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Home My WebLink About20253303 Mariah Higgins From: Bill Fritz Sent: Wednesday, February 4, 2026 8:18 AM To: CTB Cc: Jason Chessher; Shaun May Subject: STI Option Letter#4 for Communication Attachments: 2025-1321 Checklist (1).pdf; OL.docx.pdf; CT 2025-1321 OL#4 -Weld County Budget.pdf Follow Up Flag: Follow up Flag Status: Flagged Attached is Option Letter#4 for the STI program to add funding to the extension of the existing grant. It adds about $11 k to the 5 months left in the grant. Please add as Communication to the board.Thanks bill MU& COUNTY,CO Bill Fritz Finance Manager Weld County Department of Public Health and Environment Desk: 970-400-2122 1555 North 17th Ave., Greeley, CO 80631 0X 0 00 Join Our Team IMPORTANT:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: DocuSign NA3 System <dse_NA3@docusign.net> Sent:Tuesday, February 3,2026 5:09 PM To: Bill Fritz<bfritz@weld.gov> Subject:Completed: Request for Signature-02/09-2025*1321 0L4 WELD This Message Is From an External Sender This email was sent by someone outside Weld County Government. Do not click links or open attachments unless you recognize the sender and know the content is safe. CotAKui ;Co.-i-;onS cc•. HL, ACT(cv) 2025-3303 o2/1 I/26 o.2/o9 126 !.- L o o S S C .� COLORADO Department of Public COMEHealth&Environment III Your document has been completed View Completed Documents Shruti Pandey shruti.pandey@state.co.us All parties have completed Request for Signature - 02/09 - 2025*1321 OL4 WELD . You are receiving an option letter for review and signature. Powered by le docusign Do Not Share This Email This email contains a secure link to Docusign. Please do not share this email, link, or access code with others. Alternate Signing Method Visit Docusign.com, click'Access Documents', and enter the security code: F3C357C0428543C79DB0270013CB84DE3 Copyright©2026 Docusign, Inc. All rights reserved. 221 Main Street, Suite 1550 San Francisco, CA 94105 This message was sent to you by Shruti Pandey who is using the Docusign Electronic Signature Service. If you would rather not receive email from this sender you may contact the sender with your request. 2 Docusign Envelope ID:CEC254D6-2115-44E2-9ACF-28CEBEEE6BAB GRANT AGREEMENT - SUBMITTAL CHECKLIST CONTRACTOR NAME: BOCC of Weld County CONTRACT REVIEWER NAME(MGR): CORE ENCUMBRANCE NUMBER(CURRENT): 2025*1321 CONTRACTOR OR SUBRECIPIENT: Subrecipient IF 0C2 OR MOD,ALL PREVIOUS 17 FHHA 95844, 18 FHHA 105307, 19 FHHt FEDERAL FUNDING AMOUNT: ENCUMBRANCE NUMBERS: $ TERM OF CURRENT ACTION(MM/DD/YY- 2/9/2026-6/30/2026 STATE FUNDING AMOUNT: $ 11400 MM/DD/YY): If Internal HR Waiver Enter Category C1 OTHER FUNDING(TYPE&AMOUNT): $ or If Waived Service Enter Category: CONTRACT TYPE: OL PROCUREMENT TYPE AND NUMBER: Exempt CONTRACT ADMINISTRATOR: Shruti Pandey PEER QA REVIEWER NAME(IF APPLICABLE): PROGRAM UNIT: STI Prevention BUDGET APPROVER NAME: Original Budget: Budget Modification: Year 1: $11,935.00 Year 1: Year 2: $13,020.00 Year 2: Year 3: $13,020.00 Year 3: Year 4: $13,020.00 Year 4: Year 5: $31,759.00 Year 5: Year 6: $116,077.00 Year 6 Year 7: $71,760.00 Year 7: Year 8: $73,572.00 Year 8: Year 9: $96,210.00 Year 9: $11,400.00 Total All Years: $440,373.00 Total All Years: $11,400.00 Add additional terms,as needed. Grand Total: $451 773.00 To be Signed by Program By signing below,I certify that the performance measures and standards,data sources and data collection methods included in the contract provide a valid basis for assessing the contractor's performance during the term of the contract. Lacy Digitally signed by Lacy Mulleavey Mulleavey Date:2026.01.27 _ 13:27:29-07'00' Print Name,Title&Sign Lacy Mulleavey,Prevention and Field Services Program Manager Date Docusign Envelope ID:CEC254D6-2115-44E2-9ACF-28CEBEEE6BAB State of Colorado Contract Modification Option Letter#4 State Agency Contract Performance Beginning Date State of Colorado for the use Et benefit of February 2, 2017 the Department of Public Health and Current Contract Expiration Date Environment June 30, 2026 Contractor Current Contract Maximum Amount Board of County Commissioners of Weld Initial Term County (a political subdivision of the state 02/02/2017-12/31/2017: $11,935.00 of Colorado) for the use and benefit of Extension Terms Weld County Department of Public Health 01/01 /2018-12/31 /2018: $13,020.00 and Environment 01/01/2019-12/31 /2019: $13,020.00 Option Letter Number 01/01/2020-12/31/2020: $13,020.00 Option Letter #4 01/01 /2021-12/31 /2021: $31,759.00 Original Contract Number 01 /01 /2022-12/31/2022: $116,077.00 17 FHHA 95844 01/01 /2023-12/31/2023: $71,760.00 Option Contract Number 01/01 /2024-01/31/2025: $73,572.00 2025*1321 OL#4 02/01 /2025-06/30/2026: $107,610.00 Total for all State Fiscal Years: $451,773.00 1. Options: A. Option to change the quantity of Services under the Contract 2. Required Provisions: A. In accordance with Section 5Bv of the Original Contract referenced above, the State hereby exercises its option to Increase the quantity of the Services at the rates stated in the Original Contract, as amended. B. The Contract Maximum Amount table on the Contract's Signature and Cover Page is hereby deleted and replaced with the Current Contract Maximum Amount table shown above. 