HomeMy WebLinkAbout20121492.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR FAMILY PLANNING 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 Family
Planning 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
June 30, 2012, and ending June 29, 2013,with further terms and conditions being as stated in said
task order contract, and
WHEREAS, after review,the Board deems it advisable to approve said task order 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 Family Planning 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 task order contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 18th day of June, A.D., 2012.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST:d,�
Sean Pep* Chai
Weld County Clerk to the Board A
William/F. Garcia, Pro-Tem
o-1
BY: , t < /�
Deputy CI k to the Board �� �`� CUSED
•ara Kirkmeyer
1861 tr- ! '
0
r ED a ORM: 1 ca1� r i/
• '/ V id E. Long
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' Cou Attorney "rte .. c u a
Douglas ademach'
Date of signature: -7- d / a
3 on j 4t To lc& de: /-/z 2012-1492
U. l 8-1 a /O 3' /a HL0039
1861
Memorandum
TO: Sean Conway, Chair
Board of County Commissioners
JFROM: Mark E. Wallace, MD, MPH, Director
v, �- Y Dept of Public Health & Environment
DATE: May 7,2012
SUBJECT: Family Planning Program
Task Order Contract FY12-13
Enclosed for Board review and approval is a Task Order Contract between the Colorado
Department of Public Health and Environment and the Weld County Board of County
Commissioners on behalf of the Department of Public Health and Environment (WCDPHE) for
continuation of a comprehensive family planning program.
Under the provisions of this contract, WCDPHE will continue providing comprehensive family
planning services to men and women in their reproductive years. These services will include
comprehensive health and social histories, physical examinations, contraceptive information and
supplies. Education and counseling regarding all family planning methods, infertility,
sterilization, nutrition, sexually transmitted disease, follow-up and/or referrals will also be
provided.
For the above services, Weld County will be reimbursed an amount not to exceed $172,500.00.
Of this amount, $122,529.00 is from Federal funding and $49,971.00 is funding from the State of
Colorado. This reflects a slight increase of$318.00 from fiscal year 2011-2012. The term of the
contract is from July 1, 2012, through June 29, 2013.
I recommend your approval of this Task Order Contract.
Enclosure
2012-1492
I
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
ROUTING NO.12 FLA 43697
APPROVED TASK ORDER CONTRACT
This Task Order Contract is issued pursuant to Master Contract made on January 23,2007 contract routing number 08
FAA 00052 with a term end date of June 30,2012 and pursuant to Master Contract made on January 17,2012 contract
routing number 13 FAA0005I with a term end date of June 30,2017. Pursuant to Section 16,Contract Modifications,of
Master Contract 08 FAA 00052 and Master Contract 13 FAA 00051 this Task Order Contract shall be reassigned and
governed by Master Contract 13 FAA00051 effective July 1,2012.
STATE: CONTRACTOR
State of Colorado for the use&benefit of the Board of County Commissioners of Weld County
Department of Public Health and (a political subdivision of the state of Colorado)
Environment 915 10th Street, Greeley,Colorado 80632-0758
PSD-FPP for the use and benefit of the
4300 Cherry Creek Drive South Weld County Department of Public Health and
Denver, Colorado 80246 Environment n
1555 North 17 Avenue
Greeley,Colorado 80631
TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE:
04/24/2012 Colorado Political Subdivision
PO/SC ENCUMBRANCE NUMBER
PO FLA PPG1243697
TERM: • - BILLING STATEMENTS RECEIVED:
This Task Order shall be effective upon Monthly
approval by the State Controller, or designee,
or on 06/30/2012,whichever is later. The STATUTORY AUTHORITY:
Task Order shall end on 06/29/2013. Not Applicable
PRICE STRUCTURE: coNTRACT PRICE NOT TO EXCEED:
Reimbursement $172,500.00
PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS: $122,529.00
Exempt STATE FUNDING DOLLARS: $49,971.00
BID/RFP/LIST PRICE AGREEMENT NUMBER MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR
Not Applicable FY 13: $172,500.00
LAW SPECIFIED VENDOR STATUTE:
Not Applicable
STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE:
Chandra Hardwick Tanya Geiser
Deparment of Public Health and Environment Weld County Department of Public Health and
PSD-FPP Environment
4300 Cherry-Creek Drive South 1555 North 17`h Avenue
Denver,CO 80246 Greeley, Colorado 80631
SCOPE OF WORK
Under the Family Planning Program(FPP),Contractor shall conduct a comprehensive family planning program.
•
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&O/ /5/s
F.XIi IBITS:
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-1,B-2,etc.)
Exhibit C- Budget
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.
1. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contracts
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 Contracts.
2. In accordance with section 24-30-202(1), 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 Contracts.
Contractor's commencement of perfonnance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
3. The Master Contracts 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 teens 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 Contracts 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:
1)the 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.
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4. The Contractor, in accordance with the terms and conditions of the Master Contracts and this Task Order
Contract,shall perform and complete,in a timely and satisfactory manner,all work items described in the
Statement of Work attached hereto as"Exhibit B"and the Budget attached hereto as"Exhibit C"which
are incorporated herein by this reference.
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 Contracts,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$100,000 or
higher]
By entering into this Task Order Contract, Contractor agrees to be govemed,and to abide,by the
provisions of CRS §24-102-205, §24-I02-206, §24-103-601, §24-103.5-101 and §24-105-102 concerning
the monitoring of vendor perfonnance 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
perfonnance 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
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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 §§24-109-106, 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.
