HomeMy WebLinkAbout20122513.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR VARIOUS PROGRAMS 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 Maternal and
Child Health (MCH) Program,the Adolescent Health and Injury Prevention Program, and the Health
Care Program for Children with Special Needs 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 October 1, 2012, and ending September 30, 2013,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 Maternal and Child Health (MCH) Program,
the Adolescent Health and Injury Prevention Program, and the Health Care Program for Children
with Special Needs 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.
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9-/S)- /C -/5-/, 2012-2513
HL0039
TASK ORDER CONTRACT FOR VARIOUS PROGRAMS
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 17th day of September, A.D., 2012.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: f+i'`u III
1a
Sean ay, Chair
Weld County Clerk to the s5iNtfaCWV
x7. / 1 'am . Garca, Pro-Ter
BY: //
Deputy Clerk to the Boar. 5-�:" 22/ 1 J) /- -✓I // —
/BarbnKirk er �L
APP D RM:
!David Long
Attorney
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DouglaiRademache
10 h
Date of signature: `1
2012-2513
HL0039
8 6 , 2 0 , , Memorandum
1TO: Sean Conway, Chair
Board of County Commissioners
W E L DEC O U N T Y FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
uEnvironment
DATE: August 24, 2012
SUBJECT: Task Order Contract for the MCH
Prenatal and the Health Care Program
for Children with Special Needs Program
(HCP)
Enclosed for Board review is a task order contract between the Weld County Board of
Commissioners on behalf of the Department of Public Health and Environment (WCDPHE)
and the State of Colorado through the Colorado Department of Public Health and
Environment for the Maternal and Child Health (MCH) Program, Adolescent Health and Injury
Prevention and the Health Care Program for Children with Special Needs.
The task order issued pursuant to Master Contract made on 1-23-07 is to provide
continuation funding to facilitate the development and enhancement of community-based
systems of care. All of these programs have been ongoing for a number of years and are
successful programs. This new task order combines funding for all programs under a single
task order and provides for continuation funding in the amounts specified below. No
significant changes have been made in these programs since last year's approval.
1. Prenatal & Childhood Obesity Prevention $113,769.93:Based on the 2010 Colorado Child Health
Survey data that demonstrates that 22.9% of Colorado children ages 2 to 14 are overweight or obese,
Weld County Department of Public Health and Environment will be addressing this critical public
health issue as it exists in our community with this funding. The Weld County Five-Year Community
Health Improvement Plan identified obesity prevention as a top priority area to be addressed over the
course of the next five years. In partnership with initiatives already underway at WCDPHE (through
the Health Communication, Education, and Planning Division and Environmental Health Services
Division at WCDPHE), the goal for the strategies addressed in the Early Childhood Obesity
Prevention Action Plan is to focus closely upon the maternal and child population and be a voice for
maternal and early childhood health in existing partnerships and efforts. For these services, Weld
County will be reimbursed an amount not to exceed $113,769.93.
2012-2513
2. Adolescent Health & Injury Prevention $45,576.01:The funding for Adolescent Health is
directed to the Teen Motor Vehicle Safety program and the successful program of DRIVE
SMART Weld County to help meet their goal of decreasing deaths and injuries from motor
vehicle crashes. The program will support and expand the DRIVE SMART Weld County
community traffic safety coalition; increase knowledge of graduated drivers license laws and
willingness to issue citations among law enforcement personnel; continue providing
P.A.R.T.Y. (Prevent Alcohol and Risk-related Trauma in Youth) programs to students at Weld
County high schools; and provide classes for parents and teens about graduated driver's
licensing laws (GDL). This task order will provide continuation funding in the amount of
$45,576.01 all of which is attributable to funding from the federal government.
3. Health Care Program for Children with Special Needs—Medical Home and Care
Coordination (HCP) $ 181,946.96 : These funds will be used to facilitate the development
and enhancement of community-based systems of care for children with special health care
needs. Some of the services provided will be case finding, community involvement, and
interagency collaboration for children and their families who are determined eligible for such
services. Eligible children are those who have or are at risk for a chronic physical,
developmental, behavioral, or emotional condition. This year MCH and CDPHE required our
program to submit a divided budget that covered two action plans. The first Action Plan is for
the Medical Home Action Plan ($7,375.78) and the second is for the Care Coordination
Action Plan ($174,571.18). This contract will provide continuation funding in the amount of
$181,946.96.
This task order for the total amount of$341,292.90 will provide funding for the time period October 1,
2012 through September 30, 2013. Of this amount, $227,323.50 is attributable to a funding source of the
federal government and $113,969.40 is attributable to a funding source of the State of Colorado.
I recommend your approval.
UIFdRIAII:N I MI,PUBLIC II?.AI:I'II AND b:AA'IRONM1O(NT
ROUTING NO.13 FLA 48090
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
1 AIIC (RINIRV 1OR
State of Colorado for the use& benefit of the Board of County Commissioners of Weld
Department of Public Health and County (a political subdivision of the State
Environment of Colorado)
Prevention Services Division 915 10i0 Street
Maternal&Child Health (NICE I) Greeley,Colorado 80632-0758
4300 Cherry Creek Drive South for the use and benefit of the
Denver,Colorado 80246 AFeld County Department of Public I lealth
and Environment
1555 North 17(1'Avenue
Greeley,Colorado 80631
-I\SKOROP.R NtNth D-AIF.. CON IR A(lt1t ON III) IYI'1:
08/14/2012 Colorado Political Subdivision
PU,SC I-N..L NIISR.ANUS NO NIIiOR
PO I'LA PSD 1348090
111 RNl. till link,,I All SII.N IS RrCI.I61.I)
This Task Order shall be effective upon Monthly
approval by the State Controller,or designee,
or on 10/01/2012,whichever is later. The 1I \I1 1010 v LILORI I y,
Task Order shall end on 09/30/2013. C.S.R. 25-1.5-101,25-1-709
PRR SIRICILfile C.ONIR NCI I'RIC1.Not IO I SCI'.PA.)
Cost Reimbursement $341,292.90
PROD RI NII N I Nn<ruoo. I.DI R VI.Pr Nnf>n D011-\RS: $227,323.50
Exempt ',INN I NOINI,IxnI ARY $113,969.40
BID 111^P:LIST['RI(] A(R]I.A[PNT NI 1IIl1.R. Al A snICAI.AvFCN I AYVII..ARI ILP! R I ISCAI_YI.1R
Not Applicable EY13: $255,969.68
FY14: $ 85,323.22
L AAr Sri NIIOR 51-VI'rl lc
Not Applicable
SLAII,IU.I'RLSI.N I.A'IIVI(: CONIRACIOIt R]:I'Itl SI Al AtEVL:
Kathy Jacobsen Tanya Geiser
Department of Public Health and Environment Weld County Department of Public Health and
Prevention Scn'iccs Division Environment
V1CIi 1555 North 1?^' avenueA
4300 Cherry Creek Drive South Greeley,Colorado 80631
Denver,CO 80246
scull P:Of At ORK.
Develop,implement and evaluate a comprehensive plan in accordance with state and federal MCH
guidelines, to improve the health and well-being of the NIGH population,including children with
special health care needs.
Page I of 6 Rev 6/25/09
Pxuuli IS.
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(and its attachments if any—e.g.,C-1,C-2,etc.)
Exhibit D- Grant Funding Change Letter Sample
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()rder 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(I),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 S100,000 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 §24-103.5-10I,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 §§24-109-106, 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.
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: STATE OF COLORADO:
BOARD OF COUNTY COMMISSIONERS OF John W.Hickenlooper, GOVERNOR
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 ?)Alt/cRirfrattAZA,„_____—.
For Executive Director
fl
Department of Public Health and Environment
Signature of Authorized Officer P 1 7 2012
Sean P. Conway
Print Name of Authorized Officer
Department Program Approval: `
Chair 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
•
Date 9%27-,Z
Page 5 of 6 Rev 6/25/09
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 08/14/2012-Contract Routing Number 13 FLA 48090
These provisions are to be read and interpreted in conjunction with the provisions of the
Task Order Contract specified above.
