HomeMy WebLinkAbout20112433 RESOLUTION
RE: APPROVE AMENDMENT#1 TO 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 Amendment#1 to the Task Order Contract
for the Maternal and Child Health (MCH) Program, the Teen Motor Vehicle Safety Program, the
DRIVE SMART Weld County Program,the Tailgate the Safety Way Community Event,the Prevent
Alcohol and Risk-related Trauma in Youth Program (PA R.T.Y.), 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, 2011, and ending September 30, 2012, with further terms and conditions
being as stated in said amendment, and
WHEREAS,after review, the Board deems it advisable to approve said amendment,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 Amendment#1 to the Task Order Contract for the Maternal and Child Health
(MCH) Program, the Teen Motor Vehicle Safety Program, the DRIVE SMART Weld County
Program, the Tailgate the Safety Way Community Event, the Prevent Alcohol and Risk-related
Trauma in Youth Program (P.A.R.T.Y.), 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 amendment.
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AC) li C�. NL 2011-2433
la- 11 HL0038
AMENDMENT#1 TO 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 14h day of September, A.D., 2011.
BOARD OF COUNTY COMMISSIONERS
LD COUNTY, COLORADO
ATTEST: 5 y � \\' t� ha
r 'rkmeyer, C air
Weld County Clerk to the Board 1361
. n , Pro-Tern
BY: i� 1 '..OJ ~ . 1 7_(I
Deputy C - k to the Board j1 n „its
Garci.
APyD AS •
David E. L�
i
oun ttorney
ouglas ademach
Date of signature: 9/7r'///
2011-2433
HL0038
Memorandum
1861 - 2011
TO: Barbara KCounty
Co, Chair
Board of County Commissioners
WELD_ e 0 U N T Y FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
Environment
DATE: August 16, 2011
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 all last year's approval.
1. Prenatal $116,241.82: The task order will be used to address the MCH performance
measures for Weld County and the State of Colorado and to help ensure all families have
access to direct care services. For these services, Weld County will be reimbursed an
amount not to exceed $116,241.82.
2. Adolescent Health & Injury Prevention $46,572.31:
The funding for Adolescent Health is directed to the Teen Motor Vehicle Safety program
in partnership with DRIVE SMART Weld County to help meet the goal of decreasing
deaths and injuries from motor vehicle crashes. The program will provide support to:
coordinate the DRIVE SMART Weld County community traffic safety coalition; assist
with coordinating the Tailgate the Safety Way (a community-wide traffic safety event
focusing on teens and parents); continue providing P.A.R.T.Y. (Prevent Alcohol and Risk-
related Trauma in Youth) programs to students at Weld County high schools; provide
classes for parents and teens about graduated driver's licensing laws (GDL); work with
student groups to plan and coordinate seat belt pledge drives and no texting while
operating a motor vehicle drives in Weld County High Schools; collaborate with NCMC to
offer car seat installation services for all families of newborns; and offer community wide
car seat installation check points at safety events throughout Weld County. This task
2011-2433
order will provide continuation funding in the amount of$46,572.31 for a .5 FTE (existing
staff) and operating expenses.
3. Health Care Program for Children with Special Needs (HCP) $185,903.33: 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 contract
will provide continuation funding in the amount of$185,903. Of this amount, $46,476 is
attributable to a funding source of the federal government, and $139,427 is attributable to a
funding source of the State of Colorado.
This task order for the total amount of$348,717, will provide funding for the time period October
1, 2011 through September 30, 2012. I recommend your approval.
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
PSD-MCH
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
12-31701
AMENDMENT FOR TASK ORDERS#1
This Amendment is made this 25th day of July,2011,by and between the State of Colorado,acting by and through
the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place of
business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as the"State";and,
BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY,(a political subdivision of the state of
Colorado)915 10's Street,Greeley,Colorado 80632-0758,for the use and benefit of the WELD COUNTY
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT„whose address or principal place of business
is 1555 North 171h Avenue,Greeley,Colorado 80631,hereinafter referred to as the"Contractor".
FACTUAL RECITALS
The parties entered into a Master Contract,dated January 23,2007 with contract routing number 08 FAA 00052
Pursuant to the terms and conditions of the Master Contract,the parties entered into a Task Order Contract,dated
August 12,2010 with contract encumbrance number PO FLA 1121566 and contract routing number 11 FLA 21566
collectively referred to herein as the"Original Task Order Contract,whereby the Contractor was to provide to the
State the following:
Develop,implement and evaluate a comprehensive plan in accordance with state and federal
MCH guidelines,to improve the health and well-being of the MCH population,including
children with special health care needs.
The State promises to pay the Contractor the sum of Three Hundred Forty-Eight Thousand Seven Hundred
Seventeen Dollars,($348,717.00)in exchange for the promise of the Contractor to continue to perform the work
identified in the Original Task Order Contract for the renewal term of 12 months,ending on September 30,2012.
NOW THEREFORE, in consideration of their mutual promises to each other,stated below,the parties hereto agree
as follows:
1. Consideration for this Amendment to the Original Task Order Contract consists of the payments and
services that shall be made pursuant to this Amendment,and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order
Contract,contract routing number 11 FLA 21565 collectively referred to herein as the Original Contract,
which is by this reference incorporated herein. All terms,conditions,and provisions thereof,unless
specifically modified herein,are to apply to this Amendment as though they were expressly rewritten,
incorporated, and included herein.
3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified,
altered,and changed in the following respects only:
Page 1 of4 Rev 3/16/2010
A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified
by contract routing number 11 FLA 21566. This Amendment is for the renewal term of October
1,2011 through and including September 30,2012 The maximum amount payable by the State
for the work to be performed by the Contractor during this renewal term is Three Hundred
Forty-Eight Thousand Seven Hundred Seventeen Dollars,($348,717.00) for an amended total
financial obligation of the State of SIX HUNDRED NINETY-FOUR THOUSAND TWO
HUNDRED THIRTY-ONE DOLLARS($694,231.00) Of the amended financial obligation for
the renewal term One Hundred Eleven Thousand Five Hundred Forty-One Dollars,
($111,541.00)are attributable to a funding source of the State of Colorado and Two Hundred
Thirty Seven Thousand One Hundred Seventy-Six Dollars,($237,176.001 are attributable to a
funding source of the United States Government(see Catalog of Federal Domestic Assistance
(CFDA)number 93.994). Of the amended total financial obligation of the State referenced above
Two Hundred Nine Thousand One Hundred Forty Dollars,($209,140.00)are attributable to a
funding source of the State of Colorado and Four Hundred Eighty Five Thousand Ninety-One
Dollars,($485,091.00)are attributable to a funding source of the United States Government. The
replacement Additional Provisions is incorporated herein by this reference as"Exhibit A". The
replacement Statement of Work is incorporated herein by this reference and identified as
"Exhibit B". The replacement Budgets and Budget Narratives is incorporated herein by this
reference and identified as"Attachment B-1,0-2,and B-3".