3. Option Effective Date: The effective date of this Option Letter is upon approval of the State Controller or February 9, 2026 whichever is later. Page 1 of 2 Docusign Envelope ID:CEC254D6-2115-44E2-9ACF-28CEBEEE6BAB State of Colorado State Controller Jared S. Polls, Governor Robert Jaros, CPA, MBA, JD Colorado Department of Public Health and Environment Jill Hunsaker, Ryan, MPH, Executive Director DocuSlgned by: p-DocuSigned by: EK4.4114414,4 ma2C1 1241 524Bi... i3 SF4Ay 0 : Cersea Gilbertson, Procurements a By: urt �liams, Controller Contracts Section Director Option Effective Date: 2026-02-03 Date: 2026-02-03 In accordance with 524-30-202, C.R.S., this Option is not valid until signed and dated above by the State Controller or an authorized delegate. Page 1 of 2 Docusign Envelope ID:CEC254D6-2115-44E2-9ACF-28CEBEEE6BAB Exhibit C C O L O R A D O Colorado DepartMenl of Publie Health and Enoiroment C Department of Public Budget Justification Form Health b Environment Contract RountinK0 2025.1321 OL)IJ Annette Odell Conlncum Nam. Weld County Department of Public Health and Environment Plop-am Contact Name NP Coordinator Title,Phone and Email 9704 0-2324 • aodcll a,uoIdgov cot Bill Fntz Budget Period 2,1.2025-6,30,7A2G Fiscal Contact Name Finance Manages Title.Phone and Email 970-40F2122 bi'ntr'dweldgoy Project Name PCHD Clinical Contract Number 2025.1321 Expenditure Categories Percent of Personnel Services S+IanMoutly Fringe Actual Time Funding Source Original Amount Amount to Add New Amount Benefits on Contract/ (Base or SUPP) Requested Purchase Position Title/Employee Name II. 1pta of3aorktfur hourly mph,re,.MO.Include the hotuly 44.34% rate and mother or hen,.In rout dr...Option, l^ Media ss l Assistant ProLe and collect samples and prepare them for lab S52,500110 $23}76.30 403 Base $8,965 01 S0.00 S1965.01 Nunan Collect samples_review remits and provide eaunmt if corded S77,300.00 S34,274.82 2'. Base $8,694.96 $0.00 S8,694.% Nurse Practitioner Collect samples.rmnewromits and provide treatment if needed $1500W.00 S66900.06 45. Bose S18,712.00 90.00 S18,712.00 con Supervise ' Roods program oversight con reports sod skim data to h - 11'i:.a P' OOu o,din fir& (',,..,vu,,,I,,,,,am„c,,:ight.Iou,.hgal anIdang.and operational m,el mean 6 Incc w hall wpaun a,.0d losing and ucaunem Ina those S77,619.00 S34,416.26 23a. Supplemental S22334.99 52,9110.00 S25,234.99 Admtmsltauon Prrw qru car 0sl olu,no acting and a aanamthog Sits in the community , Outreach Public IIeallli Nurse II Prue.,and collect samples and prepare than fro Iah outreach events S81,I7700 S35,993.88 T. Supplemental 18,2202.00 S6,00000 S14,202.00 Teal Personal Services(Including Fringe Benefits) .$74,724.% 58,906.00 $83,624.96 Supplies&Operating Expenses Ilea Description Rate Qnnn6r. Funding Source Orlgln.IAmount Amount In Add New Amount (Batt or SUPP) Requested CT/OC Sureemng Tess CT'OC Screening Test S20,00 143 Bee $1,195.04 S0.00 $1,195.04 Syphilis 00,000nt 31,o014 22 per drug $0.22 25 Br S5.50 $0.00 S5.50 Chlan,vdu treatment t)ozycvz6nc I col per nesmmmt $1.00 50 Bane S50.00 $0.00 $50.00 rhea trmtrcnt Cottr,aua,c 2 23 pre dose S2.23 15 Bee $33 45 S0 00 $3345 Orusting Expenses.; SLpMvwaum,4rdmwew„141cerpphto,waiaravioraorala I Bun CT'OC Screening Tc.l III,,Sy7 itl Tag $20.00 Supplemental $7,180.00 •.52,500.90 $9,680.00. Syphiha treatment 0nu18 22 pee dose S0,22 10 Supplemental S2.20 $0.00 S2,20 Chlamyd,a treatment Dogoyclinc I W pa treatment S1.00 2i Supplemental S25.00 50.00 S25.00 Genmrha treatment C000ru'a,c 2 23 pa(loan 52.73 111 Supplemental $22.30 $0.00 S22.30 Education and Matenala Fduuum totals for chats a materials medal fa pamoung the S50.00 I Sopplemen.I $50.00 50.00 $50.00 program t the conman,N Supplio&opnruhng Ezpenam Sopaupplahmay acshlsu sucppl,es h u advausemem otlice supplies,sauna serv,as or other S70.00 I Supplemental 570.00 $0.00 $70.00 Total Supplies&Operating Expenses S8,919.49 S2,500.00 S11,419.49 Travel Item Dunipdou Rate Quointy Fum$ng So0ree Ot/gtualAmout Amount to Add New Amount (lime a SUPP) Requested Mileage Travel to and horn events or ac0ssu0'travel for the/monism 50.67 05- Supplemental S36.84 S0.00 5136.84 Total Travel S437.00 50.00 S437.00 Other Coats Item Description Rate Qoannt). Funding Source Otidnal Amoul Amount to Add New Amount (Base or SUPP) Requested Sit oil $016) SO 00 Total Other Cats SOW MOO SOW Contractual(payments to third parties nl enntkq Item Description Rate Qumnry Funding Source Original Amount Amount to Add New Amount (Base or SUPP) Requested t 50.00 N100 SO00 Tonal Contractual S0.00 S0.00 $1.00 Sub-Total Before Indirect Base S45,757.96 50.00 545,757.