I 5
4
5
3
2
#
Task
a
Activity
Identify and secure commitment of two (2 I long-term care
facilities andtwo (2) schools for consulta ion (consultation
consists of identifying current practices, a sessing barriers
to improve and training best practices)
Help develop protocol for consultation of ;leanerindoor
air in larger facilities
Collaborate with DOH to provide indoor air q ality
consultation pilot to include :
r Conduct consultation in two (2) long-tem care facilities
r Conductconsultationin hvo (2) schools
Collaborate with DOH to assess the ability to chieve cleaner
indoor air during wildfire smoke events by ser ring as themain
contactwith residences using the protocolesti rlished by DOH
to include:
r Collect air quality measurements to evah lte intervention
strategy
r Assess ten(10) residences
Collaboratewith DOH to assess cleanerindoc "airin larger
facilities to include:
r Assess current practices in two (2) long-tr :m care facilities
andtwo (2) schools
o Assess barrien to improving indoor air q ality practices in
two (2) long-term care facilities and two t) schools
Collaboratewith DOH aslead of qualitativea ;sessmentto
estimate the effectiveness and efficacy of the rtervention to
reduce exposures through access to cleaner in oor air spaces to
in residences include:
r Quantifyingthenumberofpeople impac :dbythe
intervention
forlocal
a
Adapt intewention and local communication esources
use based on information from evaluation to i ,clude:
. Developing a plan for revising local com nunication
resources
Incorporatingrevisions in local commun .:ation resources
Payment Information
and/or Amount
August 31,2022
August 31,2022
August 31,2022
August 31,2022
Due Date/Time f,'rame
Submit a copy of revised local
communication resources based on
information from the evaluation
# ofvulnerable people in residences
impacted by the intervention
# ofpeople completing qualitative
assessment
# of residences assessed by DOH and LHJ,
and summary of airquality measurements
collected
# of scores of current practices in long-
term care facilities
# of scores of currentpracticesin schools
# of long-term care facilities with
obstacles to indoor air qualitY
improvem ents characterized
# of schools with obstacles to indoor air
quality improvements chara ctenzed
Deliverables/Outco mes
# of consultation sessions provided to
long-term care facilities on best practices
for indoor air quatty
# of consultation sessions provided to
schools on best practices forindoor air
quality
Exhibit A, Statement of Work PageZ of 5 ContractNumberCLH3 I 01 5
Payment Information
and/or Amount
costs not to exceed
$58,000 on Master Index
Code2545O222.
for actua
costs not to exceed
$25,000 on Master Index
Code2545O222.
for actua
Due Date/Time Frame
August 31,
August 31,2022
3t,
August 31,2022
Deliverables/Outco mes
at-risk target population and criteria for
recipients
LHJ presents to DOH method to collect
demographics of recipients
ofprioritypresents to DOH
A copy of distribution plan
# of HEPA portable air cleaners purchased
# of vulnerable individuals receiving
intervention
# ofrecipients with reported demographics
LHJ presents to DOH summary report and
presentation
at-risk target population and criteria for
participation
A recruitment plan forparticipation in
residential cleaner air room project
LHJ presents a list of selected households
for residential cleaner air room project
# ofpeople providing informed consent
for participation in residential cleaner air
room project
Certification of completion forhuman
subj ects research training
A copy of recruitment summary
ofpriorityLHJ presents to DOH
copy of updated commrmication
An updated protocol for applying
interventions in residences
resource
A
Activity
smoke intervention (IIEPA portable air cleaner) to include:r Establishing selection criteria forrecipientso Developing method to collect demographics of
recipients
vulnera ls
r Establishing a plan for distributionr Purchasing HEPA portable air cleanersr Distnbuting HEPAportableaircleaners (target 100)o Collect demographicsofrecipients with developed
method
e Developing summaryreportofintervention
distribution
(r{EPA ailleportab
include:to
intervention
individual
smoke
vulnerable
wildfire
to
Distribute
cleaner)
of residential cleaner air room project to include:r Identifying vulnerable population based on health risk
and county need
e Establishing selection criteria forparticipation. Identifying individuals for intervention and enrolling
participants in project
. Project staff takinghuman subjects research trainingr Summarizingrecruitmentprocess
in a repetition
with to residences
Collaboratewith DOH to develop
repetition o f residentia I c lea n er a ir ro om proj ect to include :r Updatingcommunicationresourceto trainresidences on
creating cleaner air rooms
' Updating protocol for applying intervention and
tra ining and protocol for
ect in residences
Task
#
6
7
8
9
Exhibit A, Statement of Work Page 3 of5 Contra ct NumberCLH3 I 0 I 5
l2
1l
10
Task
#
a
Activity
Incorporatingheat intervention into proto o
borate to implement rn strategy
repetition of residential cleaner air room proje t by serving as
mainpoint of contact forparticipantsto includ :':
r Implementingintervention strategy in ten esidences, such
as establishing the intervention in homes i nd notifying
participants when to imPlement it
r Purchasing HEPA portable air cleaners fo participants
. Managtngandcommunicatingwithreside tces throughout
project, including addresshg technicaldil'iculties,
coordinating visits, etc., as needed
r Summarizingimplementationofinterven on
te as lead of a sessment
repetition of residential cleaner air room proje :t to include
. Updating qualitative intervention assessil :nt tool
. Leadingdisseminationofqualitativeasse smentto
residences
. Analyzing qualitative assessment data
Continue collaborationwith DOH to pilot tesl knplementation
ofthe intervention strategy for creating cleanl :indoor air in
residences by serving as main point of contac forparticipants
to include:
oIm intervention stra in ter 0
DoH program and Fiscal Contact Information for a ConCon SoWs can be found on the DoH Finance SharePoint site. Questions related to this SoW, or any other
finance-related inquiry, may be sent to finance(Ddoh'wi gov'
Federal Funding Accountabilitv and Transparency l ct GFATA) (Applies to federalsubrecipient funding')
ThisstatementofworkissupportedbyfederalfunTiill tr"q"ir"."*ptlancewittrtheFederalFundingAr"oontabilityandrransparencyActGFATAortheTransparencyAct)'
ThepurposeoftheTransparencyactLtomakeinform tionavailableonlinesothepubliccanseehowthefederalfundsarespent'
To comply with this act and be eligible to perform the a ,tivities in this statement ofwork, the LHJ must have a Data Univers alNumbering system (DUNS@) number'
Information about the LHJ and this statement of work v 1l be made avaitable on WlSpendilg'gp:t by DoH asrequired by P'L' 109-282'
Pro eram Specific Requirements
ResfrictionsonFunds (i.e.,disallowedexpensesorar ifvities'indirectcostsretc.): , -1---1^aL^-:1^f ^+..r-. D--+;
The funds can be used to complete the activities outline above to conduct community engagement and implement and evaluate th e pilot study. Restrictions on funds imposed by
the CDC include:
Exhibit A, Statement of Work
TBD on Masterlndex
Code 25440 I 00.
Payment Information
and./or Amount
August 31,2022
August 31,2022
August 31,2022
Due Date/Time Frame
Intervention equipment purchased (i.e.
portable air cleaners)
# of residences receiving interventions
from DOH and LHJ
6pfiT quatratFe assessment tool
# of residences completing qualitative
assessment
Summary of qualitative assessment results
# of residences receiving intervention
Summary of implementation of
intervention
air cleaners# of HEPA porta
purchased
Deliverables/Outcomes
Page 4 of 5 ContractNumberCLH3 1 0 1 5
\"-,)
r Sub-recrpients maynotuse fundsforresearch.o sub-recipients maynotuse fundsforclinical careexceptas allowed by law.t Sub-recipients may use funds only for reasonable program purposes, including personnel, trave! supptes, and services.r Generally, sub-recipients may not use funds to purchase furniture or equipm"rrt-. arry such proposed spending must be clearly identified in the budget.r Reimbursement ofpre-award costs generally is notallowed, unless the cbc provides vnitten approvalto the sub-recipient.r Other than fornormalandrecognized executiveJegislative relationships, no iundsmaybeused for:o publicity or propaganda purposes, forthe preparation, distribution, or use of any material designed to support or defeat the enactment of legislation before anylegislative bodyo the salary or expenses of any grant or contract sub-recipient related to any activity designed to influence the enactment of legislation, appropriations, regulation,administrative action, or Executive order proposed or pending before anylegislative body
' Inaccordancewith theunited statesProtecting Life in GlobalHealthAssistance poli.y, ultrrorr-jovemmentalorganization(NGo) applicantsacknowledgethatforeipNGos thatreceive fundsprovidedthroughthis award,eitherasaprime recipient orsuurecipient, arestrictly prohibited,regardless of thesourceof funds,fromperforming abortions as a method of family planning or engaging in any aciivity that promotes abortion as a method of family planning or to provide financialsupport toanyotherforeign non'govemmentalorganizationthatconduitssuchactivities. See AiditionalRequirement(AR) 35 forapplicability(http s ://www.c dc.gov/grants/a dditiona lrequirem ents/ar_3 5.hhnD.
Monitoring Visits (i.e., frequency, type, etc.):
Project staff from Kittitas county Public Health and DoH will have, at a minimum, monthlyphone or video calls to check-in on the progress of the grant for the duration of theprojectperiod. These may be substituted for in-person meetings in the eventthat covlD restrictions are lifted during the projectperiod.
Exhibit A, Statement of Work Page 5 of5 Contract NumberCLH3 I 0 1 5
Exhibif A
Statement of Work
Contract T erm: 2022-2024
DOII ProgramName or Tifle COWD-I9 MassVac rination-FEMA -
Effective Januarv 1.2 l22
Local Health Jurisdiction Name: Kittitas County Public Health Department
Contract Number: CLH3 1 015
SOW Type: Original Revision # (for this SOV )
Type of Payment
X Reimbursement
I Fi*"d Ptice
Federal Compliance
(check if applicable)
X nnnfe ffransparencyAct)! Research & Development
Funding Source
El Federal Contractor
I state
! oth.tPeriod of Performan ce; January l.2022through Apri l' 2022
mass vaccination clinics in Washington state
Revision Purpose: N/A
DOII Chart of Accounts Master Index Title
l0IYo
OT
Activity
Task r Mass ,n in this
statement ofwork are NOT CONSIDEREI
SUBRECIPIENT but are as a CONTRAC] OR of DOH'
DOH reimbursement provided forlocalm: rss vaccination
clinic (see definition below) planning, impl mentation and
operations in coordination between Unifier Command and
the Regional Incident Management Team t IMT) to
adminilster the vaccine efficienfly, quickly, rquitably, and
safelyin all regions of Washington State. I i:ate Supported,
Regionally Coordinated" Locally Implemer ted.
Definition: Mass vaccination clinics defined i s those outside of
the usualhealthcare delivery. method such as pop-up clinics,
mobile c non- clinical
0
0
0
0
0
0
0
Total
Allocation
0
0
0
0
0
Allocation
Change
None
0
0
0
Current
Allocation
0
0
0
0
0
0
a4t0Ll220I/01/22
LIIJ Fund ing Period
Start Date End Date
333.91 .03
BARS
Revenue
Code
97.036
Assistance
Listing
Number
Master
Index
Code
934V0200
#
Task
I
Payment Information
and/or Amount
*Reimbursement of
eligible costs.
MASS VACCINATION
FEMA 100% Funding
(Mr 934V0200)
(See Program Specific
Requirements below)
Due Date/Time FrameDeliverables/Outcomes
Exhibit A, Statement of Work
etc
Page I of4 Contract Number CLH3 10 1 5
Payment Information
and./or AmountDue Date/Time F'rame
contract amendment
execution.
30 ofcontract
amendment execution.
Monthly
Daily
Deliverables/Outco mes
to DOH a mass p lan
including:
' tYPe of site,
. site locations,
r throughput,
e considerationsmadetoensure
equity to historically
marginalized populations,
r and to the extent possible a
regional map of sites/locations.
Submit estimated budget for the mass
vaccination plan.
Monthly Cost Summary Spreadsheet to
the IMT/IMOby the fifth ofthe following
month.
Submission of vaccine use into WA IIS
database within 24hrs of use.
Activity
Guidance on vaccination protocols must be followed as
provided byDOH andCDC.
J urisdiction coordina te p and
implementation of mass vaccination clinics/sites provided
within the county(s) with a regional incident management
team/organnation as approved by DOH.
Request for regional IMT should be submitted through the
norrnalprocess through WebEOC.
LHJ is the coordinating agency for the mass vaccination plan
within the county.
Regional IMT will be under the delegation authority of DOH
and they are to provide support and coordination forall efforts
a round vaccine p la nning re source supp ort and genera I
guidance and information sharing in order to regionally
coordinate efforts. Local jurisdictions will maintain all
decisional authority around vaccination planningand execution
within their j urisdiction/district.
Provide any information as requested by the regional IMT.
for ss Vaccination a are relm
on actualcosts as outlined in the DOH guidance to provide the
services and to carry out the mission. Funding will be
dependent on full participation in the LHJ and IMTprocesses
and all documentation will be required to be provided to fully
close out funding requests by the end of the mission period of
performance.
Allowable costs include expenses such as facility rentals, staff
to conductplanning management, support and operation of the
site, medical personnel for vaccinations, site security personnel,
wrap around services for staff (meals, travel lodging),
equipment (which must b e pre -approved by IMT/DOH if it
exceeds $5,000 each), supplies for vaccinations and site
operation. LHJs should provide narratives to help a ssist IMT
and DOH finance know what exp enditures were necessa ry to
carryr outthe mission.
