HomeMy WebLinkAbout20131115.tiffRESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR TUBERCULOSIS PROGRAM AND
AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Task Order Contract for the Tuberculosis
Program between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment, and the Colorado Department of Public Health and Environment, commencing July 1,
2013, and ending June 30, 2018, with further terms and conditions being as stated in said contract,
and
WHEREAS, after review, the Board deems it advisable to approve said contract, a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Task Order Contract for the Tuberculosis Program between the County
of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on
behalf of the Weld County Department of Public Health and Environment, and the Colorado
Department of Public Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 6th day of May, A.D., 2013.
BOARD OF COUNTY COMMISSIONERS
WELD ' O TY, COLORADO
ATTEST:cs8 ta
Weld County Clerk to th
BY:
Deputy Clerk to the
AS TO F
ney
Date of signature:
illia F. G- Chair
fly'
Dougl- Radem.:chjer„Pro-Tem
Sean P. Conway
Mike Freeman
EXCUSED
Barbara Kirkmeyer
cc: NL
2013-1115
HL0040
WELD-EOUNTY
u
Memorandum
TO: William F. Garcia, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
Environment
DATE: April 26, 2013
SUBJECT: Task Order Contract: Funding for the
Tuberculosis Program
Enclosed for Board review and approval Task Order Contract between the Colorado Department of
Health and Environment and the Board of County Commissioners of Weld County on behalf of the
Department of Public Health and Environment (WCDPHE). This contract is for continuation of the
Tuberculosis (TB) Prevention and Control Program.
If approved, the funding for this contract will allow the Department to provide TB prevention and control
activities in Weld County. WCDPHE staff members will collect specimens for testing on all persons
suspected of having TB. These activities include QuantiFERON testing or skin testing, provide for
interpretation of chest x-rays, provide active TB treatment including Directly Observed Therapy (this is a
process where staff assures that TB clients comply with and complete TB therapy), ensure contacts to all
newly identified infectious TB cases receive appropriate evaluation, and follow-up with active patients to
ensure they receive appropriate information and education.
The term of this contract is five years, beginning July 1, 2013 and ending on June 30, 2018. The TB
contract funding is determined on the basis of the number of active TB cases in the county that have been
treated over a period of time. This Master Contract is for an amount not to exceed $208,260, which will
be divided over fiscal years 2014, 2015, 2016, 2017 and 2018. Of this amount $37,500 is attributed to
Federal Funding dollars and $170,760 is attributed to State Funding Dollars. Our number of active cases
has increased in the last year so the annual funding for fiscal year 2014 will be increased from $46, 030 to
$52,065.
I recommend your approval of this task order amendment.
Enclosure
2013-1115
DEPARTMENT OF PUBLIC I [LAUD! AND ENVIRONMICN t
ROUTING NO. 14 FHA 55247
APPROVED TASK ORDER CONTRACT - WAIVER #154
This Task Order Contract is issued pursuant to Master Contract made on 01/17/2012, with routing number 13 FAA 00051
State of Colorado for the use & benefit of the
Department of Public Health and
Environment
Disease Control and Environmental
Epidemiology Division
Tuberculosis
4300 Cherry Creek Drive South
Denver, Colorado 80246
CASK ORDER MADI ❑A TT:
04/17/2013
PO/SC ENCUMBRANCE NUMBER
PO FHA EPI1455247
TERM:
This Task Order shall be effective upon
approval by the State Controller, or designee,
or on 07/01/2013, whichever is later. The
Task Order shall end on 06/30/2018.
PRICE 5I RUC I URIC
Cost Reimbursement
PROCUREMENT MI_111OD:
Exempt
BID REP/I.IST PRICE Ac,R' IIMUNT NUMBER:
Not Applicable
I.A\C' SPLA:.IIIP:D VENDOR STA II
Not Applicable
SLATE RI PRI SENIATWI_
Pete Dupree
Department of Public Health and Environment
DCEED
Tuberculosis
4300 Cherry Creek Drive South
Denver, CO 80246
CONIRVC1(TIE
Board of County Commissioners of Weld County
915 101" Street
Greeley, CO 80632-0758
for the use and benefit of the
Weld County Department of Public Health and
Environment
1555 North 17th Ave
Greeley, CO 80631
C ON'I RAC YOR ENTITY IY 'TYPE_
Colorado Political Subdivision
BILLINGS ,VIE.MLNIS RECEIVED:
Monthly
S'EA'TCTORY ALITIORITY
N/A
CON IRA(: I PRICE NO•1 1OLX XCC:I )
$208,260.00
EP.DEwv. FUNDING DOI.1.:vRE $37,500.00
SI AIE PENDING DOI.I.ARS. $170,760.00
MAXIMUM AMOLNI AVAIEAIBLU PER I IS1. Al YEAR:
FY 14: $52,065.00
FY 15: $39,049.00
FY 16: $39,049.00
FY 17: $39,049.00
FY 18: $39,048.00
CONIRACI OR REPRESENTATIVE:
Tanya Geiser
Weld County Public Health and Environment
1555 North 1711 Avenue
Greeley, CO 80631
SCOPE OF WORK:
Provide or coordinate the Tuberculosis (TB) prevention and control activities for individuals within
its service area.
Page 1 of 6 Rev 6/25/09
L'XI❑5O5:
The following exhibits are hereby incorporated:
Exhibit A - Additional Provisions (and its attachments if any — e.g., A-1, A-2, etc.)
Exhibit B - Statement of Work (and its attachments if any — e.g., B -t, B-2, etc.)
Exhibit C - Budget (and its attachments if any — e.g., C-1, C-2, etc.)
Exhibit D - Grant Funding Letter
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses, the more specific provision shall control.
I. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including
any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall
be performed according to the standards, terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(l), C.R.S., as amended, this Task Order Contract is not valid until it
has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not
authorized to, and shall not; commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegee. The State shall have no financial obligation
to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor
prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order
Contract on or before its proposed effective date, then the Contractor shall commence performance under
this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order
Contract after its proposed effective date, then the Contractor shall only commence performance under this
Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through
and including the date specified on page one of this Task Order Contract, unless sooner terminated by the
parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract.
Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made
a part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task
Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated,
the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event
of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits
and/or attachments), or between this Task Order Contract and its exhibits and/or attachments, such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: I) the
Page 2 of 6 Rev 6/25/09
Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its
exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 4) the
Additional Provisions -Exhibit A, and its attachments if included, to this Task Order Contract; 5) the
Scope/Statement of Work - Exhibit B, and its attachments if included, to this Task Order Contract; 6) other
exhibits/attachments to this Task Order Contract in their order of appearance.
4. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order
Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the
Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and
attached hereto as "Exhibit B" and "Exhibit C".
5. The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend
the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or
decrease the amount payable under this Task Order Contract, or add to, delete from, and/or modify this
Task Order Contract's Statement of Work through a contract amendment. To be effective, the amendment
must be signed by the State and the Contractor, and be approved by the State Controller or an authorized
delegate thereof. This contract is subject to such modifications as may be required by changes in Federal
or State law, or their implementing regulations. Any such required modification shall automatically be
incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set
forth herein.
6. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum
standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's
Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope/Statement of Work -
Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP, then the
Contractor shall also meet those standards of performance under this Task Order Contract.
7. STATEWIDE CONTRACT MANAGEMENT SYSTEM [This section shall apply when the Effective
Date is on or after July 1, 2009 and the maximum amount payable to Contractor hereunder is 5100.000 or
higher]
By entering into this Task Order Contract, Contractor agrees to be governed, and to abide, by the
provisions of CRS §24-102-205, §24-102-206, §24-103-601, §24-103.5-101 and §24-105-102 concerning
the monitoring of vendor performance on state contracts and inclusion of contract performance information
in a statewide contract management system.
Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order
Contract, State law, including CRS §24-103.5-101, and State Fiscal Rules, Policies and Guidance.
Evaluation of Contractor's performance shall be part of the normal contract administration process and
Contractor's performance will be systematically recorded in the statewide Contract Management System.
Areas of review shall include, but shall not be limited to quality, cost and timeliness. Collection of
information relevant to the performance of Contractor's obligations under this Task Order Contract shall be
determined by the specific requirements of such obligations and shall include factors tailored to match the
requirements of the Statement of Project of this Task Order Contract. Such performance information shall
be entered into the statewide Contract Management System at intervals established in the Statement of
Project and a final review and rating shall be rendered within 30 days of the end of the Task Order Contract
term. Contractor shall be notified following each performance and shall address or correct any identified
problem in a timely manner and maintain work progress.
Should the final performance evaluation determine that Contractor demonstrated a gross failure to meet the
performance measures established under the Statement of Project, the Executive Director of the Colorado
Department of Personnel and Administration (Executive Director), upon request by the Colorado
Department of Public Health and Environment and showing of good cause, may debar Contractor and
Page 3 of 6 Rev 6/25/09
prohibit Contractor from bidding on future contracts. Contractor may contest the final evaluation and result
by: (i) filing rebuttal statements, which may result in either removal or correction of the evaluation (CRS
§24-105-102(6)), or (ii) under CRS §24-105-102(6), exercising the debarment protest and appeal rights
provided in CRS §§24-I09-106, 107, 201 or 202, which may result in the reversal of the debarment and
reinstatement of Contractor, by the Executive Director, upon showing of good cause.
8. If this Contract involves federal funds or compliance is otherwise federally mandated, the Contractor and
its agent(s) shall at all times during the term of this contract strictly adhere to all applicable federal laws,
state laws, Executive Orders and implementing regulations as they currently exist and may hereafter be
amended. Without limitation, these federal laws and regulations include the Federal Funding
Accountability and Transparency Act of 2006 (Public Law 109-282), as amended by §6062 of Public Law
110-252, including without limitation all data reporting requirements required there under. This Act is also
referred to as FFATA.
Page 4 of 6 Rev 6/25/09
THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR:
Board of County Commissioners of Weld
County
(a political subdivision of the State of Colorado)
For the use and benefit of the Weld County
Department of Public Health and Environment
Legal Name of Contracting Entity
Signature of Authorized Officer
William F. Garcia
MAY 062013
Print Name of Authorized Officer
STATE OF COLORADO:
John W. Hickenlooper, GOVERNOR
For Executive Director
Department of Public Health and Environment
Department Program Approval:
Chair, Board of Weld
County Commissioners By
Print Title of Authorized Officer
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until
signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until
such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor
for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER:
David J. McDermott, CPA
By
Date . 29-/3
Page 5 of 6 Rev 6/25/09
This page left intentionally blank.
Page 6 of 6 Rev 6/25/09
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 04/17/2013 - Contract Routing Number 14 FHA 55247
These provisions are to be read and interpreted in conjunction with the provisions of the
Task Order Contract specified above.
1. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination.
The State has determined that this contract does not constitute a Business Associate relationship under
HIPAA.
2. To receive compensation under this Task Order Contract, the Contractor shall submit a signed Monthly
CDPHE Reimbursement Invoice Form. This form is accessible from the CDPHE internet website
http://m, ww. co lorado.gov/cs/Satellite/CDPHE-Main/CBON/ 1 251622941228. CDPHE will provide
technical assistance in accessing and completing the form. The CDPHE Reimbursement Invoice Form
must be submitted within thirty (30) calendar days of the end of the billing period for which services were
rendered. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B
and incorporated herein and the associated Budget attached hereto as Exhibit C and incorporated herein.
Submit completed CDPHE Reimbursement Invoice Form one of three ways:
Mail:
Pete Dupree, Assistant TB Program Manager
Tuberculosis
Colorado Department of Public Health and Environment
A3-TB-DCEED
4300 Cherry Creek Drive South
Denver, Colorado 80246
Fax: (303)759-5538
Attn: Pete Dupree
Email: peter.dupree@state.co.us
To be considered for payment, billings for payments pursuant to this Task Order Contract must be received
within a reasonable time after the period for which payment is requested, but in no event no later than
thirty (30) calendar days after the relevant performance period has passed. Final billings under this Task
Order Contract must be received by the State within a reasonable time after the expiration or termination of
this Task Order Contract; but in no event no later than thirty (30) calendar days from the effective
expiration or termination date of this Task Order Contract.
Unless otherwise provided for in this Task Order Contract, "Local Match", if any, shall be included on all
invoices as required by funding source.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
3. Tuberculin skin testing, chest x-rays, and chest x-ray interpretations are not eligible for reimbursement
under this Contact for the following:
a. Correctional facility inmates
b. Persons other than Class A or B TB immigrants undergoing medical examinations;
To be attached to CDPHE
Task Order v1.0 (3/12) contract template
Page I oft Revised: 12/19/06
EXHIBIT A
c. Paid or volunteer employees of health care facilities, long-term care facilities, drug
treatment centers, correctional facilities, shelters, schools, or child care facilities that
undergo skin testing as part of a routine employment skin testing program.
4. Time Limit For Acceptance Of Deliverables.
a. Evaluation Period. The State shall have thirty (30) calendar days from the date a deliverable is
delivered to the State by the Contractor to evaluate that deliverable, except for those deliverables
that have a different time negotiated by the State and the Contractor.
b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design
specifications for that particular deliverable, or is otherwise deficient, then the State shall notify
the Contractor of the failure or deficiencies, in writing, within thirty (30) calendar days of: I ) the
date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or
deficiency at the time of delivery; or 2) the date the State becomes aware of the failure or
deficiency. The above time frame shall apply to all deliverables except for those deliverables that
have a different time negotiated by the State and the Contractor in writing pursuant to the State's
fiscal rules.
c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed
deliverable, the Contractor shall have a reasonable period of time, not to exceed thirty (30)
calendar days, to correct the noted deficiencies. If the Contractor fails to correct such deficiencies
within thirty (30) calendar days, the Contractor shall be in default of its obligations under this
Task Order Contract and the State, at its option, may elect to terminate this Task Order Contract or
the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract.
5. Pursuant to 25-4-501, 8 C.R.S., as amended, the General Assembly has declared that tuberculosis is an
infectious and communicable disease, that it endangers the population of this state, and that the treatment
and control of said disease is a state responsibility and further, pursuant to 25-4-511, 8 C.R.S., assistance
under section 25-4-501, shall be given to any applicant who is suffering from tuberculosis in any form
requiring treatment and is without sufficient means to obtain such treatment. The State, through the
Tuberculosis Program has a mandate to provide care coordination services for the residents of the State of
Colorado.
6. The State Promises to make available to the Contractor a portion of the Statewide funds for the
Tuberculosis Direct Observed Therapy and Statewide funds for the Tuberculosis Ouantiferon (OFT)
Diagnostic Testing for the one year term, in exchange for the promise of the Contractor to perform the
work described herein. Of the total financial obligation of the Stated referenced above, one hundred percent
is derived from the State General Fund. The liability of the State, at any time, for such payments shall be
limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds
appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately
reduce the funding for this Contract or terminate this Contract in its entirety.
7. The State may increase of decrease funds available under this Contract using a Grant Funding Letter
substantially equivalent to Exhibit D. The Grant Funding Letter is not valid until it has been approved by
the State Controller or designee.