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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: STATE OF COLORADO:
Board of County Commissioners of Weld John W.Hickenlooper, GOVERNOR
County(a political subdivision of
the state of Colorado)for the use and benefit of
the Weld County Department of Public Health
and Environment
Name
Legal off Contracting Entity 1 y , N„ j�
• For Executive Director
PDepartment of Public Health and Environment
Signature of Authorized Officer JUN 1 2012
Sean P. Conway 8
Print Name of Authorized Officer
Deplane t ro App or'vat:
Chair By
Print Title of Authorized Officer
ALL CONTRACTS MUST BE APPROVED BY 1'1-IL 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
. .. .4.4-2-0/71.1"e-
Date
7- Z
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EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 04/24/2012-Contract Routing Number 12 FLA 43697
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order
Contract specified above.
1!) .niHcipz kuigu.h.ctirto 1'r,tgraph i v\ill be included p:io to the controller.,:,ienaturc
1. The list of acronyms attached hereto as Attachment A-1 may be referenced to in Exhibit A,Exhibit B,
and all and any attachments thereof in this Task Order Contract.
2. This Task Order Contract contains federal and state funds(see Catalog of Federal Domestic Assistance
(CFDA)number 92.217).
3. The United State Department of**********("US****"),through the********** ("***")has awarded
federal funds under Award number**********,hereinafter"Award",to perform the following-
***********
If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as
of the effective date of that Award,then the State shall reimburse the Contractor for any allowable and
allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective
date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable
and allocable expenses of a contractor as of the effective date of that Award,then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by
the Contractor on or after the effective date of this Task Order Contract,with such effective date being the
later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the
State Controller or delegee.
4. Notwithstanding the terms contained in General Provisions of the Master Contract,Section 27,Annual
Audit,for the purpose of this Task Order,the Contractor is a Vendor as defined by Office of Management
and Budget(OMB)Circular A-133 (Audits of States,Local Governments,and Non-Profit Organizations).
5. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 25,
Conformance with Law,Contractor shall comply with all applicable requirements of the following for
Contractor's respective entity type:
a. 2 Code of Federal Regulations(CFR) Part 215, Uniform Administration Requirements for Grants
and Agreements with Institutions of Higher Education, Hospitals, and Other Non-Profit
• Organizations,formerly known as OMB Circular A-110;b. OMB Circular A-102,Grants and Cooperative Agreements with State and Local Governments;
c. 2 C.F.R. 230, Cost Principles for Nonprofit Organizations, formerly known as OMB Circular A-
122;
d. 2 C.F.R.225,Cost Principles for State,Local, and Indian Tribal Governments,formerly known as
OMB Circular A-87;
e. 2 C.F.R.220, Cost Principles for Educational Institutions, formerly known as OMB Circular A-
21;
f OMB Circular A-I 33,Audits of States, Local Governments, and Non-profit Organizations
6. 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 intemet website
httpJ/wvvw.cdphe.state.co.us/Standardizedlnvoice/index.html. CDPHE will provide technical assistance in
accessing and completing the form. The CDPHE Reimbursement Invoice Form must be submitted within
sixty(60)calendar days of the end of the billing period for which services were rendered. Expenditures
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EXHIBIT A
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 to:
Colorado Department of Public Health and Environment
Fiscal Officer
PSD-(FPP)-A5
4300 Cherry Creek Drive South
Denver,CO 80246
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 sixty
(60)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 sixty(60)calendar days from the effective expiration or
termination date of this Task Order Contract.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
7. Health Insurance Portability and Accountability Act(HIPAA)Business Associate Determination.
The State has determined that this Task Order Contract does not constitute a Business Associate
relationship under HIPAA.
8. Contractor must notify the State within thirty(30)days of a change of the Project Director or Principal
Investigator responsible for the performance of services provided under this Task Order Contract.
9. Contractor shall request prior approval in writing from the State for all modifications to the Statement of
Work/Work Plan or for any modification to the Budget in excess of ten percent(10%)of the total budget.
Contractor shall submit a Budget Revision Request Form to request prior approval for all budget
modifications in excess of ten percent(10%)of the total budget. The Budget Revision Request Form is
incorporated herein by reference and is located at
http://www.cdphe.state.co.us/pp/women/FPNursingConsntsFonns.html?colt=open. Any request for
modification to the Budget in excess of thirty percent(30%)of the total budget or$1,000,000.00,
whichever is less,shall be submitted to the State by February 28,2013 and may require an amendment in
accordance with Section 5 of this Task Order Contract. Requests for modifications to the Statement of
Work/Work Plan may require an amendment regardless of dollar amount.
10. Contractor shall submit an Annual Family Planning Work Plan and semi-annual work progress reports by
due dates specified by the State at
htip:,,www.cdphe.state.co.us/pp/vomens!FPNursingConsntsFonns.html?col2=open and in a format
acceptable by the State. Failure to submit acceptable reports by the due date may result in a delay or denial
of the reimbursement request.
11. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9,Rights in
Data, Documents and Computer Software or Other Intellectual Property,unless otherwise provided for,all
data collected or produced or derived exclusively from the Contractor's or subcontractor's work under this
• Task Order Contract shall remain the sole property of the State,whether in individual,aggregate,identified •
or de-identified form or any other form required by the State. To facilitate follow-up,research,surveillance
and evaluation, any such data collected,used or acquired shall be made available in any fonn required by
the State,to the State and any other entity designated by the State.
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EXHIBIT A
Any such data collected,used or acquired shall be used solely for the purposes of this Task Order Contract.
The Contractor and its subcontractors agree not to release,divulge,publish,transfer,sell,or otherwise
make known any such data to unauthorized persons without the express prior written consent of the State or
as otherwise required by law.This includes a prior written request by the Contractor to the State for
submission of abstracts or reports to conferences,which utilize data collected under this Task Order
Contract.
Notwithstanding the foregoing,the Contractor shall be entitled to retain a set of any such data collected or
work papers necessary to perfonn its duties under this Task Order Contract and in accordance with
professional standards.
