HomeMy WebLinkAbout20111506.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR CANCER, CARDIOVASCULAR DISEASE,
AND PULMONARY DISEASE PREVENTION COMPETITIVE GRANT FOR THE WELD
COUNTY CARDIOVASCULAR DISEASE PREVENTION PROGRAM AND AUTHORIZE
CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Task Order Contract for the Cancer,
Cardiovascular Disease, and Pulmonary Disease Prevention Competitive Grant, for the Weld
County Cardiovascular Disease Prevention Program, from 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, to the Colorado Department of Public Health and
Environment, Office of Health Disparities, commencing July 1, 2011, and ending June 30, 2012,with
further terms and conditions being as stated in said contract, and
WHEREAS, after review, the Board deems it advisable to approve said contract, a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Task Order Contract for the Cancer, Cardiovascular Disease, and
Pulmonary Disease Prevention Competitive Grant, for the Weld County Cardiovascular Disease
Prevention Program, from 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, to the Colorado Department of Public Health and Environment, Office of Health
Disparities, be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the restrictions on lobbying by anyone using
funds pursuant to this grant shall apply to any lobbying, as defined in Section 24-6-301 (3.5) (a),
C.R.S., shall apply to all local government bodies, as well as their members.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said contract.
onc� -k-c) rr. LU' 2011-1506
le - dO- II —) , loll HL0038
TASK ORDER CONTRACT FOR THE WELD COUNTY CARDIOVASCULAR DISEASE
PREVENTION PROGRAM
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 20th day of June, A.D., 2011.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COL RADO
ATTEST: �': I IA'n• � er,bcidif
ara Kirkmeyer, hair I
Weld County Clerk to t ��•=�,' ,.N'•b, �`
%a;-3-kr EXCUSED
!eel,
' / . Sean P. Conway, Pro-Tem
BY: .Ft-
Deputy Clerk to the Bo Y+�G// '�j EXCUSED
W F. Garcia
AP D cT • cal
vid E. Log
Sney E.
o e vvo c V
Douglas ademac r
Date of signature: 424.1.21
2011-1506
HL0038
. 86 . 20 , Memorandum
TO: Barbara Kirkmeyer, Chair
Board of County Commissioners
W E L DEC OUNT 1 FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
Environment
DATE: May 26,2011
SUBJECT: Health Disparities Task Order Contract
Enclosed for Board review and approval is the task order contract between the Colorado
Department of Public Health and Environment's Office of Health Disparities and Weld County
Department of Public Health and Environment for the "Love Your Life, Take Care of Your
Heart" (Ama Tu Vida, Cuida to Corazon) program for the prevention of cardiovascular disease
(including diabetes and other precursors) among Hispanic and other minority populations in
Weld County.
This program expands on the Heart of Weld program (2008-2010) to address the issue of
cardiovascular disease by targeting men, women and families who are among Weld County's
low income, minority populations most affected by lack of insurance and access to health care.
Strategies will include cardiovascular disease prevention and self management programs offered
at sites already frequented by the target population, such as churches, community centers, food
banks and other service agencies. We will also work with Sunrise Community Health Center,
Salud Family Health Centers, other local health care providers and service agencies to recruit
clients into the program.
The task order includes funding for existing staff, a .5 FTE program coordinator, a .5 FTE
bilingual health educator and operating expenses such as educational materials, office supplies,
mileage, and travel expenses for state meetings.
The total amount of the task order is $95,668.00 for the time period of July 1, 2011 —June 30,
2012.
I recommend approval of this task order contract with the Office of Health Disparities.
Enclosure
2011-1506
STATE OF COLORADO
John W.Hickenlooper,Governor
Christopher E. Urbina,MD, MPH �OFcO�O�
Executive Director and Chief Medical Officer ��— �'o
0
Dedicated to protecting and improving the health and environment of the people of Colorado * *,
4300 Cherry Creek Dr.S. Laboratory Services Division
Denver,Colorado 80246-1530 8100 Lowry Blvd.
Phone(303)692-2000 Denver,Colorado 80230-6928 Colorado Department
Located in Glendale,Colorado (303)692-3090 of Public Health
http://www.cdphe.state.co.us and Environment
June 30, 2011
Weld County Department of Public Health and Environment
Attn: Dr. Mark Wallace
1555 North 17th Avenue
Greeley, CO 80631
Dear Dr. Wallace,
Enclosed is your copy of the fully executed Colorado Department of Public Health
and Environment Contract listed below.