To be attached to CDPHE
Task Order v1.0 (3/12) contract template
Page 2 of 2 Revised: 12/19/06
EXHIBIT B
STATEMENT OF WORK
To Task Order Contract Dated 04/17/2013 — Contract Routing Number 14 FHA 55247
These provisions are to be read and interpreted in conjunction with the provision of the Task Order
Contract specified above.
I. Project Description:
Funds provided under the Task Order are to assist in supporting tuberculosis (TB) prevention and
control activities as stated in Colorado Revised Statues (CRS) 25 -4 -501 -Part 5 Tuberculosis (et
seq) and Rules and Regulations Pertaining to Epidemic and Communicable Disease Control (6-
CCR-1009-1, Regulation 4). Contractor shall provide or coordinate the following services for all
individuals within its service area according to the statutes and regulations listed above and
according to Colorado Department of Public Health and Environment (CDPHE) Tuberculosis
Manual, but in no event less than those duties required by statute and rules (listed above). Use of
funds will be prioritized as follows: priority I) finding all patients with active TB and ensuring
completion of appropriate therapy, priority 2) finding and evaluating contacts of TB patients and
ensuring completion of appropriate therapy, 3) evaluation of newly arrived immigrants and
refugees with Class B TB designation, and priority 4) targeted testing of high -risk persons and
ensuring completion of therapy for latent TB infection (LTBI). If available, use patient's medical
insurance as primary payment source. CDPHE will reimburse for diagnostic and clinical services
at current Medicaid rate unless prior approval has been given by the CDPHE TB Program.
II. Definitions
LTBI — Latent Tuberculosis Infection
MTB — Mycobacterium Tuberculosis
DOT - Directly Observed Therapy
III. Performance Requirements/Deliverables
A. Suspected or confirmed active TB
1. The Contractor shall provide, or arrange for, chest x-rays and interpretations.
2. The Contractor shall collect, or arrange for the collection of, specimens for mycobacteriology
testing on all persons suspected of having TB. Assure appropriate testing is performed, e.g.,
smears for acid -fast bacilli, (using concentrated fluorescent method), isolation of
mycobacteria (using rapid methods), identification of Mycobacterium tuberculosis complex
(MTB) (using rapid methods), and susceptibility testing (isoniazid, rifampin, ethambutol, and
pyrazinamide) on isolates of MTB. Contractor shall the CDPHE Laboratory for testing. The
CDPHE Laboratory will, at no charge to the Contractor, supply specimen containers and
perform the above testing for the Contractor. The Contractor shall arrange for the
transportation of the specimens to the CDPHE Laboratory for testing.
3. The Contractor shall provide, or arrange for, the placement of patients who require isolation.
The Contractor shall contact CDPHE TB Program for assistance, if needed, and to request
reimbursement from CDPHE for those costs incurred by the Contractor in isolating a patient.
4. The Contractor shall provide, or arrange for, all other necessary laboratory testing and
medical evaluation services.
5. The Contractor shall order TB medications through the CDPHE TB Program.
6. The Contractor shall provide CDPHE with the medical insurance information for those
patients who have medical insurance.
To be attached to CDPHE
Task Order
Page 1 of6 Revised 04/11/2013
EXHIBIT B
7. The Contractor shall provide, or arrange for, the treatment of patients with suspected or
confirmed active TB, including directly observed therapy (DOT), and ensure adherence to
treatment.
8. The Contractor shall provide, or arrange for, a HIV antibody test for all persons diagnosed
with TB disease, regardless of their age or the apparent absence of risk factors for HIV
infection. In accordance with section 25-4-1401, et seat, C.R.S., as amended, the Contractor
shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform
those individuals whom refuse testing of the risks associated with HIV/TB co -infection.
9. A minimum of once a month, the Contractor shall monitor and evaluate those persons with
suspected or confirmed active TB.
10. The Contractor shall monitor and evaluate those persons with LTBI a minimum of once a
month.
1 I. The Contractor shall increase the proportion of persons that complete LTBI treatment to meet
the state objective of 80% by 2015 and maintain or improve on that rate thereafter.
12. The Contractor shall provide culturally appropriate patient education and information
pertaining to TB treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
13. All reports of suspected or confirmed active TB disease will include: reason for initiating,
patient name, date of birth, country of birth, date arrived in U.S., demographic information,
locating information, provider information, TB risk factors, results of diagnostic testing,
results of mycobacteriology including susceptibility results, dates of infectious period,
treatment information, changes in patients' status, diagnosis, or any other information as
appropriate. The Contractor shall report to CDPHE when a TB patient completes treatment,
moves, or transfers out of the Contractor's service area. Information may be reported via
web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance
and Case Management Report" (TB 17), which is incorporated herein by this reference, made
a part hereof, and attached hereto as "Attachment B -I". Confirmed cases of TB will include
all data elements identified in the "Report of Verified Case of Tuberculosis (RVCT)", which
is incorporated herein by this reference, made a part hereof, and attached hereto as
"Attachment B-2". The CDPHE will provide the format and instructions for any additional
information requests. Report forms are subject to revision and Contractor agrees to use most
recent version.
B. Newly identified infectious TB (smear and/or culture positive pulmonary or laryngeal)
I. The Contractor shall ensure that all contacts to newly identified infectious TB cases are
identified, investigated, and receive appropriate evaluation. Contact investigation and any
follow-up needed as a result of an occupational exposure shall be conducted by the local
Health Department.
2. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations
for all such contacts.
3. When indicated, the Contractor shall provide, or arrange for, other laboratory testing, and
other necessary medical evaluation services for all such contacts.
4. The Contractor shall provide, or arrange for, the treatment of patient (including directly
observed preventive therapy (DOT) when appropriate), and ensure the completion of therapy
for infected contacts.
To be attached to CDPHE
Task Order
Page 2 of 6 Revised 04/11/2013
EXHIBIT B
5. The Contractor shall order TB medications through the CDPHE TB Program for all such
contacts.
6. The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
7. The Contractor shall provide, or arrange for, an HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et
seq. C.R.S., as amended, the Contractor shall report all known HIV antibody test results to
the State. The Contractor shall inform all individuals whom refuse testing of the risks
associated with HIV/TB co -infection.
8. A minimum of once a month, the Contractor shall monitor and evaluate persons with LTBI
during treatment for all such contacts.
9. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
10. The Contractor shall submit a preliminary Tuberculosis Contact Investigation Record, (which
is incorporated herein by this reference, made a part hereof, and attached hereto as
"Attachment B-3" to the CDPHE TB Program after initiation of each contact investigation.
The Contractor shall submit a final report to CDPHE when a contact investigation is
completed. Report forms are subject to revision and Contractor agrees to use most recent
version.
II. For those persons identified, as part of a contact investigation, with latent TB infection, or
those with suspected latent TB infection requiring treatment recommendations from CDPHE,
the Contractor shall report reason for initiating, patient name, date of birth, country of birth,
date arrived in U.S., demographic information, locating information, provider information,
TB risk factors, results of diagnostic testing, treatment information, or any other information
as appropriate. The Contractor shall report to CDPHE when a patient completes treatment,
moves, or transfers out of the Contractor's service area. Information may be reported via
web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance
and Case Management Report" (TB 17). CDPHE will provide format and instructions for any
additional information requests. Report forms are subject to revision and contractor agrees to
use the most recent version.
C. Newly arrived immigrants and refugees with Class B TB designation
I. The CDPHE TB Program will notify the Contractor of all newly arrived Class B TB
immigrants/refugees via follow-up worksheet which is incorporated herein by this reference,
made a part hereof, attached hereto as "Attachment B-4". Report forms are subject to
revision and contractor agrees to use most recent version.
Within thirty (30) calendar days of the Contractor's receipt of written notification from the
State of the arrival of a Class B immigrant/refugee, the Contractor shall contact that
immigrant and conduct, or arrange for, a TB screening that includes medical evaluation,
tuberculin skin test or whole blood interferon y assay, chest radiograph, and three spontaneous
sputum specimens for AFB smear and culture collected on consecutive days.