The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original
Task Order Contract are reaffirmed.
4. The effective date of this Amendment is October 1,2011 or upon approval of the State Controller,or an
authorized delegate thereof,whichever is later.
5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General
Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance,or
contradiction between the terms and provisions of this Amendment and any of the terms and provisions of
the Original Task Order Contract,the terms and provisions of this Amendment shall in all respects
supersede,govern,and control. The Special Provisions and other terms and conditions of the Master
Contract shall always control over other provisions of the Original Task Order Contract or any subsequent
amendments thereto. The representations in the Special Provisions to the Master Contract concerning the
absence of personal interest of state of Colorado employees and the certifications in the Special Provisions
relating to illegal aliens are presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR
ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED,BUDGETED,
AND OTHERWISE MADE AVAILABLE.
This page left intentionally blank.
Page 2 of 4 Rev 3/16/2010
IN WITNESS WHEREOF,the parties hereto have executed this Amendment on the day first above written.
* 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:
BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO
OF WELD COUNTY,for the use and benefit John W.Hickenlooper,Governor
WELD COUNTY DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT,
(a political subdivision of the state of Colorado)
i
Signature of A� � By:
-- - uU orized Offic r For the E I utive Director
SEP 14 2011 DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT
Barbara Kirkmeyer
Print Name of Authorized Officer
Chair
Print Title of Authorized Officer
PROGRAM APPROVAL:
By: `tc .
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, A
By:
Date: 4 A
Page 3 of 4 Rev 3/16/2010
(_Qt/7`.a?y33
This page left intentionally blank.
Page 4 of 4 Rev 3/16/2010
Replacement Additional Provisions
Exhibit A
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
ADDITIONAL PROVISIONS
To Contract Made 08/12/2010-Contract Routing Number 11 FLA 21566
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
The revised Statement of Work is effective October 1,2011.
I.The United States Department of Health and Human Services("HHS"),through the Maternal and Child Health
(MCH)Services Block Grant has awarded the State Title V federal funds under Notice of Grant Award("NGA)
number B04MC04248 (See, Catalog of Federal Domestic Assistance("CFDA")number 93.994). 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.
The award authorizes the State to pay all allowable and allocable expenses of a contractor as of the effective date of
that Award,then the State shall reimburse the Contractor for any allowable and allocable expenses of the Contractor
that have been incurred by the Contractor since the proposed effective date of this Contract.
2. To receive compensation under this Contract,the Contractor shall submit a signed Quarterly or Monthly
Contract Reimbursement Request in a format acceptable to the State. A separate request must be submitted for each
of the following population groups: Prenatal, Child/Adolescent and CSHCN.The Contractor shall declare the
frequency with which they plan to submit their Contract Reimbursement Request in writing to their MCH Generalist
Consultant by the beginning of the contract period. The Contract Reimbursement Request form is available on
the Colorado MCH web site at www.mchcolorado.org under the local health agency planning, implementation and
reporting page under the implementation tab. A Contract Reimbursement Request must be submitted within sixty
(60)calendar days of the end of the billing period for which services were rendered. 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.
Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B. These items may
include,but are not limited to, the Contractor's salaries, fringe benefits, supplies,travel, operating,allowable
indirect costs, and other allocable expenses related to its performance under this Contract.
To be attached to CDPHE Page I of 4 Revised:7/19/10 JC
Version 1.0(4/04)contract template
Replacement Additional Provisions;
Exhibit A
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
Contract Reimbursement Requests shall: I)reference this Contract by its contract routing number, which the
number is located on page one of this Contract; 2)state the applicable performance dates; 3)state the names of
payees; and, 4)show the total requested payment. Payment during the term of this Contract shall be conditioned
upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this
Contract. Contract Reimbursement Requests shall be sent via email to:
Attn: Sara Wargo
Matemal 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(M,state.co.us
To be considered for payment, billings for payments pursuant to this 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 Contract must be received by the State
within a reasonable time after the expiration or termination of this Contract; but in no event no later than sixty(60)
calendar days from the effective expiration or termination date of this Contract. Contractors may not receive
payment for billings that exceed sixty(60)the calendar day period.
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 he 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.
3. 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 your MCH generalist consultant if guidance is necessary.
4. 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 10%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. Permanent changes in any MCH-funded line item supporting staff positions, require the Contractor to
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. Temporary changes in
any MCH-funded line item funding staff positions in the Contractor's Budget,require the Contractor to notify their
MCH Generalist Consultant in writing.
5. Contractor shall retain and use all revenues generated by the individual MCH Programs(Prenatal,
Child/Adolescent, and HCP)for services in those programs. The revenue cannot be used for other programs or
purposes.
To be attached to CDPHE Page 2 of 4 Revised: 7/19/10 JC
Version 1.0(4/04)contract template
Replacement Additional Provisions
Exhibit A
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
6. 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).
7. 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 any subcontracts which contain
provisions for children's services and that all contractors shall sign and agree accordingly.
8. 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.
9. 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 (I)(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.
10. 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.
I I. 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
To be attached to CDPHE Page 3 of 4 Revised: 7/19/10 JC
Version 1.0(4/04)contract template
Replacement Additional Provisions ,
Exhibit A,
As Replaced By Amendment#1 •
Contract Routing Number 12 FLA 31701
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.
12.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 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.
13. 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.
14.Notwithstanding anything herein to the contrary,the parties understand and agree that all terms and conditions of
this contract and the exhibits and attachments hereto which may require continued performance, compliance or
effect beyond the termination date of this contract shall survive such termination date and shall be enforceable by
the State as provided herein in the event of such failure to perform or comply by the Contractor.
15. 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.hcncolorado.org.
16. The State has determined that this contract does not constitute a Business Associate relationship under the
Health Insurance Portability and Accountability Act(HIPAA).
17. The State may increase or decrease funds available under this Contract using a Grant Funding Letter
substantially equivalent to Exhibit C,as found in the original contract.
To be attached to CDPHE Page 4 of 4 Revised: 7/19/10 JC
Version 1.0(4/04)contract template
Replacement Statement of Work
Exhibit B
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
STATEMENT OF WORK
To Contract Made 08/12/2010-Contract Routing Number 11 FLA 21566
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
This replacement Statement of Work is effective October 1,2011.
Only the following sections of this Statement of Work marked with an X below apply to this contract:
X Maternal and Child Health Program
X Health Care Program for Children with Special Needs
X Care Coordination
_ Specialty Clinics
_ Multi-County Regional Office
Maternal and Child Health Program
1. The Contractor shall perform in accordance with the FY 12 MCH Guidelines and shall follow the policies,
procedures, and program expectations set forth in the FY12 MCH Guidelines. The FY12 MCH Guidelines
are incorporated and made part hereof by reference, and are located on the Colorado MCH web site:
www.mchcolorado.org.