Publications,journal articles,etc.produced under a Centers for Disease Control and Prevention(CDC)
grant supported project must bear an acknowledgment and disclaimer,as appropriate,for example: "This
publication(journal article,etc.was supported by the Cooperative Agreement Number above from the
Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do
not necessarily represent the official views of the Centers for Disease Control and Prevention."
12. Neither the U.S.Department of I-Iealth and Human Services(HSS)nor the Centers for Disease Control
(CDC)logo may be displayed on any conference materials if such display would cause confusion as to the
conference source or give false appearance of Government endorsement.Use of the MIS name or logo is
governed by U.S.C. 1320b-10,which prohibits misuse of the HHS name and emblem in written
communication. A non-federal entity is unauthorized to use the HHS name or logo governed by U.S.C.
1320b-10. The appropriate use of the HHS logo is subject to review and approval of the Office of the
Assistant Secretary for Public Affairs(OASPA).
13. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9,Rights in
Data, Documents and Computer Software or Other Intellectual Property,or Section 23.i, General
Provisions, Media or Public Announcements,the State of Colorado,specifically the Department of Public
Health and Environment, shall be the owner of all printed materials,graphic representations,educational
materials, audio-visual products,or any other media,in whatever form,created under this Task Order
Contract.This requirement applies,but is not limited to, any brochure,flyer,presentation,billboard,radio
spot,website,banner advertisement. The State reserves the right to require logos,or other wording on any
material,representation,product or other media fonn created under this Task Order Contract.
Any material,representation,product or other media form that will use the State's or logo or information
must be approved by the State prior to production and distribution.A minimum of ten(10)business days is
required for the review and approval process.
14. Notwithstanding terms contained in General Provisions of the Master Contract,Section 23f,Assignment
and Change in Ownership, Address, Financial Status,Contractor is responsible for all work performed
under this Task Order Contract by subcontractor(s)and shall maintain,at a minimum,a Memorandum of
Understanding or other binding contractual agreement with all subcontractor(s)performing work under this
Task Order Contract. Contractor shall provide a list of all current subcontractor(s)to the State within
fifteen(15)calendar days of the execution date of this Task Order Contract and shall provide a list of any
new subcontractor(s)at a minimum of fifteen(15)calendar days prior to the execution of any subcontract
agreement. Contractor shall maintain records of any subcontractors in accordance with the time periods
specified in General Provisions of the Master Contract, Section 11, Records, Maintenance, Performance
Monitoring&Audits.
15. The State may require forms attached to this Task Order Contract and incorporated herein to be updated by
the Contractor during the term of this Task Order Contract. The State shall notify the Contractor of newly
developed forms. Fonns may be sent to the Contractor or posted on
http:;/www.cdphe.state.co.us//pp/womens/famplan.hunl.
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EXHIBIT A
16. Notwithstanding the terms contained in the General Provisions of the Master Contract, Section 25,
Conformance with Law,the Contractor shall comply with the provisions of Section 601 of Title VI of the
Civil Rights Act of 1964, as amended,which states that"no person in the United States shall on the
grounds of race,color or national origin,be excluded from participation in,be denied the benefits of,or be
subjected to discrimination under any program actively receiving Federal financial assistance." The Office
for Civil Rights has established that it is the responsibility of any program that is a recipient of federal
funds to ensure that any Limited English Proficient(LEP)person or beneficiary have meaningful access to
programs, services and information. The Contractor and contract personnel shall adopt and implement
policies and procedures in which reasonable steps are taken to provide language assistance in order to
ensure equal access to LEP persons or beneficiaries. The Contractor and contract personnel shall advise
LEP individuals that language assistance will be provided at no cost to the LEP person or beneficiary.
17. Contractor agrees to provide services to all Program participants and employees in a smoke-free
environment in accordance with Public Law 103-227,also known as"the Pro-Children Act of 1994",(Act).
Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or
leased or contracted for by an entity and used routinely or regularly for the provision of health,day care,
early childhood development services,education or library services to children under the age of 18,if the
services are funded by Federal programs either directly or through State or local governments,by Federal
grant,contract,loan,or loan guarantee. The law also applies to children's services that are provided in
indoor facilities that are constructed,operated,or maintained with such Federal funds. The law does not
apply to children's services provided in private residences;portions of facilities used for inpatient drug or
alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or
Medicaid;or facilities where Women,Infants and Children(WIC)coupons are redeemed. Failure to
comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty
of up to 51,000 for each violation and/or the imposition of an administrative compliance order on the
responsible entity. By signing this Task Order Contract,Contractor certifies that Contractor shall comply
with the requirements of the Act and shall not allow smoking within any portion of any indoor facility used
for the provision of services for children as defined by the Act. Contractor agrees that it shall require the
language of the Act be included in any subcontracts which contain provisions for children's services and
that all subcontractors shall sign and agree accordingly.
18. Notwithstanding the terms contained in the General Provisions of the Master Contract, Section 10,
Confidential or Proprietary Information,the Contractor shall protect the confidentiality of all applicant or
recipient records and other materials that are maintained in accordance with this Task Order Contract.
Except for purposes directly connected with the administration of this Task Order Contract,no information
about or obtained from any applicant or recipient shall be disclosed in a form identifiable with the applicant
or recipient without the prior written consent of the applicant or recipient,or the parent or legal guardian of
a minor applicant or recipient with the exception of information protected by Colorado Statute as it applies
to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal
guardian must provide consent or as otherwise properly ordered by a court of competent jurisdiction.
Contractor shall have written policies governing access,duplication,and dissemination of all such
information. Contractor shall advise its employees,agents,servants,and any subcontractors that they are
subject to these confidentiality requirements.
19. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding
Letter substantially equivalent to Attachment A-2.The Grant Funding Change Letter is not valid until it
has been approved by the State Controller or designee.