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. This Task Order Contract contains federal funds(see Catalog of Federal Domestic Assistance(CFDA)
number 93.994)
3. The United States Department of Health and Human Services("HHS"),through the Maternal and Child
Health(MCH) Services Block Grant has awarded Title V federal funds under Notice of Grant Award
("NGA)number B04MC04248 to perform the following: The State's Prevention Services Division(PSD)
is charged with the administration of funds from the Title V MCH Block Grant to improve the health and
well being of the maternal and child/adolescent populations through assessing population needs,
influencing health policy,engaging in strategic planning and coordinating/implementing best practices and
evidenced-based programs.
The authority for the administration of the Title V MCH Block Grant, including the maternal,child and
children with special health care needs resides in Title V of the Social Security Act, §§ 501-509.
Each state that receives MCH funds from the HHS must demonstrate to the HHS that it has served three(3)
distinct population groups with the MCH funds.These three(3)distinct population groups are: -the
perinatal population", which is defined to include women of childbearing age,pregnant women,and
mothers;the`child and youth population",which is defined to include infants,children,and adolescents
from birth through age twenty (20);and,the"children with special health care needs"population
(CSHCN), which is defined as those children who have,or are at increased risk for a chronic physical,
developmental, behavioral,or emotional condition and who also require health and related services of a
type or amount beyond that required by children generally.
The State has formulated a comprehensive statewide plan to carry out a Maternal and Child Health
Program, funded by Title V MCH dollars,and a CSHCN Program, funded by Title V MCH dollars and
state general funds. As part of the comprehensive plan,it is the expressed intent of the state to support local
public health agencies in contributing to a coordinated,efficient statewide program which focuses on
specific MCH performance measures set by the MCH state and Federal agencies. Local public health
agencies,working in partnership with other community organizations,facilitate the development and
enhancement of community-based systems of services and supports for the maternal and child population.
If the underlying Notice of Grant Award"NGA"authorizes the State to pay all allowable and allocable
expenses of a contractor as of the effective date of that NCAA,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 Contract. If the underlying NGA does not authorize the
State to pay all allowable and allocable expenses of a contractor as of the effective date of that NCAA,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 Contract,with such effective date
being the later of the date specified in this contract or the date the contract is signed by the State Controller
or delegee.
4. 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
To be attached to CDPHE Page I of 5 Revised:03/13/12
Task Order v1.0(3/12)contract template
EXHIBIT A
http://www.cdphe.state.co.us/StandardizedInvoice/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
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.
A separate CDPHE Reimbursement Invoice Form must be submitted for each of the following applicable
population groups: Women of Reproductive Age,Child/Adolescent, CYSHCN—HCP Care Coordination,
CYSHCN—Medical Home,and CYSHCN—Specialty Clinics.
All Counties,Local Public Health Agencies and select intergovernmental Contractors will undergo a
financial risk assessment conducted by the CDPHE Financial Risk Management System. Until such
assessment is completed and the Contractor has been notified of the results,the Contractor shall provide the
following documentation with the completed invoice; Contract Reimbursement Requests must be
accompanied by a detailed cost ledger to reflect all purchases being invoiced under that contract and should
include date of payment,payee name and amount,and check or voucher number,when available.
This supporting documentation shall be submitted with the completed CDPHE Reimbursement Invoice
Form and sent to:
Sara Wargo
Maternal and Child Health Program
Prevention Services Division
Colorado Department of Public Health and Environment
PSD-A4—MCH Admin
4300 Cherry Creek Drive South
Denver, CO 80246
cdphe.psmchreports@state.co.us
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 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 any event no later than sixty(60)calendar days from the effective expiration or
termination date of this Task Order Contract.
The State shall reimburse the Contractor for actual indirect costs up to the Prevention Services Divisions
maximum of twenty-five percent(25%)when the Contractor's indirect rate is based on Total Direct Costs,
twenty-seven percent(27%)when the Contractor's indirect rate is based on Total Direct Salaries,or thirty
percent(30%)when the Contractor's indirect rate is based on Total Direct Salaries and Fringe where no
other direct costs are charged.
Local Match or in-kind, if any, shall be reported on all contract reimbursement requests.The source of
funding for all local match and in-kind will be reported on the final contract reimbursement request.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
5. 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.
To be attached to CDPHE Page 2 of 5 Revised:03/13/12
Task Order v1.0(3/12)contract template
EXHIBIT A
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: 1)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.
6. The Contractor shall adhere to the same guidance as the State when considering food and beverage
purchases. Food or beverages may be purchased for events related to the MCH operational plan such as
training,community meetings or events that engage external stakeholders,and/or multi-county regional
meetings. Title V and State General funds may not be used to purchase food or beverages while conducting
routine staff meetings and specialty clinics. Contact the MCH generalist consultant if guidance is
necessary.
7. The Contractor is authorized to make transfers of funds from one line item in its Budget to another line
item in its Budget. If a transfer of funds occurs however from the Personnel Budget Category to another
Budget Category and the amount of funds being transferred is greater than 25%of the Budget Category
Total,then the Contractor shall request and receive prior written approval from the MCH Generalist
Consultant by completing and submitting a Budget Revision Request Form,available on the MCH web
site at www.mchcolorado.org before the transfer can be made. The Contractor is required to request and
receive prior approval in writing via email by the MCH Generalist if there are permanent or temporary
changes in any MCH-funded line item supporting staff positions..
8. Contractor shall retain and use all revenues generated by MCH Programs for services in those programs.
The revenue cannot be used for other programs or purposes.
9. Title V, Section 504(b)(6).Title V funds may not be used to pay for any item or service(other than an
emergency item or service)furnished by an individual or entity convicted of a criminal offense under the
Medicare or any State health care program(i.e., Medicaid, Maternal and Child Health,or Social Services
Block Grant Programs).
10.. The 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 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$1,000 for each violation
and/or the imposition of an administrative compliance order on the responsible entity. By signing this
contract,the Contractor certifies that the Contractor will comply with the requirements of the Act and will
not allow smoking within any portion of any indoor facility used for the provision of services for children
as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in
To be attached to CDPHE Page 3 of 5 Revised:03/13/12
Task Order v1.0(3/12)contract template
EXHIBIT A
any subcontracts which contain provisions for children's services and that all contractors shall sign and
agree accordingly.
11.. The Contractor certifies,to the best of its knowledge and belief,that no federally appropriated funds have
been paid or will be paid by or on behalf of the Contractor,to any person for influencing or attempting to
influence an officer or employee of any agency,a Member of Congress, an officer or employee of
Congress,or an employee of a Member of Congress in connection with the awarding of this contract,and
the extension,continuation,renewal,amendment,or modification of this contract,or any grant, loan,or
other cooperative agreement that utilizes Federal funds. If any funds other than federally appropriated funds
have been paid or will be paid to any person for influencing or attempting to influence an officer or
employee of any agency, Member of Congress,an officer or employee of Congress in connection with this
contract,or any other grant, loan,or other cooperative agreement,then the Contractor shall complete and
submit Standard Form- LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions.
The Contractor shall require that the language of this certification be included in the award documents for
subawards at all tiers(including subcontracts, subgrants,and contracts under grants, loans,and cooperative
agreements)and that all subrecipients shall certify and disclose accordingly. This certification is a material
representation of fact upon which reliance was placed when this transaction was made or entered into. This
certification is a prerequisite for making or entering into this transaction imposed by section 1352,title 31,
U.S.Code. Any person who fails to file the required certification shall be subject to a civil penalty of not
less than$10,000 and not more than$100,000 for each such failure.
12. The Contractor shall not charge for services for those individuals of families at or below the official
poverty guidelines,updated periodically in the Federal Register by the U.S. Department of Health and
Human Services(DHHS) under the authority of 42 U.S.C.9902(2), in accordance with Title V,Section 501
(1)(B)and Section 505 (5)(D).The most current version of this document is available on the DHHS web
site at http://aspe.hhs.gov/poverty/and the Colorado HCP web site: www.hcpcolorado.org. If the State
receives new poverty guidelines from the DHHS during the term of this Contract,then the State shall
immediately update the guidelines on the HCP web site. The Contractor shall use these new poverty
guidelines, if any, upon receipt thereof from the State.
13. If any charges are imposed for services to clients who are above the one hundred percent(100%)of
poverty level, such charges must be on a sliding scale which takes into account the client's family size,
income and resources. These charges and the sliding fee scale must be made available to the general public
and to all clients and must be based on the agency's usual and customary cost for the service.Clients must
understand they shall not be denied services for inability to pay any of the sliding fee charges.
14. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that
are maintained in accordance with this contract. Except for purposes directly connected with the
administration of this 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. The Contractor shall have written policies governing
the access to,and duplication and dissemination of,all such information. The Contractor shall advise its
employees,agents,servants,and subcontractors, if any,that they are subject to these confidentiality
requirements.
I5. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are
carried out.That Act states that"no person in the United States shall on the ground of race,color,or
national origin,be excluded from participation in,be denied the benefits of,or be subjected to
discrimination under any program or activity receiving Federal financial assistance." The Office of Civil
Rights has concluded that it is the responsibility of any program which is a recipient of funds from the
Department of Health and Human Services to ensure that clients who do not speak or understand English
well,be provided interpretation services to ensure that the service provider and the client can communicate
effectively.The Contractor shall have policies and procedures to ensure that interpretation services are
To be attached to CDPHE Page 4 of 5 Revised:03/13/12
Task Order v1.0(3/12)contract template
EXHIBIT A
available for clients with Limited English Proficiency and will advise such clients that an interpreter will be
provided for them. If a client has their own interpreter,they shall be advised that the Contractor will
provide an interpreter if the client so chooses.
16. The services or activities under this Contract may be carried out by the Contractor,or through subcontracts
with other providers or,through collaborative partnerships with other community partners. The State
authorizes the Contractor to subcontract some,or all,or the services that are to be performed under this
Contract. However,a subcontractor is subject to all of the terms and conditions of this Contract.
Additionally,the contractor remains ultimately responsible for the timely and satisfactory completion of all
work performed by any subcontractor(s)under this Contract. If the Contractor desires to subcontract
some,or all,of the services that are to be performed under this Contract,the Contractor shall obtain
the prior,express,written consent of the State before entering into any subcontract.The Contractor
shall maintain,at a minimum a Memorandum of Understanding or other binding contractual agreement,
and provide a copy fifteen(15)calendar days from the date the agreement is executed to the State,upon
request.The Contractor shall maintain records of any subcontractors for a minimum of three years.
17. The State may require forms attached to this contract and incorporated herein by reference be updated
during the term of this contract. The Contractor will be informed of the new forms as they are developed.
Forms may be sent to contractors or will be available on the MCH web site: www.mchcolorado.org or the
HCP web site: www.hcpcolorado.org.
18. The State may increase or 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 Page 5 of 5 Revised:03/13/12
Task Order v1.0(3/12)contract template
EXHIBIT B
STATEMENT OF WORK
To Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090
These provisions are to be read and interpreted in conjunction with the provisions of the Contract Agreement specified
above.
I. Project Description:
The Colorado Maternal and Child Health Program contracts with local public health agencies(LPHAs)to
develop,implement and evaluate evidence-based MCH Action Plans,HCP Care Coordination services,and
HCP Specialty Clinics. Contractors are responsible for contributing to the improvement of 10 state and 18
national MCH performance measures and outcomes.
II. Definitions:
• CRSCN -Colorado Responds to Children with.Special Needs
• CYSHCN-Children and Youth with Special Health Care Needs
• HCP-Health Care Program for Children with Special Health Care Needs
• HCP Care Coordination-The state HCP-developed intervention model for providing care
coordination for families of children and youth with special health care needs.
• LPHAs-Local Public Health Agencies MCH-Maternal and Child Health
• MCH-Maternal and Child Health
• MCH Action Plans-Action Plans are work plans that Contractors select or develop and describe the
goals,objectives,key activities,persons responsible,and timelines of the MCH effort. Action Plans
may be state-developed and related to the MCH priorities or developed by the Contractor.
• MCH Generalist Consultants-The primary MCH Program staff who monitor LPHAs'MCH contracts
and who provide technical assistance and consultation to Contractors on program development
and implementation.
III. Performance Requirements/Deliverables:
The attached Action Plans outline MCH deliverables that shall be implemented over a period of three years
to reach short-term and long-term outcomes.CDPHE will monitor the progress of each deliverable based on
key activity completion(short-term outcomes)for the period of October 1,2012-September 30.2013.Some
deliverables will continue beyond the current contract period and will be monitored in subsequent contract
periods.Contractors will be expected to report on the progress of activities outlined in the three year action
plans by the deliverable dates specified.
Maternal and Child Health Program
I. The Contractor shall perform in accordance with the FY13 Action Plans: Early Childhood Obesity
Prevention; Teen Motor Vehicle Safety; and Medical Home, referenced herein as Attachment B-1,
Attachment B-2,and Attachment B-3 respectively.
2. The Contractor shall perform in accordance with the FY13 MCH Guidelines and shall follow the
policies,procedures,and program expectations set forth in the FY13 MCH Guidelines.The FY13
MCH Guidelines are incorporated and made part hereof by reference,and are located on the
Colorado MCH web site:
Page 1 of 5
Exhibit B-Statement of Work
V VMAR2012
EXHIBIT B
www.mchcolorado.org.
3. The MCH Guidelines are periodically updated and the Contractor will be notified by email when
updates/revisions are made.The Contractor is responsible for complying with any
updates/revisions. Revised MCH Guidelines would be posted to the MCH web site referenced in
I1I.1.
4. The Contractor shall apply the public health approach throughout the process of developing,
implementing,and evaluating its MCH Action Plans in order to serve the MCH population in the
community.Brownson's evidence-based public health approach is described in the FY13 MCH
Guidelines and involves the following steps:
o Community assessment
o Quantify the issue
o Develop a concise statement of the issue
o Determine what is known through the scientific literature
o Develop/identify and prioritize program and policy options
o Develop an Action Plan and implement interventions
o Evaluate the program or policy
5. The Contractor shall contribute to the accomplishment of the MCH state priorities,and state and
national performance measures and outcomes that are outlined in the FY13 MCH Guidelines.
6. The Contractor shall focus at least 10%of total MCH/HCP funds on MCH-priority Action Plans,
including the medical home priority.
7. The Contractor must focus a majority of their effort and funding for each Action Plan on population-
based and infrastructure-building strategies from the MCH pyramid,per the review and approval
by the state MCH Program. Enabling services are allowable if they are evidence-based and enhance
the population-based and infrastructure-level work in the Action Plan.Enabling services should not
comprise a majority of the effort,with the exception of HCP Care Coordination.
For definitions of the different levels of the MCH Pyramid,see the FY13 MCH Guidelines available
online at www.mchcolorado.org.
S. The Contractor must use evidence-based strategies/programs to address issue in the community.
A strategy or program is considered evidence-based if:
a. It is based on a sound theoretical approach such as health behavior change theory or peer-
reviewed literature;
b. And/or if there is research or program evaluation data that supports the effectiveness of
the approach.
9. During the contract term,the Contractor shall follow the timelines identified in FY13 Action Plans
to implement and evaluate work performed under the Action Plans.
10. The Contractor shall participate in and submit the following processes or reports,incorporated by
reference.These processes and reports,including instructions for completion and submission,are
available in the FY13 MCH Guidelines located online at www.mchcolorado.org.
a. Progress check-in meetings (3)
MCH Generalist Consultants conduct three progress check-in meetings with the Contractor
during the contract period in order to monitor the Contractor's progress on the FY13
Action Plans as well as to provide technical assistance and support during plan
implementation. During the progress check-in,the Contractor and MCH Generalist
Page 2 of 5
Exhibit 6-Statement of Work
V 1/MAR2012
EXHIBIT B
Consultant use a standardized set of questions to discuss the Contractor's progress and/or
challenges of planning,implementing or evaluating the MCH Action Plans and to review
any relevant work products developed as part of the plan,such as team charters,reports,
community road maps,etc. The standardized questions are available at the MCH web site
www.mchcolorado.org.
The MCH Generalist is responsible for scheduling the check-in with the Contractor.The
format(via phone or in person) of the check-in is at the discretion of the MCH Generalist
Consultant and will be communicated to Contractor in advance. The MCH Generalist
Consultant will send a follow-up summary of the check-in meeting and will highlight any
issues that require follow-up.Three progress check-in meetings or phone calls will take
place during the fiscal year.The first check-in will occur in December/January. Another
check-in will take place in April/May. Finally,a meeting will occur in September
b. MCH Annual Report on FY13 Action Plans
The FY13 MCH Action Plan Annual Report is due November 29,2013 for the period of
October 1,2012 to September 30,2013.The Contractor shall submit the completed report
via the MCH database accessible at www.mchcolorado.org.