2. 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: www.mchcolorado.org.
3. The Contractor shall apply the public health approach throughout the process of developing, implementing,
and evaluating its MCFI operational plans in order to serve the MCH population in the community. The
public health approach is described in the FY12 MCH Guidelines and involves the following five steps:
• Monitor and assess health issues in the community among the MCH population;
• research and understand the causes of these issues and the populations most affected;
• identify/develop effective strategies to address and impact the identified issues;
• implement the interventions;
• assess whether the interventions are effective and apply the program evaluation findings to future
implementation efforts.
4. The Contractor shall contribute to the accomplishment of the MCH state priorities and/or national
performance measures and outcomes that are outlined in the FY12 MCH Guidelines.
5. The Contractor shall address the prenatal and/or child/adolescent populations. The Contractor shall address
the children with special health care needs population.
6. The Contractor shall focus a majority of its MCH efforts on public health strategies that are population-
based and infrastructure-building.
7. The Contractor shall use evidence-based strategies/programs to address MCH priorities in the community.
A strategy or program is considered evidence-based if:
o It is based on a sound theoretical approach such as health behavior change theory or peer-reviewed
literature.
o It appears in an Action Guide.
o And/or if there is research or program evaluation data that supports the effectiveness of the
approach.
To be attached toCDPHE Page 1 of 5/17/11 GF
Version 1.0(4/04)contract template
Replacement Statement of Work ,
Exhibit B, •
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
8. The Contractor shall implement and evaluate the FYI2 Prenatal and/or Child/Adolescent,and HCP
Operational Plan during the course of this contract.
9. The State shall provide guidance and technical assistance to the contractor to support the implementation
and evaluation of the Contractor's Prenatal, Child/Adolescent, and HCP Operational Plans for FY12.
10. The Contractor shall submit, but not limited to,the following reports, incorporated by reference. These
documents, including instructions for completion and submission are available in the FY 12 MCH
Guidelines, located on the MCH web site: www.mchcolorado.org.
a.)MCH Annual Operational Plan Report for FY12
b.)HCP Annual Performance Measure Report for FY12
c.)MCH Core Services Final Report for FY12
d.)Numbers Served by Title V Report for FY12—Tables I& II
II. The Contractor shall revise or develop, according to the FY I3 MCH Guidelines, the Contractor's Prenatal,
Child/Adolescent, and HCP Operational Plans for FY I3, and an Operational Plan for each year of renewal.
The MCH Guidelines are located on the MCH web site: www.mchcolorado.org.
12. The State shall provide guidance and technical assistance to the Contractor to support the revision or
development,according to the FY13 MCH Guidelines,of the Contractor's Prenatal,Child/Adolescent, and
HCP Plan for FYI3. The MCH Guidelines are located on the MCH web site: www.mchcolorado.org.
13. The Contractor shall cooperate with the State and provide all requested records regarding services provided
under this contract.
14. The Contractor shall provide MCH Generalist Consultants and other State administrators with reasonable
access to its operations to perform: periodic site visits, data reviews, fiscal reviews or other evaluations of
the contractor's program. The contractor shall cooperate during all periodic site visits, data reviews, fiscal
reviews and other evaluations or audits conducted by the State.
15. 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
Prenatal, Child/Adolescent, and HCP Operational Plan; 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 and HCP.Notification shall be in writing within fifteen(15)business days of the
said change.
16. If the State believes in good faith that an activity or service fails to meet the standard for a particular
activity or service,or is otherwise deficient, then the State shall notify the Contractor of the failure or
deficiencies in writing. Corrective action shall be addressed through a Performance Improvement Plan
(PIP)or some other method defined by the State. Due dates for completion of activities listed in a PIP will
be negotiated on a case-by-case basis. If the Contractor fails to correct such deficiencies, the Contractor
shall be in default of its obligations under this Contract and the State, at its option, may elect to withhold
payment or terminate this Contract.
Children with Special Health Care Needs(CSHCN)
I. The Contractor shall perform in accordance with the HCP Policy and Guidelines and HCP Database User
Manual and shall follow the policies and procedures detailed in these documents. The HCP Policy and
Guidelines and the HCP Database User Manual are incorporated and made part hereof by reference, and are
located on the Colorado CSHCN web site: www.hcpcolorado.org.
To be attached to!CDPHE Page2of4 5/17/11 GF
Version 1.0(4/04)contract template
Replacement Statement of Work
Exhibit B
• As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
2. The HCP Policy and Guidelines, and the HCP Database 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 Policy and Guidelines and the HCP Database User
Manual would be posted to the CSCHN web site: www.hcpcolorado.org.
3. The Contractor shall work collaboratively with the State for consultation, technical assistance,oversight
and training on using the HCP Database for documentation of HCP Care Coordination.
4. The Contractor shall adhere to the CDPHE Security Policy and Procedures and use the Secure External
User ID forms according to the HCP Policy and Guidelines, located on the CSHCN web site:
www.hcpcolorado.org.
5. The Contractor shall attend scheduled HCP Policy Advisory Committee(H-PAC)meetings, the HCP
Annual Fall Meeting,the Spring H-PAC Meeting and any scheduled state training to promote learning and
increase skills for HCP practitioners as referenced in the HCP Policy and Guidelines. The HCP Policy and
Guidelines are located on the CSHCN web site: www.hcpcolorado.org.
6. The Contractor shall provide orientation,technical assistance and ongoing training for the HCP agency
staff by referencing the HCP Policy and Guidelines,the HCP Orientation Module,the HCP Database User
Manual, and HCP Resources, located on the CSHCN web site: www.hcpcolorado.org.
7. The Contractor shall collaborate with community partners to identify service and systems barriers to
improve ease of service use for families of CSHCN by referencing HCP Policy and Guidelines, located on
the CSHCN web site: www.hcpcolorado.org.
8. The Contractor shall report on collaboration and local systems development by completing the annual
MCH Operational Plan Report.
9. The Contractor shall utilize CYSHCN and their families as the consumer voice when serving the CSHCN
population according to the HCP Policy and Guidelines and by referencing the Colorado MCH Medical
Home Action Guide and Family Leadership Resources located on the CSHCN web site:
www.hcpcolorado.org.
10. The Contractor shall report on family participation activities by completing the family participation
questions in the HCP Annual Performance Measure Report. This report is available on the MCH web site:
www.mchcolorado.org.
Care Coordination
11. The Contractor shall provide HCP Care Coordination to en sure a medical home approach for CSHCN
residing in the counties the agency is contracted to serve according to the HCP Care Coordination Policy
and Guidelines, located on the CSHCN web site: www.hcpcolorado.org.
12. The Contractor shall complete required data documentation in the HCP Database for HCP Care
Coordination Services according to the HCP Policy and Guidelines and the HCP Database User Manual.