% Sub-Total Before Indirect Supplemental S30,323.49 511,400.00 S49,723.49 SUBTOTAL BEFORE INDIRECT S84,001.45 S11.400.00 S93481.45 Indirect Item Description gam Ft".&"5 Suuree Orlpnn Amount Ain 0unito Add New Amqut (Base or SUPP) Requested 20251ndirect Rate 19.74.% Base 54,564.00 5000 54,564.00 2025 Indirect Rate 19.74.: Supplemental .S7,565.00 50 that 57.56500 Total indirect S12,129.00 50.00 512,129.00 Sub-Total Before Indirect♦Indirect PCHD BASE Funding 550,32100 NAM 550322.00 Sub-Total Before Indirect+Indirect PCHD SUPP Funding S45.088.00 S11,400.00 557.290.00 Funding Told 596,210.01 S11,400.00 $107,6I0.00 Espeodllure Categories Orlglaol Amuual Amount to Add New Amount Personal Semites Including Fringe Benefits S74,724.96 58,900.00 S83,624.96 Supplies and Operating Expenses _ S8,919.49 $2,50000 $11,419.49 Travel S437.00 50.00 S437.00 Other Cats S0.00 50.00 50.00 Contractual Payments 50.00 S0.011 50.00 - Subtotal Before Indirect 50,001.45 511,41$M S96,4111.45 Indirect S12,129.00 MOO S12,129.00 Total S96,210.01 511.400.IN $107.610110 CT 2025*1321 Option Letter 4 1 Mariah Higgins From: Bill Fritz Sent: Monday, November 24, 2025 1:19 PM To: CTB Cc: Jason Chessher; Shaun May Subject: STI Grant OL#3 for communication Attachments: OL# 3 STI.pdf Follow Up Flag: Follow up Flag Status: Flagged Please find Option Letter#3 for our STI grant attached. Please share with the board as a communication.Thanks Bill aouHrr,o Bill Fritz Finance Manager Weld County Department of Public Health and Environment Desk: 970-400-2122 1555 North 17th Ave., Greeley, CO 80631 0LI 00 Joky Ow Team IMPORTANT:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. Co KTAutn.co o 1S cc: AcT(sww/cn) 2025-3303 ►.2/og/25 ►2 /04 (25 hll-oo5g Docusign Envelope ID:379C2512-5079-4AE4-ACE9-3BCF98B66DD5 State of Colorado Grant Modification Option Letter#3 State Agency Agreement Performance Beginning Date State of Colorado for the use f>: benefit of the February 2, 2017 Department of Public Health and Environment Current Agreement Expiration Date Grantee June 30, 2026 Board of County Commissioners of Weld County Current Agreement Maximum Amount (a political subdivision of the state of Colorado) Initial Term for the use and benefit of Weld County 02/02/2017-12/31/2017: $11,935.00 Department of Public Health and Environment Extension Terms Grantee UEI 01/01/2018-12/31/2018: $13,020.00 MKKXT9U9MTV5 01/01/2019-12/31/2019: $13,020.00 Option Letter Number 01/01/2020-12/31/2020: $13,020.00 Option Letter#3 01/01/2021-12/31/2021: $31,759.00 Original Agreement Number 01/01/2022-12/31/2022: $116,077.00 17 FHHA 95844 01/01/2023-12/31/2023: $71,760.00 Option Agreement Number 01/01/2024-01/31/2025: $73,572.00 2025*1321 OL#3 02/01/2025-06/30/2026: $96,210.00 Total for all State Fiscal Years: $440,373.00 Grant Option Letter Page 1 of 3 Version 11/2024 Docusign Envelope ID:379C2512-5D79-4AE4-ACE9-3BCF98B66DD5 1. Options: A. Option to extend for an Extension Term B. Option to change the quantity of Goods under the Agreement 2. Required Provisions: A. In accordance with Section 5 of the Original Agreement referenced above, the State hereby exercises its option for an additional term, beginning November 20, 2025 and ending on the current agreement expiration date shown above, at the rates stated in the Original Agreement, as amended. B. In accordance with Section 5Bv of the Original Agreement referenced above, the State hereby exercises its option to Increase the quantity of the Services at the rates stated in the Original Agreement, as amended. Exhibit C, Budget is deleted and replaced in its entirety with Exhibit C, Budget attached to this Option Letter. The budget is as follows: 2/1/2025-6/30/2026 $73,572.00 and an additional $22,638.00 available upon execution of this option letter. C. The Agreement Maximum Amount table on the Agreement's Signature and Cover Page is hereby deleted and replaced with the Current Agreement Maximum Amount table shown above. 3. Option Effective Date: The effective date of this Option Letter is upon approval of the State Controller or November 20, 2025 whichever is later. Grant Option Letter Page 2 of 3 Version 11/2024 Docusign Envelope ID:379C2512-51379-4AE4-ACE9-3BCF98B66DD5 STATE OF COLORADO STATE CONTROLLER Jared S. Polls, Governor Robert Jaros, CPA, MBA, JD Colorado Department of Public Health and Environment Jill Hunsaker Ryan, MPH, Executive Director DocuSigned by: DocuSigned by: [ asp aidU4SoLit, F4..4 Wdlz40.4 733051-4MA004oC... Ll. L4715OL4lf 7 By: l elsea Gilbertson, Procurements it By: Kurt Williams, Controller Contracts Section Director Date: 2025-11-24 Amendment Effective Date:2025-11-24 In accordance with §24-30-202, C.R.S., this Agreement is not valid until signed and dated below by the State Controller or an