Vaccination data -will be
and federalrequirements.
maintained accordingto current staie
Task
#
1A
IB
1C
Exhibit A, Statement of Work Page 2 of 4 Contract NumberCLH3 I 0 I 5
1D
!
Task
ccme
Activity
- If a loca or reglon
does not have a registration system(s) the inch ,le intemet
based, phone option and other methods to enst re equitable
registralion, the state hepMod system and toc s will be
available foruse.
Regularly report on vaccinations sites and ope
(number of vaccinations,personnel to operate
challenges, successes to share for leaming acr
ational activities
he site,
ss the public
health system).
DOII program and Fiscal Contact Information for al ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW' or any other
finance-related inquiry, maybe sent to finance@.doh.wa ,9914.
DOIf General Mass Vaccination Program and Fiscal lSontact
Patrick Plumb
COVID FEMA Proj ect Management Analyst
Washington State Department of Health
Office of Financial Services
I I I IsraelRoad SE, Tumwater, WA 98501
patrick.plumb@doh.wa.gov I (3 60) 23 6 429 1
Program Manual, Handbook' Policy References
Emergency Response Plan (or equivalent)
Medical Countermeasure/Mass Vaccination Plan
Billing Requirements:
uontn"ly invoices must be submitted timely to the regior ll IMT/organization for reviedapprovalprior to submission to DoH for reimbursement'
Contrait Ma ster Index (MI) Code : 93 4V02 0 0 General Il a ss Vaccination
BARS Revenue Code: 333 .97 .03 Mass Vaccination Rei nbursement
Exhibit A, Statement of Work Page 3 of 4
f,'ederal Fundine Accountabilitv and Transoarency I ,ct (FFATA) (Applies to federal grant awards.)
Thisstatementofworki'@I'"q"i''*-pliancewiththeFederalFundingAccountabi1ityandTransparencyAct(FFATAortheTransparencyAct).
The purpose ofthe TransparencyActL to makeinform tionavailableonline so the public cansee howthe federalfundsarespent.
Tocomplywiththisactandbeeligible toperformthea tivitiesinthisstatementofwork,theLHJmusthaveaDataUniversalNumberingsystem(DtlNs@) number'
Information about the LHJ and this statement of work u rLl be made available on USASpendins.gov by DOH asrequired by P'L' 109-282'
Pro gram Specific Requirements
Payment Information
and/or Amount
Ivlonthly
Due Date/Time Frame
furisaictioVnegions will ensure a fairand
equitable process for registration ol
eligible Washingtonians across all
available modalities.
Provide monthly situation report to
IMT/IMO on status of implementation of
mass vaccination plan, or more frequently
if thatis the LHJ procedure. Sites
operating for the time period, vaccines
administered by site for the time period,
estimated costs for the time period, any
challenges/successes of note, including
assistance recuested.
Deliverables/Outcomes
ContractNumberCLH3 I 0 I 5
Special fnsttuctions:
The LHJ is considered a coNTRACToR of DoH not a subrecipient forthis portion of the statement of work. An allocation of funds is not provided as these FEMA funds are onlyavailable asreimbursement of costs assocjated with implementation of the miss vaccination plan.
Detailed documentation must be maintained as directed by the regional lMT/Organization and DOH to substantiate costs associated with these activities for submission to FEMAuponrequest by DOH.
must be billed as a direct charge; timesheets are required aoc-umlntati6n and must be ;";tLG;;;n request by DoH. r.rai..rt rates are not applicable to these funds. Eligible
over $5,000 a piece must be preapproved by the IMT and should be feased ratfrer tnun iur.rrur"E. ery iiversion irom the lisi ofpre-approved expenses will require a narrative on
time-out must be recorded, as well as a brief description of iheir activities. A general description of activities is acceptable f orthose working at the vaccine site, moredetailed/specific description is reqriired for those not working at the vaccine site.
Exhibit A, Statement of Work Page 4 of 4 ContractNumberCLH3 I 01 5
Exhibit A
Statement of Work
Contract T erm:. 2A22-2024
DOH ProgramName or Tifle
Type of Payment
fl Reimbursement
X Prriodi" Distribution
Federal Compliance
(check if applicable)
I n'fefe (fransparency Act)
E Research & Development
Funding Source
I Federal<Selectone>
X state
E oth.t
Statement of work purpose: The pu{pos€ of this statr nent of work (Sow) is t9 rp_.9.tfy how state funds ibr FoundationalPublic Health Services (FPHS) will be used for the
p*"a"rp..r"nnance.ferRCWqi.l6.stz,th,esefund areforthegovernmentatpubrcneamsystemtodlliverFPHsservicesstatewideinthemosteffective,efficientand
equitable mannerpossible with the funds available.
TheFpHsSteeringcommitteewithinputfromFpHsS bjectMatterExpert(SME)WorkgoupsandtheTribalTechnicalWorkgroupisthedecisionmakingbodyforFPHS' For
the 2021- z123biennium, the Steering Committee is us ,r! an iterative approach to decision making. Determining investments first for S FY22 (July l, 2021 - 1une30,2022),
then for SFy23 (July l, 2022 -June 3 0, 2023). This mr rns that additionaitasks and/orfunds may be added to an LHJ's FPHS SOW as these decisions are made.
These funds are to be used as directed and allocate d by 1 re FPHS steering Committee. As the global covlD -19 pandemic and the public health response to it continues and
begins to abate,theseFpHs funds canbebraided with a rdusedto supplementothershort-term pandemicresponse fundingas neededforFPHS activities during this period of
pelormancethiough 06/30/22. Respondingto pandem :s, epidemiciandpublic health emergencies are foundationalservices of the govemmentalpublic health system'
Note:
Iumpsumamountsthat,}llbedisbursedatthibeginnir,Joieachsixmonil.periodasfoilows: IulyL,2\2l;Januaryl'2022;IuIyl,2022;Januaryl,2023'Eachyear,theJuly
p ayment will be disbursed upon completion of the FPH I Annual Report'
TheSFy22 July l,2llldisbursementoffundswascor pletedin the2018-2021 consolidatedcontractanoisincludedinthisstatementofworkforinformationalpurposesonly.
each state fiscalyear. (RCW 43.88.140)
Spendingandspendingprojectionsmustbereportedas;quiredbytheFPHsSteeringcommittee.Fundsthatareprojeotedtobeunspentbythecloseofthestatefiscalyearmust
be reallocated per the process developedby the FpHS s :ering Committee to assure tlhat all funds,appropriatedby thelegnlature can be spent by the govemmentalpublic health
systemtodeliverFpHswithintheyearthattn.r"na*n, :appiopriated. unspentfundsreverttothe3taGtreasuryandmustberelumedtoDoHbyJulyl5thofeachyearfor
retum to the Office of Financial Management.
2021-2023 Biennium
.SFY22 (July 1, 2021-1we30,2022)
. SFY23 (July 1, 2022- June 30, 2023)
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
FoundationalPublic I ealth Services €PHS) -
Effective Januaw 1.2 t22
Local llealth Jurisdiction Name Kittita s Countv Public Hea lth Dep artment
Conkact Number: CLH3 101 5
SOW Type: Original Revision # (for this SOlt '
Period of Performancez larruaw 1.2022 througlr June li0' 2023
Total
Allocation
Allocation
ChangeCurrent
Allocation
I,IIJ Funding Period
Start Date End Date
BARS
Revenue
Code
Assistance
Listing
Number
Master
Index
Code
Exhibit A, Statement of Work Page 1 of5 Contract Number CLH3 1 0 I 5
605,000
0
0
0
0
00I
00
Increase (+;
605,000
0
0
0
0
0
0
0
06130t22
0
01101t22
t/22
336.04.2s
336
N/A99202111
112
FPHS-LHJ-PROVTSO CYR I )
/0U2ttionis forNote: TotalYRt
TOTALS
60,000
10
30,00030,000
Communicable Disease (CD)
lPublic
10
20,21,,23-29,
93
40-53,93
TOTAL
Paymenf Information
and/or Amount
Ea ch year, the July
payn ent will be disbuned
upon completion of the
FPHS AnnualReport.
Reinforcing Capacity In coordination with the FPHS Steering Comm ittee and SubjMatterExpert(sME)Workgroups,provide FPHS Comm ect
unlca ble Disease (cD),EnvironmentalPublic Health (EPH),Assessm ent (Suweillance &Epidemiology )andloranyoralloftheotherFPHSCross-cutting Capa bilities (ccc)as defined In the mo st current verslon of the FPHS definitions.
Suggested BARS expenditure co des: 652.xx - 10-17, 20, 2 l, 23 .Zg, 40 -53
Due Date/Time Frame
TBD
For SFY22 (07101/21-
0 6 / 3 0 122) dteby 08 I 1 5 I 22
For SFY23 (07/01/22-
0 6 I 30 123) daeby 08 I 1 5 /23
Deliverables/Outco mes
Routine reporting of spending and
spending projections. Process and
reporting template TBD and providedby
the FPHS Steering Committee via DOH,
FPHS annualreporting (template provided
by theFPHS Steering Committeevia
DOH)
Activity
In coordina tion with EPHS Steering Committee and Subject
Ma tter Exp ert (sME)workgroups FPHS funds are to be used to
increase delivery of FPHS services statewide asmeasured
through FPHS annualreporting, indicators, metrics and other
data compiled andanalyzedby contractors, DOH and Subject
MatterExpert (SME) Workgroups. Resuts are published in the
annualFPHS Investment Report. FPHS indicator metrics
available here.
Task
#
I
2
Exhibit A, Statement of Work Page 2 of 5 Contract NumberCLH3 I 0 I 5
Activity
. Conduct a local and/orregional coml ehensive community health assessment (CHA) every three to five years in conjunction with community partners.
o Develop a localand/orregionalcomn unityhealthimprovementplan(CHIF) in conjunctionwith communitypartners.
ThesefundscanbeusedforanyCHA,/CHIpa tivityorservice(e.g.,dataanalysis,focusgroups,reportwriting,processfacffiation)andmaybeusedtocontractwith
other LHJs for staff time o, ,.*i."r. Coordin, te #tir the Spokani Regional Health District to participate in county Health Insiehts.
Suggested BARS expendifure codes: 562'll
(cD)ns C.1, 2,3,4,co rvith the
FPHS Steering Committee and Subject MatteI
The se funds can (and actually are intended to)
retain stafftherewere hired with pandemic en
LHJs for staff time or services for delivering I
FPHS CD services. This includes maintaininl
contact tracing for sexually transmitted diseas'
addressing syphilis and gonorrhea cases.
:3xpert (SME) Workgroups, provide FPHS CD services as defined in the most current version of the FPHS definitions.
re braided with temporary pandemic emergency funding such thatwhenthose fundsrun out,FPHS fundscanbe used to
:rgency funds if the jurisdictions desires to retain them a nd/or to hire additional staffifneeded and/orcontract with other
'HS CD. As the pandemic resP onse wains, staff funded with FPHS funds are to shift focus to providing some or all or the
accessto anduse ofdata system s created during the pandemic and others underd evelopment and case investigation and
and othercommunicab le and notifia ble conditions within the mandated timeframes. Empha sis should be p la ced on
1. provide timely, statewide, locally releva rt and accurate information statewide and to communities on prevention and control of communicable disease and other
notifiable conditions.
2. Identify statewide and local community ,rssets for the control of communicable diseases and othernotifiable conditions, develop and implement a prioritized
controiplan addressing communicable, iseases and othernotifiable conditions and seek resources and advocate forhigh priority prevention and control policies
and initiatives regarding communicable liseases and othernotifiable conditions.
3. homote immunizationihrouglr evidenc ,-based strategies and collaboration with schools, health care providers and other community partners to increase
immunization rates.
4. Ensure disease surveillance, investigatic :r andcontrolforcommunicablediseaseandnotifiableconditions in accordancewith local, stateandfederalmandatesand
guidelines.