For annual reporting,update the following sections of the MCH priority-related action
plans:
• Evaluation of Objective-provide a brief narrative on the progress of the objective,
including successes and challenges.Discuss how the strategy contributed to
moving the objective forward.Include assessment of"as measured by"indicators
that correspond to"criteria for success"in this section.
• Activity Monitoring Plan Completion-comment if the activity was met or unmet.
For annual reporting,update the following sections of the"other"MCH action plans:
• Evaluation of Measure-provide the actual measure of progress for the
measure/indicator previously selected
• Evaluation of Objective-provide a brief narrative on the progress of the objective,
including successes and challenges.Discuss how the strategy contributed to
moving the objective forward.
• Activity Monitoring Plan Completion-comment if the activity was met or unmet.
c. HCP Annual Performance Measure Report for FY13
The FY13 HCP Annual Performance Measure Report is due November 29,2013 for the
period of October 1,2012 to September 30,2013. The FY13 HCP Annual Performance
Measure Report Form will be available on the MCH web site at www.mchcolorado.org.The
Contractor shall submit the completed report via the MCH database accessible at
www.mchnlanningcolorado.com.
The HCP Annual Performance Measure Report is a requirement as part of HCP annual
reporting.This report provides summary information of your community family
participation efforts and how your program includes family leaders for program planning,
local systems work and care coordination.The HCP Annual Performance Measure Report
provides valuable information on an annual basis for state planning and federal reporting
on the national outcome measure for family participation.
Page 3 of 5
Exhibit B-Statement of Work
V 1/MAR2012
EXHIBIT B
d. MCH Core Services Final Report for FY13
The Final Report for MCH Core Services should be reported on Part B of the MCH Budget
form that will be available at the MCH web site www.mchcolorado.org.The report is due
November 29,2013 for the period of October 1,2012 to September 30,2013. The
Contractor shall submit the completed report via the MCH database accessible at
www.mchcolorado.org.
For each of the Contractor's FY13 Planning Budgets,review the objectives and activities
included in the corresponding MCH Action Plan(s),report on the percentage of total budget
funds expended on the different levels of the MCH pyramid.
• Direct Services
• Enabling Services
• Population-based Approaches
• Infrastructure Building Approaches
For the Contractor's FY13 HCP Care Coordination Planning Budget,enter the actual
number of children and youth with special health care needs who received HCP Care
Coordination services(with an HCP Care Coordination family action plan)in FY13. This
number should include all of the children and youth who have completed the intake
interview,assessment process,and have a current action plan.
11. The Contractor shall develop or revise,according to the FY14 MCH Guidelines,the Contractor's
MCH Action Plans for FY14.
12. The Contractor shall notify the State of programmatic changes that might affect the viability,
effectiveness or productivity of the programs,including but not limited to: changes in personnel;
physical facilities in which services are provided; scope of services that deviates from those
proposed by the Contractor in the MCH Action Plans;sources of funding and support as declared in
the Contractor's submitted proposal for funding;and local interagency or political circumstances
that might impact the MCH Program.Notification shall be in writing within fifteen(15) business
days of the said change.
Children with Special Health Care Needs(CSHCN)
I. The Contractor shall perform in accordance with the FY13 Action Plan Medical Home,referenced herein
as Attachment B-3.
2. The Contractor shall attend scheduled HCP Policy Advisory Committee(H-PAC)meetings,HCP
Annual Meetings,and any scheduled state training to promote learning and increase skills for HCP
practitioners.
3. The HCP Team Leader shall provide orientation,technical assistance and ongoing training for other
HCP agency staff by referencing the HCP Policy and Guidelines,the HCP Orientation Module,the
HCP CYSHCN Data System User Manual,and HCP Resources available online at
www.hcpcolorado.org.
4. The Contractor shall engage families with CYSHCN and community family leaders to solicit
consumer feedback when serving the CYSHCN population by referencing the Colorado MCH
Medical Home Action Guide and Family Leadership Resources available online at
www.hcpcolorado.org.
Page 4 of 5
Exhibit B-Statement of Work
V 1/MAR2012
EXHIBIT B
Care Coordination
I.. The Contractor shall provide HCP Care Coordination to ensure a medical home approach for
CYSHCN residing in the counties the agency is contracted to serve according to the HCP Care
Coordination Policy and Guidelines,available online at www.hcpcolorado.org
2. The Contractor shall complete required data documentation in the HCP CYSHCN Data System for
HCP Care Coordination services according to the HCP Care Coordination Policy and Guidelines and
the HCP CYSHCN Data System User Manual available online at www.hcpcolorado.org.
3. The HCP Care Coordination Policy and Guidelines,and the HCP CYSHCN Data System User Manual
are periodically updated and the Contractor will be notified by email when updates/revisions are
made.The Contractor is responsible for complying with any updates/revisions.Revised HCP Care
Coordination Policy and Guidelines and the HCP CYSHCN Data System User Manual available online
at www.hcpcolorado.org
4. The Contractor shall participate in consultation,technical assistance,oversight and training by
state HCP staff on using the HCP CYSHCN Data System for documentation of HCP Care Coordination.
IV. Monitoring:
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted
throughout the contract period by the Program's MCH Generalists and HCP Care Coordination Nurse
Consultants. Methods used will include review of documentation reflective of performance to include
progress meetings,site visits,and data reports. 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 by email within seven(7) calendar days of discovery of a compliance issue.
Within 30 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 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 MCH Unit Manager or HCP Unit 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 5 of 5
Exhibit B-Statement of Work
VI/MAR2012
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EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Planning Budget FY13 - PART A
Agency: Weld County Department of Public Health and Environment Date Completed: July 2.2012
Program Contact Approval Fiscal Contact Approval
Name: Debbie Drew,RN-c,NP Name:Tanya Geiser
Title: Public Health Services Director Title:Administrative Services Director
Phone:970-304-6420 x 2304 Phone:970-304-6420 x2122
Email:ddrew{Stco.weld.co.us Email: iseiser(8tco weld_co.us
Due Date:July 1,2012
(for the period of October 1,2012 through September30,2013)
Instructions: Refer to instructions for completion of this form in the MCH Guidelines.Enter numbers in yellow highlighted areas below.Total columns will calculate automatically.
SELECT POPULATION FOR THIS BUDGET PROPOSAL: SELECT ALL ACTION PLANS RELATED TO THIS BUDGET:
CYSHCN - HCP Care Coordination A r Early Childhood Dental Caries E Pregnancy-related Depression
r Early Childhood Obesity Prevention E Teen Motor Vehicle Safety
r Early Childhood Screening(ABCD) E Youth Sexual Health
r—Other: I
IVERIIr rat Amount Sources of Funding
EXPENSE CATEGORIES Annual Salary Rate Annual Fringe FTE Required 'Other(Match or In- Received front
Kind) CDPHE
PERSONNEL SERVICES(Names&Titles): --
Amy Antuna,Public Health Nurse III $61,297.49 $23,863.11 0.90 $76,644.54 $76,644.54
Beverly Earley,Public Health Nurse II $58.543.60 $22,791.02 0.63 $51,240.81 $51,240.81
Tracy Nunnally,Public Health Nurse II $53,605.89 $20,868.77 0.90 $67,027.20 $67.027 20
Aurora Medina,Public Health Social Worker $57,964.86 $22,565.72 0.80 $64,424.46 $64,424.46
Sara Torres,Office Technician III $0.00 $0.00 0.00 $0.00
Kathy Smith-Stillson,Manager $63,648.17 $24,778.23 0 05 $4,421.32 $4,421.32
Debbie Drew,Director $97,374.00 $37,907.70 0.05 $6,764.08 $6,764.08
Victoria Zacharko,Office Technician III $31,445.54 $12,241.75 0.83 $36,260.45 $36,260.45
$0.00 $0.00,
$0 00 $0.00
TOTAL PERSONNEL SERVICES(S and FTE) $423,879.55 $165,016.31_ 4,16 $306,782.87 $138,215.74 $168,587.12
OPERATING EXPENSES(which are not part of indirect)
Supplies $1,200.00 $672.46 $527.54
TOTAL OPERATING EXPENSES $1,200.00 $672.46 $527.54
TRAVEL EXPENSES
Travel $4,800 00 $4.800.00
'TOTAL TRAVEL EXPENSES $4,800.00 $4,800.00 $0.00
CONTRACTUAL EXPENSES
TOTAL CONTRACTUAL EXPENSES $0.00 $0.00 $0.00
TOTAL DIRECT COSTS(Personnel Services+Operating+Travel+Contractual) $312,782.87 $143,688.20 $169,094.66
Indirect Rate: 13% 840,661.77 $35 185 25 $5,470 52
Indirect Type:I Total Direct Costs(TDC)capped at 25%
TOTAL INDIRECT COST $40,661.77 $35,185.25 $5,476.52
TOTAL PROJECT COST $353,444.84 $178,873.45_ $174,571.18
`Source for funding for"Other"(Match or In-kind) Methodology used for reporting"Source of Funds"
Local/County Funding: $178.873.45 Ld Method A OFZJ Method E
Medicaid(will not be used to match).