3. Upon completion of testing and examination, the Contractor shall fill out, sign, and date the
Follow-up worksheet, and return it within 90 days to:
To be attached to CDPHE
Task Order
Page 3 of 6 Revised 04/11/2013
EXHIBIT B
Colorado Department of Public Health and Environment
Tuberculosis Program
Attn: Class B Coordinator
4300 Cherry Creek Drive South
Denver, CO 80246
4. The Contractor shall, when indicated, provide, or arrange for, treatment and ensure
completion of therapy.
5. The Contractor shall order TB medications through the CDPHE TB Program.
6. The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
7. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
8. For those persons identified with LTBI or active TB, the Contractor shall report patient name,
date of birth, country of birth, date arrived in U.S., demographic information, locating
information, provider information, TB risk factors, results of diagnostic testing, treatment
information, or any other information as appropriate. Contractor shall report when a patient
completes treatment, moves, or transfers out of the jurisdiction. Information may be reported
via web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance
and Case Management Report" (TB 17). CDPHE will provide format and instructions for any
additional information requests. Report forms are subject to revision and Contractor agrees to
use most recent version.
D. Other high -risk persons with LTBI
1. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations.
2. When indicated, the Contractor shall provide, or arrange for, all other necessary laboratory
testing and medical evaluation services.
3. The Contractor shall provide, or arrange for, the treatment of patient and ensure the
completion of therapy.
4. The Contractor shall order TB medications through the CDPHE TB Program.
5. The Contractor shall provide the CDPHE with the medical insurance information for those
patients that have medical insurance.
6. The Contractor shall provide, or arrange for, a HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et
seq., C.R.S., as amended, the Contractor shall report all known HIV antibody test results to
the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks
associated with HIV/TB co -infection.
7. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during
treatment.
8. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
To be attached to CDPHE
Task Order
Page 4 of 6 Revised 04/11/2013
EXHIBIT B
patient's language using medical interpretation resources such as AT&T language line as
needed.
9. For persons with LTBI, the Contractor shall report reason for initiating, patient name, date of
birth, country of birth, date arrived in U.S., demographic information, locating information,
provider information, TB risk factors, results of diagnostic testing, treatment information, or
any other information as appropriate. Contractor shall report when a LTBI patient completes
treatment, moves, or transfers out of the jurisdiction. Information may be reported via web -
based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and
Case Management Report" (TB 17). The CDPHE will provide format and instructions for any
additional information requests. Report forms are subject to revision and Contractor agrees to
use most recent version.
10. Tuberculin skin testing, chest radiographs, chest radiograph interpretations, other diagnostic
testing, and medical evaluations are not eligible for reimbursement under this Task Order for
the following:
i. Correctional facility inmates;
ii. Persons, other than Class B TB immigrants/refugees, undergoing
immigration medical examinations;
iii. Paid or volunteer employees of health care facilities, long-term care
facilities, drug treatment centers, correctional facilities, shelters, schools, or
child care facilities that undergo skin testing as part of a routine
employment skin testing program.
E. TB education and consultation
As needed, the Contractor shall provide consultation services to providers in its service area
regarding TB reporting, screening, treatment, and follow-up.
F. Reports for contract monitoring
The Contractor shall provide CDPHE with a Tuberculosis Semi -Annual Progress Report on TB
activities in its service area. A sample of the Tuberculosis Semi -Annual Progress Report is
incorporated herein by this reference, made part hereof, and attached hereto as "Attachment B-5".
Report forms are subject to revision and contractor agrees to use most recent version or submit a
similar type of report. The Contractor shall submit report within one month after funding period
ends.
G. Confidentiality
The Contractor shall maintain internal medical and administrative records in a manner which
ensures the confidentiality and security of those records in accordance with all applicable statutes
including, but not limited to, 25-1-107, C.R.S., as amended.
IV. Monitoring
CDPHE's monitoring of this Contract for compliance with performance requirements will be
conducted throughout the contract period by the TB Program's Assistant Program Manager.
Methods used will include review of documentation reflective of performance including progress
reports, site visits, and review of electronic data. The performance of Contracts shall be evaluated
at quarterly intervals and communicated to the Contractor. A Final Contractor Performance
Evaluation will be conducted at the end of the life of the contract.
To be attached to CDPHE
Task Order
Page 5 of 6 Revised 04/11/2013
EXHIBIT B
V. Remedies for issues of non-compliance
The contractor shall be notified by email within 14 calendar days of discovery of a compliance
issue. Within thirty (30) calendar days of discovery, the Contractor and CDPHE will collaborate,
when appropriate, to determine the action(s) necessary to rectify the compliance issue and
determine when the action(s) must be completed. The action(s) and time line for completion will
be documented by email and agreed to by both parties. If extenuating circumstances arise that
requires an extension to the time line, the Contractor must email a request to the Assistant TB
Program Manager and receive approval for a new due date. CDPHE will oversee the
completion/implementation of the action(s) to ensure time lines are met and the issue(s) resolved.
If the Contractor demonstrates inaction or disregard for the agreed upon compliance resolution
plan, CDPHE may exercise its rights under the Remedies section of this contract.
To be attached to CDPHE
Task Order
Page 6 of 6 Revised 04/11/2013
ATTACHMENT B -t
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT
Last Name
Colorado Department of Public Health and Environment
Tuberculosis Program
4300 Cherry Creek Drive South
DCEED-TB-A3
Denver, Colorado 80246-1530
(303) 692-2638 phone (303) 759-5538 Fax
DEMOGRAPHICS
LOCATING INFORMATION
Date of Birth
Race: ❑ American
Indian/Alaskan
Asian
Black/African
American
Native
Hawaiian/Othe
r Pacific Is,
❑ White
❑ Unknown
Occupation:
First Name
Gender:
Ethnicity: ❑
Country
of Birth:
Date
Arrived in US:
Male
Female
Not Hispanic/Latino
Hispanic/Labno
United States
Mexico