Suggested BARS expenditure codes: 562.xx- 20,21,23-29
Environmental Public Ileatth @PI!,clefinitions 8.3 &4) -In coordination rvith the(FPHS
MatteFPHS Steering Committee and Subject Expert (SME) Workgroups, these funds are for each LHJ to deliver FPHS EPH in their jurisdiction as defined in
the most current version of the FPHS definitio rs and supplement existing funding specificallY for:
Develop, implement and enforce law , rules, policies and procedures for maintainingthe health and safety of retail food serv ice inspections and shellfish
monitoring ihat addtess environmen ralpublic health concems. (8.3'b)
Develop, implement and enforce law , rules, policies and procedures for ensuring the health and safety of wastewaterand facilities, including onsite septic
desip and inspections, wastewater b iatmenf and reclaimid water, that address environmentalpublic health concems. @.3.e)
Develop, implement and enforce law , rules, policie s and procedures for ensuring the health and safety of solid waste and fac ilities, including hazardouswaste
streams (e.g. animalwaste, solid was e permitting and sotid waste inspections), that address environmentalpublic health concems. (8.3'f)
Develop, implementandenforcelaw , rules, policies andproceduresforensuring the healthandsafetyof schools, including througheducationandplanreview
that a ddress environmental public he, lth concems' (B.3,g)
a
a
a
a
These funds can be used to retain,'hire and/or
services that are not appropriately funded witl
@PHS funds are intended to build capacity ar
:ontract with other LHJs for staff time or services and for staff training as needed to provide the following FPHS EPH
fees. Each LHJ will be responsible to report on their prcgress on FPHS deliverables even if contracted with otherlHJs
,l not intended to justify the reduction of existing fee revenue):
Payment Information
and/or AmountDue Date/Time FrameDelivera bles/Outcomes
4
J
Task
#
Exhibit A, Statement of Work Page j of 5 Contract NumberCLH3 I 0 I 5
Payment Information
and/or Amount
Due Date/Time FrameDeliverables/Outco mesActivity
a Food Sa fety (FPHS definitions B .J .b )Respond to food safety conc€ms tha not na tely fundedtechnicalreapprop such foodbome illness threats,requests forassistanceandaddressingnewandemergmgbusinessmodels.Every loca urisdiction Washington rs expected respondoutbreaks,food fety inquiries
m to to fo odbome illnesssaandprovidepreventativeeducationforthegenerapublicandtechnicaassistance.
r Sewage safety (FPHS definitions B'3 'e-f) - Respondto sewage concems and public health threats andprovide technicalassistance that are not appropriatelyfundedto ensure thatsewage is handledappropriatelyto limit-potentialexposureto sewage. Every local jurisdiction in washington is expectedto ensuresewage is proper$ managed'on-Site Septic (oss) pemritting, enforcementandprovidio'gt."hni.alussistanceandeducationtoosS ownen are fee fundedactivities and should be funded through fees or locai govemrn'ent who sets the fees. These FPHS funds provide resources to su pport activities for which a feecannot be charged such as: responding to OSSfailures, surfacing sewage,_OSS safety concems, and similar issues. These funds can also be used for concemsrelated to large on+ite sewage systems, other oSS-related .orr.i*, thit do not invoive locally f ermittatre sysiems, arra otler sewage-related issues, regardlessof whether they are related to a fee-for-service activity. Examples of activities FpHS funds can be used for:
o Work with partners to educate and inform public on OSS monitoring and maintenanceo Work with the public, policy makersand partnem to assess needs and develop plans and solutions for wastewatermanagement in their communities.o Respondto complaints,actasneeded, andassurethatfailingosS are iaentiiLi andpromptlyrepaired.o conduct Pollution Identification and conection @IC) invesiigations where water qu'ality is impaired to identify failing septic systems and otherpollutionsources.
o Ensure thatsewage from bothosS andothersources is adequatelyhandled.tocreatebarriers to potentialexposureto sewage.o Adequate qualified staff to evaluate proposals, inspect new installations and repairs, assess cause of oSS failure, and comply with requirements in statelaw
' Schools Safety(FPHS definition B'3.g) -Assure safeandeffectiveleamingenvironmentsforchildren attendingK-I2 schools-public, privateandparochialEvery local jurisdiction in washington is expected to work collaboratively with DoH, ESDs and loc al school districts and use the modelprogram to assureconsistencytoregularly evaluateeachK-l2forhealthandsafetyconcemsandprovidemandatedservicesperWAC 246-366. Initialpriorities include:o Build partnerships with school officials, loca l boards of education, parent teacher associations, education service districts, and other school focused entities.o Participate with statewide public health groups to standardize schoolprogam implementation.o Focus on schools that have not previously been inspected to assess current conditionso Focus on existing elementary schools for first phasi of inspections programr IndoorAir eualityr Classroom. Healthy cleaning and indoor environments. Playground. Drinking water(lead)
Suggested BARS expenditure codes: 562.xx- 40-53.
#
Task
DoH Program and Fiscal 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, ma y be sent to finance@doh.wa. go v.
Pro gram Snecific Reouirements
Program Manual, Handboolg policy References:
All FPHS Resources - www.doh.wa.gov/fphs or FpHS I powered bv Box
Exhibit A, Statement of Work Page 4 of 5 ContractNumberCLH3 I 0 I 5
Special References (i.e., RCWs, WACs, etc.):
Link to RCW 43.70.5 1 2 - RCW 43.70.5 1 2 : Public heaitl
Link to RCw 43.70.515 - RCW43.70.515: Foundationa
slrstem-Foundationaloublic health serviges-Intent. (wa. gov)
oublic health services-Fundine. (wa.Eov)
Definitions:
FPHS Definitions - https://wsalpho.box.com/s/qb6ss I 0n xbraix0flaT 42lw6zcfxzohk
Special Instructions:
TherearetwodifferentBARSRevenuecodesfor"state lexiblefunds"tobetrackedseparatelyandreportedseparatelyonyourannualBARSreport' ThesetwoBARSRevenue
codes and definitions from the state Auditor,s ofrice 1s, .o's) are listed below along wiih a lini< to the-neRS Manual. 336 -04.25 is the new BARS Revenue code to use forthe
FoundationalPublic Health Services (FPHS) fundsinclur ed in this statement of work'
336.04.24- County Public Health Assistance
to the legislature from this revenue source.
33 6,0 4,2 5 - Fo undatio nal Public Health Servic es
Usethisaccountforthefundingdesignatedfortheloc lhealthjurisdictionstoprovideasetofcoreservicesthatgovemmentisresponsibleforinallcommunitiesinthewA
state. This set of core services provides the foundatior to support the work of the broaderpublic health system and community partnen' At this time the funding from this
account is for de livering ANy or all of the FpHS .o- rori*tle disease services (listed above) and can aiso be used for the FPHS capabilities that support FPHS communicable
disease services as defied in the most curent venion rf FPHS Definitions.
public HealthBudgeting AccountingandReportingSys ;m (BARS) Resources: www.doh.wa.gov/lhjfunding
DOH Program Contact
Marie Flak"e, Special Projects, FoundationalPublic Heal r Sewices, Washington State Department of Health
Mobile Phone 3 60 -9 5 l -7 5 6 6 / marie.flake@doh.wa.eov
Exhibit A. Statement of Work Page 5 of5 Contract Number CLH3 1 0 1 5
Exhibit A
Statement of Work
Contract T erm: 2022-2024
Local Health Jurisdiction Name Kittita s Countv Public Health Department
Contract Number: CLH3 l0 15
SOW Type: Original Revision # (for this SOW)Type of Payment
E Reimbursement
E Fixed Price
Federal Compliance
(check if applicable)
El Prere (Transparency Act)
Ll Research & Development
Fundine Source
ElE"aJrr Subrecipient
E state
t]othe.
Statement of \ilork Purpose: The purpose of this statement
State Physical Activity andNutririon program (SPAN).
of work is to establish funding for Local Strategies for Physical Activity and Nutrition (LSPAN), a project of the
Revision Purpose: N/A
DoH ProgramName or Tifle: LSpAN-Locar Strategies forphysicalActivity &
Nutrition - Effective Januarv 1.2022
Period of Performa nce: I anuaw l -2022 through Seotember 29. 2022
Exhibit A, Statement of Work
Template Created Septe mber 2021
Total
Allocation
03
0
0
0
0
0
00
Allocation
Change
Increase (+)
34
0
0
0
0
0
3
Current
Allocation
0
0
0
0
0
0
0
LHJ Funding Period
Start Date End Date
0L/01/22
BARS
Revenue
Code
333.93.43
Assistance
Listing
Number
93.43
Illlaster
Index
Code
440241
DOH Chart of Accounb Master Index Title
FFY2I PHYS ACTVTY NUTRITION
TOTALS
Payment Information
and,/or Amount
Reimbursement for
actualcosts, notto
exceed totalcontract
funding. See Program
Specific Requirements
Reimbursement for
actualcosts, notto
exceed totalcontract
funding. See Program
Specific Requiements
Due Date/Time Frame
January 1,2022 - September 29 ,2U22
January - Septem 2022
Deliverables/Outcomes
Desigrated KCPHD
staff will participate in
contract management
calls.
Designated KCPHD
sta ff will participate in
calls, webinars, and
meetings.
Activity
STRA
Participate in calls, at a minimum of
once everymonth,with DOH contract
manager. Dates andtime for calls are
mutually agreed upon between DOH
and Kittitas County Public Health
ent
TION:
Particip ate in DOH-sponsored LSPAN
related quarterly conference calls
andlorwebinars, including up to one
Task
#
I
Page I of3 ContractNumberCLH3 I 0 I 5
PRO-GRAM C OMMI-INI C ATI ON:
Inform partners and Public about
program successes and related best
practices, including social media posts
andpublication.
Write a success story related to LSPAN
projects.
PROGRAM EVALUATION:
Participate in performance measure
data collection and program evaluation
activities in collaboration with DOH.
PROGRAM IMPLEMENTATION:
Report quarterly expenditures using
DOH provided template.
PROGRAM iMPLEMENTATION:
Finalize Work Plan andBudget
Workbook using DOH-Provided
templates.
PROGRAM IMPLEMENTATI ON:
Implement finalized community work
plan focused on LSPAN that include:
. Addressing atleast two (2) state
strategies required bY this grant
funding.
r Achieving potcy, systems, or
environmenta I changes consistent
with the strategies.
r Identifyingandreaching
oopulations with health disparities.
Activity
PROGRAM ADMINISTRATION:
Perform administrative duties related to
LSPAN
J
4
2c
2b
1c
2a
#
Task Deli erables/Outcomes
Qua progress
repo ts to DOH via
Shar :Point site or email
ork Plan to
DOI contractmanager
via r rnail
Qua terly progress
rep( ts to DOH via
Sha :Point site oremail
Re; :rt quarterly
exp ndituresusing
DO l-provided
tem rlate.
Qur rlerly progress
repr rts to DOH via
Sha ePoint site or email
copres o any
rele'ant communication
pro .ucts with quarterlY
pro tress reports to
DO I via SharePoint
site rrr email
On, success story using
Exhibit A, Statement of Work
Template Created SePtemb er202l
Reimbunementfor
actual costs, not to
exceed total contract
funding. See Program
Specific Requirements
Reimbursement for
actual costs, not to
exceed totalcontract
funding. See Program
Specific Requirements
Reimbursement for
actualcosts, notto
exceed total contract
funding. See Progam
Specific Requirements
Reimbursement for
actualcosts, notto
exceed total contract
funding. See Program
Specific Requirements
Reimbursement tbr
actualcosts, notto
exceed totalcontract
funding. See Program
Specific Requirements
Payment Information
and/or Amount
Reimbursement for
actualcosts, notto
exceed total contract
funding. See Program
Specific Requirements
r January 17 ,2}z}(covering September 30, 2021-December30, 2021)
r April 15, \O2z(covering December 31,2}Zl}4arch30,2022)
. July 15,2\2z(covering March3l, 2022June29,2022)
r October 17,z}2z(covering June 30, 2022-September29,2022)
Year 4-FFY21:
Draftdue: hily1,2022
Final due: July 29,2022
Year
Year 4-FFY21:
r January 17 ,2022 (covering September 30, 2021-December3},202l)
. April 15,2022 (covering December 31, 2021March30,2022)
15,2022 (covering March 31, 2022Iune 29,2022)Julya
a June 3 0. 2A22 - Seotember 29, 2022\October 17 . 2022 (covering
Year 4-FFY21:
r January 17,2}22(covering September 30,2021 -December30, 2021 )
. April 15, 2}2z(covering December31.,2021March30,2022)
. July 15,2\22(covering March3l, 2022 June 29'2022)
r October 17,z}z2(covering June 30, 2022'Seplember29,2022)
July 15,2022
March25,2
Final due: Year 4 - FFY2l
Year
Due Date/Time Fname
a
a
a
a
January 17 ,2022 (covering September.30 ,2021'December30, 2021)
April 1 5, 2022 (cov ein'g Decemb er 3 1, 202 | March 3 0, 2022)
Juiy 15, 2022 (covermg March 3 1 , 2022 J:une 29,2022)
Year
202292422-June 32022October 17
DO
Page 2 of3 ContractNumberCLH3 1 0 1 5
DoIr Program and Fiscal contact Information for all concon Sows can be found on the DoH Finance sharepoint site. euestions related to this soq or any otherfinance-related inquiry, may be sent to finance@doh.wa.gov
Federat Fundtns Acc (Applies to federalsubrecipient funding.)This statement of work is supported by federal fundt thut t"quit";;phance with the Federal Furroiog a."ourriuuility and rransparency Act (FFATA or the Transparency Act).Thepurpose ofthe TransparencyActis to makeinformationavailableonline so thepublic cansee howthe federalfirndsarespent.
Tocomplywiththisactandbeeligible toperformtheactivitiesinthisstatementofwork,theLHJmusthaveaDatauniversalNumberingSystem(DUNS@) number.
InformationabouttheLHJandthisstatementofworkwillbemadeavailableonUSASpending.govbyDoHasrequiredbyp.L. l0g-2g2.