Patient Fees. Can NON-FEDERAL funds be used as a match?
All Other' OO YES O NO
(TOTAL $178,873.45
Core Services - PART B
What percentage of funding from the budget total is allocated to work at each level HCP CARE COORDINATION ONLY
of the MCH pyramid? What is the estimated number of children/youth with special
Direct Services health care needs who will receive HCP Care Coordination
Enabling Services 60 services(with an Action Plan)in FY13?
Population-based Approaches 20 I 75
Infrastructure Building Approaches 20 Is your agency"opting in"to receive CRCSN notifications'?
Total to equal 100% 100 ❑0PT_IN
EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Budget Narrative FY13
Agency: Weld County Department of Public Date Completed: July 3, 2012
Health and Environment
Program Contact Person Fiscal Contact Person
Name: Debbie Drew, RN-c, NP Name: Tanya Geiser
Title: Director of Public Health Services Title: Administrative Services Director
Phone: 970-304-6420 x 2304 Phone: 970-304-6420 x2122
Email: ddrew@co.weld.co.us Email: tgeiser@co.weld.co.us
Population Group and Action Plan(s)
Select appropriate"Population Group"and the corresponding MCH action plans below. Complete
a separate budget narrative for each budget.
Select population for this budget proposal: CYSHCN - HCP Care Coordination
Select all MCH action plans related to the population group:
F Early Childhood Dental Caries F Pregnancy-related Depression
F Early Childhood Obesity Prevention F Teen Motor Vehicle Safety
F Early Childhood Screening (ABCD) F Youth Sexual Health
F Other:
Personnel Services: $168,567.12
-Amy Antuna, Registered Nurse/HCP Team Leader, salary at $76,644.54, .9 FTE (90%) to
implement HCP care coordination, program oversight, planning, and reporting. $76,644.54 is
requested from CDPHE.
-Beverly Earley, Registered Nurse, salary at $51,240.81, .63 FTE (63%) to implement HCP care
coordination services and create awareness about the HCP program among community
partners/agencies. $51,240.81 is requested from CDPHE.
-Tracy Nunnally, Registered Nurse, salary at $67,027.20, .9 FTE (90%) to implement HCP care
coordination services and create awareness about the HCP program among community
partners/agencies. $67,027.20 is match/in kind from Weld County.
-Aurora Medina, Social Worker, salary at $64,424.46, .8 FTE (80%) to implement HCP care
coordination services with a psychosocial emphasis and create awareness about the HCP
program among community partners/agencies. $64,424.46 is match/in kind from Weld
County.
-Victoria Zacharko, Office Technician, salary at $36,260.45, .83 FTE (83%) to provide technical
and clerical support for HCP staff, clients, and families. $36,260.45 is requested from
CDPHE.
-Kathy Smith-Stillson, Manager, salary at $4,421.32, .05 FTE (5%) to provide direct supervision
and oversight of Weld HCP program/staff. $4,421.32 is requested from CDPHE.
EXHIBIT C
Contract Routing Number 13 FLA 48090
-Debbie Drew, Registered Nurse-c, Director of Public Health Services, salary at $6,764.08, .05
FTE (5%) to provide oversight of Weld HCP program. $6,764.08 is match/in kind from
Weld County.
Operating Expenses: $527.54
-Supplies - will be utilized for HCP program outreach/marketing/systems building activities,
copies, postage, office supplies, computer services (network fees, software, and printers),
phone services, facility fees for official HCP functions.
Total supplies: $1,200. $527.54 is requested from CDPHE; $672.46 is match/in kind
from Weld County.
Travel Costs: $0
Travel costs are reimbursed at 53.5 cents/mile per agency policy. $4,800.00 are estimated
during the contract term to provide mileage reimbursement of travel to client home visits,
required trainings, and program outreach with community partners/agencies. It will also cover
the estimated costs to provide transportation, lodging, and meals to send 2 local MCH staff to
MCH related meetings/trainings. $4,800.00 is match/in kind from Weld County.
Contractual Services: $0
-None anticipated at this time.
Indirect Costs: $5,476.52
Indirect rate is 13% of the total direct cost.
In Weld we have divided our entire MCH budget into 4 components [HCP, Medical Home,
Prenatal & CASH (aka Adolescent Injury Prevention)] with a bottom line budget for each, which
was determined by Weld's MCH group in a meeting earlier this year. When the cells in the
indirect area of the spreadsheet were completed it was done so with the end goal of hitting the
bottom line budget (CDPHE-reimbursable budget) that was established for each MCH program
component. In order to do that the reimbursable indirect amount needed to add-up to the
remainder of what the State was willing to reimburse Weld. Therefore, the remaining indirect
amount that took us over the CDPHE budget had to become county match.
The true indirect amount should be $21,982.31, however, in order to meet the budget amount
Weld requests $5,476.52 from CDPHE and the rest will be in-kind.
Total Budget for Care Coordination $174,571.18
- —
EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Planning Budget FY13 - PART A
Agency: Weld County Department of Public Health and Environment Date Completed: May 30.2012
Program Contact Approval Fiscal Contact Approval
Name: Gaye Morrison Name:Tanya Geiser
Title: Director of Health Commuication.Education and Planning Title:Administrative Director
Phone:970-304-6470 x 2380 Phone:970-304-6420 x 2122
Email:gmorrisontco.weitl-co.us Email: tgeserSca.weld.co.us
Due Date:July 1,2012
(for the period of October 1,2012 through Septernber30,2013)
Instructions: Refer to instructions for completion of this form in the MCH Guidelines.Enter numbers in yellow highlighted areas below.Total columns will calculate automatically.
SELECT POPULATION FOR THIS BUDGET PROPOSAL: SELECT ALL ACTION PLANS RELATED TO THIS BUDGET:
Child/Adolescent E Early Childhood Dental Caries T Pregnancy-related Depression
E Early Childhood Obesity Prevention P Teen Motor Vehicle Safety
Early Childhood Screening(ABCD) I—Youth Sexual Health
r Other:
Total Amount Sources of Funding
EXPENSE CATEGORIES Annual Salary Rate Annual Fringe FTE Required 'Other(Match or In- Received from
Kind) CDPHE
PERSONNEL SERVICES(Names&Titles)'
Cindy Kronauge.Health Data Specialist $78.578.51 $30,590 61 0.05 $5,458.46 $5,458.46
Kelly Imus.Health Communication Specialist II $56,699.66 $22.073.18 0.25 $19,693.21 $19.693 21 $0.00
Malone Hanson.Office Tech II $36,574.63 $14,238.50 0.25 $12,703.28 $12,703.28
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
TOTAL PERSONNEL SERVICES($and FTE) $171,852.80, 566,902.30 0.55 $37,854.95 $19,693.21 $18,161.74
OPERATING EXPENSES(which are not part of indirect)
Printing $3,500.00 $2,500.00 $1,000.00
Meeting Expenses $2,000.00 $1,000.00 $1,000.00
Incentives for high school students in traffic safety programs $800.00 $400.00 $400.00
Trailer Maintenance $1,265.00 $0.00 $1,265.00
Survey Monkey Membership Fee $800.00 $0.00 $800.00
TOTAL OPERATING EXPENSES $8,365.00 $3,900.80 $4,465.00
TRAVEL EXPENSES
Local Travel in Slate(avg 200 miles/month) $1,272.00 $0.00 $1.272.00
TOTAL TRAVEL E]SPEHSES $1,272.00 $0.00 $1,272.00
CONTRACTUAL EXPENSES
Contract with Public Relations/Marketing professional to promote programs.coordinate media campaigns. $27,000.00 $12,275.00 $14,725 00
coordinate the implementation of the P.A.R.T.Y.program at participating high schools and assist with stake-
holder and law enforcement advocacy campaigns.Contractor will serve as the community liason and media
contact for DRIVE SMART Weld County
TOTAL CONTRACTUAL EXPENSES $27,000.00 $12,275.00 $14,725.00
TOTAL DIRECT COSTS(Personnel Services+Operating+Travel+Contractual) $74,491.95 $35,868.21 $38,623.74
Indirect Rate. 18% $13.408.55 $6,456.28 $6.952.27
Indirect Type:I Total Direct Costs(TDC)capped at 25%
TOTAL INDIRECT COST $13,408.55 $6,456.28 $6,952.27
TOTAL PROJECT COST $87,900.50 $42,324.49 $45,576.01
'Source for funding for"Other"(Match or In-kind) Methodology used for reporting"Source of Funds"
Local/County Funding $42.324.49 Method A ORCI Method B
Medicaid(will not be used to match).