Specify other
Month/Year
New health care worker
Current health care worker (HAS patient contact)
Current health care worker (NO patient contact)
Corrections employee
Migrant farm worker ❑ Unknown
Unemployed past 24 months ❑ Other
Employer
■
Current
TST Type: ❑
Mantoux- Tubersol
Mantoux- Aplisol
Mantoux- Unspecified
Not done
Unknown
Specify other
Current Home Address (Number & Street Name) Apt #
City
State Zip Code -Cory
Other Address (Number & Street Name) Specify Type
City State
Zip Code oZty
{come Rhone Number Other Phone Number Specify Type
Work Phone Number
TUBERCULIN SKIN TEST (TST)
■
Reason
For Test: ❑
Vame of Clinic/Local Health Agency Placing TS1
Current / / / /
TST Date Given Date Read
Current TST Result ❑ Negative
TST positive at 5 mm or greater
❑ HIV positive person
❑ Recent, close contact to active TB
❑ Has fibrotic lesions on CXR consistent
with previous TB disease
❑ Patients with organ transplants or other
immunosuppressed patients
❑ TB suspects
Collection Date
OFT
Results
Administrative
Class B TB Notification
Contact investigation
Employment
Immigration status change
Known active
Source case investigation
mm Previous
Reading TST
❑ Positive (please select criteria below)
TST positive at 10 mm or greater
❑ Recent arrival from a country with
a high prevelance of TB
Injection drug user
Resident of high risk congregate setting
Employee of high risk congregate setting
Mycobacteriology laboratory personnel
H'gh risk clinical conditions
Child < 4 years old, or child or adolescent
exposed to adult in high risk category
Positive
Negative
Testing Laboratory
❑ Indeterminate
❑ Unknown
Current CXR / /
•
Suspect case
❑ Symptomatic
❑ Targeted testing- individual
❑ Targeted testing- pregnancy
❑ Targeted testing- specific project
❑ Transfer case/suspect
❑ Unknown
/ /
ante Reading
❑ Not read
mm
TST positive at 15 mm or greater
❑ No known risk factors for TB
■ Cavitation ■
❑ Infiltrates ❑
Results: Date Taken ❑ Pleural disease
Previous CXR / /
Results: Date
❑ Cavitation ❑
❑ Infiltrates ❑
❑ Pleural disease
Non -TB abnormality
Normal
Other
Non -TB abnormality
Normal
Other
Page 1 of 2
ATTACHMENT B-1
Patient Last Name
First Name
MI
Date of Birth
Symptoms: Symptom Length: Alcohol ❑ Yes
None Abuse: ❑ No
❑ Cough > 3 wks O Unknown
❑ Productive
cough
Hemoptysis
Chest pain
Weight loss
Night sweats
Urinary
Fever
Other (specify)
❑❑❑❑❑❑❑
Drug ❑ Injecting
Abuse: ❑ Noninjecting
❑ No
❑ Unknown '
Previous ❑ Yes
TB ❑ No
DiagnosiL Unknown
HIV ❑
Test: ❑
HIV ❑
Result: ❑
Yes
No
Unknown
Allergies:
Positive Medications:
Negative
Not done
Unknown
HIV Test Date
Weight:
RISKS AND SPECIAL CONDITIONS
Exposure ❑
Risks: ❑
None ❑ Resident of long
Homeless term care facility
Resident of (if Yes check one)
correctional facility ❑ Nursing home
(if Yes check one) ❑ Hospital
Federal prison ❑ Residential
❑ Mental health
❑ Alcohol/drug treatment Special ❑
❑ Other Conditions: ❑
❑ Unknown ❑
❑ TST conversion in last 2 years
State prison
Local jail
Juvenile
Other
Unknown
Medical
Risks:
None
Heart disease
Diabetes mellitus
Weight loss > 10 lbs
Gastrectomy
Jejunoileal bypass
Silicosis
Immunosuppressive
therapy
Cancer
Hepatitis
Renal failure
Pregnant EDC
Postpartum breast feeding
Other special conditions
TREATMENT
❑ Current treatment
❑ Past treatment
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
Therapy Start Date
mg
mg
mg
mg
Other
Other
Other
CASE COMPLETION
Final Case Status: ❑ Closed
❑ Moved away ❑ Not determined
❑ Lost contact
❑ Died
If Moved New Address (Number & Street Name)
City
tr Zip Code
Therapy End Date
mg Reason ❑
mg Stopped: ❑
mg ❑
Died
Lost to follow-up
Moved
Adverse reaction
Course completed
Uncooperative/refused
Unknown
Other
SOURCE INFORMATION
If the person is a contact to an active case
complete information on the source case
Last Name
Relation to Source
First Name
to / /
Exposure Dates
PROVIDER INFORMATION
Local Health Agency (LHA)
LHA Phone Number LHA Fax Number
Nurse
PCP/Clinic Name
PCP/Clinic Address
PCP City
PCP State
PCP Phone Number
PCP Fax Number
PCP Zip Code
COMMENTS
Person completing torm
/ /
Date
Page 2 of 2
ATTACHMENT 8-2
Patient's Name
Last)
(First)
IM.0
Street Address
RIP coon
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
cpc
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES -
FORM APPROVED OMB NO. 0920-0026 Exp. Date 05/31/2611
REPORT OF VERIFIED CASE OF TUBERCULOSIS
1. Date Reported
Month
Day Year
2. Date Submitted
Month
Day
Year
3. Case Numbers
State
Case Number
City/County
Case Number
Linking State
Case Number
Linking State
Case Number
Year Reported {YYYY) State Code
Locally Assigned Identification Number
r
Reason:
El
4. Reporting Address for Case Counting
City
County
ZIP CODE
within City Limits (select one)
OYES ❑ NO
B. Date of Birth
Month
Day
Year
9. Sex at Birth (select one)
❑ Male O Female
5. Count Status (select one)
Countable TB Case
Count as a TB case
Noncountable TB Case
Verified Case: Counted by
another U.S. area (e.g., county, state)
Verified Case: TB treatment
initiated in another country
Specify
Verified Case: Recurrent TB within 12
months after completion of therapy
6. Date Counted
Month Day
Year
10. Ethnicity (select one)
O Hispanic or Latino
❑
Not Hispanic
or Latino
11. Race (select one or more)
❑
American Indian or
Alaska Native
❑ Asian: Specify
❑ Black or African American
❑ Native Hawaiian or
Other Pacific Islander:
Specify
❑ White
7. Previous Diagnosis of TB Disease (select one)
❑Yes ON
If YES, enter year of previous TB disease diagnosis'
12. Country of Birth
'U.S.-born" (or born abroad to a parent who was a U.S. citizen)
(select one) ❑ yes ❑ No
Country of birth: Specify
13. Month -Year Arrived in U.S.
Month Year
J
14. Pediatric TB Patients (<15 years old)
Country of Birth for Primary Guardian(s): Specify
Guardian 1
Guardian 2
Patient lived outside U.S. for >2 months?
(select one)
If YES, list countries, specify:
❑ Yes ❑ No ❑ Unknown
15. Status at TB Diagnosis (select one)
❑Alive ❑ Dead
If DEAD, enter date of death:
II DEAD, was TB a cause of death? (select one)
❑ Yes 0 No 0 Unknown
Month
Day
Year
16, Site of TB Disease (select eft that apply)
❑ Pulmonary O Bone and/or Joint
O Pleural ❑Genitourinary
❑ Lymphatic: Cervical ❑ Menungeal
❑ Lymphatic: Intrathoracic 0 Peritoneal
❑ Lymphatic: Axitlary
❑ Lymphatic: Other ❑ Site not stated
❑ Lymphatic: Unknown
❑ Laryngeal
1
❑ Other Enter anatomic code(s)
(see list):
2
3
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and main-
taining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond toe collection of information unless It
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information. including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0026). Do not send the completed form to Nis address.
Information contained on this tom) which would permit identification of any individual has been collected with a guarantee that it will be held In strict confidence. will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Pubkc Health Service Act (42 U.S.C. 242m).
CDC 72.9A Rev 09/15/2008 CS121321
1st Copy
REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 1 of 3
Page 1 of 6
ATTACHMENT B-2
Patient's Name State Case No.