Pro gram Soecific Requirements
The Local strategies for Physical Activity and Nutrition (LlpeN project is providing funds to Kittitas county public Health Department to implement policy, systems and
priorify populations *ho experience health disparities. LSPAN is part of DoH's State Physical Activity and Nutrition-washington (spANwA) progam. Funding for spANWAisthroughacooperativeagreementawardedtoDoHfromtheceniersforDiseasecontroi andPrevention's(cDC) Dplg-1g07:StatephvsicalActivityandNutritionpropram
Reouired Disclosures for Federal Awardee Perfqr.mance and Integritv Information Svstem ftTAITIJS);Consistentwith45cFR75.1l3,app1icantsandrecipientseCentersforDiseaseControlandPrevention(CDC),withacopytothe
andto the HHS OIG atthe following addresses:
CDC, Office of Grants Sewices, Romero Stokes, Grants Management Officer/Specialist, Centers for Disease Control and prevention Chronic Disease and Birth Defects SericesBnnch,2920 Brandywine Road, Mailstop E49, Atlanta, Georgia 30341, Email, lrr.i0@"o..nou (Include "Mandatory Grant Disclosures,, in subject line)AND
u'S' DepartmentofHealthandHuman services, office of thelnspectorGeneral, ATTN: MandatoryGrantDisclosures, Intakecoordinator,330IndependenceAvenue SW, cohenBuilding Room5527, washington, DC 20201 ,Fax:Q02)2054604(Include"MandatoryGrantDisclosures,, in suuiecttinel orEma il: MandatorvGranteeDisclosures@ois.hhs.eov
Restrictions on Funds:
. Only DOH-approvedbudget expenditureswill be reimbursed.r Subrecipients may not use funds to purchase fumifure or equipment.. Funds cannotbespenton capitalprojectsto supportbuilt environmentchanges.
r Reimbursement ofpre-award costs generally is not allowed, unless DoH provides written approvalto the subrecipient.r The direct and primary recipient in a cooperative agreement program must perform a substantialrole in carrying out project o utcomes and not merely serve as a conduit for anaward to anotherparty orprovider who is ineligfole.
Monitoring Visits: In-person site visits at least once a year
Billing Requirements: Must use the budget workbook supplied by the program
Exhibit A, Statement of Work
Template Created Septemb er2027
Page 3 of3 Contract NumberCLH3 I 0 1 5
Exhibit A
Statement of Work
Contract T erml 2022-2024
DOII ProgramName or Titlel Matemalandchild H ralth Block Grant -
Effsctw e Januaw 1 . 2 122
Local Health Jurisdiction Name : Kittita s county Public Health Department
Contract Number: CLH3 1 0 15
SOW Type: Original Revision # (for this SO\\ I
Type of Payment
X Reimbursement
n Fixed Price
Federal Compliance
(check if applicable)
X rnefa (fransparency Act)
n Research & Development
Funding Source
El Federal Subrecipientn stute
flothetPeriod of Performance: JSny?E-1-Mthrough Seotr rnber30' 2022
statement of workpurpose: The pulpose of this statr nentofwork(sow) is to support localinterventions thatimpaatthetargetpopulationof theMatemalandchildHealth
Block Grant.
Revision Purpose: N/A
DOH Chart of Accounb Master Index Title
Activity
Maternal and Child Ilealth Block Grant Administration
Report actual expenditures forthe six-monthp :riod
October I, 2021 through March 3 1', 2022
Develop 20 22-2023 MCHBGBudget Workbo :kfor
October 1,2022through
provided template.
September 30 ,2023 t sing DOH
Implementation
Exhibit A, Statement of Work
Template Created SePte mber 202 |
3?-147
Total
Allocation
33.t47
0
0
0
0
0
0
0
0
0
33.147
Allocation
Change
Increase (+)
33,147
0
0
Current
Allocation
0
0
0
0
0
0
09130122ot/0U22
LHJ Funding Period
Start Date End Date
333.93.99
BARS
Revenue
Code
93.994
Assistance
Listing
Number
7810122r
Master
Index
Code
1a
1b
#
Task
Payment Information and/o r
Amount
Reimbursement for actual costs,
not to exceed totalfunding
consideration. Action Plan and
Progress Reports must onlY reflect
activities paid for with funds
provided in this statement of work
for the specified fundingperiod.
See Program Specific
Requirements and Special Billing
ents"
Due Date/Time Frame
May27,2022
Septernber9,2022Submit MCHBGBudget
DOH contractmanager
Workbookto
Deliverables/Outco mes
Submit actual expenditures using the
MCHBG Budget Workbook to DOH
contract
Page 1 of3 ContractNumberCLH3 I 0 I 5
Payment rmation and/or
Amount
Reimbursement for actual costs,
not to exceedtotal funding
consideration. Action Plan and
Progress Reports must only reflect
activities paid for with funds
provided in this statementofwork
for the specified funding period.
See Program Specific
Requirements and Special Billing
Requirements.Children and Youth with Health Care Needs
3a Com Health (cH IF)data into Access 15,2022CHIFAutomated System on all infants and children served
bunement for actua
by theCYSHCN Program asreferenced in CYSHCN
Washington website:
https: //secureaccess.wa. eov
Aplil'15,2022
IuIy 15,2O22
not to exceed total funding
consideration. Action Plan and
Progress Reports must only reflect
activities paid for with funds
provided in this statementofwork
for the specified funding period.
unmet CYSHCN on and refer co Health 30 daysato DOH CYSHCN Program forapprovalto access
Diagnostic and Treatment funds to meet the need.
ate
Authorization forrns and Central completed
Treatment
CYSHCN
Fund requests directly to the
as needed.
3c Work with partners to share updated local CYSHCN Review resources foryourlocal area on September30, 2022 See Program Specific
Requirements and Special Billingresources with Within Reach/ Help Me Grow ([IMG).ParentHelg l23.ore annually for accuracy
and submit to Within Reach.
Due Date/Time tr'rame
January 15,2022
April 15,2022
JuIy 15,2O22
DraftAugust 19,2022
Final- September 9,
2022
Deliverables/Outco mes
lubmit quarterly Action Plan reports to
DOH Contractmanager
Submit MCHBGAction plan to DOH
contractmanager
Activify
Report activities and outcomes of 2022 MCHBG Action
Plan using DOH- provided template.
Develop 2022-2023 MCHBG Action Plan for Octo b er 1
2 022 through Septemb J 0 2023er usmg DOH -provided
template.
Task
#
2a
2b
DOH Program and tr'iscal contact Information for all concon Sows can be found on the DoH Finance Sharepoint site. euestions related to this sow, or any otherfina nce-related inquiry, may b e sent to fina nce@.doh.wa. gov
rqq"rat Ftndtng Att (Applies to federalsubrecipient funding.)This statementofwork is supportedby federalfundsthatrequire comptiancewith the FederalFunaiog el.orrliailrty andrransparencyAct(FFATA or theTransparencyAct).The purpose of the Transparency Act is to make information available online so the public .uo r". no* the federalfunds are spent.
To comply with this actand be eligible to perform the activities in this statement of work, the LHJ must have a Data Univen al Numbering System @uNS@) number.
InformationabouttheLHJandthisstatementofworkwillbemadeavailableonusASoendine.govbyDoHasrequiredbyp.L. l0g-2g2.
Pro gram Specific Requirements
Program Manual, Handbootg Policy References:
Children and Youth with Special Health Care Needs Manual -
Health Services Authorization (HSA) Form
http://lvlvw.doh.wa.eov/Portals/l/Documents/pubs/910402-AoprovedHSA.docx
Exhibit A, Statement of Work
Template Created Septemb er202l
Page2 of3 ContractNumberCLH3 1 0 1 5
Restrictions on Funds (i.e., disallowed expenses or ac vities, indirect costs, etc.):
1. At least30% of federalTitle V fundsmustbe used i rrpreventive andprimarycare services forchildren andatleast30To mustbe used services forchildren with
specialhealthcare needs. [Social Security Law, Sec 505(a)(3)].
2. Funds maynotbe usedfor:
a. Inpatient sewices, other than inpatient services or children with special health care needs or higb risk pregnant women and infants, and otherpatient services approved by
Health Resources and Sewices Administration t SRSA)"
b. Cash payments to intended recipients of health ervices.
c. Thepurchaseorimprovementofland,thepurcl ase,construction,orpermanentimprovementofanybuildingorotherfacility, orthepurchaseofmajormedical
equipment.
d. Meeting otherfederalmatchingfundsrequirem nts.
e. . providing fundsforresearch oitraining to any ntityotherthanapublic ornonprofitprivate entity.
f. paymenttbranyservicesfumisheduyapro,nid rorentitywhohasbeenexciudedunderTitleXVlll(Medicare),TitleKX(N4edicaid),orTitle)o((socialservicesblock
grant).fsocial Security Law, Sec 504O)].
3. Ifanychargesareimposedfortheprovisionofheal lhservices usingTitle V MCHBlockGrant)funds,suchchargeswill bepursuanttoapublic scheduleofcharges; will not
be imposed with respect to services provided to low income mothers or children; and will be adjusted to reflect the income, resources' and family size of t he individual
provided the services. [Social Security Law, Sec. 5( :t (1) (D)].
Monitoring Visits: Telephone calls with DOH contract nanagerasneeded.
Billing Requirements: payment is contingent upon DO I receipt and approval of all deliverables and an acceptable Al 9 -1 A invoice voucher. Payment to compietely expend the
of the "TotalConsideration" will notbe accepted orapp oved.
Special Instructions: ContactDOH contractmanagert ,rlow forapprovalof expensesnot reflected in approvedbudgetworkbook.
MCHBG funds may be expended on CoVID-l 9 respon 3 activities that align with matemal arrd child health priorities. Examples may include:
r providingsupportineducatingtheMCHpopu itionaboutCOVID-lgthroughpartnershipswithotherlocalagencies,medicalproviders,andhealthcareorganizations.
. Working closely with state and local emergenc ,preparedness staff to assure that the needs of the MCH population are represen ted'
. Funding infrastructure that supports the respon e to coviD-l9. For example, Public HealthNurses who are routinely supported through the Title V program maybe able
to be mobilized, using Title Vfunds or separat , emergency funding, to support a call center or deliver health services.
r partnering with parent networks and health ca1 , providers to provide accura te and reliable infonnation to all famillies.
. EngagJng community leaders, including faith-l ased leaders, to educate community members about strategies forpreventing illness
Restrictions listed above continue to apply.
Exhibit A, Statement of Work
Template Created SePtemb er 2021
Page 3 of3 ContractNumberCLH3 I 0 I 5
DOH ProgramName or Tifle:
Ianuary 1.2022.
SOW Type: Original Revision # (for this SOW)
Period of Performance: Ianuary l,.2022through December 31. 2022
Statement of Work Purpose: The purpo
community and non-community Group A
Revision Purpose: N/A
Exhibit A, Statement of Work
Template September202 1
Exhibit A
Statement of Work
Conhact T ermt, 2022-2024
Local Health Jurisdiction Name: Kittitas countv public Health Department
Contract Number: CLH3 l0l5
Type of Payment
I Reimbunement
X Pixed Price
Federal Compliance
(check if applicable)
El rrera (Transparency Act)
LJ Research & Development
Fundins Source
El P"AJ*I ContractorX stut"
D other
se of this statement of work is to provide funding to the LHJ for conductingsanitary surveys and providing technical assistance to smallwater systems
TotaI
Allocation
J
J
I
0
0
Allocation
Change
Increase (+)
-t
3
I
0
0
0
Current
Allocation
0
0
I
12t31/22
I
LHJ F'unding Period
Start Date End Date
I
0r/0t/22
I
BARS
Revenue
Code
346.26.65
346.26
Assistance
Listing
Number
A
NiA
N/A
Masfur
fndex
Code
24249224
TE
I
DOII Chart of Accounts Master Index Tifle
STIR
24 SRF .SSASST
-LOCALYR
Payment Information and./or Arnount
Upon ODW acceptanceo f the Final Sanitary Survey
Report, the LHJ shall be paid $400 for each sanitary
suruey of a nonrommunity system with three or
fewer connections.
Upon ODW acceptance of the Final Sanitary Survey
Report, the LHJ shall be paid $800 for each sanitary
survey of a'non+ommunity system with fouror more
connections and each community system.
Paymentis inclusive of all associatedcostssuch as
travel, lodging per diem.
*!4yment is authorized upon receipt and acceotance of
Due Date/Time tr'rame
Final Sanitary Survey
Reports must be
received bythe ODW
RegionalOffice within
30 calendar days of
conductingthe sanitary
survey.
Deliverables/Outcomes
Provide Final*Sanitary Survey
Reports to ODW Regional Office.
Complete Sanitary Survey Reports
shall include:t. Cover letter identifying
significa nt defic iencies,
significant findings, observations,
recommendations, and referra ls
for further ODW follow-up.2. Completed SmallWater System
checklist.
3. UpdatedWaterFacilities
Inventory(WFI).
Activity
LHJ conduct
surveys of small community and non-
community Group A water systems
identified by the DOH Office of Drinking
Water (ODW) Regional Office.
See Special Instructions fortask activity.
The purpose of this statement ofworkis to
provide funding to the LHJ forconducting
sanitary surveys and providing technical
assistance to small community andnon-
A water
Task
#
I
Page 1 of4 ContractNumberCLH3 1 0 I 5
Activity
will conduct I
Purpose Investigations (SPI) of small
community and non-community Group A
water systems identified by the ODW
Regional Office.
See Special Instructions fortask activity.
staffwill
technicalassistance (IA) to small
community and non-community Group A
water systems identified by the ODW
Regional Office.
See Special Instructions fortask activity'
the
tasks I , 2 and3 attend periodic required
survey training as directed by DOH.