authorized delegate. Grant Option Letter Page 3 of 3 Version: 11.2024 Docusign Envelope ID:379C2512-5D79-4AE4-ACE9-3BCF98B66DD5 Exhibit C 4 . COLORADO e T W Department of Public ' ' Health ftEnvirolunent Colorado Department of Public Health and Environment • BUDGET JUSTIFICATION FORM CT 2025.1321 ,... Annette Odell CentnetorNeme Weld County Department of Public Health and Environment Pngram Contact Naaia- NP Coordinator T3ne,.Phane ind Ettai- 970-400.2324 aodell@weldgov.com Bill Fritz er HadgetPer'4od 2/1/2025-6/30/2026 ' Ttde,Phone and - - Frnrocr0 Man22 bfritz(a)weld.tov Project Neme Oil Screening&Treatment : Co..Eeeumbnnee - 2025 .321 Brpemdimre Categoeei, - • . t r SJa7Prlouri Aumoyot to Add NesAmount ! � ' 181hge 'Adtiial'I9meun PYdln��l'�butre Otljiud timemt ` Penennel�`ervlcu i '-` _ ; � )leileIIn Canter wed�srnpih Reyu«taa ''! ""'"I''-:' �� ,Pnrdyae Opde[ .._ Po,ltim Tltle/EmployeeName t.rioipHonafWork(forhaurlyempl177eUieueinciude 44.34% - - - tlee toady ran and number of hour n year dacdpdon) Medical Aaeiateot Process and collect samples and prepare them for lab S52,500.00 S23,278.50 4% Bane $6,465.01 52,500.00 58,965.01 Nurse Collect samples,review results end provide treatment if S77,300.00 $34,274.82 2% Base 54,194.96 $4,500.00 58,694.96 needed Nurse Practitioner Collect eemplee,review regatta and provide treatment if S150,900.00 S66,909.06 4% Base $8,712.00 S10,000.00 $18,712.00 needed Program Supervisor Provide program oversight, m ight,run reports and submit data to $150,900.00 S66,909.06 1% Base 52,178.00 55,638.00 S7,816.00 CDPIE for grant Provide outreach program oversight,logistical,scheduling,and Outreach Coordinator& opvataal overnight.Iacreaer local capacity"nand tegtiug $77,619.00 $34,416.26 23% SUP? S22,334.99 $0.00 522,334.99 Administration Personnel and treatment for those at greatest risk of contracting and/or transmitting SII,in the community Outreach Public Health Nurse IIPr��e and collect ampler and prepare them for lab outreach 581,177.00 535,993.88 7% SUPP 58,202.00 50.00 $8,202.00 ." ,,�.', =TotalPuaoidel 9ersieea(lnekldngl glEetUBf4) St 4gli.96 - S32,b3800 7d,73L96 ' i°"i _ SnppBef dFOpenthil Expehttee 1 ! i a dty ehodirig1oli#5. OHgnndAmonht _'� l+b�,`. d ,� -., .6aeriptian Bata - ��+n^`] (Baaetlr..,'.•t "."`aitip4etr+t _ Ameuat toldd NeatAmomsf:.: CT/GC Screening Teat CT/GC Screening Ten $20.00 143 Base 51,195.04 $0.00 51,195.04 Syphilis treatment Bicilln.22 per dose $0.22 25 Base $5.50 $0.00 55.50 Chlamydia treatment Doxycyotne 1.00 per treatment $1.00 50 Base $50.00 $0.00 $50.00 Gonorrhea treatment Ceftriaxone 2.23 per done S2.23 15 Base $33.45 $0.00 533.45 Ole+�8 Supply coma ruckpeadver s7peioi,ofce s'Miea,couriv S tea& a E pxa amvices or oNv opantional aupptea 5286.00 1 Base 5286.00 $0.00 5286.00 CT/GC Screening Test CT/GC Scraping Ten $20.00 359 SUPP 57,180.00 $0.00 $7,180.00 Syphilis treatment Bicillio.22 per dose $0.22 10 SUPP $2.20 . $0.00 $2.20 Chlemydia treatment Doxycycline 1.00 per treatment $1.00 25 SUPP $25.00 $0.00 $25.00 Gonorrhea treatment Cefbiexone 2.23 per doer $2.23 10 SUPP $22.30 $0.00 $22.30 Education and Materials Education materials for clients or materiels needed for 550.00 1 SUPP $50.00 $0.00 $50.00 promoting the program to the community Supplies&Opvathrg Expense. Supply arts each as advertisement,office supplies,courier $70 00 1 SUPP $70.00 50.00 $70.00 xrvica or other opvational suppler r '.;,�. ,-Tanl supplies.A Opehtlng Ropensd• r;:$8,919.49 • !S.no. • ',10919A9 4°4" - DeorWPdou "1 Rate- Qnu Fnnding$amar, Oflghn.IAmemt- Amopee to Add NeewAmeaut i (HMeerBUPP) 14*,6,d Mileage Travel to and from events or neeaaary travel for the program $0.67 652 SUPP 5436.84 50.00 S436.84 -^;E4,.:P w,' a �.° a`,., ,w '," ,;, v Tot'alTravel ,,0431.:60 ;nee r $4ax0C, _ ' j. Other ens. � " -_ i . Itepef Den reipdeh a'Rte.. .Cl'!endly (Bate.$tt,*. .-Oet� t AmamtitoA{!d Ne,eAnmmnt Training for STI for aurae 5299.00 1 Hue $0.00 $0.00 50.00 Ix,. - "..,`1btal Ohara Crete `g $0.00 4001 30310 -- .i r i, -.a fit ''i;;; Contractual(peymmin te third porn..oragtNiea),,,; '" Item:cr - "{,;:- Duetlption •• #ate 41400ty jBassar$UPP) edupd , Amount taAJd 7.N1gtmaunt.... $0.00 $0.00 $0.00 ^^ Sub-Total Before Indirect -_ flue $13,110.96 - 522,638.00 545,757,96- -- -,` - Sub-Tani Befoielndlvet SUPP $38,323.49- - 50.00, S38,323,49 p PYmdte $mxe Ot*-44M-°rat --- u;�a9 Xkul 3 {`/q°�i 1k°celpNo° Rate= g (g�orSl7PPf� l'keJpatad 4Rriti*toddd 'NewAmoml`.- .Contract Number 2025*1321 Option Letter 11 1 Docusign Envelope ID:379C2512-5D79-4AE4-ACE9-3BCF98B66DD5 Exhibit C 2025 Indirect Rate 19.741/e Base 54,564.00 $0.00 $4,564.00 2025 Indirect Rate I9.74.% SUPP 57,565.00 50.00 57,565.00 Tote'Indirect $12,129.00 $0,00 $12,129.00 Sub-Total Before indirect+Indirect PCHD BASE Funding $27,604,00 $22,638,00 $50,322.00 Sub-1bhi Before Indirect+tndtrert.PCRD SUIT Funding S45,609.00 50.00 $45888.00 . i_ !'1 ,. Fttudlustnod .