13. The Contractor shall provide follow-up and documentation in HCP Database for monthly CRCSN
Notifications according to CRCSN Policy and Guidelines and HCP Database User Manual.
Specialty Clinics
14. The Contractor agrees to sche dule and facilitate regional HCP Specialty Clinics according to the HCP
Specialty Clinic Benchmarks, HCP Specialty Clinic Policy and Guidelines and HCP Specialty Clinic
Provider Handbook, located on the CSHCN web site: www.hcpcolorado.org.
To be attached to CDPHE Page 3 of 4 5/17/11 GF
Version 1.0(4/04)contract template
Replacement Statement of Work
Exhibit
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
15. The contractor shall provide clinic coordination with a medical home approach for all CSHCN attending
Specialty Clinics according to the HCP Specialty Clinic Policy and Guidelines, located on the CSHCN web
site: www.hcpcolorado.org.
16. The Contractor shall collect clinic fees according to the HCP Specialty Clinic Policy and Guidelines
located on the CSHCN web site: www.hcpcolorado.org.
17. The Contractor shall retain and use HCP Specialty Clinic revenues generated by the Contractor according
to the HCP Specialty Clinic Policy and Guidelines located on the CSHCN web site: www.hcpcolorado.org.
Multi-County Regional Offices
18. The Contractor as a multi-county regional office shall provide consultation and technical assistance for
regional Local Public Health Agencies the regional office is contracted to serve and as defined in HCP
Policy and Guidelines located on the CSHCN web site: www.hcpcolorado.org. The Local Public Health
Agencies included in this Regional Office's service area include:.
19. The Contractor shall work collaboratively with the State when providing consultation,technical assistance
and training for regional county staff.
20. The Contractor, as a m ulti-county regional office,shall provide one HCP Regional Meeting to include HCP
staff from regional Local Public Health Agencies the regional office is contracted to serve according to the
HCP Policy and Guidelines, located on the CSHCN web site: www.hcpcolorado.org.
To be attached to£DPHE Page 4of4 5/17/11 GF
Version 1.0(4/04)contract template
Replacement Budget and Budget Narrative
Attachment 8-1 Prenatal
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
Maternal and Child l lcalth (MCH).
-' Plann ng„Budget F Y12
Agency: Weld County Department of Public Health&Environment Date Completed: July 11 2011
,.,Program Contact Approval ., . 4: Hsca(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 Ext.2122
Email: ddrew@co.weld.co.us Email: tgeiser@co.weld.co.us
Due Date:July 1,2011
(for the period of October 1,2011 through September 30,2012)
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.
In CHILDREN AND ADOLESCENT POPULATION
In PRENATAL POPULATION
n CHILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATION
$o'utce of Funds
EXPENSE CATSGdt(IES Anneal Salary Feb Time Total Amount e,
Rite Equivalent Required Othet' .� Received item COME
PERSONNEL SERVICES(Names&Titles): $0.00
Melanie Cyphers PHN II $59,236 34 0 125 $7,404.54 37,404.54
Health Communication Specialist I Vacant $45,934.46 1 00 $45,934.46 $45,934.46
Cindy Kronague Health Data Spec.$ 77,669.03 0 05 $3,883.45 $3,883.45
Mary Lloyd-Cumley PHS Supervisor $66,849 83 0 30 $20,06405 $8,332.57 $11,722 38
Debbie Drew Director PHS $95,339 20 0.20 :.$19,007,84. $19,067.84
$0.00'.
SUBTOTAL $345,028 86 168 $96,345.24 $27,400.41 $68,944 83
Fringe Benefits: Rate= 38.93% N/A N/A $37,507.20 $10,666.98 $26,840 22
TOTAL PERSONNEL SERVICES'($and pm).:(,. - ... 1.66 .:1$133,652.45 $38,07'39 '..:$95,145:05
OPERATING EXPENSES(winch are not part of indirect)
Supplies $3,400 00 $400 00 $3,000 00
Media $3,000 00 $3,000 00
TOTAL OPERATING EXPENSES- . . _ '.:. $6,400.00 i $406:0(1 <"$8,00:00
TRAVEL EXPENSES $930.00 $200.00 $730.00
TOTAL TRAVEL EXPENSES _ $930.00 $200.00 $730:00
CONTRACTUAL EXPENSES
TOTAL CONTRACTUA 'EXPENSES' ,` .! $0.00 'r $0600 ! $0,00
TOTAL DIRECT COSTS(Personnel Services+Operating+Travel+Contractual) $141,182.46 $38,667.39 $102,515.05
INDIRECT COST: Rate= 13.39% $18,525 11 $5,177.56 $13,726.77
TOTAL INDIRECT COST $18,525.11 I' $5,177.56 :i$13,726.77
TOTAL PROJECT COST $159,707.56 $43,844.95 $116,241.82
`Source for funding for"Other"(Match or In-kind)
Local/County Funding: $43,844.95 Methodology used for reporting"Source of Funds"
Medicaid(will not be used to match)'.
Patient Fees: Method A n
All Other:
TOTAL.;. .. , -.$43,844.95 Method B n
Can NON-FEDERAL funds be used as a match', Yes n No n
Page 1 of 4
Replacement Budget and Budget Narrative
Attachment B-1 Prenatal
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
Maternal and Child Health (MCH)
Budget Narrative FY12
Agency: Weld County Department of Public Date Completed: 7-01-2011
Health & Emvironment
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 Ext. 2122
Email: ddrew@co.weld.co.us Email: tqeiser@co.weld.co.us
Population Group
Check the appropriate box below to indicate the population group that applies to this budget
narrative. Complete a separate budget narrative for each population group budget.
❑ Children and Adolescent Population
® Prenatal Population
❑ Children with Special Health Care Needs Population
Due Date: July 1, 2011
General Instructions:
The purpose of the Budget Narrative is:
➢ To describe how each line item included the proposed planning budget relates to your
agency's MCH plan and
> To explain how you arrived at each cost.
The Budget Narrative should provide a clear and reasonable rationale for the costs associated
with implementing your proposed MCH plan. The MCH plan, planning budget, and budget
narrative should all be aligned. Be sure to describe how you arrived at each line item amount
by providing detailed and specific information for EACH line item. The Budget Narrative should
reflect the MCH plan period from October 1, 2011 through September 30, 2012. Please provide
narrative for each cost category in the spaces below. Examples are included for each budget
category. Additional examples are available in the FY12 MCH Guidelines.
Personnel Services: List the name and title of each staff member (employed by your
agency), annual salary and Full Time Equivalent (FTE) that the staff member will commit to the
MCH plan. Briefly describe the role of the staff member in the MCH Plan andidentify the
components of the Plan that this person will be responsible for completing.