See Special Instructions fortask activity
Task
!
2
3
4
Deliverables/Outco mes
, ny supporting documents and photos
o ODW Regional Office.
comp arLy
lupporting documents and photos to
l)DW Regional Office.
For tra a person, pnor
to attendingthe training, submit an
"Authorization for Travel (Non-
Employee)" DOH Form 710-013 to
the ODW Program Contactfor
approval(to ensure enough funds are
s of water system with text
identifying t-eatures
. Any other suPPorting documents.
Final Reports reviewed and accepted
theODW Office.
co and
DoH program and Fiscal contact rnformation for a l concon sow's can be found on the DoH Finance SharePoint site' Questions related to this sow' or any other
fmance-reLted inquiry, may be sent to finance@'doh'w 'gov'
ExhibitA,statementofwork Page2of4 contractNumberclH3 1015
Template September202 I
Upon accebtance of the completed TA Report, the
LHJ shall be paid for each technicalassistance
activity as follows:
o Up to 3 hours of work: $250
o 3-6 hours of work: $500
. More than 6 hours of work: $750
Payment is inclusive of all associated costs such as
consulting fee, travel, lodgrng per diem.
Payment is authorized upon receipt and acceptance of
completed TA Report within the 30-day deadline.
Late or incomplete reports may not be accepted for
DaYment.
e of the completed SPI Report, the
LHJ shall be paid $800 for each SPI.
Payment is inclusive of all associated costs such as
travel lodging, per diem.
Payment is authorized upon receipt and acceptance of
completed SPI Reportwithin the 2-working day
deadline.
Late or incomplete reports may not be accepted for
Upon acceptanc
Davment.
Payment Info rmation and./or Amount
the Final Sanitary Survey Report within the 30-day
deadline.
Late or incomplete reports may not be accepted for
payment.
Annually
CompletedTA Report
must be received bY the
ODW Regional Office
within 30 calendar
days of providing
technicalassistance.
Completed SPI RePorts
mustbe received bY the
ODW Regional Office
within 2 working daYs
ofthe service request.
Due Date/Time Frame
To comply with this act and be eligible to perform the activities in this statement ofwork, the LHJ must have a Data Univers al Numbering system (DSNS@) number.
InformationabouttheLHJandthisstatementofworkwillbemadeavailableonUSASpending.eovbyDoHasrequiredbyp.L.
10g-2g2.
ProgramManual, Handboolg PolicyReferences: Field Guide @OH Fublication33l4g6).
Special References:
chapter246'290 wAC is the set of rules that regulateGroup A water systems. By this statement of work, oDW contracts with the LHJ to conduct sanitary surveys (and SpIs and
SPIs and provide technical assistance) for small community ana non-cLmmuniiywater"y.t&". *ittt r*;;.;;;";;;";;;;.g" water sysrems, and systems with complextreatment.
LHJ staff assigned to perform activities under tasks 1,2, and3 must be trained and approved by oDW prior to performing work. See special instructions underTask 4, below.
Special Billing Requirements
The LHJ shall submit quarter$ invoices within 30 days following the end of the quarterin which work was completed, notins on the invoice the ouarterand vearbeing billed for.Paymentcannot exceed a maximum accumulative fee of $7,200}orTask 1, and $1,000 for Task 2, Task 3 and rask 4 combined during the contractingperiod, to bepaid attheratesspecifiedinthePaymentMethod/Amountsectionabove.
346.26.6s.
when invoicing for Task 1, submitthe list of wS Name, ID #, AmountBilled, Suwey Date andLetterDate forwhich youare requestingpayment.when invoicing for Task 2-3, submit the list of wS Name, ID#, TA Date and description of rA work performed, andAmount Billed.when invoicing for Task 4, submit receipts and the siglea' pre-aJrto.i"utio" ro.- f;;;;-;;;;f ee travel to the oDW program contact below and a signed A1 9-l A Invoicevoucher to DoH Grants Management, billing to BARS Revenue cod e 346.26.66 under technicai Assistance (TA).
(Applies to federalgrant awards.)This statementof work is supported by funds tha trequire compliance with the Federal Funding Accountability and Trans parency Act (FFATA or the Tra nsparency Act).Th e purpose ofthe Transparency Act is to make information available online so the public can see how the federal funds are spent.
Special Instructions
Task I
guidanceis providedin the FieldGuideforsanitarysirveys, specialPurposelnvestigationsind^TechnicarAssistance(Field Guide). The sanitarysurveywill include an
,rrt"i:l[fffTJr#"T:1"*ment and operation; and certified operator.o.opliuo".. If a system is morJ comptex tian anticipar ed ororhersipificant issues arise, the LHJ may
r No morethan2 surveys ofnon-communitysystemswith three of fewer connectionbecompletedbetween January l,z022andDecembe r31,2022.o No morethan8 surveys ofnon-communitysystemswith fourormore connectionsandallcommunitysystemsto be completerdbetweenJanuary 1,2022and,December 3l ,2022.
frt#L":j *f#ttrfrT:"j*rv;ria:: the LHJ, notification of the water svstem, and oDW follow-up wirh unresponsive water systems; and orherroles and responsibilities of
Task 2
Exhibit A, Statement of Work
Template September202 I
Page3 of4 ContractNumberCLH3 I 0 I 5
Coia.. fn."OOW Regional Office must authorize in ad, ance any SPI conducted by LHJ staff'
Task 3
Trained LHJ staff will conduct Technical Assistance as ssigred by oDW. Technical Assistance includes assisting wat€r svstem penonnel in completing work or verifying work
Field Guide. The oDW d"gio"ur 6ffice must authorizi n advance any technicalassistance provided by the LHJ to a water system '
Task 4
LHJstaffassignedtoperformactivitiesundertasksl,2 and3mustbetrainedandapprovedbyoDWpriortoperformingwork'
LHJstaffpersonmay,withoDWapproval,substitutec hertrainingactivitiestobedeterminectyoow. suchsubstituteactivitiesmayincludeone-on-onetrainingwithoDW
staff,co-surveyswith oDw staff,orotheractivitiesas,,nangeouniptr-uppiou.auyopw. LHf staffmaynotperformtheactivitiesundertasksl,2,and3 withoutcompleting
the tra ining that has b een arranged and approved by OD V'
Exhibit A, Statement of Work
Template September202 1
Page 4 of 4 Contract NumberCLH3 1 0 1 5 {
Exhibit A
Statement of Work
Conhact T erm: 2022-2024
DOII ProgramName or Tifle: Office ofDrinking WaterGrouo B Proerams - Effective LocalHealth Jurisdiction NameIatuawl.2022
Period of Performance: Januarv 1.2022 through June 30. 2023
Kittitas County Public Health Deoartment
Contract Number: CLH3 101 5
SOW Type: Original Revision # (for this SOW)Type of Payment
E Reimbursement
X Fixed Price
Federal Compliance
(check if applicable)
n PPefe (fransparency Act)
LI Research & Development
Funding Source
I f.AJ*f <Select one>
EI staten otne.
StatementofworkPurpose: Thepurposeofthisstatementofwork(sow) istoprovidefinancialsupporttoLHJsimplementinglocalGroupBwatersystemsprograms.
Revision Purpose: N/A
DoIr Program and Fiscal contact Information 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.gov.
*Forrnformationonly:FundingisnottiedtotherevisedStandards/Measureslistedhere. Thisinformationmaybehelpfulindiscussionsofhowprogramactivitiesmight
contnbute to meeting a Standard/Measure. More detail on these and/orother Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:htto://www.phaboard.org/vp-content/uploads/PHAB-Standards-and-Measures-Version-l.0.odf
SpecialBillingRequirements: ForJanuaryl,2022-June30,2022,theLHJsha11 submitoneinvoicenotlaterthanJune30,2022andpaymentcannotexceedamaximum
cumulative fe e of $25,87 7 .
Exhibit A, Statement of Work
Template September202l Page I of I gontractNumberclH3l0l4
Total
Allocation
25,877
0
0
0
0
7
Allocation
Change
lncrease (+)
25 7
0
0
0
0
77
Current
Allocation
0
0
0
0
0
0
LIIJ Funding Period
Start Date End Date
01 t/22
BARS
Revenue
Code
3
Assistance
Listing
Number
Master
Index
Code
24240t03
DOH Chart of Accounts Master Index Title
B
TOTALS
Payment Information
and/or Amount
Lump sum payment (See
Special Billing
Requirements)
Due Date/Time
Frame
January 1,2022
thru June 30,2022
Deliverables/Outco mes
An executed Memorandum of Agreement (MOA) with
DOH identifying responsibilities of a full Group B
progam thrqugh a LocalOrdinance.
Activity
Implement a Group B water
Loca I Ordinance. Reference
system program through a
DOH MOA #CLH23577
Task
#
1
SOW Type: Original Revision # (for this SO$
'
Period of Performan cel. lztryWJ$22 through June li0. 2024
Statement of work purpose: The purpose of this statt :nent of work (Sow) is to provide funding to conduct CovID-l9 vaccine activities'
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
COVID19
TOTALS
Activity
DOH ProgramName or Title: office oflmmunizati ncouD-l9 Vaccine -
Effective January 1.2 122
Local Ilealth Jurisdiction Na me : Kittita s Countv Pub Lic Hea lth Deo artme nt
Contract Number: CLH31015
Exhibit A
Statement of Work
Contract T erm: 2O22-2024
Identify a ctivity/activities to supp o rt COVID a c c ine re sp onse
in youicommunity,using the examplesbelov as a guideline.
Example 1: Develop and implement commul ication strategies
with health care providers, community, and/c otherpartnen to
help build vaccine confidence broadlyand au onggroups
anticipated to receive early vaccination, as we il as dispel
vaccine misinformation. Document and provi .e a plan that
shows the communication strategies used witl health care
providers and other p artners and the loca lly id :rntified
population anticipated to reach.
Example 2: Engage in other vaccination plar
such ai partnership development, provider ed
ringactivities
lcation,
vaccination int of
Type of Payment
EI Reimbursement
! rixed Price
Federal Compliance
(check if applicable)
X ffefe (Iransparency Act)
n Research & Development
Funding Source
E Federal Subrecipientn state! other
0
0
0
0
0
359,803
Total
Allocation
3 59,803
0
0
0
0
0
3s9"803
Allocation
Change
Increase (+)
359,8030
0
0
0
0
0
0
Current
Allocation
06130124
LI{J Fund ing Period
Start Date End Date
01/01/22
BARS
Revenue
Code
333.93.2693.268
Assistance
Listing
Number
Master
Index
Code
74310230
Task
#
3.A
Payment Information
and/or Amount
Reimbursement for actual
costs incurred, not to
exceed totalfunding
consideration amount.
Due Date/Time Frame
January 3l,AnnuallySummary of the engagement strategies to
be used with health care providers and
other partners, and the lo cally identified
population to be reached.
Deliverables/Outcome s
Exhibit A. Statement of Work Page I of3 ContractNumber CLH3 I 0 I 5
Payment Information
and/or Amount
Reimbursement for acfu al
costs incurred, not to
exceedtotalfunding
consideration amount.
Reimbursement for actual
costs incurred, not to
exceed totalfunding
consideration amount.
Reimbursement for actual
costs incuned, not to
exceed totalfunding
consideration amount.
Reimbursement for actual
costs incurred, not to
exceed total funding
consideration amount
Due Date/Time Frame
June 30, Annually
December 31, Aanually
March 3 l, Annually
June 30, Annually
a. Prior to implementing
b. March 31, Annually
June 30, Annually
Deliverables/Outco mes
Mid-tenn written report describing-
aclivrty / actwities and progress made to -
date and strategies used (template to be
provided)
(template to be provided)
Fina
used
I written report, showing the strategies
and the final progress of the reach
Quarterly reports summarizing quantity,
type, and frequency of activities
a
b
LHJ Incentive Plan hoposa
Quarterly report that summarizes
quantity of incentives purchased and
distributecl
Activity
exerc engagementwith leaders, non-
traditionalprovider, or vulnerable populations to develop
stra to ensure ble access to vaccination seryices
Implement the communication strategies or other activities,
working with health care providers and otherpartners to reach
the loca lly identified p opula tion, supp ort providers in
vaccination plans, and support equitable tccess to vaccination
services.
Cata lo g a ctivities and conduct
used
an evaluation of the strategies
to meet needs,operatlons to
increase vaccine throughput (i.e., providing vaccinations during
evenings, ovemight, and onweekends). Activities may include
vaccine strike teams, mobile vaccine clinics, satellite clinics,
temporary, or off-site clinics to travel and provide vaccination
services in non-traditionalsettings, or to supplementthe work
of local health departments in underserved communities, and
may include administration costs for other vaccines co-
administered atthe events. These activities
local health department orin collaboration
may be done by the
with communify
see Restriction on Funds
COVID va cctne,adhering to LHJ Guidancefor
to persons recervmgs
COTID
Initi atives Application req urements nd a llowa ble/unallowab le
of federal
Task
#
3.8
3.C
3.D
3
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DoH Finance SharePoint site. Questions relatedto this sow, or any otherfinance-related inquiry, may be sent to finance@doh.wa.eov.
Federal Funding Accountability and Transoarency Act (F,FATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and rransparency Act (FFATA or the Transparency Act).The purpose of the TransparencyAct is to make information available online so the public can see how the federalfunds are spent.