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EXHIBIT A
20. The State of Colorado,specifically the Colorado Department of Public Health and Environment,shall be
the owner of all equipment as defined by Federal Accounting Standards Advisory Board(FASAB)
Generally Accepted Accounting Principles(GAAP)purchased under this Task Order Contract. At the end
of the term of this Task Order Contract,the State shall approve the disposition of all equipment.
21. The Contractor shall not use funds provided under this Task Order Contract for the purpose of lobbying as
defined in Colorado Revised Statutes(C.R.S.)24-6-301(3.5)(a).
•
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Attachment A-1
Commonly Used Acronyms and Abbreviations That May Be Referenced In the Scope of Work:
ACS American Cancer Society
ACNS Alamosa County Nursing Service
ACE Administration for Children and Families
ADA Americans with Disabilities Act
ADAD Alcohol and Drug Abuse Division
AMA American Heart Association
AIDS Acquired Immune Deficiency Syndrome
ALA American Lung Association
ALA(C) American Lung Association(of Colorado)
AMCHP Association of Maternal Child Health Programs
ANR Americans for Non-Smokers' Rights
ARC Addiction Recovery Centers
ARRA American Recovery and Reinvestment Act
ASC Adams State College
ASSIST American Stop Smoking Intervention Study
ASTHO Association of State and Territorial Health Office
B&G Boys&Girls
BACCHUS BACCIIUS Peer Education Network
BAG Build a Generation
BBLHC Boulder Broomfield Latino Health Coalition
BC Boulder County
BCCP Breast and Cervical Cancer Program
BCitD Bent County Health Dept
BCPH Boulder County Public Health
BCPIIA Baca County Public Health Agency
BCDSS Baca County Dept Social Services
BCTEPP Bent County Tobacco Education Prevention Partnership
BGC Boys&Girls Club
BGCMD Boys&Girls of Metro Denver
BHS Broomfield High School
BMTF Baby&Me Tobacco Free
BOCES Board of Cooperative Educational Services
Boll Board of Health
BRFSS Behavioral Risk Factor Surveillance System
BVBAG Buena Vista Build a Generation
BVSD Boulder Valley School District
Bx Biopsy
C Choice
CAD Coronary Artery Disease
CASB Colorado Association of School Board
CB Community-based System
CBE Clinical Breast Exam
CBO Community-based Organization
CC Clear Creek
CC Custer County
CC Community Coordination/Coordinator
CCAP Larimer County Child Care Assistance Program
CCC Colorado Cancer Coalition
CCCHE Colorado Community Coalition for health Equity
CCGC Colorado Clinical Guidelines Collaborative
CCMC Colorado Clinical Managed Care Network
CCMC Commission for Case Manager Certification
CCPD Cancer,Cardiovascular,and Pulmonary Disease
CCIAA Colorado Clean Indoor Air Act
CCTCI Colorado Chew Tobacco Collaborative Initiative
Page 1 of 6
Attachment A-1
CCTEPP Custer County Tobacco Education Prevention Partnership
CDC Centers for Disease Control and Prevention
CDE Colorado Department of Education
CDPHE Colorado Department of Public Health and Environment
CDU Chronic Disease Unit
CEC Career Education Center
CEO Chief Executive Officer
CFDA Catalog of Federal Domestic Assistance
CFTC Colorado Foundation for Families and Children
CHIN Community Health Information Network
CICP Colorado Indigent Care Program
CID Colorado Judicial Department
CM Case Management
CMC Colorado Mountain College
CMS Contract Management System
CMS Creative Media Solutions
CNCC Colorado Northwestern Community College
CNS County Nursing Service
CO Colorado
COD Colorado Donated Dental Services Program
COPAN Colorado Physical Activity and Nutrition Program
COV Colorado Van Program
CPCF Colorado Parent and Child Foundation
CPUA Colorado Public Health Association
CPT Current Procedural Technology
CRUE Culturally Responsive Urban Education
CSAP Colorado Student Assessment Program
CSII Coordinated School I lealth
CSU Colorado State University
CSU-P Colorado State University-Pueblo's
CTC Connect to Care
CTEPA Colorado Tobacco Education and Prevention Alliance
CTFK Campaign for Tobacco-Free Kids
CTRP Colorado Tobacco Research Program
CTP Crossroads Turning Point
CU University of Colorado,Boulder
CWCCI Colorado Women's Cancer Control Initiative
CY Contract Year
DAISI Denver At-home Intervention Service Initiative
DAISI Division of Adolescent&School Health (CDC)
DCMII Delta County Memorial Hospital
DM Denver Health
DHHA Denver Health and Hospital Authority
DHS Department of Human Services
DI-tIIS Unites States Department of Health and Human Services
DOR Department of Revenue
DOS Delta Opportunity School
DSS Department of Social Services
E&I Education and Information
EAP Employee Assistance Program
EBHV Evidence-Based Home Visiting to Prevent Child Maltreatment Grant Program
ECC Early childhood council
ECC Electrocardiogram
ECCLC Early Childhood Council of Larimer County
ECLC Early Childhood Leadership Council/Commission
E.D. Executive Director
EHS Early Head Start
EMR Electronic Medical Record
Page 2 of 6
Attachment A-1
EMT Emergency Medical Technicians
EPA Environmental Protection Agency
EPE Epidemiology Planning and Evaluation
ESL English as a Second Language
ETS Environmental Tobacco Smoke(a.k.a.secondhand smoke)
FIRC Family and Intercultural Resource Center
FICA The Federal Insurance Contribution Act
FDA Food and Drug Administration
FNA Final Needle Aspiration
FP? Family Planning Program
FPL Federal Poverty Level
FRCC Front Range Community College
FTE Full Time Equivalent
FTP File Transfer Protocol
FY Fiscal Year
FYI Family Youth Initiatives
GASO Great American Smoke-out
GED General Education Development