(Last
(Fvst)
REPORT OF VERIFIED CASE OF TUBERCULOSIS
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
17. Sputum Smear (select one)
Date Collected:
Month Day Year
• Positive ❑ Not Done
• Negative U Unknown
18, Sputum Culture (select one)
Date Collected:
Month Day Year
Dale Result Reported:
Month Day Year
Positive Not Done
U Negative ❑ Unknown
Reporting Laboratory Type (select one): ❑ Public Health n Commercial
Laboratory ❑ laboratory ❑ Other
19. Smear/Pathology/Cytology of
Tissue and Other Body Fluids (select one)
Date Collected:
Month Day Year
Enter anatomic code Type of exam (select all that apply):
(see list):IN
• Positive U Not Done
. ❑
Smear Pathology/Cytology
Negative Unknown
20. Culture of Tissue and Other Body
Fluids (select one)
Date Collected:
Month Day Year
Enter
anatomic code Date Result Reported:
(see list):
Month Day Year
MI Positive U Not Done
❑
Negative Unknown
f
t
Reporting Laboratory Type (select one): • Public Health • Commercial M Other
Laboratory Laboratory
21. Nucleic Acid Amplification Test
Result (select one)
Date Collected:
Month Day Year
Date Result Reported:
Month Day Year
MI Positive ❑ Not Done
Negative II Unknown
t
• Indeterminate
Enter specimen type: ❑ Sputum
Reporting Laboratory Type (se/ect one):
OR
If not Sputum, enter anatomic code (see list):
❑ Public Health • Commercial � Other
Laboratory Laboratory
Initial Chest Radiograph and Other
22A. Initial Chest Radiograph
(select one)
228. Initial Chest CT Scan Of
Other Chest Imaging
Study (select one)
Chest Imaging Study
O Normal ❑ Abnormal' (consistent with TB) ❑ Not
' For ABNORMAL Initial Chest Radiograph:
Done • Unknown
Evidence of a cavity (select one): U Yes O No U Unknown
Evidence of miliary TB (select one): ❑ Yes O No ❑ Unknown
II Normal ❑ Abnormal (consistent with TB) ■ Not Done U Unknown
- For ABNORMAL Initial Chest Radiograph:
Evidence of a cavity (select one): ❑ Yes U No U Unknown
Evidence of miliary TB (select one): U Yes O No III Unknown
23. Tuberculin (Mantoux) Sldn Test
at Diagnosis (select one)
❑ Positive O Not Done
❑ Negative ❑ Unknown
Date Tubercukn Skin Test (TST) Placed:
Month
Day
J
Year
Millimeters (mm)
of induration:
24. Interferon Gamma Release Assay
for Mycobacterium tuberculosis at Diagnosis
(select one)
O Positive ❑ Not Done
O Negative ❑ Unknown
O Indeterminate
Date Collected:
Month Day
Year
Test type:
Specify
25. Primary Reason Evaluated for TB Disease
(select one)
❑ TB Symptoms
❑ Abnormal Chest Radiograph (consistent with TB)
❑ Contact Investigation
❑ Targeted Testing
❑ Health Care Worker
❑ Employment/Administrative Testing
❑ Immigration Medical Exam
❑ Incidental Lab Result
O Unknown
CDC 72.9A Rev 09/15/2008 CS121321
1st Copy
Page 2 of 6
REPORT OF VERIFIED CASE OF TUBERCULOSIS
Page 2 of 3
ATTACHMENT B-2
Patient's Name State Case No.
IM.I.I
IFS
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
26. HIV Status at Time of Diagnosis (select one)
III Negative U Indeterminate . Not
Offered • Unknown
Done, Results Unknown
In Positive U Refused . Test
If POSITIVE, enter.
State HIV/AIDS
Number
City/County HN/AIDS
Patient Number
Patient
27, Homeless Within Past Year
(select one)
28. Resident
If YES,
❑ Federal
❑ State
of Correctional Facility at Time of Diagnosis (select one)
(select one):
Prison ❑ Local Jail ❑ Other
U No . Yes U Unknown
If YES, under custody of
Immigration and Customs
Correctional Facility Enforcement? (select one)
• No III Yes . Unknown
Prison III Juvenile Correction Facility III Unknown I No ❑ Yes
29. Resident of Long -Term Care Facility
If YES, (select one):
at Time of
Facility
Health Residential
Diagnosis (select one) III No ❑ Yes ❑ Unknown
• Nursing Home U Residential
U Alcohol or Drug Treatment Facility U Unknown
El Hospital -Based Facility O Mental
Facility U Other Long -Term Care Facility
30. Primary Occupation Within the Past
Year (se/ect
Migrant/Seasonal
Other Occupation
one)
(e.g. student, homemaker, disabled person)
• Health Care Worker ❑
Worker • Retired • Not Seeking Employment
• Correctional Facility Employee ❑
III Unemployed ■ Unknown
31. Injecting Drug Use Within Past Year
(select one)
32 Non -Injecting Drug Use Within Past Year
(select one)
33. Excess Alcohol Use Within Past Year
(select one)
❑ No • Yes U
Unknown
U No III Yes U Unknown
❑ No ll Yes U Unknown
34. Additional TB Risk Factors (select all
❑ Contact of MDR -TB Patient (2 years
that apply)
or less)
years or less)
❑ Incomplete LTBI Therapy O Diabetes Mellitus
U Other Specify
• Contact of Infectious TB Patient (2
MI TNF-a Antagonist Therapy II End -Stage Renal Disease . None
❑ Missed Contact (2 years or less)
HIV/AIDS)
U Post -organ Transplantation U lmmunosuppression (not
35. Immigration Status at First Entry to the
U.S. (select
a parent who
U.S. Island
one)
• Not Aopllcable
III Immigrant Visa II
Tourist Visa • Asylee or Parolee
• "U.S.-born" (or born abroad to
• Born in 1 of the U.S. Territories,
was a U.S. citizen) U Student Visa ❑ Family/Fiance Visa III Other Immigration Status
Areas, or U.S. Outlying Areas O Employment Visa III
Refugee IN Unknown
36. Date Therapy Started
Month Day
Year
REPORT OF VERIFIED CASE OF TUBERCULOSIS
Page of 3
CDC 72.9A Rev 09/15/2000 CSt21321
3T. Initial Drug Regimen (se/ect one option for each drug)
No Yes Unk
Isoniazid ❑ ❑ ❑
Rifampin 000
Pyrazinamide 000
Ethambutol 000
Streptomycin
Rifabutin
Rifapentine
No Yes Unk
Ethionamide
Amikacin
Kanamycin
Capreomycin
Ciprofloxacin ❑ D ❑
Levofoxacin 0101=1
Ofloxacin O ❑ ❑
tst Copy
Page 3 of 6
Moxi loxacin
Cycloserine
Para -Amino
Salicylic Acid
Other
Specify
Other 000
Specify
No Yes Unk
O 00
O 00
000
O 00
ATTACHMENT B-2
Patient's Name
(Ltitl
(Furl
IMO
Street Address
Number Street, City, Steel
OP Goer)
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 30333
FORM APPROVED OMB NO. Venous Eve. Date 05/31/2011
REPORT OF VERIFIED CASE OF TUBERCULOSIS
Initial Drug Susceptibility Report
Year Counted
(Follow Up Report -1)
State
Case Number
City/County
Case Number
Submit this report for all culture -positive cases.
38. Genotyping Accession Number
Isolate submitted for genotyping (select one): ❑ No ❑ Yes
If YES, genotyping accession number for episode:
39. Initial Drug Susceptibility Testing
Was drug susceptibility testing done? (select one) ❑ No ❑ Yes ❑ Unknown
If NO or UNKNOWN, do not complete the rest of Follow Up Report -1
If YES, enter date FIRST isolate collected for which drug susceptibility
testing was done:
Month Day Year
Enter specimen type: ❑ Sputum
OR
If not Sputum, enter anatomic code (see list):
40. Initial Drug Susceptibility Results (select one option for each drug)
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
Rlfabutin
Ritapentine
Ethionamide
Am ikacin
Kanamycin
Resistant Suernotible Not Drone Unknown
❑ ❑❑❑❑❑❑❑❑❑
❑ ❑❑❑❑❑❑❑❑❑
❑ ❑❑❑❑❑❑❑❑❑
Suareotibe Not Oone Unknown
Capreomycin ❑ ❑ ❑ O
Ciprofloxacin ❑ ❑ 0 ❑
Levofloxacin ❑ ❑ ❑ ❑
Ofloxacin ❑ ❑ ❑ ❑
Moxitoxacin ❑ ❑ ❑ ❑
Other Ouinclones ❑ ❑ ❑ ❑
Cycloserine ❑ 0 ❑ ❑
Para -Amino Salicylic Acid ❑ ❑ ❑ ❑
Other ❑ ❑ ❑ 0
Specify
Other
Specify
❑ ❑ ❑
Pubic reporting burden of this collection of information IS estimated to average 35 minutes per response, Including the tlmefor reviewing instructions, searching existing data sources. gathering and man -
taming the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or arty other aspect of this collection of information, including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1609 Clifton Road, MS 0-74, Atlanta, GA 30333, ATN: PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would perms identification of any individual has been collected with a guarantee that it will be held in strict confidence, w91 be used only (or surveillance purposes,
and will not be disclosed or released without the consent of the Individual in accordance with Section 308(0) of the Public Health Seneca Act (42 U.S.C. 242m).