$15,572.00 $22,,68.06 - 596,210.00' Contract Number 2025*1321 Option Letter 11 2 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 CONTRACT MODIFICATION SUBMITTAL CHECKLIST Contractor/Subrecipient Name Weld County Public Health 0 All Contractor name occurrences and Secretary of State Status Summary Page match exactly Modification Routing# 2024*2731 OL#2 Original Routing# 2020*3023 CORE# 2024*2731 or r NO ENCUMBRANCE Modification Start Date 1/1/2024 Modification End Date %31/2025 SOW Modification Pre-approval-OnBase Approval# Enter# (if applicable) Division Acronym STI/HIV/VH Unit Acronym STI Prevention Submitter Name Chad Jones Email chad.jones@state.co.us SOW Delegate Name Chad Jones Email chad.jones@state.co.us Purpose(s)of Modification(Select all that apply) fl Scope of Work ❑ Budget ® Renewal ❑ No Cost ❑ Assignment ❑ Other If'Other' Describe Modification DOCUMENT TYPE Select Only One A B C A. Amendment ❑ B. Option Letter C. Assignment ❑ Modification - DocuSign BackupDocuments MakalltDotnfTr ee ii selected Document Type. Include requested backup documents(as required)and contract in DocuSign envelope in order from 1-11. A B C 1. Contract Modification Quality Assurance Checklist ❑ ❑ ❑ 2. Contract Modification Submittal Checklist ❑ ® ❑ 3. Cover Page of original contract document and cover page of most recent assignment,if applicable ❑ ® ❑ 4. If Subrecipient,Pre-Award Financial Risk Assessment#(See Internal Audit Site) Enter# ❑ ❑ (Renewal required each year) 5. Insurance Certificate(s)***Insurance Policy Dates must be current on effective date of contract*** If Assignment,Certificate of Insurance(COI)for Assignee only. NOT required for Interagency Agreement or Intergovernmental Contract. ❑ ❑ ❑ Waiver-OnBase Approval ID# Enter# Insurance Waiver Type: Enter Type of Waiver Granted 6. ❑Sole Source REVISION(Modification required when increased amount,change in SOW,or date change) New PCS Sole Source Request# Enter PCU Request# ❑ ❑ New PCS Sole Source Term Select SS Term Start Date to Select SS Term End Date New NPSS1# Enter NPPSS1# 7. Secretary of State Status Summary Page(Amendment or Option Letter for a new term) (Must state the entity is in'good standing') ❑ ❑ ❑ (If Assignment,SOS for Assignee only; NOT required for Interagency Agreement,Intergovernmental Contract) If'Doing Business As'(dba),Secretary of State Status Summary Page for dba ❑ ❑ ❑ 8. Signature Authority Letter or Corporate Documentation(If contract signed by other than apparent authority) ❑ ❑ (See OSC Policy Signature Authority Delegation) 9. SAM Exclusion Summary Page(Record verified and no exclusions/restrictions)(See SAM Verification Guidance( ❑ ❑ ❑ (If Assignment,SAM for Assignee only; NOT required for Interagency Agreement Contract or LPHA) 10. Contract Modification(cover page,signature page,main body) ❑ ® ❑ 11. Contract Modification Exhibits(as shown on cover page of modification being submitted) ❑ ® ❑ Modification Submittal Checklist Version 08.24.23 1 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 CMS RECORD (X)= Required for contracts$100,000 over the life of the contract Completed 1. Record Type—Record type chosen is'Modification'. ❑ 2. Linked Record—Record is linked to the Master Record ONLY. 0 3. Record Title—Title follows the naming convention for a Modification to a Master Record. 0 4. Data Field: Vendor Name—Has been selected in the'Contractor/Vendor'field. 0 5. Data Fields: If this Modification is to renew or extend a contract,has the contractor's work to date been certified as complying with the terms of the contract AND the Master CMS contract record updated? Choose'Yes'when renewing or extending the expiration date and enter'Yes'in the corresponding field in ❑ the Master Record. If the Modification is not to renew or extend,choose'N/A'and do not make any changes in the corresponding field in the Master Record. 6. Data Field: Certification—If applicable,enter date of MOST RECENT annual certification of contractor work—If contract has been renewed or extended,enter expiration date of the contract.We are using the expiration date of the contract to represent the last contractor performance evaluation of the contract ❑ period(quarterly or 3x per year).If the Modification is not to renew or extend, leave blank. If the corresponding field in the Master Record is set to'Yes'as a result of a previous renewal/extension,do not change it. 7. Data Fields: All other relevant data fields are completed per CDPHE protocol. ❑ 8. Update Master Record—Cumulative Dollar Amount,Latest Performance End Date,and Recertification data ❑ fields have been updated as applicable. NOTES: Click here to enter text Modification Submittal Checklist Version 08.24.23 2 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT CMS ROUTING NO. 17 FHHA 95844 APPROVED TASK ORDER CONTRACT - WAIVER #154 This task order contract Is issued pursuant to master contract made on 