Patient Fees. Can NON-FEDERAL funds be used as a match?
All Other OO YES 0 NO
TOTAL $42,324.49
Core Services - PART B
What percentage of funding from the budget total is allocated to work at each level HCP CARE COORDINATION ONLY
of the MCH pyramid? What is the estimated number of children/youth with special
Direct Services 0% health care needs who will receive HCP Care Coordination
Enabling Services 0% services(with an Action Plan)in FY13?
Population-based Approaches 60%
Infrastructure Building Approaches 40% Is your agency"opting in"to receive CRCSN notifications?
Total to equal 100%, 100% pOPT-tN
EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Budget Narrative FY13
Agency: Weld County Department of Public Date Completed: May 30, 2012
Health and Environment
Program Contact Person Fiscal Contact Person
Name: Gaye Morrison Name: Tanya Geiser
Title: Director of Health Communication, Title: Administrative Services Director
Education and Planning
Phone: 970-304-6420 x2380 Phone: 970-304-6420 x2122
Email: gmorrison@co.weld.co.us Email: tgeiser@co.weld.co.us
Population Group and Action Plan(s)
Select appropriate"Population Group"and the corresponding MCH action plans below. Complete
a separate budget narrative for each budget.
Select population for this budget proposal: Child/Adolescent
Select all MCH action plans related to the population group:
F Early Childhood Dental Cares F Pregnancy-related Depression
F Early Childhood Obesity Prevention r Teen Motor Vehicle Safety
F Early Childhood Screening (ABCD) F Youth Sexual Heath
F Other:
Personnel Services: $18,161.74
Cindy Kronauge, Data Analyst, salary at $78,578.51 per yr, .05 FTE (2hrs/wk) to coordinate
pre/post and 3 month follow-up on-line surveys for P.A.R.T.Y. programs and Parent of Teen
Drivers classes and to do data analysis for evaluation of these programs. Assist in analyzing the
results from the coalition's collaboration survey, assist with the stakeholder interviews, create a
county specific fact sheet and assist in developing a presentation about evidence-based motor
vehicle policies to be used to educate key decision makers. $5,458.46 requested from
CDPHE.
Marjorie Hanson, Designer/Audio Visual/Technician, salary $36,574.62/yr, .25 FTE (25%) to
provide clerical support and coordination for DRIVE SMART Weld County and their teen motor
vehicle activities. To design and update the DRIVE SMART Weld County website and all printed
program materials. $12,703.28 requested from CDPHE.
Health Communication Specialist II: $19,693.21 is match/in kind from Weld County.
Operating Expenses: $4,465.00
Printing: Print flyers and posters for community traffic safety events, to print evaluations for
these events, to advertise Parent of Teen Drivers Classes, to print evaluations and materials for
Parent of teen Drivers Classes, to print agendas and materials for the DRIVE SMART Weld
EXHIBIT C
Contract Routing Number 13 FLA 48090
County Coalition meetings, to print county specific traffic data fact sheets and to print Driver's
Education Scholarship applications. $3,500.00 total: $2,500.00 will be match/in kind from Weld
County. $1,000.00 requested from CDPHE.
Meeting Expenses: Purchase refreshments (water/juice/cookies) for students attending the
day-long P.A.R.T.Y. programs and for the parents and teens attending the Parent of Teen
Drivers classes. Over 1,550 students attended a P.A.R.T.Y. program in 2011/2012. Also, to
provide refreshments for Parent of Teen Drivers Class participants, DRIVE SMART Weld County
volunteers during monthly coalition meetings, to participants at stakeholder meeting, for law
enforcement during GDL trainings and for attendees at community presentations. Room rental
for stakeholder meetings and community presentations. $2,000.00 total: $1,000.00 will be
match/in kind from Weld County. $1,000.00 requested from CDPHE.
Incentives for high school students in traffic safety programs: Purchase items selected
by student groups at the high schools to use as incentives for teens who sign seat belt pledges,
no texting while driving pledges and/or participate in traffic safety activities. Examples might
include coffee mugs, cell phone cases, lip balm, notebooks and pens, highlighters or key chains
with traffic safety logos. $800.00 total: $400.00 will be match/in kind from Weld County.
$400.00 requested from CDPHE.
Trailer Maintenance: $1,265 to conduct maintenance and purchase tires for three trailers
that haul DRIVE SMART Weld County educational displays (crashed vehicles with story boards)
to all P.A.R.T.Y. programs and community traffic safety events. $1,265.00 requested from
CDPHE.
Survey Monkey Membership: Purchase of a one year Platinum Membership to Survey
Monkey to be used to conduct pre/post and post-post surveys with all high school participants
attending P.A.R.T.Y. programs. $800.00 requested from CDPHE.
Travel Costs: $1,272.00
Local travel: This covers an estimated 200 miles per month @ $0.535 per mile for Adolescent
Motor Vehicle Safety Coordinator, Office Technician and Marketing Specialist to drive to county
high schools and other locations for P.A.R.T.Y. programs, Parent of Teen Drivers classes,
stakeholder meetings, and other locations throughout the county to conduct presentation about
evidence-based motor vehicle policies. Amount requested from CDPHE: $1,272.00
Contractual Services: $14,725.00
Public Relations/Marketing Contract: $14,725/yr will be used to contract with a Public
Relations/Marketing professional ($24.54/hour x 12 hours/week x 50weeks = $14,725) to
coordinate DRIVE SMART Weld County programs with schools and other entities, to work with
local media to promote events and DRIVE SMART Weld County initiatives, to create and
facilitate presentations about DRIVE SMART Weld County programs and initiatives to
organizations as needed, to assist on site as needed during programming and initiatives, to
assist with the creation and development of logos, brochures and other print materials and to
attend monthly DRIVE SMART Weld County board meetings. Total budget: $27,000.00.
$12,275.00 will be match/in kind from Weld County. Amount requested from CDPHE:
$14,725.00
EXHIBIT C
Contract Routing Number 13 FLA 48090
Indirect Costs: $6,952.27
Provide your indirect rate. An indirect rate cap will be applied. The caps are as follows per
CDPHE agreement: 25% of total direct costs; 27% of total direct salaries and/or fringe; 30% of
total direct salaries and fringe where no other direct costs are charged. If your rate exceeds
the indirect rate caps, identify those indirect costs above the allowed rate as match or in-kind
contributions.
Indirect costs: 17.77% of total direct costs for the Health Communications, Education and
Planning Division (compared to 13% in the Nursing Division). In order for the WCDPHE to meet
their MCH budget approved by CDPHE, WCDPHE will absorb additional indirect costs exceeding
allocated amounts within the Teen Motor Vehicle Safety budget. Total amount: $13,408.55.