GASP CO Group to Alleviate Smoking Pollution of Colorado
Get R!EAL(GR) Resist! Expose Advertising Lies(Youth Empowerment Program)
GLBT Gay,Lesbian,Bisexual,and Transgender
GYN Gynecological
HCP Health Care Program For Children with Special Needs
HCYS Huerfano County Youth Services
HIIS Health and Human Services
HIPPA Health Insurance Portability and Accountability Act of 1996
HIPPY Home Instruction for Parents of Preschool Youngster
I IIT Health Improvement Team
HIV Human Immunodeficiency Virus
I1PV Human Papillomamavirus
HR Human Resources
hr hour
HRSA Health Resources and Services Administration
HSL High School Leadership
ID Identification
IIK Invest in Kids
ISHT Interagency School Health Team
IT Information Technology
JAC Juvenile Assessment Center
KIS Keeping in STEPP
KMII Keefe Memorial Hospital
KPC Kevin Patrick Caleum
LAIICDIID Las Animas I lucrfano Counties District I lealth Department
LBW Low Birth Weight
LC Learning Community
LGBT Lesbian,Gay,Bisexual,Transgender
LEM Latinas en Movimiento
LIIA Local Health Agency
LI-ID Local Health Department
LLC Limited Liability Company
LRCC Latino Regional Community Coalition
LRPC Latino a Research and Policy Center
LST Life Skills Training
LSTPEN Latino Statewide Tobacco Prevention and Education Nctw
LWB Live Well Broomfield
MCHA Montezuma Housing Authority
MCHD Montezuma County Health Department
MCI-IS Montezuma-Cortez high School
Page 3 of 6
Attachment A-1
MCPN Metro Community Provider Network
MCRC Media Campaign Resource Center—CDC
MD Medical Doctor
MHCBBC Mental Health Center Serving Boulder and Broomfield Counties
MIECHV Maternal,Infant and Early Childhood home Visiting Program
MO Month
MOB Medical Office Building
MOU Memorandum of Understanding
MPA Master of Public Administration in I Health and Human Services
MPH Master of Public Health
MRI Magnetic Resonance Imaging Scan
MS Master of Science
MSA Master Settlement Agreement
Mutt Multi-user Housing
MYAT Multi-Disciplinary Youth Assessment Team
N/A Not Applicable
NACCHO National Association of County and City Health Officials
NACR Native American Cancer Research
NAQC North American Quitline Consortium
NASBE National Association of State Board of Education
NCHD Northeast Colorado Health Department
NCI National Cancer Institute
NE North East
NFP Nurse-Family Partnership
NFPNSO Nurse-Family Partnership National Service Office
NIIVP Nurse Home Visitor Program
NIDA National Institute on Drug Abuse
NLH National Institute of Health
NJH National Jewish Medical and Research Center
N-O-T Not-on-Tobacco,(ALA's Youth Smoking Cessation Program)
NP Nurse Practitioner
NPP Nurturing Parenting Program
NRT Nicotine Replacement Therapy
NSBA National School Boards Association
OSH Office on Smoking or Health (CDC)
OTC Over the Counter
PA Physician's Assistant
PAC Prevention Awareness Crew
PACT Partners Assessing Chew Tobacco
PAT Parents as Teachers
PCCIID Pueblo City-County Health Department
PPC Personal Care Providers
PE Presumptive Eligibility
PEN Parent Engagement Network
PVCHC Peak Vista Community Health Center
PI1N Public Health Nurse
PIO Public Information Officer
PM Peer Mentor
PMC Parkview Medical Center
PMR Planning Management Region
PN Patient Navigator
PO Purchase Order
PPC Policy Partner Committee
PPFC Pikes Peak Family Connections
PPN Prevention Policy Network
PRA Policy Resource Alliance
PRAMS Pregnancy Risk Assessment and Monitoring Survey
PRIDE Pure Respect Initiative Direct Education
Page 4 of 6
Attachment A-1
PSA Public Service Announcement
PSD Prevention Service Division
PTEPP Pueblo Tobacco Education and Prevention Partnership
PVC Prairie View Clinic
QI Quarter One
Q2 Quarter Two
Q3 Quarter Three
Q4 Quarter Four
QI Quality Improvement
QOL Quality of Life
RDAC Regional Disparities Advisory Council
RFA Request for Applications
REP Request For Proposals
RIE Reach,Implementation and Effectiveness
RIHEL Regional Institute for Health and Environment
RMC Rocky Mountain Center for Health Promotion&Education
RMRH Rocky Mountain Rural Health
RMYC Rocky Mountain Youth Corps
RN Registered Nurse
Rx Prescription
RY Reconnecting Youth
SafeCarc
SAMHSA Substance Abuse Mental l lcaIth Services Administration
SB School-based System
SBAG Salida Build A Generation
SBHC School-Based Health Centers
SCYC School Community Youth Coalition
SCRHC Southern Colorado Regional Health Collaborative
SD Service Delivery
SECH Southeast Colorado Hospital
SEMHS Southeast Mental Health Services
SES Socio-Economic Status
SEW School Employee Wellness
SGR Surgeon General's Report
SHAC Smoke-free Housing Action Committee
SHI School I tealth Index
SHS Secondhand Smoke
SIDS Sudden Infant Death Syndrome
SLV San Luis Valley
SMART Staying Motivated at Reducing Temptations
SMART OUTCOME OBJECTIVE Specific,Measurable,Achievable,Realistic,Time-Bound
SMSU Self Management Service Unit
SRO School Resource Officer
STD Sexually Transmitted Disease
STEPP State Tobacco Education and Prevention Partnership
STW Straight-to-Work
SVVSD St.Vrain Valley School District
SWOT Strengths,Weaknesses,Opportunities,Threats
SYNAR Synar Regulation
TA Technical Assistance
TABS Tobacco Attitudes and Behavior Survey
TAG Technical Advisory Group(for evaluation&TPEG)
TANF Temporary Aid to Needy Families
TARP Tobacco Advocacy and Resource Partnership
TBD To Be Determine
TCP Tobacco Control Partners
TDAC Tobacco Disparities Advisory Council
TDG Tobacco Disparities Grant
Page 5 46
Attachment A-1
TDS Tobacco Disparities Subcommittee
TEACI I Teaching Equity to Advance Community Health
TEFAP The Emergency Food Assistance Program