Contractor Name: Weld County Department of Public Health and
Environment
Contract Number: 12 FAA 31515
Original Contract Number: N/A
Division: Administration/ADM
Program Name: Office of Health Disparities/OHD
Project Name: Ama Tu Vida, Cuida to Corazon (Love Your Life, Take Care of
Your Heart), A Healthy Weld 2020 Project
Reason for Contract: New Contract
Please contact me with questions or concerns. My contact information is listed
below.
Sinderely,
‘4.-40/0-1
Tracey C
Fiscal Analyst for Special Health Programs
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246 (303)692-2154
( )303 692-2154 phone .� o ax-(303)691-7950
Gmad:tracey elark(rystate.co.us
(303) 691-7950 - fax �
tracey.clark@state.co.us coloaduDepartment
of Public Health Tracey Clark
and Environment Fiscal Analyst for Special Health Programs
Administration and Financial Services Division
4300 Cherry Creek Drive South
Denver,Colorado 80246-1530
DEPARTMENT OF PUBLIC ITEADPIT AND ENVIRONMENT
ROUTING NO.12 FAA 31515
APPROVED TASK ORDER CONTRACT-WAIVER#154
This Task Order Contract is issued pursuant to Master Contract made on 01/23/2007,with routing number 08 FAA 00052
STAI'L CONTRACTOR
State of Colorado for the use&benefit of the Board of County Commissioners of Weld County
Department of Public Health and (a political subdivision of the state of Colorado)
Environment 915 10i5 Street
Administration Greeley,Colorado 80632-0758
Office of Health Disparities for the use and benefit of the
Weld County Department of Public Health and
4300 Cherry Creek Drive South
Environment
Denver, Colorado 80246
1555 North 17 'Avenue
Greeley,Colorado 80631
TASK ORDER MADE DATE CONTRACTOR I iNITtY IYRL_
05/09/2012 Colorado Political Subdivision
]'O/SC ENCUMBRANCE NUMBER:
PO FAA ADM12031515
'I I RRM.. 0I TM NG STATEMENTS RECEIVED:
This Task Order shall be effective upon Monthly
approval by the State Controller,or designee,
or on 07/01/2011,whichever is later. The STATUTORY AUTIMEM':
Task Order shall end on 06/30/2012. Not Applicable
PRICE STRUCTURE: CONTRACT PRICE Nt)T TO EXCEED:
Cost Reimbursement $ 95,668.00
PROCUREMENT MEN 1 OD: FEDERAL FUNDING DOLLARS: $
Exempt sTATr:FUNDING DoI.I.^RS' $ 95,668.00
BID/101'/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE.PER FISCAL YEAR:
Not Applicable FY 12: $95,668.00
FY XX: $
LAW SPECIFIED VENIMASIATUIIC FYXX: $
Not Applicable FY XX: $
FY XX: $
STATE REPRI6nNIAtIVE: CONTRACTOR REPRESENTATIVE:
Deanna Butler Dr.Mark Wallace
Department of Public health and Environment Weld County Department of Public Health and
Administration Environment
Office of Health Disparities 1555 North 17^'Avenue
4300 Cherry Creek Drive South Greeley,CC) 80631
Denver,CO 80246
SCOPE of WORK:
The project will implement a linguistic and culturally specific, multi-faceted, risk factor reduction
program,within the Hispanic/Latino community. The interventions are targeted to reduce
cardiovascular disease (CVD).
Page I of 6 Rev 6/25/09
8XI11131Ps:
The following exhibits are hereby incorporated:
Exhibit A- Additional Provisions (and its attachments if any—e.g.,A-1,A-2, etc.)
Exhibit B - Statement of Work (and its attachments if any—e.g., B-1,B-2, etc.)
Exhibit C - Amendment Template for Task Orders
Exhibit D- Budget
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses,the more specific provision shall control.
I. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including,but not limited to,Exhibit One thereto. The total term of this Task Order Contract, including
any renewals or extensions, may not exceed five(5)years. The parties intend and agree that all work shall
be performed according to the standards,terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(1),C.R.S.,as amended,this Task Order Contract is not valid until it
has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not
authorized to, and shall not;commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegee. The State shall have no financial obligation
to the Contractor whatsoever for any work or services or,any costs or expenses, incurred by the Contractor
prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order
Contract on or before its proposed effective date,then the Contractor shall commence performance under
this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order
Contract after its proposed effective date,then the Contractor shall only commence performance under this
Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through
and including the date specified on page one of this Task Order Contract,unless sooner terminated by the
parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract.
Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made
a part hereof as if fully set forth herein. Unless otherwise stated,all exhibits and/or attachments to this Task
Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated,
the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event
of conflicts or inconsistencies between the Master Contract and this Task Order Contract(including its exhibits
and/or attachments),or between this Task Order Contract and its exhibits and/or attachments,such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: 1)the
Page 2 of 6 Rev 6/25/09
Special Provisions of the Master Contract;2)the Master Contract(other than the Special Provisions)and its
exhibits and attachments in the order specified in the Master Contract;3)this Task Order Contract;4)the
Additional Provisions- Exhibit A,and its attachments if included,to this Task Order Contract;5) the
Scope/Statement of Work-Exhibit B,and its attachments if included,to this Task Order Contract;6)other
exhibits/attachments to this Task Order Contract in their order of appearance.
4. The Contractor,in accordance with the terms and conditions of the Master Contract and this Task Order
Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the
Statement of Work and Budget, which are incorporated herein by this reference,made a part hereof and
attached hereto as"Exhibit B".
5. The State,with the concurrence of the Contractor,may,among other things,prospectively renew or extend
the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or
decrease the amount payable under this Task Order Contract, or add to,delete from, and/or modify this
Task Order Contract's Statement of Work through a contract amendment. To be effective,the amendment
must be signed by the State and the Contractor,and be approved by the State Controller or an authorized
delegate thereof This contract is subject to such modifications as may be required by changes in Federal
or State law,or their implementing regulations. Any such required modification shall automatically be
incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set
forth herein.
6. The conditions,provisions,and terms of any RFP attached hereto, if applicable,establish the minimum
standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's
Proposal, if attached hereto,or any attachments or exhibits thereto, or the Scope/Statement of Work-
Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP,then the
Contractor shall also meet those standards of performance under this Task Order Contract.
7. STATEWIDE CONTRACT MANAGEMENT SYSTEM(This section shall apply when the Effective
Dale is on or offer July 1, 2009 and the maximum amount payable to Contractor hereunder is$100,000 or
higher]
By entering into this Task Order Contract,Contractor agrees to be governed,and to abide,by the
provisions of CRS §24-102-205, §24-102-206, §24-103-601, §24-103.5-101 and §24-105-102 concerning
the monitoring of vendor performance on state contracts and inclusion of contract performance information
in a statewide contract management system.
Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order
Contract, State law, including CRS §24-103.5-101,and State Fiscal Rules, Policies and Guidance.
Evaluation of Contractor's performance shall be part of the normal contract administration process and
Contractor's performance will be systematically recorded in the statewide Contract Management System.
Areas of review shall include, but shall not be limited to quality,cost and timeliness. Collection of
information relevant to the performance of Contractor's obligations under this Task Order Contract shall be
determined by the specific requirements of such obligations and shall include factors tailored to match the
requirements of the Statement of Project of this Task Order Contract. Such performance information shall
be entered into the statewide Contract Management System at intervals established in the Statement of
Project and a final review and rating shall be rendered within 30 days of the end of the Task Order Contract
term.Contractor shall be notified following each performance and shall address or correct any identified
problem in a timely manner and maintain work progress.
Should the final performance evaluation determine that Contractor demonstrated a gross failure to meet the
performance measures established under the Statement of Project,the Executive Director of the Colorado
Department of Personnel and Administration(Executive Director),upon request by the Colorado
Department of Public Health and Environment and showing of good cause, may debar Contractor and
Page 3 of 6 Rev 6/25/09
prohibit Contractor from bidding on future contracts. Contractor may contest the final evaluation and result
by: (i) filing rebuttal statements,which may result in either removal or correction of the evaluation(CRS
§24-105-102(6)),or(ii) under CRS §24-105-102(6),exercising the debarment protest and appeal rights
provided in CRS §§24-109-106, 107,201 or 202,which may result in the reversal of the debarment and
reinstatement of Contractor, by the Executive Director, upon showing of good cause.
8. If this Contract involves federal funds or compliance is otherwise federally mandated,the Contractor and
its agent(s)shall at all times during the term of this contract strictly adhere to all applicable federal laws,
state laws, Executive Orders and implementing regulations as they currently exist and may hereafter be
amended. Without limitation,these federal laws and regulations include the Federal Funding
Accountability and Transparency Act of 2006(Public Law 109-282), as amended by§6062 of Public Law
110-252, including without limitation all data reporting requirements required there under. This Act is also
referred to as FFATA.