01/17/2012,with routing number 13 FAA 00051. STATE: CONTRACTOR: State of Colorado for the use&benefit of the Board of County Commissioners of Weld County Department of Public Health and Environment (a political subdivision of the state of Colorado) Disease Control and Environmental Epidemiology 915 10th Street Chlamydia Greeley,Colorado 80632-0758 4300 Cherry Creek Drive South for the use and benefit of the Denver,Colorado 80246 Weld County Department of Public Health and Environment 1555 North 17th Avenue Greeley,Colorado 80631 CONTRACTOR DUNS: 075757955 CONTRACTOR ENTITY TYPE: CONTRACT MADE DATE: 1 1/29/2016 Political Subdivision CORE ENCUMBRANCE NUMBER: BILLING STATEMENTS RECEIVED: 201700002993 Monthly TERM: STATUTORY AUTHORITY:Not Applicable This contract shall be effective upon approval by the State Controller,or designee,or on 2/12017, CLASSIFICATION:Sub-Recipient whichever is later.The contract shall end on 12/31/2017. CONTRACT PRICE NOT TO EXCEED: $11,935.00 PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS: $11,935,00 Exempt STATE FUNDING DOLLARS: $0.00 BIDRFP LIST PRICE AGREEMENT NUMBER: OTHER FUNDING DOLLARS: $0.00 Not Applicable Specify"Other": MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR: LAW SPECIFIED VENDOR STATUTE: FY17: $5,425.00 Not Applicable FYI 8: $6,510.00 STATE REPRESENTATIVE: Maria Jackson Department of Public Health and Environment Disease Control and Environmental Epidemiolog PRICESTRt1C1URE: Cost Reimbursement 4300 Cherry Creek Drive South CONTRACIDRREPRESENTATIVE: Denver,Colorado 80246 Mark Wallace,Executive Director Weld County Department of Public Health and Environment 1555 North 17th Avenue Greeley,Colorado 8063 PROJECT DESCRIPTION: This project serves to support the prevention of infertility and C.trachomatis and N.gonorrhea infection through the provision of screening, treatment,and partner management for these infectious diseases. CT Temp 17 95844_doCJs Page 1 of 6 0/16 y, DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 OPTION LETTER#2 State Agency: Original Contract Number: Colorado Department of Public Health and Environment 17 FHHA 95844 4300 Cherry Creek Drive South Denver,Colorado 80246 Option Letter Contract Number: Contractor: 2024*2731 Option Letter#3 Board of County Commissioners of Weld County (a political subdivision of the state of Colorado) 1150"O"Street Greeley CO 80631 for the use and benefit of the Weld County Department of Public Health and Environment 1555 North 17th Avenue Greeley CO 80631 Contract Performance Beginning Date: Current Contract Expiration Date: February 2,2017 January 31,2025 CONTRACT MAXIMUM AMOUNT TABLE Document Contract Federal Funding State Funding Other Funding Term(dates) Total Type Number Amount Amount Amount Original Contract 17 FHHA $11,935.00 $0.00 $0.00 02/02/2017- 95844 12/31/2017 $11,935.00 Contract 18 FHHA $13,020.00 $0.00 $0.00 01/01/2018- Amendment#1 105307 12/31/2018 $13,020.00 Contract 19 FHHA $13,020.00 $0.00 $0.00 01/01/2019- Amendment#2 121540 12/31/2019 $13,020.00 GFCL#1 2020*3023 S13,020.00 $0.00 $0.00 01/01/2020- $13,020.00 GFCL#1 12/31/2020 Contract 2020*3023 $21,759.00 $0.00 $0.00 01/01/2021- Amendment#3 Amendment#3 12/31/2021 $21,759.00 Option Letter#1 2020*3023 $10,000.00 $0.00 $0.00 09/20/2021- Option Letter 12/31/2021 $10,000.00 #1 Contract 2022*2474 $116,077.00 $0.00 $0.00 01/01/2022- Amendment#4 Amendment#4 12/31/2022 $116,077.00 Contract 2023*3868 $71,760.00 $0.00 $0.00 01/01/2023- $71,760.00 Amendment#5 Amendment#5 12/31/2023 Option Letter#2 2024*2731 $73,572.00 $0.00 $0.00 01/01/2024- $73,572.00 Option Letter 01/31/2025 #2 Current Contract Maximum $344,163.00 Cumulative Amount Page 1 of 3 Option Letter Contract Number:2024*2731 Option Letter#2 Ver.27.01.20 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 1) OPTIONS A. Option to extend for an Extension Term 2) REQUIRED PROVISIONS: A. In accordance with Section(s)5 of the Original In accordance with Section 2C of the Original Master Task Order Contract referenced above,the State hereby exercises its option for an additional term,beginning January 1,2024 and ending on the current contract expiration date shown above,at the rates stated in the Original Task Order Contract,as amended for the following reason: to renew the contract for an additional term. B. The Contract Maximum Amount table is deleted and replaced with the Current Contract Maximum Amount table shown above. 