TEPP Tobacco Education Prevention Partnership
TFCCI Tobacco-Free Colorado Communities Initiative
TFLC Tobacco Free Larimer County
TFS Tobacco-Free Schools
TFS Law Tobacco-Free Schools Law
TGYS Tony Grampsas Youth Services
Title V Title V of the Social Security Act
TND Project Toward No Drug Abuse
TPEG Tobacco Program Evaluation Group
TPI Tobacco Prevention Initiative
'IRC Tobacco Education and Prevention and Cessation Program Review Committee
'IR1 Tobacco Rapid Improvement Activity
TRIA Tobacco Rapid Improvement Assessment
TTI Tony Grampsas Tobacco Initiative
UCD University of Colorado—Denver
UCDIISC Health Sciences Center at UCD(sometimes abr. UCHSC)
UCDHSC University of Colorado at Denver and Health Sciences Center
US United States of America
USSTC US Smokeless Tobacco Company
VP Vice President
Well COA Wellness Councils of America
WIIU Women's Health Unit
WIC Women,Infants,Children
WWC Women's Wellness Connection
Y@C Youth at Crossroads
YE Youth Empowerment
YPI I Youth Partnership for Health
Yr Year
YRBS Youth Risk Behavior Survey
YSAP Youth Substance Abuse Prevention Coalition
YTS Youth Tobacco Survey
YVMC Yampa Valley Medical Center
5 A's Ask,Advise,Assess,Assist,Arrange
2A's R Ask,Advise,Refer
Page 6 of 6
Attachment A-2
GRANT FUNDING CHANGE LETTER
Date: State Fiscal Year: Grant Funding Change Letter# ] CMS Routing #
TO: Insert Grantee's name
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), renewals) 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: Lisa Ellis, Purchasing & Contracts Unit Director By:
Date:
ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS§24-30-2U2 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
EXHIBIT B
STATEMENT OF WORK
To Task Order Contract Dated 04/24/2012-Contract Routing Number 12 FLA 43697
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract
specified above.
I. Project Description:
Under the Family Planning Program(FPP),Contractor shall conduct a comprehensive family planning program,
herein referred to as"the program"in Weld County. The program shall comply with section 1001 of the federal
Act and all applicable federal regulations,as amended,contained in Title X,42 C.F.R., Subpart A,Part 59,as well
as all applicable state regulations. (Federal funding from FIHS,CFDA#93.217 FP Services).
Contractor shall make its program available to men and women in their reproductive years and shall offer the
services,as appropriate.
II. Performance Requirements/Deliverables:
1. Contractor shall make its program available to men and women in their reproductive years and shall offer the
following services,as appropriate:
a. Outreach services and/or other program efforts designed to improve client recruitment;
b. Nursing and medical services,which shall include a comprehensive health and social history and physical
examination administered in accordance with all applicable Title X regulations and,all applicable
nursing-medical policies or procedures which have been,or may be established by the State,specifically
the Women's Health(W11)Branch ;
c. Contraceptive information,education,and supplies regarding all family planning methods;
d. Education and counseling services regarding family planning,family planning methods,child spacing,
infertility,sterilization,nutrition,sexually transmitted diseases,HIV/AIDS,adolescent counseling and
other related health issues, as outlined in the Nursing and Administrative Manual;
e. Follow-up and/or referral services,as appropriate.
2. The services provided by the Contractor to the clients it serves shall be performed pursuant to law in
accordance with prevailing medical standard of care for the same or similar medical,nursing and
professional services. The services provided shall also comply with applicable Title X regulations, CDPHE
FPP nursing-medical policies and procedures,and any applicable fiscal or administrative policies of the State
or Federal government which can be located at
http://www.cdphe.state.co.us/pp/womens/FPNursingPolicies.html?colt=open. Contractor acknowledges that
it has reviewed these policies and procedures.
3. The services provided by the Contractor must be deemed acceptable and in good faith by the State. For a
service to be"acceptable" it must comply with all applicable: Title X regulations,CDPHE FPP nursing-
medical policies and procedures,and any applicable fiscal and administrative policies and procedures of the
State and Federal government. All applicable Title X regulations,CDPHE FPP nursing-medical policies
and procedures, and all applicable fiscal or administrative policies of the State have been provided to the
Contractor by the State as of the effective date of this Task Order Contract.
Page 1 of 4
Exhibit B-Statement of Work
V l/MAR2012
EXHIBIT B
4. Contractor shall identify a Primary Data Coordinator who shall annually submit to the State a list of Family
Planning data system users. Contractor shall notify the State within thirty(30)days of a change of the
Primary Data Coordinator.
5. On a monthly basis,Contractor shall collect and provide to the State,by the fifteenth calendar day of the
following month unless otherwise specified by the State,all pertinent data as defined by the State regarding
all services offered,and all family planning clients served,by its program during the preceding month,
submitted through the Family Planning data system. This data shall be verified on a quarterly basis to help
assure accuracy. Contractor also agrees to respond to other data requests required by the program.