$6,456.28 will be match/in kind from Weld County. Amount requested from CDPHE:
$6,952.27
Total Budget for Child/Adolescent Programs: $45,576.01
EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Planning Budget FY13 - PART A
Agency: Weld County Department of Public Health and Environment Date Completed: July 3.2012
Program Contact Approval Fiscal Contact Approval
Name: Debbie Drew,RN-c,NP Name:Tanya Geiser
Title: Public Health Services Director Title:Administrative Services Director
Phone: 970-304-6420 x 2304 Phone:970-304-6420 x2122
Email:ddrewialtco.weld.co.us Email:taeisertteco.welecvas
Due Date:July 1,2012
(for the period of October 1,2012 through September 30,2013)
Instructions: Refer to instructions for completion of this form in the MCH Guidelines.Enter numbers in yellow highlighted areas below.Total columns will calculate automatically
SELECT POPULATION FOR THIS BUDGET PROPOSAL: SELECT ALL ACTION PLANS RELATED TO THIS BUDGET:
CYSHCN - Medical Home +.' f Early Childhood Dental Caries E Pregnancy-related Depression
J T Early Childhood Obesity Prevention f Teen Motor Vehicle Safety
I—Early Childhood Screening(ABCD) r Youth Sexual Health
r Other: I
Sources of Funding
Total Amount
EXPENSE CATEGORIES Annual Salary Rate Annual Fringe FTE Required 'Other(Match or In- Received from
Kind) CDPHE
PERSONNEL SERVICES(Names&Titles):
Kathy Smilh-Stillson,Manager $63,648.17 $24.778.23 0.05 $4,421.32 $3.85.5 32 $566 00
Amy Antuna,Public Health Nurse III $61,297.49 $23,863.11 0.07 $5.961.24 $5,961.24
$0.00 $0.00
$0.00 $0.00,
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
TOTAL PERSONNEL SERVICES($and FTE) $124,945.66 $46.641.35 0.12 $10,382.56 $3,855.32 $6,527.24
OPERATING EXPENSES(which are not part of indirect)
Supplies $300.00 $300.00
TOTAL OPERATING EXPENSES $300.00_ $300.00 $0.00
TRAVEL EXPENSES
Travel $200.00 $200.00
TOTAL TRAVEL EXPENSES $200.00( $200.00 $0.00
CONTRACTUAL EXPENSES
TOTAL CONTRACTUAL EXPENSES $0.00 $0.00 $0.00
TOTAL DIRECT COSTS(Personnel Services+Operating+Travel+Contractual) $10,882.56 $4,355.32 $6,527.24
Indirect Rate: 13% $1 414.73 $566.19 $848 54
indirect Type:i Total Direct Costs(T DC)capped at 25% -I
TOTAL INDIRECT COST $1,414.73 $586.19 $848.54
TOTAL PROJECT COST $12,297.30 $4,921.51 $7,375.78
'Source for funding for"Other"(Match or In-kind) Methodology used for reporting"Source of Funds"
Local/County Funding $4,921.51 ill Method A ORri Method Ei
Medicaid{will not be used to match).
Patient Fees Can NON-FEDERAL funds be used as a match?
All Other t YES 0 NC
TOTAL $4,921.51
Core Services - PART B
What percentage of funding from the budget total is allocated to work at each level HCP CARE COORDINATION ONLY
of the MCH pyramid? What is the estimated number of children/youth with special
Direct Services health care needs who will receive HCP Care Coordination
Enabling Services services(with an Action Plan)in FY13?
Population-based Approaches 50
Infrastructure Building Approaches 50 Is your agency"opting in"to receive CRCSN notifications?
Total to equal 100% 100 O0Fr-IN
EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Budget Narrative FY13
Agency: Weld County Department of Public Date Completed: July 3, 2012
Health and Environment
Program Contact Person Fiscal Contact Person
Name: Debbie Drew, RN-c, NP Name: Tanya Geiser
Title: Director of Public Health Services Title: Administrative Services Director
Phone: 970-304-6420 x2304 Phone: 970-304-6420 x2122
Email: ddrew@co.weld.co.us Email: tgeiser@co.weld.co.us
Population Group and Action Plan(s)
Select appropriate"Population Group"and the corresponding MCH action plans below. Complete
a separate budget narrative for each budget.
Select population for this budget proposal: CYSHCN - Medical Home
Select all MCH action plans related to the population group:
r Early Childhood Dental Caries F Pregnancy-related Depression
r Early Chidhood Obesity Prevention F Teen Motor Vehicle Safety
F Early Childhood Screening (ABCD) F Youth Sexual Heath
F Other:
Personnel Services: $6,527.24
-Kathy Smith-Stillson, Manager, salary at $4421.32, .05 FTE (5%) to implement the medical
home action plan. Total amount: $4,421.32. $3,855.32 will be match/in kind from Weld
County. Amount requested from CDPHE: $566.00
-Amy Antuna, Registered Nurse/HCP Team Leader, salary at $5961.24, .07 FTE (7%) to
implement the medical home action plan. Amount requested from CDPHE: $5,961.24
Operating Expenses: $0
-Supplies - $300.00 will be utilized for outreach and systems building activities, copies, postage,
office supplies, computer services (network fees, software, and printers), and phone services
to implement the medical home action plan. Total amount: $300.00 will be match/in
kind from Weld County.
Travel Costs: $0
Travel costs are reimbursed at 53.5 cents/mile per agency policy. Costs of $200.00 are
estimated to provide mileage reimbursement of travel to site visits and program outreach with
community partners/agencies and required trainings related to the medical home action plan.
Total amount: $200.00 will be match/in kind from Weld County.
Contractual Services: $0
-None anticipated at this time.
EXHIBIT C
Contract Routing Number 13 FLA 48090
Indirect Costs: Provide your indirect rate. An indirect rate cap will be applied. The caps are
as follows per CDPHE agreement: 25% of total direct costs; 27% of total direct salaries and/or
fringe; 30% of total direct salaries and fringe where no other direct costs are charged. If your
rate exceeds the indirect rate caps, identify those indirect costs above the allowed rate as
match or in-kind contributions.
Amount requested from CDPHE: $848.54
Indirect rate is 13% of the total direct cost.
In Weld we have divided our entire MCH budget into 4 components [HCP, Medical Home,
Prenatal 8L CASH (aka Adolescent Injury Prevention)] with a bottom line budget for each, which
was determined by Weld's MCH group in a meeting earlier this year. When the cells in the
indirect area of the spreadsheet were completed it was done so with the end goal of hitting the
bottom line budget (CDPHE-reimbursable budget) that was established for each MCH program
component. In order to do that the reimbursable indirect amount needed to add-up to the
remainder of what the State was willing to reimburse Weld. Therefore, the remaining indirect
amount that took us over the CDPHE budget had to become county match.
Total amount: $1,414.73. $566.19 will be match/in kind from Weld County.
Amount requested from CDPHE: $848.54
Total Budget for Medical Home $7,375.78
EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Planning Budget FY13 - PART A
Agency: Weld County Department of Public Health and Environment Date Completed: May 21,2012
Program Contact Approval Fiscal Contact Approval •
Name: Debbie Drew Name:Tanya Geiser
Title: Director Public Health Services Title: Director Administrative Services
Phone: 970-304-6420 X 2304 Phone:970-304-6420 X 2122
Email:Lckewace.weld.co_us Email:tgeiserg_co.weld.co.us
Due Date:July 1,2012
(for the period of October 1,2012 through September30,2013)
Instructions: Refer to instructions for completion of this form in the MCH Guidelines.Enter numbers in yellow highlighted areas below.Total columns will calculate automatically.