To comply with this act and be efigible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS@) number.
Information about the LHJand this statement of work will be made available on USASpending.gov by DOH as required by p.L. l0g-2g2.
Pro gram Specific Reouirements
Restrictions on Funds (i.e., disallowed expenses or activities, indirect cosh, etc.):
Exhibit A, Statement of Work Page 2 of3 Contract Number CLH3 I 0 1 5
Coverageofco-administrationcostsforothervaccinesa(rninisteredatvaccinationeventsdoesNOTapplytotheFEMAMassVaccinationfunding. Coverageofco-
adminis'iration costs only applies to the vaccine funding (r IOVIDl g Vaccine R4, MI 7 4310230)allocated forTask 3 of the consolidated contract. FEMA Mass Vaccination
i""Ji"g L onty availaUie to cover the costs for COVIDIr ccine administration and cannot beused for co -administration costs of other vaccines'
Exhibit A. Statement of Work Page i of3 ContractNumberCT.H3 1 0 1 5
e
Exhibit A
Statement of Work
Contract T erml. 2022_2024
DOHProgramNameorTitIe:LocalHealthJurisdictionName:
Effective January I . 2022
SOW Type: Original Revision # (for this SOW)
Period of Performance: January 1.2022through December 31. 2024
Type of Payment
El Reimbursement
I Fixed Price
Federal Compliance
(check if applicable)
El rFera (Iransparency Act)
LJ Research & Development
f,'undins Source
El E.OJrat Subrecioient
U State
E otttet
SupplementalNutrition Assistance Program -Education (SNAP-Ed) to improve the likelihoodchoices within a limited budget and choose ac tive lifestyies consistent witt the current USDA
Kittitas Countv Public Health Deoartment
Contract Number: CLH3 l0l 5
statement of work Purpose: The purpose of this statement of work is to providethat persons eligible for SNAp (Basic Food, Food stamps; win make heattny rooadietary guidelines.
RevisionPurpose: N/A
Exhibit A, Statement of Work
Template Sep temb er 2021
Total
Allocation
l830
0
0
0
0
0
3
Change
Increase (+)
18J
0
0
0
0
0
Current
Allocation
0
0
0
0
0
0
0
09130t22
LHJ Funding Period
Start Date End Date
0l/01t22
BARS
Revenue
Code
333.10.56
Assistance
Listing
Number
10.561
Master
Index
Code
76701937
DOH Chart of Accounts Master Index Title
MGNT-R-EGION 2PROGEDSNAPIARFFT22
Payment Information
and/or Amount
Reimbursementupon
on-time receipt and
approval ofacceptable
deliverables/out-
comes forthe funding
period will not exceed
$30,818. Kittitas
County Public
Health Department
will be paid the
allowable costs
Due Date/Time Frame
For the Period:
0l/01/22to 09/30/23
| 0 / 0 1 / 23 to 12 / 3 1 / 24 TBD
Due: per the approved work
plan andperthe required due
dates during the federalfiscal
year, and no later than
09 /30 /23. r0 I 0 | /23 to lzl 3 I I 24
TBD.
Activify Delivera bles/Outcomes
Project Planning,Implementation, and ProJ ectprovides 100% of SNAp-Ed activities atPerformance
For SNAP-Ed, the Subrecipient will develop,
implement, and evaluate a SNAp-Ed project
included in the Washington SNAp-Ed Stlte plan
approved by Department of Social and Health
Services (DSHS) and United States Department of
Agriculture (USDA); and,asdescribed in the
Subrecipient's project work plan approved by
Department of Health @OH).
I
2.
eligible sites and/orwith eligible audiences.
On-time delivery, implementation, and
evaluation of Project activities as scheduled in
approved state plan and proj ect work plan.
Project plan supports at least one State SNAP-
Ed goal as selected by Subrecipient.
Demonstrates progress towards prdect
objective(s), and additionalproject goa(s)
deterrnined by Subrecipient are demonstrated
J.
4.
and
#
Task
1.0
Page 1 of12 Contract Number CLH3 I 0 1 5
1.1
T
Task Activity
Monitoring and ComPlia rce
Subrecipient will demonst lteProject Progress:
For SNAP-Ed, the
includes shown in the
satisfactory progress of the approved Proj ect i s
documentedinDOH SNAP-Ed progress repo ts,
progress reviews, and project and fiscalmoni :ring
reports.
Monitoring of Subrecipient Project progress i 'cludes
butis notlimited to thefollowing activities:
i. one-on-one progress reviews with DOH'
ii. progress reports submittedto DOH'
iii. projectmonitoring completedwith DOH rr
DSHS or USDA, and
iv. projectmonitoring site visits completedl 'y
SNAP-Ed statewide initiative teams'
Satisfactory pro gress of the Subrecipient's Pr ,j ect
s and
Exhibit A, Statement of Work
Template September202 I
See payment
information as
referenced in task
number 1.0
Payment Information
andUor Amount
based on theh
approved budget and
program allowability.
See special billing
requirements section.
**NOTE: The DOH
SNAP-Ed progftIm
will denypaymentfor
any costs not
submitted by the
required due dates
without prior DOH
approvalin writing.
For the Period:
0l/01/22to09130123
"l0/0I /23 to l2I3 | I24 TBD
Due: Progress reviews. Occur
atminimum once a fiscalYear,
a nd no hter than 09 I 3 0 123'
10 /01 123 to I2l3l 124 TBD'
Due; Project monitoring.
Occurs atminimumonce
within every other fiscalYear'
Ifproject monitoring
documents maj or deficiencies
or corrective action, the
Subrecipient will be monitored
again within the fiscal Year.
canbeect
Due Date/Time Frame
site(s) or audience(s) to DOH.
All sites and/oraudiences are determined to be
eligible per current SNAP-Ed eligibility
guidanci and DoH pro cess before pro gramming
begins with site(s) or audience(s).
Dernographic data of class participants is
collected and reported for all direct education
strateges.
4. On-time reporting of actualparticipant reach to
DOH in aPProved method/fomt'
5. Intervention strategies implemented as planned
or using approved altemate strategies'
6. Approved evaluationplansand methods
implemented for the project (e.g' pte and post
suweys for direct education; PSE assessments)'
J
il.
2.
f proposed list of Proj ectOn-time delivery o
Deliverables/0utcomes
approved cost-effective mea sure
MEASURX
Sites and audiences included in Project by
Subrec ip ient do cumente d a s a pproved eligib le sites
or audiences.
Documented required reporting by Subrecipient of
the delivery, implementation, and evaluation of
approved Proj ect activities in the required PEARS
on-line reporting modules, where relevant to Project
@rognm Activities, PSE Site Activities, Indirect
Activities, Co alitions, Partnership s, and Success
Stories), andin a progress report fonn/system
approvedbyDOH.
Documented reviews of Subrecipient Project
activities througtr required reporting andproject and
fiscal monitoring reviews and reports.
Cost per reach meets current cost-effective measure
5 ss per currentmaect
providedby
DOH or DSHS.
DOH.when
are
Page2 of 12 Contra ct Nurnber @1-gL5
a
Payment Information
and./or Amount
Due Date/Time Frame
deemed necessary by DOH, or
if agreed upon by both parties.
Due: Fiscal monitoring. Each
Subrecipient receives one (1)
annual fiscal monitoring visit
every other year, unless
Subrecip ient monitoring results
in corrective action or finding
in which case Subrecipient will
be monitored again the
following year. Fiscal
monitoring can be scheduled
more frequently if deemed
necessary by DOH, or if agreed
upon by both parties.
ifmore
Deliverables/Outco mes
and outcomes of project, and to adapt the proj ect
as needed.
8. Strategy as feasible for working with one or
more CSOs implemented and demonstrated to
increa se knowledge, awa reness, or p articip atio n
of SNAP-Ed eligible audience.9. Strategy forpromoting available Federal, state,
or local fruit and vegetable incentive progam(s)
is implemented and demonstrated to incriase
knowledge, awareness, or participation of
program(s) in SNAP-Ed eligible audience.
10. Direct education strategies only: Statewide
SNAP-Ed Curriculum team orDOH monitoring
reviews show education delivered with fidelity,
with no major deficiencies. If majordeficiencies
docum ented, corrected prop erly within tim eline
required.
1 1. Compliance maintainedwith cunent SNAp-Ed
financialand costpolicy guidance, 2 CFR 200
federa I Uniform Adm inistrative Require m ents
(OMB guidance), andrelated DOH SNAp-Ed
fiscal policy and procedures.
MEASI]RE
Progress reviews - documentation of one-on-one
meeting(s) with DOH SNAp-Ed staffperson(s) and
Subrecipient completed in person, web conference ,
phone, or vja email as needed. Documentation of
progress review notes.
Project monitoring - completed in person, web
conference, phone, or via emailas needed.
Completion of on-site program obssrvations where
applicable. Completion of project monitoring report
form s, with monitoring results documented and
provided to Subrecipient.
Fiscal monitoring - documentation of completed
fiscal reviews scheduled by SNAp-Ed fiscal analyst
orDOH fiscal monitoring unit, with corresponding
reports where applicable. Fiscal monitoring
completed in person, web conference, phone, or via
email asneeded.
are used to report progress7
Activity
completed:
I . Progress demonstrated in achieving goal(s)
outlined in the project.
2. Progress demonstrated in achieving objective(s)
outlined in theproject's interventions.
-
3. Progress demonstrated in creating a sustainable
project.
4. Progress demonstrated in engaging or involving
the community in proj ect planning
implementation, and/or evaluation.5. Progress demonstrated inworking with DSHS
community services offices (CSOg.
6. Progress demonstrated in promoting available
Federal state, or local fruit and vegetable
incentive programs to SNAp clients.7. Progress demonstratedinusing strategies that
are evidence-based and delivered with fidelity,
where applicable.
8. Compliancewith current SNAp-Ed financial
and costpolicy guidance and 2 CFR 200 federal
Uniform Administrative Requirements (OMB
guidance).
ln and/orrepo
#
Task
Exhibit A, Statement of Work
Template September202 I
Page 3 of 12 ContractNumberCLH3 1 0 1 5
2.0
#
Task Activity
tion Data a rts
For SNAP-Ed, the Subrecipient will report prol ess
of the approved project and work plan, includin
ongoing evaluation of the project and outcomet
using an approved form/system on a regular bar ls
that will at a minimum include:
1. Progress rePorts
2. Reporting in PEARS online reporting
system of all SNAP-Ed activities
SNAP-Ed activities implemented and evaluatic r of
the proj ect and outcomes are reported in an onL te
pro gram evaiuation and reporting system @EA'S)
through the following required modules as
appropriate for the approved proj ect: Progam
eitivity (direct education),Indirect Activity (h alth
promotion,indirect educationchannels), PSE S te
Activities, Partnerships, Coalitions, Success Stt :ries,
and Social Marketing.
The following evaluation activities and inform tion
are required based on the Subrecipient's appro ed
project and work plan.
r Formative evaluation
. Process evaluation
r Outcome evaluation
r Qualitativeevaluation. Evaluation of PSE strategies
Please Note : the deliverables may change ba st i on
state SNAP-Ed Evaluation guidance, DSHS, or
USDA requirements.
Please Note: Topics included in Progress Rept rt
subject to change based on Department of Hea lh
(DOH), Department of Socia I and Health Serv :;es
(DSHS), WashingtonSNAP-Ed (WA SNAP-E ), or
United States Department of Agriculture (JSD r)
Food andNutrition Services (USDA) requiren :nts'
Exhibit A, Statement of Work
Template September202 I
Payment Information
and./or Amount
See payment
information as
referenced in task
number 1.0
Due Date/Time Frame
01101122to 09130/23
1 Ct I 0 1 123 to 1 21 3 1 124 TBD
Progress Reports: Due at
minimum quarterly, and no
larter than 10 calendardays afto
the end of the quarter, except
for the last month of the FFY
which is due by 9lI5l22.If the
1 Oth calendar day falls on a
weekend day, the report is due
the nextbusiness day.
r lst Progress report due
1,/11122
r 2ndProgress report due
4/12122
. 3rd Progress report due
711,2122
. Final Progress report due
9115/22 or follow close-out
procedures.
n FFY 23-24TBD
PEARS: Project evaluation and
reporting required between
10/1121to9175122.
Direct education
strategies only: PEARS
Pro gram Activities module
updatedwith completed
activities no later than two
(2) weeks afterservices are
provided.
Due: PEARS Indirect
Activities, PSE Site
Activities, Partnenhips,
Coalitions, Success Stories,
and Social Marketing
modules completed no
later thanthe last business
a
a
Deliverables/Outcomes
and materials for all SNAP-Ed funded activities
implem ented, including:
1. Progress for all intervention strategies reported
for approved project Plan.2. All evaluationresults reported for approved
project plan (fomrative, process, outcome,
qualitative, PSE).
3. Success stories reported forapprovedproject
plan describing progress or success of project
activities, or positive change or improvement in
SNAP-Ed eligible site(s) or audience(s)'
4. Required release form(s) for allphotos
submitted.
5. Direct education strategies only: All required
information for scheduled direct education
lessons submitted to Statewide SNAP-Ed
Curriculum team, using approved form/system,
by datesrequired.