6. Within thirty(30)calendar days of receipt of a written request from the State,the Contractor shall submit
nursing-medical chart audits,client satisfaction surveys,Full Time Equivalent(FTE)reports and other
documentation required for the Family Planning Annual Report(FPAR)to the State.
7. Contractor shall only use program income generated from client fee collections and donations for family
planning purposes that further the objectives of the legislation under which this Task Order Contract is
entered into. In accordance with Title X guidelines,the Contractor shall not charge for any Title X required
services provided to clients who are at or below 100%of the official poverty line as defined by the Federal
Register by the U.S.Department of Health and Human Services under the authority of 42 U.S.C. 9902 (2). A
copy of this guideline has been posted at
http://www.cdphe.state.co.us/pp/womens/FederalPovertvGuidelines.html by the State as of the effective date
of this Task Order Contract. If the State receives new poverty guidelines during the term of this Task Order
Contract,then the State shall immediately notify the Contractor. The Contractor shall use these new poverty
guidelines,if any,upon receipt of notification thereof from the State.
8. The Contractor's charges for services to clients who are above 100%of poverty level shall be based on a
sliding fee scale that takes into account a client's family size and/or individual income and is approved by the
State. These charges and the sliding fee scale shall be made available to all clients of the Contractor,the
general public,and the State. This most current version the approved sliding fee scale templates are
available on the Family Planning website
(http://www.cdphe.state.co.us/pp/womens/FPNursingConsntsForms.html?colt=open),under the"Fiscal
Forms"tab,under the"Sliding Fee Scale"topic towards the bottom. Charges shall be based upon the
Contractor's actual costs to provide these services as determined by a cost analysis. The Contractor and the
State shall review these costs annually. The Contractor shall insure that all clients understand that they will
not be denied services because of an inability to pay any of the Contractor's sliding fee charges.
All money received by the Contractor from the State under this Contract shall be used by the Contractor to
provide contraceptive services to qualified family planning clients(fertile clients receiving contraceptive
services)including approximately 2247 target family planning clients.
9. Contractor shall either use a cytology laboratory chosen by the State or,a laboratory proposed by the
Contractor and approved by the State.
10. In addition to the submission of specified reports in accordance with Additional Provisions of this Task
Order Contract,Contractor shall provide the State with the semi-annual Family Planning
Expenditure/Revenue Reports, incorporated and made part hereof by reference.This document is located at:
http://www.cdphe.state.co.us/pp/womens/FPNursingConsntsFonns.html?col2=open,under the"Fiscal
Forms"tab under the"Expenditure Revenue Report"topic towards the middle. The first report is for the
months of July through December;the second report is for the months of January through June. These
reports will be due on dates specified by the State.
11. Contractor shall refer families participating in any and all programs in its agency such as the Special
Supplemental Program for Women,Infants and Children(WIC),Early and Periodic Screening,Diagnosis
and Treatment(EPSDT), Immunization Clinics,Health Care Program for Children with Special Health Care
Needs(HCP),Prenatal Plus(PNP),etc. to appropriate enabling and direct care service programs in the
community. Contractor shall provide all pregnant women in need of resources for prenatal medical care
Page 2 of 4
Exhibit B-Statement of Work
V I/MAR2012
EXHIBIT B
information about programs such as WIC,PNP,etc. as needed and shall ensure that children ages birth
through two years who may be eligible for early intervention services are referred to Early Intervention
Colorado,
12. Contractor shall participate in meetings or trainings as requested by the State.
13. Contractor shall require any new family planning coordinator or fiscal staff working on Family Planning
Program services to participate in Fiscal Orientation within forty-five(45)days of employment.
III. Personnel:
Contractor shall follow personnel requirements as specified in most recent CDPHE FPP nursing and
administrative manuals. Professional health care providers must be in compliance with State and Federal licensing
requirements and regulations.
IV. Monitoring:
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted throughout
the contract period by the Program's Manager. Methods used will include review of documentation reflective of
performance to include progress reports,site visits, surveys, electronic data,chart audits,intemal medical audits,
FTE reports,expenditure revenue reports and other deliverables such as sliding fee scale, cost analysis,and
accounts payable estimates. The Contractor's performance will be evaluated at set intervals and communicated to
the contractor. A Final Contractor Performance Evaluation will be conducted at the end of the life of the contract.
V. Resolution of Non-Compliance:
The Contractor will be notified in writing within thirty(30)calendar days of discovery of a compliance issue.
Within sixty(60)calendar days of discovery,the Contractor and the State 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 in writing 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 Program Manager and receive approval for a new due date.The State will oversee the
completion/implementation of the action(s)to ensure time lines are met and the issue(s)is resolved. If the
Contractor demonstrates inaction or disregard for the agreed upon compliance resolution plan,the State may
exercise its rights under the Remedies section of the General Provisions of this contract.