Example: Susan Johnson, Registered Dietitian, salary at$50,000/year, .5 FTE (50%) to implement the
Healthy Baby campaign on prenatal weight gain and smoking cessation, Objective 2.
Health Communication Specialist, Prenatal Education Coordinator, salary at $45,934.46/yr, 1.0
FTE ($45,934.46 requested from CDPHE) to coordinate and provide activities related to Healthy
Baby Program, (Objectives 1, 2, 3, and 4).
Debbie Drew, RN,NP, Director of Public Health Services, salary $95,339.20/yr, .2 FTE, with no
funding requested from from CDPHE. Provides leadership and infrastructure support to all
Maternal Child Health activites provided at WCDPHE. Division Director for Public Health
Services, and supervises all staff in Division. Assists with planning and development of program
Page 2 of 4
Replacement Budget and Budget Narrative
Attachment B-1 Prenatal
• As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
activities (Objective 4).
Mary Lloyd-Cumley, RN, Clinical Services Manager, $66,849.83 salary/yr, .3 FTE, (the amount
requested from CDPHE is $11,722.38 and remainder of FTE is from other sources). Directly
supervises Health Communication Specialist, program development, plan development, and
execution. Provides support and assists with planning and development of program activities,
(Objectives 1, 2, 3, and 4).
Cindy Kronauge, MPH, Health Data Analyst, $77,669.03 salary/yr, 0.05 FTE (2 hours/week).
Participates in WC Healthy Baby Evaluation Team, provides support and assists with the
planning, implementation, and evaluation of program activities through data analysis and
development of evaluation tools, (Objective 3,4 and 5).
Melanie Cyphers RN, Public Health Nurse II, $59,236.34 salary/year, 0.125 FTE (5 hours per
week). Participating in the start-up of Fetal Infant Mortality Review (FIMR) project at Weld
County Helath Department. Assisting with the planning, implementation and evaluation of the
FIMR project. (Objective 5)
Fringe is at 38.93%.
Operating Expenses: Include expenses that are not included in the indirect rate for your
agency. Examples: office supplies, copies, postage, telephone, computer network fees, project
supplies and materials, professional development and training registrations. Include funding for
equipment, including computers and software.
Provide a brief explanation to justify the need for each line item for the MCH Plan and identify
the objective in the MCH Plan for any line items over$1,000.
Example: $1,500 will provide a new computer for S. Johnson, R.D.,who will implement the Healthy Baby
campaign,Objective 2.
*Operating expenses for supplies are needed to accomplish: Objective 1 and 2 (including office
supplies, project supplies and materials, printing of meeting agendas and program materials,
presentation supplies, printing of class flyers and posters to promote campaign and educational
classes, and prenatal nutrition education training materials). Objective 3 office supplies include
printing consent forms, pre/post class surveys, client satisfaction surveys, and outcomes
reports. Objective 5 supplies for printing flyer,brochures and food for community meetings for
FIMR project. The supply costs are estimated at$3,400.00 with $3,000.00 requested from
CDPHE.
*Operating expenses for media costs are needed to accomplish: Objective 2 (including media
costs for newspaper ads, radio ads, tv station ads, advertising on billboards and bus benches,
and the development of class flyers and posters for local media campaigns. These funds are for
internal development of the media plan approaches. The media request from CDPHE is
$3,000.00.
Travel Costs: Travel costs to be incurred while implementing the MCH Plan and/or travel to
attend trainings. Note:It is required that the LHA includes the cost for two LHA MCH staff
person to attend a one-day, state MCH meeting in the Metro Denver area.
Example:Travel costs are reimbursed at 32 cents/mile per agency policy. Costs of$1,144 are estimated
to provide transportation, lodging, and meal costs to send 2 staff working on the MCH Plan to the
Preconception Summit in September 2012.
Travel costs are currently reimbursed at 53.0 cents/mile per Weld County policy. Costs of
$930.00, with $730.00 requested from CDPHE, are estimated to provide mileage reimbursement
Page 3 of 4
Replacement Budget and Budget Narrative
Attachment B-1 Prenatal
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
for traveling throughout the county to various health care facilities and community-based
organizations for meetings, outreach activities, presentations, teaching classes, and follow-up
visits (Objectives 1, 2 and 5). It will also cover the cost of at least one staff person to attend full
day MCH conference in Denver. (Objective 4). It will also cover the cost of for at least 1 staff
member to attend CitiMatch PPOR conference in Denver, October 2011.
Contractual Services: Describe costs for contractors (person or company not employed by
your agency) working on the MCH Plan. Briefly describe the role of each contractor in
completing the MCH Plan and identify the objectives of the MCH plan that this contractor will be
accomplishing.
Example: Robert Brown, Health Educator, contracted at$13,000/year, ($50/hour x 5 hours/week x 52
weeks=$13,000)to provide training to healthcare providers regarding prenatal smoking cessation,
Objective 2.
Example: Media coverage for$10,000 will air TV ads and radio spots for the Healthy Baby campaign,
Objective 2, using ads that are already developed,adding information re: the local health agency.
n/a
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.
Example: Your indirect rate is 34.93%of total direct Salaries/Fringe. 27% can be recognized in your
request and 7.93% must be recognized as match or in-kind.
Example: Your indirect rate is 19% of total direct costs.The rate is within the 25%cap; 19%can be
recognized in your request.
Indirect rate is 13.39% of the total direct cost.
Other Funding Costs: Additional funding that supports MCH in general and/or the MCH Plan
may be included in the proposed budget. This may include the contribution of program
administrators'time (i.e., an Executive Director, Nursing Director or Program Manager's time) or
it may be other funding that supports the salaries of MCH staff. It is not necessary to
include budget narrative information for"Other"funding.
Other funding for salaries, fringe benefits, travel expenses, supplies and indirect costs is
provided by Weld County.
Page 4 of 4
Replacement Budget and Budget Narrative
Attachment B-2 CASH
• As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
M*ternakand'Child He4lth1(MCHr
Plann ng Budget PYX2. .
Agency: Weld County Department of Public Healht and Environment Date Completed: June 29,2011
Program Contact Approval ' ! , F16o21 Contact Approval `rt
Name: Gaye Morrison Name: Tanya Geiser
Title: Director of Health Communication,Education and Planning Title: Administrative Services Director
Phone: 970-304-6420 x2380 Phone: 970-304-6420 x2122
Email: gmornson@co.weldco.us Email: tgeiser@co.weld.co.us
Due Date:July 1,2011
(for the period of October 1,2011 through September 30,2012).