On-time and correct submission of required
evaluation data fordirect education strategies into
PEARS electro nica lly, or usin g ap proved rep ortin g
method, according to time frame provided,
including:
6. Direct education shategies only: Pre-test
surveys for each proj ect cla ss series are entered
into PEARS by Subrecipient no later than two
weeks aftercompletion of the pre-test survey.
7. Direct education strategies only: Post-test
surveys for each project cla ss series are entered
into PEARS by Subrecipient no later than two
weeks aftercompletion of the post-test survey.
8. Direct education skategies only: Demognphic
cards for each class series are entered into
PEARS by Subrecipient no later than two weeks
aftercollection of the demographic cards.
MEASI]RE
Documentation showing completion of progress
report and submission to DOH on or before the
required due dates, or by approved extension date'
correct-tune aOn taof reporting,
Page 4 of 12 ContractNumberCLH3 1 01 5
o
Payment Information
and/or Amount
inforrnation as
payment
Due Date/Time tr'rame
when the activitytook
place, except for the last
monthof the FFY which is
dueby9l15/22.
. Jan2o22by
: 2/26122
r Feb 2022by 3/31/22c Mar2022by 4130122. Apr 2022by 5l3l/22. May2022by6/30/22
. Jun 2022by
. 7 /30122
r Jul 2022by
o 8/31122
. Aug 2o22by 9ll5/22r Final data entry forall
activities not already
reported, due by 9 / 1, 5 /22,
orfollow closeout
schedule.
. FFY23-24 TBD
SNAP-Ed Direct education
conducted b etween 0 | / 0 I / 22
and 9 / 1 5 / 22. FFY23 -24 TBDr Direct education
strategies only:
Completed Pre- andpost-
test surveys are entered
into PEARS databaseby
Subrecipient no later than
two weeks after
completion of the survey.
All completedpre- and
post-test surveys must be
entered by Subrecipient, no
later than COB 9/15/22,or
follow clo se-out schedule.
monthv
0l/01/22to 09130/23
10/01 /23 to I2/3 1 /24 TBD
Deliverables/Outco mes
Completion o f required eva luation da ta in pro gress
reports andPEARS electronically, or using approved
reporting method/form, on or before the required due
dates, or by approved extension date.
Direct education strategies only:
1. Entry of required SNAP-Ed participant surveys
into PEARS using DOH approvedmethod,on
or before the required due dates or by approved
extension date.
2. Completion of required evaluation data into
PEARS elecfronically, or using approved
reporting method, on or before tle required due
dates for data entry, or by approved extension
date.
training for all SNAP-Ed funded sraff.
Rightsof anOn-time
Activity
All SNAP-Ed funded sta ff must co mp lete tra ining
rin civileach fiscal
Civil Righb
#
Task
Exhibit A, Statement of Work
Template September202 I
Page 5 of 12 Contract NumberCLH3 1 0 1 5
3.1
ufr
Task Activity
special requirements n- Civil Rightt
Docum entation must include:
r Training and source
. Who attended
r Date co
Other Required Training and Meetings
The following trainings or meetings are requir< i for
all Subrecioients when provided by DOH or \& :\
SNAP-Ed forthestafflisted, Unless more staf
attendance is required, minimum of one (1) sta 'f
person required to attend to satisfy requiremen ri.
Multiple sta ff may attend if co sts for attendanr ; are
covered in Subrecipient's annualbudget.
a
a
a
Fiscal training - fiscal agent or project
coordinator, whoever is mostresponsible .rr
creating and monitoring budget, procurem :ints,
invoices, budget decisions, or budget
amendmenb forthe SNAP-Ed program.
Food handler training - all staff who wil
handle,prepate, cook, assemble, and/orse ve
food or drink to participants or the public.
Training on data collectionand reporti: g -
proj ect coordinator 91 any staff person
responsible for collecting, reporting, or en ering
SNAP-Ed relateddata.
Regional meeting(s), when provided - p :oject
coordinatoror any qualified designated st ff
person.
Annual State SNAP-Ed forum, when
provided - project coordinatorg! any qut lified
designated sta ff person.
SNAP-Ed Curriculum training (either n
person or online) (only required fordire< .
education strategies) - project coordinato qg
qualified desigrated staff person responsi le for
deJivering SNAP-Ed curricula to SNAP-E t
eligible audience.
SNAP-Ed Systems Approaches forHea thy
Communities training (online or inper on,
when
a
a
Exhibit A, Statement of Work
Template September202 1
Payment Information
and/or Amount
referenced in task
number 1.0
See payment
information as
referenced in task
number 1.0
Due Date/Time Frame
Due: 0 I I 0 1 I 22 for all SNAP-Ed
funded staff. FFY23-24 TBD.
New hires to complete within
30 days of hire.
For1he JEnsd:-
0l/0r/22to 09/30123
10 l0t /23 to r2/3 1 124 TBD
Fiscal: Annually, andno later
tlran March 3 1,2022. FFY23-
24TBD.
SNAP-Ed Curriculum: New
direct education staff trained
within 3 0 days for specific
curriculum to be used in direct
education strategy, or before
providing SNAP-Ed direct
education activities to SNAP-
Ed audience. Project
c o ordinator or qua lified
desigrated sta ff person to
c omp lete additiona I SNAP-Ed
Cjurriculum training when new
information is provided for
specific curriculum to be used
in direct education strategY.
Data collection and rePorting:
Annually, or more often as
needed. If approved data
collection system chauges,
every SNAP-Ed funded staff
memberentering data will be
required to complete training
on any new expectations or
system changes on the daY of,
or within 30 days of when the
training is provided.
Submission of docum entation showing completed
Civil Rights training for all SNAP-Ed funded staff
on or before the required due date.
On-tim e comp letio n o f a ll required tra inings by
required SNAP-Ed staff.
Attendance of required or appropriate staff person(s)
at a 1l required meetings.
Demonstra tion o f satisfactory understandin g of the
information and concepts included in required
trainings.
SNAP-Ed Curriculum: On-time completion of
required training forspecific curriculum to be used
in direct education strategyby project coordinator or
qualified desigrated staff person responsible for
delivering SNAP-Ed curricula to SNAP-Ed eligible
audience.
tr'ood handler training: Completion of a
Washington State authorized food handleror food
worker training by all staff who will handle and
serve foodto the Public.
Coordinator meetings: Attendance of project
coordinatoror qualified, desipated staff person to at
least 50% of a1l coordinatormeetings provided.
Regional meetings: Attendance of project
coordinatoror qualified, designated staffperson to at
least 50% of all regional meetings provided.
State Forum: Attendance of project coordinatoror
qualified, desigrated staff penon to all state forums
provided.
SNAP-Ed Systems Approaches for IIealtW
Communities: Demonstrate satisfactory
understandingof the information and concepts
included in the training. Satisfactory application of
knowled ge and skill leamed fro m tra ining to SNAP-
Ed project, asneeded.
Deliverables/Outcomes
coordinator all
Page 6 of 12 ContractNumber@!9L5
s
l9
Payment Information
and/or Amount
See payment
information as
referenced in task
number 1.0
See payment
information as
referenced in task
number 1.0
Due Date/Time Frame
when provided, andno later
than 9 I 30 /22.FFY23 -24 TBD
Coordinator meetings:
Completed on dates scheduled
by DOH, when provided.
Regional meetings : Completed
on dates scheduled by DOH,
when provided.
SNAP-Ed systems approaches
training online: At leastonce
within the three yearperiod of
performance, and no Iater than
the end of the first fiscal year
within the three yearperiod of
performance.
r Due: Onorbeforeg/30/22.
FFY23.24 TBD.
Annual tr'orum
For the Period:
0l/01/22to 09130/23
l0 /01 /23 to l2/3 I /24 TBD
Due: Inventorylist is required
to be updated atminimum
annually and no later than
9 / 1 5 I 22. FFY23 -24'tBD.
At the time of a fiscal or project
monitoring review, or when
requested, an up-todate
inventory list mustbe made
available.
For the Period:
01/01/22to 09/30/23
l0/01 /23 to l2/3 I /24 TBD
Due: Monthly- Submit
invoices to DOH no later than
DeliverableVOutcomes
Subrecipient is notrequired to makeup requirements
for attendance and will be in compliance. Attendance
atrequired meetings and completion of required
trainings required only when provided.
MEAST]RE
Documentation showing required penon(s) and
date(s) of attendance forall web-based and in-person
required meetings.
Documentation showing required person(s); date(s)
of attendance; and, completion of training for all '
web-based and in-person required trainings.
Documentation o f satisfactory understanding gained
from required trainings, and application of applicable
knowledge andskills in progress reviews and-/or
monitoring reports.
meeting or rs
On-time tes to mventory
1 Inventorylist updatedperduedatesrequired.2. Inventory list contains complete list of all items
purchasedwith SNAP-Ed funds in current fiscal
yearandprevious fiscalyears still in use andin
possession of the Subrecipient.
MEAST'RE
Completed documentation showing updated SNAp-
Ed inventory using approved form/system provided
On-time delivery of correct comp letion of SNAP-Ed
A19 invoices, using the cunent form for the fiscal
year.
On-time delivery of
costs to be reviewed
detailed ledger supporting the
by SNAP-Ed prosam via rhe
Activity
staff invo ln
evaluating SNAP-Ed project activities.
Project coordinator meetings (conference
calls or in person) -project coordinatorqg
qualified designated staffperson.
a
SNAP-Ed Subrecipients are required by regulation to
keep an up-to-date inventory list that includes all
non+ap ital equipm ent, approved cap ital equipment,
purcha sed curriculum, and other SNAp-Ed
purchased items that are not disposable. This list
should include items purchased in prior fiscal years
still in use and in possession of the Subrecipient.
This list should be updatedperthe due dates
required. Agencies are required to follow the DOH
SNAP-Ed Inventory policy and procedure.
*See special requirements section - Monitoring
SNAP-Ed A19 Invoices
Subrecipients must use the Al9 invoice form
specific to the DOH SNAP-Ed program. This
documentwill be sent to all Subrecipients prior to
October 3 I st of the cunent fiscal year.
Task
#
5.0
Exhibit A, Statement of Work
Template September202 I
PageT of12 Contract NumberCLH3 1 0 I 5
#
Task Activity
DoIr program and Fiscal Contact Information for r ll ConCon SoWs can be found on the DoH Finance SharePoint site. Questions related to this sow, or any other
finance-related inquiry, may be sent to finance@.doh.u 1499'
Federal Funding Accountability and Transparency \ct fFF.'ATA) (Applies to federal grant awards')
This statementofwork is supportedby federalfuffii ,rtr"quit *pliance with the FedJralLFunding Accountability andrransparencyAct(FFATA or theTransparencyAct)'
The purpose of the Transparency ect is to make inforn ation available online so the public can see how the federalfunds are spent'
Tocomplywiththtsactandbeeligible toperformthe ctivitiesinthisstatementofwork,theLHJmusthaveaDatauniversalNumberingSystem(DUNS@) number'
Information about the LHJ and this statement of work ' ''ill be made available on @!$pggljgggqg by DoH as required by P'L' 109 -282'
Prosram Specific Requirements/Narrative
. contractorshallensure,andshallrequireofit subcontractor,thatservicesprovidedbythesubcontractorareprovidedinaccordancewiththetermsandconditionsofthe
Contract;andContractorisresponsible forthr actsandomissionsof thesubcontractor.
r contractor shall ensure that the subcontractor lnd subcontractor,s staff who will have unsupervised access to children or vulnerable adults served unde r the Contract have
each completed and received a satisfactory br ;kground check before providing services to DSHS clients, as required under the contmct'
r contractorshallsnsurethatthesubcontractor irasandmaintainsinsurancewiththesametypesandlimits ofcoverageasrequiredofthecontractorunderthecontract'
Exhibit A, Statement of Work
Template September202 I
'
Payment Information
and./or Amount
3 0 caiendar days afterthe end
of the preceding month. (E.g.
October Al9 invoice submitted
no later thanNovember30)
cl January:2128122
c, February:3130/22
c, March:4/30122
c, April: 5/30122
c' May:6130122
cr June: 7130122
cr July: 8/30122
o August: 9l3O/22
Final invoiceis due November
3 0th,2022 or fo llow close-out
schedule. FFY23-24 TBD.
Or*ff pre-approved in nriting
by DOIf, agencies cansubmit
invoices every two months.
IJpon approval a list of
submission dates will be
nrovided.
Due Date/Time FrameDeliverables/Outcomes
Complete documentation of all actualcosts incurred
shall be accompanied by the Subrecipient's financial
system report. If Subrecipient does not have a
fina ncia I rep o rting system, the Sub recip ient must
checkwith the DOH SNAP-Ed program forfurther
guidance.
MEASURE
SNAP-Ed invoices (A1 9) with all documented costs
and any required accompanyingmaterials received at
DOH by due datesrequired, or byapproved
extension date.
procedure before approvamost curr€nt
ofpayment.
Page 8 of 12 Contract Number CLH3 1 0 1 5 P
' Contractoris responsible to ensure thatallterms, conditions, assurances,andcertificationsset forthin this Contractareincluded in thesubcontract,including allconfidentiality and. data security requirements.r AII contract terms in the above-referenced contract remain in full force and effect and nothing in this checklist shall be construed as waiver of terms in the above-referenced Contuact.