•
Page 3 of 3
Exhibit B-Statement of Work
V VMAR20I2
Exhibit C
FAMILY PLANNING AND COLORADO FP INITIATIVE BUDGET APPLICATION WORKSHEET
APPLICANT: Weld County Department of Public Health&Environment
l yederal Title X June 30,2012-June 29,2013
FOR TILE BUDGET PERIOD: State Title X July 1,2012-June 29,2013
CFPI July 1,2012-June 30,2013
Salary %Time CDPIIE-W1111 CDPHE_WHU NON-CDPHE TOTALS
SEE ABOVEFamily Planning
FOR BUDGET JULY 1,2012- Program JUNE 30,2012
PLEASE ROUND ALL FIGURES PERIODS BY JUNE30,2013 Funding JULY I, JUNE 30,2013
GRANT-FPP 2012-JUNE 30,
TO THE NEAREST DOLLAR 2013
1,YE
- _ FEDERAL& CFPI NON-CDPIIE CDPIIE PLUS
STATE TITLE X NON-CDPIIE
PERSONNEL EXPENSES:(Include name
&Mlle for each employee charged to CDPHE
funding You do not need to list the name and title
fore,,,ployees charged only to Non-CDPIIC
hi:SI el SO
Office Technician II SI 6,278 60% S 16,278 $16,278
Office Technician III $45,410 130% 545.410 S4541(I
Medical Assistant 576.343 200% $76.343 $76,343
MA Supervisor K.Dausch $24.255 60% S24.255 $24,255
Office Manager I.Vasquez $13,597 25% SI 3,597 $13,597
Public Health Nurse E.Soderholm R.N 548.993 90% $48,993 $48,993
Nurse Practitioner L.Dunn $85,283 100% 562.180 - $23,103 $85,283
Nurse Practitioner A.O'Dell $68,226 80% $47,700 $20,526 $68,226
Nurse Practitioner T.Vetter S70,559 90% $21,168 $49,391 $70,559
Nurse Practitioner Supervisor C.Horn $67,585 70% $67,585 $67,585
Clinical Service Manager Llovd-Cumlev $16,896 25% $16,896 $16,896
Nursing Director D.Drew 59,495 10% 59,495 $9,495
$0
Sub-total Salary Expenses $542,919 $109,880 $21.168 $411,871 $542,919
Fringe Benefit Role and Expenses"38.93% $211,358 $42,776 $8,241 $160,341 $211,358
Total Personnel Expenses $754,277 $152,656 $29,409 $572,212 $754.277
CONTRACTUAL:(Indcpendsm contractor for tuba)Imams Ensure vaseetono.
physicians,nurse praeid onas cic-In CFPI portion ONLY,add referral fee in this section.
SO
Banner o0GYN ISpecialiete I $4,000 - $4,000
Radiology MSG I I $1,000 $1,000
WCOPHE ref tee i $200 $200
1 SO
I $0
I SO
I _.. S0
SO
Total Contractual Expenses $0 S5,200 ':$0 S5,200
OPERATING: SO
Contracepttoo Methods(for CFPI portion ONLY,10"6 admen fee can he
included in slim line.) $67,401 $21,000 $88,401
Training coati-which includes regtatm0un tees travel I $4,000 $4,000
Cnlnmydla testa - $25,000 $25,000
Oilier Lab testa i $18,000 $18,000
Educational malenets(brochures.etc) $200 $200
ICI'mical supplies I t $15,000 $15.000
Oliee operutiog supplies(papers,(Mnns.Penn,01c) - $1,000 51.000
Office expense(reel ulilhieo,maintenance) _ $0
I OTHER(Specify)Mileage I $842 $5,500 $6,342
IFleetronic Medical Records 1 $75,000 $75,000
North Colorado Health Alliance Membership $10,000 $10,000
Total Operating Expenses SO $68,243 $174,700 $242,943
EQUIPMENT:(Computers,Office furnitures) $500 6500
SO
$0
Total Equipment Expenses - SO $0 $500 $500
TOTAL DIRECT EXPENSES $152,656 $102,852 $747,412 $1002,9211
INDIRECT:
Indirect rate: 13% Indirect Expense S19,844� $19,844
ADMINISTRATIVE(10%CFPI Sustainability Grant. Do NOT calculate the
10%admiu rate on one-time expends,contraceptive methods,training,or
contractors for tuba's,Essure,vasectomy,etc) $3.025 $3,025
ONE-TIME EXPENSE(For CFPI Sustainability Grant only) SO
TOTAL AMOUNT REQUESTED $172,500 $105,877 $747,412 $1,025,789
I i
II -_.._-
Yellow cells are not included in the CFPI admi fee calculation.
Fool free to add cells as needed. Be sure to update the total formulas if this is needed.
Page 1 of 2
Exhibit C
BUDGET NARRATIVE
FY12 Federal Title X& State Family Planning Grants
APPLICANT: Weld County Department of Public Health & Environment
FOR THE PERIOD: June 30, 2012-June 29,2013
For Personnel category list
title of position
How is the total amount required
For all other categories list Relationship to project Total
calculated?
the line item from the
budget
PERSONNEL EXPENSES:
$152,656.00
Laurie Dunn NP 1.0 NP Provides dircct FP care @ 2 sites 73%of Annual salary of$85,283 $62,1 80.00
Annette O'Dell NP 0.8 NP Provides direct FP care @ 2 sites 70%of Annual salary of$68,226 $47,700.00
Fringe 38.93% $42,776.00
CONTRACTUAL SERVICE - $0.00
OPERATING EXPENSES: so.o0
INDIRECT EXPENSES $19,844.00
Calculated at approved rate of 13% $19,844.00
ONE-TIME EXPENSES: $0.00
Total Project Costs: $172,500.00
Page 2 of 2
1 8 6 1 2 0 1 Memorandum
TO: Office of Clerk to the Board to the
Weld County Commissioners
W E L DEC OUNTY FROM: Administration Division-Department of
Public Health and Environment
RECEIVED DATE: OCfogert 5 Job a
OCT 08 2012 SUBJECT: rep Can fcacf
WELD COUNTY
COMMISSIONERS
Attached to this memo is the finalized contract that the Health Department has received.
Please sign and date below indicating you have received the finalized contract and return
this signed memo to the Administration Division of the Health Department.
Please send the confirmation receipt to my attention. Thank you for your assistance with
the processing of this document.
ATTN: `idly-)
Contract Name://gym/1H Planning 9 eo ranv eno ha et
Resolution Number: ain a - )49a
Finalized Contract Received By:
Date Received:
* 'Jhe 5-late Sent a carved toc3 OF The bEi,nej it I NeQcr (ice;r
aN OR�„"-9 Conlxael . 0 C)
Enclosure
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