CDC 72.98 Rev 09/15/2005 CS121321
1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-1/Page l of I
Page 4 of 6
ATTACHMENT B-2
Patient's Name
(F.rstl
Street Address
(Lan)
etonber, Street. Cih. Stan)
(RIP COOS)
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 't1T_;i
FORM APPROVED OMB NO. oem-to26 Exp. Date 05/51/2011
REPORT OF VERIFIED CASE OF TUBERCULOSIS
Case Completion Report
(Follow Up Report - 2)
Year Counted
State
Case Number
City/County
Case Number
Submit this report for all cases in which the patient was alive at diagnosis.
41. Sputum Culture Conversion Documented (select one) ❑ No ❑ Yes ❑ Unknown
If YES. enter date specimen collected for FIRST If NO, enter reason for not documenting sputum culture conversion (select one):
consistently negative sputum culture:
Month
Day
Year
❑No Follow-up ❑ Patient Refused
Sputum Despite Induction
❑ No Follow-up Sputum and No Induction ❑ Other Specify _
❑ Died ❑ Unknown
❑ Patient Lost to Follow -Up
42. Moved
Did the patient move during TB therapy? (select one) ❑ No ❑ Yes
It YES, moved to where (select all that apply):
❑ in state, out of jurisdiction (enter city/county) Specify Specify
❑ Out of state (enter state) Specify - Specify
❑ Out of the U.S. (enter country) Specify Specify
It moved out of the U S., transnational referral'? (select one)
❑ No ❑ Yes
43. Date Therapy Stopped
Month
Day
Year
44. Reason Therapy Stopped or Never Started (select one)
❑ Completed Therapy O Not TB If DIED, indicate cause of death (select one):
❑ Lost ❑ Died ❑ Related to TB disease ❑ Unrelated to TB disease
O Uncooperative or Refused ❑ other ❑ Related to TB therapy ❑ Unknown
❑ Adverse Treatment Event ❑ Unknown
45. Reason Therapy Extended X12 months (select all that apply)
❑ Rifampin Resistance ❑ Non -adherence
❑ Adverse Drug Reaction O Failure
❑ Clinically Indicated - other reasons
O Other Specify
46. Type of Outpatient Health Care Provider (select all that apply)
❑ Local/State Health Department (HO) ❑ IHS, Tribal HD, or Tribal Corporation ❑ inpatient Care Only ❑ Unknown
❑ Private Outpatient
O Institutional/Correctional
O Other
Public reporting burden of thls collection of Information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and main-
taining the data needed and completing and reviewing the collection of information, An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, Including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1500 Clifton Road, MS 0-74, Atlanta, GA 30333, ATTN: PRA (0920.0026. Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,
end wsl not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act 142 U.S.C. 242m).
CDC 72.9C Rev 08/15/2008 CS121321
1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report -2 / Page 1 of 2
Page 5 of 6
ATTACHMENT B-2
Patient's Name State Case No,
au.0
F")
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 30333
FORM APPROVED OMB NO. 0920-0026 Exp. Dale 0571/2011
REPORT OF VERIFIED CASE OF TUBERCULOSIS
Case Completion Report - Continued
(Follow Up Report - 2)
47. Directly Observed Therapy (DOT) (select one)
❑ No, Totally Self -Administered
❑ Yes, Totally Directly Observed
❑ Yes, Both Directly Observed and Self -Administered
❑ Unknown
Number of weeks of directly observed therapy (DOT)
48. Final Drug Susceptibility Testing
Was follow-up drug susceptibility testing done? (select one)
O No ❑ Yes ❑ Unknown
if NO or UNKNOWN, do not complete the rest of Follow Up Report -2
If YES, enter date FINAL isolate collected for which drug susceptibility
testing was done:
Month Day
Year
Enter specimen type: O Sputum
OR
if not Sputum, enter anatomic code (see list).
49. Final Drug Susceptibility Results (select one option for each drug)
Resistant $usceytible Not Done Unknown
Isoniazid O O ❑ ❑ Capreomycin
Rifampin ❑ O ❑ ❑ Clprofloxacin
Pyrazinamide ❑ ❑ ❑ ❑ Levofloxacin
Ethambutol ❑ ❑ ❑ ❑ Oftoxacin
Streptomycin ❑ ❑ ❑ ❑ Moxifloxacnn
Rifabutin ❑ ❑ ❑ ❑ Other Quinolones
Rifapentine ❑ ❑ O ❑ Cycloserine
Ethiena lamide O O O O Para -Amino Salicylic Acid
Amikacin O O ❑ ❑ Other
Kanamycin ❑ ❑ O O Specify
Other
SeaM_arA
000000000
Susceptible Not Done Unknown
000000000
Specify
000000000
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing Instructions. searching existing data sources, gathering and main-
taining the data needed and completing and reviewing the collection of Information. An agency may not conduct or sponsor, and a person is not required to respond to a cotection of information unless It
displays a currently valid OMB control number. Send Comments regarding this burden estimate or any other aspect of this collodion of information. Including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0026). Do not send the completed form to this address.
information Contained on this tone which would permit identification of any individual has been Collected with a guarantee that it will be held in ttnct confidence, will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the Individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.9C Rev 09/15/2008 CS121321
1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report -2 / Page 2 of 2
Page 6 of 6
ATTACHMENT B-3
4
C
rt
Ep
O 0
O W
C -L
W0
a • H
A 6
.O
@ H
w
= w
_U Z
ao
a -U
Q
oz
i-
c 0
O 0
E
co CO
a• 0
0
O 0
CC
CO W
O
O r
V
T
O
C
a)
O)
a
r a)
O2 3-
`o
N
CU
C E
@ Q
Z u_
Name of index case
Z^
@
9
C
O
Z
LI
Date contact investigation initiated
Infectious period
@
a) o
Z Z
DEED
X N
N N
s E 3
U to
Susceptibilities
Comments/Symptoms
t
N 0
N a
x 0
F
Chest X-ray
Results
Date
TST/IGRA
Results
Retest placed/drawn)
cc
CO
Initial placed/drawn
N
a,
22
0
0
U "L11 3
.R y O 9
o re m 8
U u.
°-' c m _
a O ' 3
O iv 0 O o
a .
W m 0 U
..
0.1 CO
.d. CO O
re O.
0 -j K
W
C •-
0 CO
0 0
O
2
C
0
0
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
(13
Q.