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.
n CHILDREN AND ADOLESCENT POPULATION
El PRENATAL POPULATION
El CHILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATION
,., q ,gull Dime i TotalAmPant .. Soutao oYJ:un '
NSECATEGORIE ilnuufioia $, ! Equlvsem R'4quired •, pth,t Revolved from CDPHE
PERSONNEL SERVICES(Names&Titles): $0.00
Kelly Imus,Health Comm Specialist II $55,010 51 0.25 .:$13;752;63. $13,752 63
Marjorie Hanson,OT II $35,454 54 0 25 . ;:+$6,$63,&1, $8,863.64
Cindy Kronauge,Health Data Specialist $77,669 03 0.05 E>$3,68 '45! $3,883.45
.•...$0:00
saOO
SO;bO
SUBTOTAL --- -- $26,499.71 ---
Fringe Benefits: Rate= 38.93% N/A N/A x:��$10,316,34', $10,316.34
TOTAL PERSONNEL SERVICES($and PTE) t: _. 0.55 , 6$35,816,05 ;! $000 ':$36,616.06
OPERATING EXPENSES(which are not part of indirect)
Printing $1,200 00 $475.00 $725.00
Meeting Expenses $500.00 $100.00 $400.00
Incentives for high school students in traffic safety program $600.00 $100 00 $500,00
Rural Traffic Safety Conference $400.00 $100.00 $400.00
TOTAL.OPERATINGIEXPENSES ii " !, .:: •,$2,700,00 !'. $775'.00 .$2,025.00
TRAVEL EXPENSES
Local Travel in state(avg. 150 miles/month) $962.00 $962.00
TOTAL.TRAVEL EXPENSES _ ?1.. :;.$962.00 .$0;00 $962:00..
CONTRACTUAL EXPENSES
Contract with marketing professional to promote programs,coordinate media $6,400 00 $3,200 00 $3,200 00
campaigns,recruit new schools for PARTY program,and serve as the media
contact erson for the DRIVE SMART Weld County Coalition
TOTAL CONTRACTUAL EXPENSES ' , a '" " i $6,400.00 ":..' „ $3,'200,00 $3,200.00
TOTAL DIRECT COSTS(Personnel Services+Operating+Travel+Contractual) $46,875.05 $3,975.00 $43,003:06
INDIRECT COST Rate= 8 30%
$3,891 00 $330 00 $3,569.25
TOTAL INDIRECT COST $3,60400 $330.00 --$3,569.25
TOTAL PROJECT COST !.$50,769;05 `. 54,305.00 $46,572.31
*Source for funding for"Other(Match or In-kind)
Local/County Funding $330.00 Methodology used for reporting"Source of Funds"
Medicaid(will not be used to match):
Patient Fees: Method A El
At Other'. $3,975 00
TOTAL $4,305.00 Method B n
Can NON-FEDERAL funds be used as a match? Yes n No El
Page 1 of 4
Replacement Budget and Budget Narrative. ,•
Attachment B-2 CASH •
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
Maternal and Child Health (MCH)
Budget Narrative FY12
Agency: Weld County Department of Public Date Completed: June 29, 2011
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
Check the appropriate box below to indicate the population group that applies to this budget
narrative. Complete a separate budget narrative for each population group budget.
® Children and Adolescent Population
❑ Prenatal Population
❑ Children with Special Health Care Needs Population
Due Date: July 1, 2011
General Instructions:
The purpose of the Budget Narrative is:
➢ To describe how each line item included the proposed planning budget relates to your
agency's MCH plan and
> To explain how you arrived at each cost.
The Budget Narrative should provide a clear and reasonable rationale for the costs associated
with implementing your proposed MCH plan. The MCH plan, planning budget, and budget
narrative should all be aligned. Be sure to describe how you arrived at each line item amount
by providing detailed and specific information for CACI I line item. The Budget Narrative should
reflect the MCH plan period from October 1, 2011 through September 30, 2012. Please provide
narrative for each cost category in the spaces below. Examples are included for each budget
category. Additional examples are available in the FY12 MCH Guidelines.
Personnel Services: List the name and title of each staff member (employed by your
agency), annual salary and Full Time Equivalent (FTE)that the staff member will commit to the
MCH plan. Briefly describe the role of the staff member in the MCH Plan and identify the
components of the Plan that this person will be responsible for completing.
Example: Susan Johnson, Registered Dietitian, salary at$50,000/year, .5 FTE(50%) to implement the
Healthy Baby campaign on prenatal weight gain and smoking cessation, Objective 2.
- Kelly Imus, Health Education Specialist, salary at $55, 010.51/yr, .25 FTE (25%) to coordinate
actvities related to DRIVE SMART Weld County and the teen motor vehicle activities, Objectives
1,2,3, & 4.
Cindy Kronauge, Data Analyst, salary at $77,669.03/yr, .05 FTE (2 hrs/wk) will develop pre/post
and 3 month follow-up on-line surveys and will do data analysis for evaluation of programs,
Objectives 2 & 3.
Marjorie Hanson, Office Technician, salary at $35,454.54/yr, .25 FTE (25%) to provide clerical
Page 2 of 4
Replacement Budget and Budget Narrative
Attachment B-2 CASH
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
support and coordination for DRIVE SMART Weld County and then teen motor vehicle activities.
Objectives 1,2,3, &4.
Fringe is at 38.93%
Operating Expenses: Include expenses that are not included in the indirect rate for your
agency. Examples: office supplies, copies, postage, telephone, computer network fees, project
supplies and materials, professional development and training registrations. Include funding for
equipment, including computers and software.
Provide a brief explanation to justify the need for each line item for the MCH Plan and identify
the objective in the MCH Plan for any line items over $1,000.
Example: $1,500 will provide a new computer for S.Johnson, R.D.,who will implement the Healthy Baby
campaign,Objective 2.
Printing: $725. To print flyers and posters for Tailgate the Safety Way, to print evaluations for
Tailgate, 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
County Coalition meetings, agendas for the Tailgate the Safety Way planning committee
meetings and to print Driver's Education Scholarship applications.
Meeting Expenses: $400.00. $400.00 will purchase refreshments (water/juice/cookies) for
students attending the day-long P.A.R.T.Y. programs and for the parents and teen attending
the Parent of Teen Drivers classes. Nearly 800 students attended a P.A.R.T.Y. program in
2010/2011. Also, to provide refreshments for volunteers at the DRIVE SMART Weld County
Coalition meetings.
Incentives for high school students in traffic safety programs: $500.00 to purchase items
selected by the student groups at the high schools to use as incentives for teens who sign seat
belt pledges and/or participate in traffic safety activities. Examples might be bracelets, lip balm,
or key chains with traffic safety logos.
Colorado Rural Traffic Safety Conference: $400.00 to pay for transportation, lodging and meal
costs for Teen Motor Vehicle Safety Coordinator and one DRIVE SMART Weld County Coalition
member to attend the 2012 Colorado Rural Traffic Safety Conference.
Travel Costs: Travel costs to be incurred while implementing the MCH Plan and/or travel to
attend trainings. Note:It is required that the LHA includes the cost for two LHA MCH staff
person to attend a one-day, state MCH meet/na in the Metro Denver area.