2) OPTION EFFECTIVE DATE: A. The effective date of this Option Letter is upon approval of the State Controller or January 1, 2024,whichever is later. Page 2 of 3 Option Letter Contract Number:2024*2731 Option Letter#2 Ver.27.01.20 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 SIGNATURE PAGE STATE OF COLORADO In accordance with§24-30-202 C.R.S.,this Option is not Jared S.Potts,Governor valid until signed and dated below by the State Controller or Colorado Department of Public Health and Environment an authorized delegate. Jill Hunsaker Ryan,MPH,Executive Director STATE CONTROLLER Robert Jaros,CPA,MBA,JD DocuSigned.by: DocuSigned by: C8CA04B14548748A.. 2EDF870A1A7D4FC... By: Signature By: Signature Lisa McGovern Jannette Scarpino Name of Executive Director Delegate Name of State Controller Delegate Procurement & Contracts Section Director ft chief Financial officer Title of Executive Director Delegate Title of State Controller Delegate 2023-10-31 2023-11-01 Date: Option Effective Date: -- Signature Page End -- Page 3 of 3 Option Letter Contract Number:2024*2731 Option Letter#2 Ver.27.01.20 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 Exhibit I gCOLORADO Errs Colorado Department of Public Health and Environment BUDGET JUSTIFICATION FORM Contract Routing#2024*2731 OL#2 Board of County Commissioners of Weld Annette Odell,NP Contractor Name County for the use and benefit of the Weld Program Contact Name Coordinator County Department of Public Health and Title,Phone and Email 970-400-2324 Environment aodell@weldgov.com Sonya Oster,Bus.Ops. Fiscal Contact Name Mgr. Budget Period 1/1/2024-1/31/2025 Title,Phone and Email 970-400-2332 soster@weld.gov Prevention of STI,CT,GC and Syphilis Project Name Core Encumbrance 2024*2731 Screening and Treatment Expenditure Categories Percent of Actual Time Personnel Services Salary/Hourly Fringe on Contract/ Funding Source Original Amount Benefits Purchase Order (Base or SUPP) Requested Description of Work (for hourly employees,please include the 43.49% hourly rate and number of hours in your Position Title/Employee Name description) Process and collect samples and prepare $52,500.00 $22,832.25 4% Base $3,013.00 Medical Assistant them for lab Collect samples,review results and provide Nurse treatment if needed $77,300.00 $33,617.77 2% Base $2,218.00 -Collect samples,review results and provide Nurse Practitioner treatment if needed $150,900.00 $65,626.41 4% Base $8,661.00 Provide program oversight,run reports and Program Supervisor submit data to CDPHE for grant $150,900.00 $65,626.41 1% Base $2,165.00 t•roviae outreacn program oversight, • logistical,scheduling,and operational oversight.Increase local capacity around testing and treatment for those at greatest $77,619.00 $33,756.50 23% SUPP $25,616.00 risk of contracting and/or transmitting STIs Outreach Coordinator&Administration Personnel in the community Option Letter Contract Number:2024*2731 Option Letter#2 Page 1 of 3 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 Exhibit I Process and collect samples and prepare Outreach Nurse them for lab outreach events S81,177.00 S35,303.88 7% SUPP S8,1.54.00 "Total Personal Services(lncluding Fringe Benefits) S49,827.00 Supplies&Operating Expenses Item Description Rate Quantity Budgeted Amount Base CT/GC Screening Test CT/GC Screening Test $20.00 100 $2,000.00 Syphilis RPR ScreeningTest Syphilis RPR ScreeningTest Base YP YP $2.00 160 $320.00 Syphilis RPR Confirmatory Test Syphilis RPR Confirmatory Test $8.00 5 Base $40.00 Supply costs such as advertisement,office supplies,courier services or other Base Supplies&Operating Expenses operational supplies $275.00 I $275.00 HIV Insti Rapid Test HIV Insti Rapid Test $13.00 50 Base $650.00 HIV Confirmatory Test HIV Confirmatory Test $8.00 2 Base $16.00 CT/GC Screening Test CT/GC Screening Test $10.00 345 SUPP $3,450.00 Syphilis RPR Screening Test Syphilis RPR Screening Test $2.00 304 SUPP $608.00 Syphilis RPR Confirmatory Test Syphilis TPPA Confirmatory Test $8.00 5 SUPP $40.00 HIV Insti Rapid Test-verify our cost HIV Insti Rapid Test $13.00 249 SUPP $3,237.00 HIV Confirmatory Test HIV Confirmatory Test $8.00 2 SUPP $16.00 Education materials for clients or materials needed for promoting the program to the Education and Materials community $50.00 1 SI'PP $50 00 Supply costs such as advertisement,office supplies,courier services or other Supplies&Operating Expenses operational supplies $50.00 1 SI PP $50.00 Total Supplies&Operating Expenses S10,752.00 Travel Item Description Rate Mileage Budgeted Amount -Travel to and from events or necessary Milc.gc travel for the program $0 63 757 SUPP $473.13 Total Travel S473.00 Other Costs Training for STI for nurse Base $299 Option Letter Contract Number:2024.2731 Option Letter#2 Page 2 of 3 DocuSign Envelope ID:9AEBF47E-39A6-4B09-A4B8-27084BFBC088 Exhibit I Total Other Costs $299.00 Contractual(payments to third parties or entities) EMR $100 Total Contractual $100.00 Sub-Total Before Indirect Base $19,657.00 Sub-Total Before Indirect SUPP $41,694.00 Indirect 2023 Indirect Rate=19.92% Base $3,916.00 2023 Indirect Rate=19.92% SUPP $8,305.00 Total Indirect $12,221.00 Total PCHD BASE Funding Base $23,573.00 Total PCHD SUPP Funding SUPP $49,999.00 TOTAL $73,572.00 Option Letter Contract Number:2024*2731 Option Letter#2 Page 3 of 3 DocuSign Envelope ID:DDO6DF85-C121-403D-9F94-A940D652D9A7 