Conhact NoncomDliance and Corrective Action f.see CFR $ 200.338 Remedies for noncomuliancel
specifiedduedateswill bedetemtinedbytheDoH sNAP-Ed progamandprovidedtothesubrecipientinwritLg. Basedoncontractperforrnance(asdocumentedinprogress
specific conditions (see httos://www.govregs.com/rezlations/2/200.207iDdu t r.ro"-"t tl. rigir to withhold up to 1 oio of funds from the next applicable payment to the
as such' After DoH sNAP-Ed provides documentation of the issue(s) and outlines the appropriate corrective action in writing and with approval from t he DoH sNAp-Edprogram manager, the first withholding of funds up to 10Yo would occur one time and allow 60 days forthe appropriate corrective action to be completed by the Subrecipient. If
afterthe 60day window, the initial 10% of funds withheld will not be irovided as reimbursim"rrt to th. subrecipient as penalty. The subse quent monthly withholdings (of up to
washington DepartmentofHealth SNAP-Educaiion, Po Box 47886,dlympia, wA 98504-7886,orin witing via emailto snap-ed@.doh.wa.gov.
All invoices mustbe approvedbyDoH prior topayment; approvalwill notbe unreasonablywithheld. DoH will authorizepayment onlyuponsatisfactoryandon-timecompletionof acceptancedeliverables/outcomesandforallowable costi asoutlined in theSNAP-Ed federalguidance, statementof woik, stateplan,and/orbudget. DoH will retum allincorrect or incomplete invoices and will not pay forservices that occur outside the period of periormance orthat are deeme d unallowable costs.
Additional Details Regarding Deliverables
DOH for required training(s) if necessary and if funds are available.
Monitoring Expectations
The Subrecipient's premises and records will be made available upon request to DoH, DSHS, and uSDA staff forthe purposes of observing project activities and reviewing for
fiscal year may be required at the discretion of the ?ol{ sNAP-Ed program, DoH fiscal analyst, or DoH fiscal monitoring unit. completed project and fiscalmonitoring reports
Staff Requirements
upon request by DoH, the Subrecipient must demonstrate that SNAP-Ed staff meetrequirements appropriate to their positions including but not limited to: background checks,food handlers' permits, qualifications, and training required by DOH.
Project Coordinator Requirements
The subrecipient mustmaintaina SNAP-Ed projectcoordinator. The projectcoordinatoris the maincontactbetweenDepartmentofHealthsNAp-Ed teamandthe Subrecipient.DoH sNAP-Ed expectations forthe project coordinatorresponsibilities include:
Exhibit A, Statement of Work
Template September202 1
Page 9 of 12 Contract NumberCLH3 I 0 1 5
. Ensure all contract deliverables are met.
r Coordinate the planning, implementation, evaluatio: , and reportingof all parts of the approved project plan.
. Complywith andremainknowledgeable aboutallS r\ SNAP-Ed andDOH SNAP-Ed poli'cies andprocedures'
. complywith andremainknowledgeable aboutthel rtionalSNAP-Ed Guidance.
. Ensure staff and any sub-subrecipients funded thror gh this contract stay informed of cunent and new SNAP-Ed policies, and are held accountable to potcies when needed'
required by WA SNAP-Ed and DOH.
. Atiend, or designate and send qualified staff membt :asproxy to, required DOH and State SNAP-Ed meetings and trainings'
r Monitor or maintain knowledge of project budget str fus, including estimated spend out and total doilars sp ent to date.
r Submitplanandbudgetamendmentsforapprovala outlined in the current year's policy andprocedures.
. Coordinate the on-time completion of all data entry rnd reporting'
e Ensure photo andmedia release formsare obtained j)rpersons featuredin sNAP-Ed programmingphotogaphsorvideos.
Communication Reouirements
The Subrecipierrt *rr.t*uiotuincommunicationwithD( H sNAP-Ed. communicationrequiredbetween DoH sNAP-Ed andthe Subrecipient wili not be unreasonableor
excessive. DOH SNAP-Ed expectations for communica lon include:
r SubmitupdatestoDOH following anychangein co rtactinformationfortheproject coordinator,fiscalagent, contractsignatory,oranySNAP-Ed fundedstaffwithin 10
business days of the change.
. Be available for regular and intermittent meetings, t rth in person and phone, with DoH sNAP-Ed as ageed upon or as needed'
r Respond to all DOH and SNAP-Ed Statewide initiat ve requests within the timeline requested.
r Maintain or obtain an internet connection forcomm rnication with DOH, for access to DOH SharePoint webpages, to view updates and messages from Washington SNAP-Ed
through the WA sNAp-Ed providers website, and f ;rreliable reporting of SNAP-Ed activities. If reliable intemet connection c annot be secured' the Subrecipient and DoH
SNAP-Ed will agree on a plan for necessary commt nication, data entry, and reporting.
. Obtain aSecure Access Washington(SAW) accoul .toaccessDOH SNAP-Ed SharePointwebpages.
SNAP-Ed Assurances:
The following assurances must be followed (see prognr
r The Subrecipient is fiscal$ responsible for activitie
Guidance httos://snaped.frrs.usda.gov/program-administration/guidance-and-templates)
funded with SupplementalNutrition Assistance Program Education funds and is liable for repayment of unallowable
costs.
r Programming is provided to approved SNAP-Ed eli ible audiences'
. Only expanded oradditionalcoverage of those acti ;Lties fundedunder the Expanded Food and Nutrition Education Program (EFNEP) maybe claimed underthe sNAP-Ed
grant. ApprovedactivitiesarethosJdesignedtoex.andtheState'scurentEFNEPcoverageinordertoserveadditionalsNAP-Edtargetedindividuals'Innocasemay
activities funded under the EFNEP grant be include . in the budget for SNAP-Ed'
r Contracts are procured through competitive bid pro edures govemed by State procurement regulations'
r progam activities are conducted in compliance witl all applicable Fedlral laws, rules, and regulations including civil Rights and oMB regulatio ns goveming cost issues'
as sirpplement them. This applies to all activities ar ,il costs underthe Federal budget-
. lrogram activities are reasonable and necessary to i ;complish SNAP'Ed objectives and goals'
. All materials developed with sNAp- Ed funds inch le the appropriate usDA nondiscrimination statement and credit sNAP as a funding source in standard font that is easily
readable.
SNAP-Ed Statewide Initiatives
Subrecipients ur" "*p."t.I-*-municate with, respor d to, and comply with requests, guidance,requirements, and/oron-site visits from all contracted sNAP-Ed statewide
initiative entities.
Exhibit A, Statement of work Page 10 of 12 contractNumber@!0-15
Template Sep tember 2021
v
Any sNAP-Ed curriculum modifications should be developed and executed based on the most current Guidance for curriculum Modification, found under ,,Guidance andProcess" on WA SNAP-Ed Providen website. subrecipients must consult DoH SNAp-Ed as directed.
After notification to the DoH sNAP-Ed implementing agency, the subrecipient may adjust or deny requests, requhements, andlor site visits from any contracted sNAp -Ed
anddeliberation betweenthe subrecipient, DoH sNAP-Ed, andthe contracted sNAp-Ed rtut"*id;^;;;;;;'.;rit;Hiiit";,uoa,*rren necessary, DsHS. Afrer appropriateconsideration and deliberation, the resulting decision about whetheror not the subrecipient must comply or can adiust or deny a specific will be provided in wdt ing to theSubrecipient from DOH SNAP-Ed and-/orDSHS.
Health and Safetv
sNAP-Ed audience or community memben in situations that could endaigertheir health, safety,or well-beiig. participation in sNAp-Ed by the SNAp-Ed audience is voluntary.
'Contract Noncompliance and Corrective Action' section.
Audits
The subrecipient must make state financialand program audits or reviews conducted by other entities available to the DoH, DSHS, usDA, or its de signee.
Indirect Rate/Allocation Plan
All indirect ratelallocation plans must be submitted-and preapproved by the DoH grants offic e and the DoH sNAp-Ed program. The subrecipient is responsible for ensuring thatindirect costs included in the Subrecipient's sNAP-Ea pL"a"au"dgeiare supportedby anindirect rateand/orcostallocationplanapprovedbytheappropriateagency. TheSubrecipient cannot bill indirect costs that are determined to be unacceptable and will be disallowed.
who supervise 'frontline staff'mustbeprovided civil rights training an"annualbasis."
Records Maintenance - Record Retenfion and Mapasqmenl - State Agencv and All Subrecipients TcIrR 272.2DoHSNAP-Edregulationsrequirethatallrecord'."lutia,,*1o;y"*sr,o-fiscalclosure.Thisrequirementappliestofiscal
documentation and procurement records, contract related documents ana ema\ progress re ports, monitoring reports, and SNAP-Ed client information (pre/post surveys,demographic cards' etc')' Supporting documentation may be kept at the Subrecipienilevel, but shall be availabie forieview within six years from the date of the last quarterlyclaimsubmittal' AnycoststhatcannotbesubstantiatedbysourcedocumentswillbedisallowedaschargestoSNAp-Ed.
Travel
The subrecipient is expected to comply with the office ofFinancial Management's TravelManagement Requirement and Restrictio ns as found in policy 10.10
Exhibit A, Statement of Work
Template September202 1
Pagellof12 Contract NumberCLH3 I 01 5
Amendments
Subrecipients should check the current year,s federalsN p-Ed guidance, the current year's DoH SNAP-Ed budget amendmentguidance, and/orwith a DoH SNAP-Ed program
consultant to know what changes they can make on their rwn and what changes require an amendment and pre -approvalin writing. Notify DoH staff prior to implementing
writtenbudgetamendmentrequesttoDoH,andreJeivei"itt.oapprovalfroiDoH,prioriomakinganychangeswithinth_eirprojectorbudgetandpriortomakinganypurchases
included within the amendment. Any requests needing u ,DA approvalmustbe subrnitted to DoH no later than April l st of each fiscalyear' or no later than date specified by
USDA" DSHS, orDOH. Following thecurrentyears"go 1"n..*i.orequired, if Subrecipients submitplanorbudgetnocostamendmentsthatdonotrequireDSHS oTUSDA
approva[DoH canreview those andmakeapprovalson ], cos€ bycase basis during the federalfiscalyearfollowing thecurrent year's guidancewhen requied' All cost
amendmens that do not require DSHS or USDA approv .l shouldbe submitted to DoH no Iater than July 16tb of each fiscan year'
Overtime
Staff overtime is not billable in the DOH SNAp-Ed prog am unless it has been reviewed by the DoH SNAP-Ed program in advance and approved in writing'
SpecialFundine Requirements ^ 6---rL- r- +L^-rran*f,,-,{i-cic nnrrancirred Ty^rFI is nnr{ernonhligati
payment fordeliverables as specified herein is depender ::on receipt-of funding from the uSDA funding sources. In the event fundingis not receiv ed' mH is under no obligation
terminate task(s), remove funds, or reallocate funds at D, )H's discretion under new funding limitations and conditions. DoH will make paymenb only upon the receipt of the
funding. DoH will notify the Subrecipient within l0 wc :king days upon notice by the funding source of funding availability'
Suecial Billins Reouirements
I . All invoices, billing, and reimbursements must be ir compliance with all applicable Federal laws, rules, re gulations including the curent year sNAP-Ed Guidance and oMB
circulars goveming cost issues.
Totalcosts billed will not exceedthe uSDA-approv :d budget amountlisted in the boxbelow'
. Bills mustbe foronly SNAP-Ed specific activi ies, using a DOH A19-1A Invoicevoucher'
r ASNAp-Ed specificAlg-lAmustbesubmitttltothezubrecipient'sdesipatedDoHSNAP-Ed staffmemberwithin30daysofthelastdayofthemonthforwhichthe
work is being biiled, OR
r ASubrecipientmayrequestpre-approvaltobil everyzmonthsinstead,inwhichcase,thatSubrecipientisrequiredtoadheretothebillingduedatesprovidedbyDoH'
TheSNAp-Edprogramwilldenypaymentforany ostsnotsubmitteauytneduedatewitb.outpriorapproval. IfforANYreasonaSubrecipientisunabletosubmittheSNAP-
Ed A-19-lA on the due date,the Subrecipient is req rired to submit a request for an exception to the DoH no later than 7 daysprior t o due date to the DoH sNAP-Ed
program. The SNAp-Ed program reserves the righi and responsibility to either approve ordeny the request for an exception andwill reply to the request'
'S"p"portlog do cumentation fo-r ea ch month must b e ubmitted with ea ch SNAP -Ed A1 9 -1 A'
. At the very least this means a copy of a Subrec rient's financial expanded/detailed general ledger level report'
. Additionally, all receipts, timecardsandothers rpporting documentation,asnotedbyUSDA! mustbe availableuponrequest'
If a Subrecipient meets one oi the criteria below, ,h t *[ nJed to submit al SNep-pa backup documentation with each bill and this requirementwill continue until further
notice by DOH.
r All new SNAP-Ed Subrecipients within their 1 tfiscalyear'
. Subrecipients with curent fiscal findings.
. Subrecipients who havenotsubmittedadequar loraccuratebaclup documentationwithin the lastyear'
r Subrecipients who receive a rating of "High" f :m the DOH Federal Subrecipient Risk Assessment Tool'
2
J
4.
5
An rrunt
ContractNumberCLH3l0l5 r
Exhibit A, Statement of Work
Template September202 1
$
Source
USDA
BI]DGET
18
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