Example: Travel costs are reimbursed at 32 cents/mile per agency policy. Costs of$1,144 are estimated
to provide transportation, lodging,and meal costs to send 2 staff working on the MCH Plan to the
Preconception Summit in September 2012.
Local Travel: $962.00 per year. This equals about 150 miles per month @ $0.535 per mile for
Adolescent Motor Vehicle Safety Coordinator and Office Technician to drive to high schools and
other location for P.A.R.T.Y. programs, Parent of Teen Drivers classes,Tailgate the Safety Way
planning committee meetings, Drivers Education Scholarship Review Commttee meetings and
other trips related to DRIVE SMART Weld County activities.
Contractual Services: Describe costs for contractors (person or company not employed by
your agency)working on the MCH Plan. Briefly describe the role of each contractor in
completing the MCH Plan and identify the objectives of the MCH plan that this contractor will be
accomplishing.
Example: Robert Brown, Health Educator, contracted at$13,000/year, ($50/hour x 5 hours/week x 52
Page 3 of 4
Replacement Budget and Budget Narrative •
Attachment 2-2 CASH
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
weeks=$13,000)to provide training to healthcare providers regarding prenatal smoking cessation,
Objective 2.
Example: Media coverage for$10,000 will air TV ads and radio spots for the Healthy Baby campaign,
Objective 2, using ads that are already developed,adding information re: the local health agency.
Marketing Contract: $3200.00 will be used to contract with Kristi Helzer, Marketing Specialist, to
recruit new high schools in rural Weld County communities to implement the P.A.R.T.Y.
program. The Marketing Specialist will also work with Weld County insurance agents to
implement parent-teen driving agreements to promote safe and responsible teen drivers.
Additionally, Marketing Specialist will serve as the media contact for requests from all media
sources for information pertaining to DRIVE SMART activities and she will coordinate media
campaigns to advertise all DRIVE SMART programming. Lastly, she will seek additional funding
sources including charitable donations to supplement MCH funding and to support the DRIVE
SMART Weld County Driver's Education Scholarship Program.
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.
Example: Your indirect rate is 34.93%of total direct Salaries/Fringe. 27% can be recognized in your
request and 7.93% must be recognized as match or in-kind.
Example: Your indirect rate is 19%of total direct costs.The rate is within the 25%cap; 19%can be
recognized in your request.
Indirect costs: 8.30% of total direct costs
Other Funding Costs: Additional funding that supports MCH in general and/or the MCH Plan
may be included in the proposed budget. This may include the contribution of program
administrators'time(i.e., an Executive Director, Nursing Director or Program Manager's time) or
it may be other funding that supports the salaries of MCH staff. It is not necessary to
include budget narrative information for"Other"funding.
Other funding for salaries is provided by Weld County. Other funding for DRIVE SMART Weld
County activities is provided by small grants from the Colorado Department of Transportation,
State Farm Insurance, Allstate Insurance and local businesses and private citizens interested in
traffic safety.
Page 4 of 4
Replacement Budget and Budget Narrative
Attachment B-3 HCP
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
Maternal;and Child Health(MCH) •
Planning Budget FY12
Agency: Weld County Department of Public Health&Environment Date Completed: June 16,2011
Program Contact Approval Fiscal Contact Approval
Name: Debbie Drew Name: Tanya Geiser
Title: Director of Public Health Services Title: Administrative Services Director
Phone: 970-304-6420 Ext 2304 Phone: 970-304-6410 Ext 2122
Email: ddrew@co.weldco.us Email: tgeiser@co.weld.co.us
Due Date:July 1,2011
(for the period of October 1,2011 through September 30,2012)
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.
In CHILDREN AND ADOLESCENT POPULATION
n PRENATAL POPULATION
n CHILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATION
Annual Salary Full Tine Total Amount Source of Funds.
EXPENSE CATEGORIES Rate. Equivalent Required Othe? Received.:f om CDPHE
PERSONNEL SERVICES(Names&Titles): $0.00
Amy Antuna,Public Health Nurse III $59,286.49 0.85 $50,393.51 $50,393.51
Beverly Earley,Public Health Nurse II $56,388.05 0.67 $31,610.83 $37,610.83
Tracy Nunnally,Public Health Nurse I $45,114.78 0.90 :'.$40,603.30 $40,603.30
Aurora Medina,Social Worker 857,508.69 0.80 $40,006.95 $16,001.95 $30,005.00
Sara Torres,OT III,Family Coordinator $35,454.54 0.90 $31,909.09 $31,909.09
Kathy Smith-Stillson,Public Health Nurse Sup $63,147.93 0.05 $3,157.40 $3,157.40
Debbie Drew,Director,Public Health Nursing $95,520.73 0.05 $4,776.04 $4,776.04
SUBTOTAL — $214,457.12 $96,447.78 $118,009.34
Fringe Benefits: Rate= 38.93% N/A N/A $83,488.16 $37,547.12 $45,941.04
TOTAL PERSONNEL SERVICES($and FTE) 4.17 .$297,945.27 $133.994.90 :$163,950.,38
OPERATING EXPENSES(which are not part of indirect)
Supplies $5,000.00 $5,000.00 $0.00
Services $4,890.00 $4,890.00 $0.00
TOTAL OPERATING EXPENSES $9,890.00 $9,890.00 $0.00
TRAVEL EXPENSES
$4,500.00 $4,500.00 $0.00
TOTAL TRAVEL EXPENSES $4,500.00 $4,500.00 $0.00
CONTRACTUAL EXPENSES
Local Team Training $2,000.00 $2,000.00 $0.00
TOTAL CONTRACTUAL EXPENSES $2,000.00 32,000.00 , SOHO
TOTAL DIRECT COSTS(Personnel Services+Operating+Travel+Contractual) $314,335.27 $150,384.90 $163,950.38
INDIRECT COST: Rate= 13.39% $42,089.49 $20,136.54 $21,952.96
TOTAL INDIRECT COST $42,089.49 $20,136.54 $21,952.96
TOTAL PROJECT COST $356,424.76 $170,521.44 $185,903.33
`Source for funding for"Other"(Match or In-kind)
Local/County Funding: $170,521.44 Methodology used for reporting"Source of Funds"
Medicaid(will not be used to match):
Patient Fees: Method A In
All Other.
I TOTAL $170,521.44 Method B n
Can NON-FEDERAL funds be used as a match? Yes n No n
Page 1 of 4
Replacement Budget and Budget Narrative
Attachment B-3 HCP
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
Maternal and Child Health (MCH)
Budget Narrative FY12
Agency: Weld County Department of Public Date Completed: June 16, 2011
Health and Environment
Program Contact Person Fiscal Contact Person
Name: Debbie Drew 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
Check the appropriate box below to indicate the population group that applies to this budget
narrative. Complete a separate budget narrative for each population group budget.