@
t
m
LL
.92
L
Y `x -4O
O 0)
t i -O J r
Y 049.y
N ` Co 'C
• a
▪ a) j U
c • v
ri
o J
JO L O
L h
O C C
c
o ▪ ▪ U o
«
C Urn
o t
CD U O N 6
O o
O C
r
LnUAN-
J
0
0 J
..• v
M 4) O
'
W e E
C
m
a
8
rc
U
ATTACHMENT B-4
A. Demographic Information
Al. Name (Last, First, Middle)
TB Follow -Up Worksheet
Version 2.0 10/30/2007
A2. Alien Number:
A3. Visa Type:
A4. Initial U.S. Entry Date:
A5. Age:
A6. Gender:
A7. DOB:
AS. TB Class:
A9. Class Condition:
Al 0.Country of Examination: I Al 1.Country of Birth:
Al2. Data Entry Q -Station:
A13. Officer in Charge:
A14. Q -Station Phone:
Al5a. Address:
Al5b. Phone:
Al5c. Other:
Al6a. Sponsor Agency Name:
Al 6b. Sponsor Agency Phone:
Al 6c. Sponsor Agency Address:
B. Jurisdictional Information
B7. Destination State: B2. Jurisdiction:
63. Jurisdiction Phone #:
C. U.S. Evaluation
Cl. Date of Initial U.S. Medical Evaluation:
C2a. TST Placed:
C2b. TST Placement Date:
C2c. TST mm:
C2d. TST Interpretation:
9 Yes
0 Positive
No Unknown
Negative Unknown
C2e. History of Previous Positive TST 9
C3a. Quantiferon (QFT) Test: Yes
C3b. QFT Collection Date:
C3c. QFT Result: 9 Positive
0 No 9 Unknown
9 Negative 9 Indeterminate
9 Unknown
U.S Review of Overseas CXR
Domestic CXR
Comparison
C4. Overseas CXR Available?
9 Yes 9 No 0 Not Verifiable
C7. U.S. CXR Done? ❑ Yes 9No 9 Not Verifiable
C8. Date of U.S. CXR:
C5. U.S. Interpretation of Overseas CXR:
9 Normal n Abnormal n Poor Quality n Unknown
C9. Interpretation of U.S. CXR:
9 Normal 9 Abnormal 9 Unknown
C6. Overseas CXR Abnormal Findings:
9 Abnormal, not TB 9 Cavity 9 Fibrosis
0 Infiltrate 9 Granuloma(ta) 9 Adenopathy
9 Other (Specify)
C12. U.S. Mocroscopy/Bacteriology 9 Specimen not collected in U.S.
C10. U.S. CXR Abnormal Findings:
9 Abnormal, not TB 9 Cavity
9 Infiltrate 9 Granuloma(ta)
Other (Specify)
9 Fibrosis
9 Adenopathy
C11. U.S. CXR
Comparison to
Overseas CXR:
9 Stable
9 Worsening
9 Improving
9 Unknown
Spec Source
Date
AFB Smear Result
Culture Result
Drug Resistance (DR)
0 Not Done
0 Negative
0 Positive
0 Unknown
0 Not Done
0 Negative
0 MTB Complex
0 Not Done
0 Negative
0 MTB Complex
0 Not Done
Negative
MTB Complex
0 NTM
0 Contaminated
0 Unknown
0 NTM
0 Contaminated
0 Unknown
0 NTM
0 Contaminated
0 Unknown
0 Not Done 0 Mono-RIF
0 No DR 0 MDR -TB
0 Mono-INH 0 Other DR
0 Not Done
0 No DR
0 Mono-INH
0 Not Done
0 No DR
0 Mono-INH
2
0 Not Done
0 Negative
0 Positive
0 Unknown
OMono-RIF
0 MDR -TB
0 Other DR
0 Mono-RIF
0 MDR -TB
0 Other DR
3
0 Not Done
0 Negative
0 Positive
0 Unknown
Page 1 of 2
ATTACHMENT B-4
TB Follow -Up Worksheet (Cant) I
Version 2.0 10/30/2007
U.S. Review of Overseas Treatment I
C13.
Recommended
Physician:
0
9
Overseas Treatment
by Panel
Yes
No
Unknown
C14. US Review of TB Disease
Overseas Treatment:
Yes ❑ No ❑ Unknown
If Yes
Patient -Reported
Panel Physician -Documented
Both
C15.
Treatment:
,
Arrived on
Yes
No
Unknown
C16.
Overseas:
,
0
Completed Treatment
Yes
No
Unknown
C17. Overseas Treatment Concerns: 9 Yes � No
D. Disposition
Dl. Disposition Date:
D2. Evaluation Disposition:
Completed Evaluation
� Initiated Evaluation / Not Completed
� Did Not Initate Evaluation
Treatment Recommended
No Treatment Recommended
�
�
Moved within U.S.
Lost to Follow -Up
Returned to Country of Origin
Refused Evaluation
Died
Other, specify
�
�
�
�
Not Located
Moved within U.S.
Lost to Follow -Up
Returned to Country of Origin
Refused Evaluation
Died
Unknown
Other, specify
D3. Diagnosis � Class 0 - No TB exposure, not infected �
Class 2 - TB infection, no disease �
Class 4 - TB, inactive disease
Class 1 - TB exposure,
Class 3 - TB, active
� Pulmonary
no evidence of infection
disease
� Extrapulmonary
� Both Sites
D4. � RVCT Reported D5. RVCT#:
E. U.S. Treatment
Et. U.S. Treatment Initiated: E2. U.S. Treatment Start Date
No Treatment
Active Disease
LTBI
Unknown
E3. U.S. Treatment Completed: E4. U.S. Treatment End Date:
� Yes
9 No
� Unknown
F. Comments
G. Screen Site Information
Provider's Name:
Clinic Name:
Telephone Number:
Physician Signature:
Date (mm/dd/yyyy)
Page 2 of 2
ATTACHMENT B-5
Tuberculosis
Semi -Annual Progress Report
Agency/Person
Date Submitted
Reporting Time Period _ July 1 - December 31
_ January 1 - June 30
Briefly describe TB activities and accomplishments during reporting period.
Describe any challenges/obstacles to providing TB services as specified in the
CDPHE TB contract during reporting time period.
Page 1 of 1
EXHIBIT C
BUDGET
To Contract Dated 04/17/2013 - Contract Routing Number 14 FHA 55247
The Budget shall govern the Contractor's expenditure of funds for the term through and including June
30, 2014.
Description
Funding Source
Amount
TB Prevention and Control
State
$44,565
TB Prevention and Control
Federal
$7,500
DOT Blanket Funds
As Administered
$23,000
Diagnostic Blanket Funds
As Administered
$23,000
Total
$52,065
Page 1 of 1
EXHIBIT D
GRANT FUNDING CHANGE LETTER
[Date: _I State Fiscal Year:
TO: Insert Grantee's name
Grant Funding Change Letter #
CMS Routing #
In accordance with Section of the Original Contract routing number , [insert the following
language here if previous amendment(s). renewal(s) have been processed] as amended by [include all
previous amendment(s). renewal(s) and their routing numbers), [insert the following word here if
previous amendment(s), renewal(s) have been processed] between the State of Colorado, Department
of Public Health and Environment and Contractor's Name beginning Insert start date <insert start date of
original contract> and ending on Insert ending date <insert ending date of current contract amendment>,
the undersigned commits the following funds to the Grant:
The amount of grant funds available and specified in Section of <insert contract amendment
number and routing number> is ❑ increased or ❑ decreased by $amount of change to a new total
funds available of $ <insert new cumulative total> for the following reason: . Section
is hereby modified accordingly.
This Grant Funding Change Letter does not constitute an order for services under this Grant.
The effective date of hereof is upon approval of the State Controller or , whichever is later.
STATE OF COLORADO
John W. Hickenlooper, GOVERNOR
Department of Public Health and Environment
PROGRAM APPROVAL:
BY:
By: Lisa Ellis, Purchasing & Contracts Unit Director
Date:
ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS §24-30-202 requires the State Controller to approve all State Grants. This Grant is not valid until signed and dated below by
the State Controller or delegate. Grantee is not authorized to begin performance until such time. If Grantee begins performing prior
thereto, the State of Colorado is not obligated to pay Grantee for such performance or for any goods and/or services provided
hereunder.
STATE CONTROLLER
David J. McDermott, CPA
By
Date
Page 1 of 1
Effective Date: 1/6/09 -Rev 8/25/09
Hello