SELECT POPULATION FOR THIS BUDGET PROPOSAL: SELECT ALL ACTION PLANS RELATED TO THIS BUDGET:
Women of Reproductive Age -I r Early Childhood Dental Canes r Pregnancy-related Depression
P" Early Childhood Obesity Prfr Teen Motor Vehicle Safety
r Early Childhood Screening(ABCD) r Youth Sexual Health
r Othei:
Sources of Funding
Total Amount
EXPENSE CATEGORIES Annual Salary Rate Annual Fringe FTE
9 'Other(Match or In- Received from
Required
-,, kind). CDPHE
PERSONNEL SERVICES(Names&Titles)'
Rachel Freeman,HCS II 550.186.11 $19,537 45 1.00 $69,723.56 $0.00 $69,723.56
Cindy Kronauge,Health Data Spec. $78,578.51 $30,590.61 0.05 $5,458.46 $0.00 $5,458.46
Kim Koeltzow,Clinical Services Manager $64,378.94 $25,062.72 0.25 $22,360.42 $2,561.09 $19,799.33
Debbie Drew,PHS Director $97,374.00 $37,907.70 0.05 $6.764.09 $6,764.09 $0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0 00
TOTAL PERSONNEL SERVICES($and FTE) • . . $290,517.56, $113,098.48 1.35 $104,306.52 $9,325.17 $94,981.35
OPERATING EXPENSES(which are not part of indirect)
Supplies $2,000.00 SO 00 $2,000.00
Media $2,000.00 $0 00 $2,000.00
Training/Professional Development $500.00 $0.00 $500.00
$0 00
TOTAL OPERATING EXPENSES $4,500.00, $0.00 $4,500.00
TRAVEL EXPENSES
Mliezrge $1.200 00 $0.00 $1200.00
$0.00
$0.00
TOTAL TRAVEL EXPENSES $1,200.00 $0.00 $1,200.00
CONTRACTUAL EXPENSES
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTAL CONTRACTUAL EXPENSES $0.00 $0.00 $0.00
TOTAL DIRECT COSTS(Personnel Services+Operating+Travel+Contractual) $110,006.52 $9,325.17 $100,681.35
Indirect Rate: 13 $14.300.85 51.212.27 $13.088 58
Indirect Type.I Total Direct Costs(TOC)capped at 25% - $0 00
SO 00
TOTAL INDIRECT COST $14,300.85 $1,212.27 $13,088.58
TOTAL PROJECT COST $124,307.36 $10,637.44 $113,769.93
*Source for funding for"Other"(Match or In-kind) Methodology used for reporting"Source of Funds"
Local/County Funding. $10,537 44 O Method A ORIO Method 13
Medicaid(will not be used to match).
Patient Fees Can NON-FEDERAL funds be used as a match?
All Other: OYES O NO
What percentage of funding from the budget total is allocated to work at each level HCP CARE COORDINATION ONLY
of the MCH pyramid? What is the estimated number of children/youth with special
Direct Services 0% health care needs who will receive HCP Care Coordination
Enabling Services 0% services(with an Action Plan)in FY13?
Population-based Approaches 40%
Infrastructure Building Approaches 60% Is your agency"opting in"to receive CRCSN notifications?
Total to equal 100% 100% O OPT-IN
EXHIBIT C
Contract Routing Number 13 FLA 48090
Maternal and Child Health (MCH)
Budget Narrative FY13
Agency: Weld County Department of Public Date Completed: 05/17/2012
Health and Environment
Program Contact Person Fiscal Contact Person
Name: Debbie Drew Name: Tanya Geiser
Title: Director Public Health Services Title: Director Administrative Services
Phone: 970-304-6420 X 2304 Phone: 970-304-6420 X 2122
Email: ddrew@co.weld.co.us Email: tgeiser@co.weld.co.us
Population Group and Action Plan(s)
Select appropriate"Population Group"and the corresponding MCH action plans below. Complete
a separate budget narrative for each budget.
Select population for this budget proposal: Women of Reproductive Age
Select all MCH action plans related to the population group:
✓ Early Childhood Dental Caries r Pregnancy-related Depressbn
d✓ Early Childhood Obesity Prevention r Teen Motor Vehicle Safety
✓ Early Childhood Screening (ABCD) r Youth Sexual Health
r Other:
Personnel Services: $94,981.35
Rachel Freeman, BS, CHES, MCH Health Educator, salary at $50,186.11/yr, 1.0 FTE to
coordinate and provide activities related to the Early Childhood Obesity Prevention (ECOP)
Action Plan, (Objectives A, C, E, F, and G). Amount requested from CDPHE includes
salary and fringe: $69,723.56.
Debbie Drew, RN, NP, Director of Public Health Services, salary $97,374.00/yr, .05 FTE Provides
leadership and infrastructure support to all Maternal Child Health activities provided at
WCDPHE. Division Director for Public Health Services, and supervises all staff in Division.
Assists with planning and development of program activities. Total amount: $6,764.09 will
be match/in kind provided by Weld County.
Kim Koeltzow, $64,378.94 salary/yr, 0.25 FTE Directly supervises Health Communication
Specialist, program development, plan development, and execution. Provides support and
assists with planning and development of program activities, (ECOP Objectives E and G). Total
amount: $22,360.42; $2,561.09 will be match/in kind provided by Weld County.
Amount requested from CDPHE: $19,799.33.
Cindy Kronauge, PhD, MPH, Health Data Analyst, $78,578.51 salary/yr, 0.05 FIE Provides
support and assists with the planning, implementation, and evaluation of program activities
through data analysis and development of assessment and evaluation tools, (ECOP Objectives
E, F, and G). Amount requested from CDPHE: $5,458.46.
EXHIBIT C
Contract Routing Number 13 FLA 48090
Operating Expenses: $4,500.00
Project supplies and materials needed to accomplish project objectives within the ECOP,
Objective A, F, and G includes office supplies, project supplies/materials, printing costs
(agendas, program materials, presentation supplies, class flyers and posters to promote
nutrition educational classes). Amount requested from CDPHE: $2,000.00.
Media-related project expenses related to ECOP Objective F will include media costs for
newspaper ads, advertising on billboards and bus benches, and the development of class flyers
and posters for local media campaigns, and internal development of the media plan. Amount
requested from CDPHE: $2,000.00
Training and professional development costs for project staff to attend training opportunities
and conferences throughout the project term related to ECOP Objectives A and G. Amount
requested from CDPHE: $500.00.
Travel Costs: $1,200.00
Travel costs of approximately 2242 miles during the project term will cover mileage estimated
at the Weld County rate of 53.5 cents per mile. Mileage will cover travel throughout Weld
County to various health care facilities and community-based organizations for meetings,
outreach activities, presentations, teaching classes, and follow-up visits (ECOP Objectives A, C,
E, F, and G). It will also cover the cost of at least one staff person to attend full day MCH
conference in Denver. Amount requested from CDPHE: $1,200.00.
Contractual Services: $0
Indirect Costs: Provide your indirect rate. An indirect rate cap will be applied. The caps are
as follows per CDPHE agreement: 25% of total direct costs; 27% of total direct salaries and/or
fringe; 30% of total direct salaries and fringe where no other direct costs are charged. If your
rate exceeds the indirect rate caps, identify those indirect costs above the allowed rate as
match or in-kind contributions.
Amount requested from CDPHE: $13,088.58
Indirect rate is 13% of the total direct cost.
Total amount: $14,300.85. $1,212.27 will be match/in kind from Weld County. Amount
requested from CDPHE: $13,088.58.
Total Budget for Women of Reproductive Age $113,769.93
EXHIBIT D
GRANT FUNDING CHANGE LETTER
Date: I State Fiscal Year: I Grant Funding Change Letter# I 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), 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: Lisa Ellis, Purchasing &Contracts Unit Director By:
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
STATE OF COLORADO
John W. Hickenlooper,Governor
Christopher E.Urbina,MD, MPH /6 coto
Executive Director and Chief Medical Officer ,:;;'
C
Dedicated to protecting and improving the health and environment of the people of Colorado t
4300 Cherry Creek Dr.S. Laboratory Services Division .t70.
Denver,Colorado 80246-1530 8100 Lowry Blvd.
Phone(303)692-2000 Denver,Colorado 80230-6928 Colorado Department
Located in Glendale,Colorado (303)692-3090 of Public Health
hitp://www.cdphe.state.co.us and Environment
September 28, 2012
Tanya Geiser
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH &ENVIRONMENT
1555 North 17th Avenue
Greeley, CO 80631
Hi, Tanya:
Enclosed is your copy of the fully executed Colorado Department of Public Health and Environment Task
Order Contract listed below. You may begin work on October 1, 2012.
Contractor Name: BOCC of Weld County/Weld County DPHE
Task Order Contract Number: 13 FLA 48090
Original Contract Number: N/A
Division: Prevention Services Division/PSD
Program Name: Children and Youth Branch/CYB-MCH
Project Name: FY13 MCH Contract
Reason for Contract: New
Please contact me if you have questions or concerns. My contact information is listed below.
Sincerely, pp
KATHY JACOBSEN,MS
Contracts Administrator
Prevention Services Division
(303)-692-2479
kathylacobsen@state.co.us
Hello