OPTION LETTER#: 1 State Agency: Original Contract Number: Colorado Department Of Public Health and Environment 17 FHHA 95844 STI/HIVNH-1901 4300 Cherry Creek Drive South Option Letter Contract Number: Denver,Colorado 80246 2020*3023 Option Letter#1 Contractor: Board of County Commissioners of Weld County 1150"0"Street,Greeley,Colorado 80631 for the use and benefit of the Weld County Department of Public Health and Environment 1555 North 17th Avenue Greeley,Colorado Contract Performance Beginning Date: Current Contract Expiration Date: September 20,2021 December 31,2021 CONTRACT MAXIMUM AMOUNT TABLE Document Contract Federal Funding State Funding Other Funding Term(dates) Total Type Number Amount Amount Amount Original Contract 17 FHHA $11,935.00 $0.00 $0.00 02/02/2017- $11,935.00 95844 12/31/2017 Contract 18 FHHA $1 ,020.00 $0.00 $0.00 01/01/2018- $13,020.00 Amendment#1 105307 12/31/2018 Contract 19 FHHA $13,020.00 $0.00 $0.00 01/01/2019- $13,020.00 Amendment#2 121540 12/31/2019 GFCL#1 2020*3023 $13,020.00 $0.00 $0.00 01/01/2020- $13,020.00 GFCL#1 12/31/2020 Contract 2020*3023 $21,759.00 $0.00 $0.00 01/01/2021- Amendment#3 Amendment 12/31/2021 $21,759.00 #3 Option Letter#1 2020*3023 $10,000.00 $0.00 $0.00 09/20/2021- Option Letter 12/31/2021 $10,000.00 #1 Current Contract Maximum $82,754.00 Cumulative Amount 1) OPTIONS A. Option to change quantity of services under the Contract 2) REQUIRED PROVISIONS: A. In accordance with Section(s)5,Exhibit A of the Original Contract referenced above, the State hereby exercises its option to increase the quantity of services at the rates stated in the Original Contract as amended.Exhibit I,Budget,is deleted and replaced in its entirety with Exhibit I,Budget,attached to this Option Letter,for the following reason:increase funding to provide services. B. The Contract Maximum Amount table is deleted and replaced with the Current Contract Maximum Amount table shown above. 3) OPTION EFFECTIVE DATE: A. The effective date of this Option Letter is upon approval of the State Controller or September 20, 2021 ,whichever is later. Page 1 of 2 Option Letter Contract Number:2020*3023 Option Letter#1 Ver.27.01.20 DocuSign Envelope ID:DDO6DF85-C121-403D-9F94-A940D652D9A7 SIGNATURE PAGE STATE OF COLORADO In accordance with§24-30-202 C.R.S.,this Option is not Jared S.Polls,Governor valid until signed and dated below by the State Controller or Colorado Department of Public Health and Environment an authorized delegate. Jill Hunsaker Ryan,MPH,Executive Director STATE CONTROLLER Robert Jaros,CPA,MBA,JD DocuSigned by: DocuSigned by: L(LiStt 1144eukt riA, 2EDF870A1A7D4FC... AC2AC54280C6401... By: Signature By: Signature Lisa McGovern Andi Hardy Name of Executive Director Delegate Name of State Controller Delegate Procurement & Contracts Section Director ft Controller Title of Executive Director Delegate Title of State Controller Delegate 2021-09-16 2021-10-13 Date: Option Effective Date: -- Signature Page End -- Page 2 of 2 Option Letter Contract Number:2020*3023 Option Letter#1 Ver.03.01.20 DocuSign Envelope ID:DDO6DF85-C121-403D-9F94-A940D652D9A7 Exhibit I COLORADO Department of Public Health b Environment Colorado Department of Public Health and Environment BUDGET JUSTIFICATION FORM Original Contract Routing# 17 FHHA 95844 Board of County Commissioners of Weld Annette Odell,NP Coordinator County for the use and benefit of the Weld Program Contact Name Contractor Name County Department of Public Health and Title,Phone and Email (970)400-2324; Environment aodell@weldgov.com Prevention of Infertility,GC&CT Fiscal Contact Name Tanya Geiser,Director,Finance Project Name Screening Title,Phone and Email (970)400-2122; tgeisergaweldgov.corn Expenditure Categories Percent of Fringe Actual Time Original Amount New Amount Total Amount Personal Services Salary/Hourly on Contract/ Benefits Purchase Requested Requested Requested Order Description of Work (for hourly employees,please include the Position Title/Employee hourly rate and number of hours in your Name description) Total Personal Services(Including Fringe Benefits) $0.00 Supplies&Operating Expenses Item Rate Quantity Budgeted Amount New Amount Total Amount CT/GC Screening Test $ 40.00 552 $15,120.00 $6,960.00 $22,080.00 Syphilis TPPA Screening Test $ 8.00 5 $16.00 $24.00 $40.00 Syphilis RPR Screening Test $ 13.00 424 $3,796.00 $1,716.00 $5,512.00 $0.00 Total Supplies&Operating Expenses $18,932.00 S8,700.00 $27,632.00 Travel Total Travel $0.00 $0.00 $0.00 Other Costs Total Other Costs $0.00 $0.00 $0.00 Contractual(payments to third parties or entities) Total Contractual $0.00 $0.00 $0.00 Sub-Total Before Indirect $18,932.00 $8,700.00 $27,632.00 Indirect 2021 Indirect Rate—14.93% $2,827.00 $1,300.00 $4,127.00 Total Indirect $2,827.00 $1,300.00 $4,127.00 TOTAL $21,759.00 $10,000.00 $31,759.00 Option Letter Contract Number:2020.3023 Option Letter#1 Page 1 of 1 Hello