❑ Children and Adolescent Population
❑ Prenatal Population
® Children with Special Health Care Needs Population
Due Date: July 1, 2011
General Instructions:
The purpose of the Budget Narrative is:
D. To describe how each line item included the proposed planning budget relates to your
agency's MCH plan and
➢ To explain how you arrived at each cost.
The Budget Narrative should provide a clear and reasonable rationale for the costs associated
with implementing your proposed MCH plan. The MCH plan, planning budget, and budget
narrative should all be aligned. Be sure to describe how you arrived at each line item amount
by providing detailed and specific information for EACH line item. The Budget Narrative should
reflect the MCH plan period from October 1, 2011 through September 30, 2012. Please provide
narrative for each cost category in the spaces below. Examples are included for each budget
category. Additional examples are available in the FY12 MCH Guidelines.
Personnel Services: List the name and title of each staff member (employed by your
agency), annual salary and Full Time Equivalent (FTE) that the staff member will commit to the
MCH plan. Briefly describe the role of the staff member in the MCH Plan and identify the
components of the Plan that this person will be responsible for completing.
Example: Susan Johnson, Registered Dietitian, salary at$50,000/year, .5 FTE (50%)to implement the
Healthy Baby campaign on prenatal weight gain and smoking cessation, Objective 2.
-Amy Antuna, Registered Nurse/HCP Team Leader, salary at $59,286.49, .85 FTE (85°k) to
implement and oversee the Weld HCP regional office activities, Objectives 1, 2, and 3.
-Beverly Earley, Registered Nurse, salary at $56,388.05, .67 FTE (67 0/0) to implement care
coordination services and create awareness about the HCP program among community
partners/agencies, Objectives 1 and 2.
-Tracy Nunnally, Registered Nurse, salary at $45,114.78, .9 FTE (90%)to implement care
coordination services and create awareness about the HCP program among community
partners/agencies, Objectives 1 and 2.
Page 2 of 4
Replacement Budget and Budget Narrative
Attachment 8-3 HCP
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
-Aurora Medina, Social Worker, salary at$57,508.69, .8 FTE(80%)to implement care
coordination services with a psychosocial emphasis and create an awareness about the HCP
program among community partners/agencies, Objectives 1 and 2.
-Sara Torres - Regional Family Coordinator/Office Technician, salary at$35,454.54, .9 FTE
(90%)to implement family support services and consultation to HCP staff/clients/families and
provide technical/derical support for HCP staff/clients, Objective 1.
-Kathy Smith-Stillson, Registered Nurse/Community Health Manager, salary at$63,147.93, .05
FTE (5%)to provide direct supervision and oversight of Weld HCP program/staff, Objectives 1,
2, and 3.
-Debbie Drew, Registered Nurse-c, Director of Public Health Services, salary at$95,520.73, .05
FTE (5%)to provide oversight of Weld HCP program, Objectives 1, 2, and 3.
Fringe is at 38.93%.
Operating Expenses: Include expenses that are not included in the indirect rate for your
agency. Examples: office supplies, copies, postage, telephone, computer network fees, project
supplies and materials, professional development and training registrations. Include funding for
equipment, including computers and software.
Provide a brief explanation to justify the need for each line item for the MCH Plan and identify
the objective in the MCH Plan for any line items over$1,000.
Example: $1,500 will provide a new computer for S.Johnson, R.D.,who will implement the Healthy Baby
campaign,Objective 2.
Supplies - $5000.00 will be utilized for HCP program outreach/marketing/systems building
activities, office supplies, copies, and postage, Objectives 1 and 2.
-Services - $4890.00 will be utilized for computers (network fees, software), printers, computer
services, phone services,facility fees for official HCP functions, Objectives 1 and 2.
Being paid by other sources.
Travel Costs: Travel costs to be incurred while implementing the MCH Plan and/or travel to
attend trainings. Note:It is required that the LHA includes the cost for two LHA MCH staff
person to attend a one-day, state MCH meeting in the Metro Denver area.
Example:Travel costs are reimbursed at 32 cents/mile per agency policy. Costs of$1,144 are estimated
to provide transportation, lodging,and meal costs to send 2 staff working on the MCH Plan to the
Preconception Summit in September 2012.
Travel costs are reimbursed at 49 cents/mile per agency policy. Costs of$4500.00 are
estimated to provide mileage reimbursement of travel to client home visits, 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.
Being paid by other sources.
Contractual Services: Describe costs for contractors (person or company not employed by
your agency) working on the MCH Plan. Briefly describe the role of each contractor in
completing the MCH Plan and identify the objectives of the MCH plan that this contractor will be
accomplishing.
Example: Robert Brown, Health Educator, contracted at$13,000/year, ($50/hour x 5 hours/week x 52
weeks=$13,000)to provide training to healthcare providers regarding prenatal smoking cessation,
Objective 2.
Example: Media coverage for$10,000 will air N ads and radio spots for the Healthy Baby campaign,
Page 3 of 4
Replacement Budget and Budget Narrative
Attachment B-3 HCP
As Replaced By Amendment#1
Contract Routing Number 12 FLA 31701
Objective 2, using ads that are already developed,adding information re:the local health agency.
-Local Team Training - $2000.00 in funds is provided to facilitate training opportunities for Weld
HCP staff, Objective 1.
Being paid by other sources.
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.
Example:Your indirect rate is 34.93%of total direct Salaries/Fringe. 27%can be recognized in your
request and 7.93%must be recognized as match or in-kind.
Example: Your indirect tate is 19%of total direct costs.The rate is within the 25%cap; 19%can be
recognized in your request.
Indirect rate is 13.39% of the total direct cost.
Other Funding Costs: Additional funding that supports MCH in general and/or the MCH Plan
may be included in the proposed budget. This may include the contribution of program
administrators'time(i.e.,an Executive Director, Nursing Director or Program Manager's time)or
it may be other funding that supports the salaries of MCH staff. It is not necessary to
indude budget narrative information for"Other"funding.
Additional funding that supports Weld HCP activities comes from local County general fund in
the amount of$170,521.44/annually.
Page 4 of 4
86 o Memorandum
1TO: Office of Clerk to the Board to the
Weld County Commissioners
W E L Die OUNTY FROM: Administration Division-Department of
Public Health and Environment
DATE: Octe Bt 1 a, a Olt
SUBJECT: ry1 C N Controc7 -Amenolmen
Attached to this memo is the finalized contract that the Health Department has received.
Please sign and date below indicating you have received the finalized contract and return
this signed memo to the Administration Division of the Health Department.
Please send the confirmation receipt to my attention. Thank you for your assistance with
the processing of this document.
ATTN: it,
,
Contract Name: IC ti Con+ oe t - Amendrn.¢n/t 4 I
Resolution Number: c2 oil - 92433
Finalized Contract Received By:
Date Received: 10 —la- I I U �)
Enclosure
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