Page 4 of 6 Rev 6/25/09
THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE OF COLORADO:
Board of County Commissioners of Weld County John W.Hickenlooper, GOVERNOR
For the use and benefit of the
Weld County Department of Public Health and
Environment
Legal Name of Contracting Entity
By?-)Cail-tJ
For Executive Director
74.hIt((.(Q�Ziiter, Department of Public I health and Environment
Signature of Authorized Officer
Barbara Kirkmeyer
Print Name of Authorized Officer
Department Program Approval:
Chair By aar.#
Prim Title of Authorized Officer juN 2 0 2011 \ t
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.MccDDerrmott,CPA
B 8 iYs ,.
Date
Page 5 of 6 Rev 6/25/09
` t ��—P,
This page left intentionally blank.
Page 6 of 6 Rev 6/25/09
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 05/09/2011 - Contract Routing Number 12 FAA 31515
These provisions are to be read and interpreted in conjunction with the provisions of the
Task Order Contract specified above.
1. Health Insurance Portability and Accountability Act(HIPAA)Business Associate Determination.
The State has determined that this contract does not constitute a Business Associate relationship under
HIPAA.
2. To receive compensation under this Task Order Contract,the Contractor shall submit a signed monthly
invoice/Cost Reimbursement Statement in a format acceptable to the State. A sample Invoice/Cost
Reimbursement Statement is attached hereto as Attachment A-I and incorporated herein by this reference.
An Invoice/Cost Reimbursement Statement must be submitted within thirty(30)calendar days of the end
of the billing period for which services were rendered. Expenditures shall be in accordance with the
Statement of Work attached hereto as Exhibit B and incorporated herein and in accordance with the work
requirements outlined in Attachment B-1. These items may include,but are not limited to,the
Contractor's salaries, fringe benefits,supplies,travel, operating, indirect costs which are allowable, and
other allocable expenses related to its performance under this Task Order Contract.
Invoice/Cost Reimbursement Statements shall: 1)reference this Task Order Contract by its contract routing
number,which number is located on page one of this Task Order Contract; 2)state the applicable
performance dates; 3)state the names of payees;4) include a brief description of the services performed
during the relevant performance dates; 5)describe the incurred expenditures if reimbursement is allowed
and requested; and,6)show the total requested payment. Payment during the initial,and any renewal or
extension,term of this Task Order Contract shall be conditioned upon affirmation by the State that all
services were rendered by the Contractor in accordance with the terms of this Task Order Contract.
Invoice/Cost Reimbursement Statements shall be sent to your assigned contract monitor to:
Office of Health Disparities Grant Program
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
To be considered for payment, billings for payments pursuant to this Task Order Contract must be received
within a reasonable time after the period for which payment is requested, but in no event no later than thirty
(30)calendar days after the relevant performance period has passed. Final billings under this Task Order
Contract must be received by the State within a reasonable time after the expiration or termination of this
Task Order Contract;but in no event no later than thirty(30)calendar days from the effective expiration or
termination date of this Task Order Contract.
3. To receive payment against this cost reimbursement contract,proof of expenditure is required. The
following forms of documentation for each category must be submitted with the cost reimbursement
statement:
A. Personnel Expenses:
"Personnel"are staff employed by the grantee organization. If not, staff should be included under
the Subcontracts/Contracts category.
• Timesheet documentation, listing the employees name,title, days and times worked, and
amount of time charged to the HDGP.
or
To be attached to CDPHE Page 1 of 3 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT A
• A copy of a general ledger that provides timeframe,personnel, and amount charged to the
HDGP.
B.Travel:
• A signed mileage reimbursement form must be completed which includes name of
traveler,number of miles traveled, mileage rate,amount, and origin/destination.
• Mileage will be reimbursed at the state's current approved mileage rate of.46 per mile.
• Travel expenses may include mileage, lodging and meals for overnight out-of-town
stays. Meals for staff may not be charged to this grant program for in-town meetings or
travel within one day.
C. Contracts/Subcontracts:
• Copy of invoice to grantee on contractor or subcontractor's letterhead addressed to the
grantee or a copy of check from grantee to contractor/subcontractor.
• Copy of proof of payment to contractor/subcontractor
• Invoices must include: subcontractor name, address, telephone number, dates worked,
description of work, location(s) work performed, hourly rate, total hours work and total
amount billed).
• Subcontractors should report their mileage(if any)on a signed travel form with the
information listed in the previous section.
D. Operating,Supplies, Equipment:
• Detailed copy of receipt for all purchases(not just credit card summary)from vendor to
grantee, including food item purchases.
E. Indirect:
• No backup is required,but the indirect rate must coincide with the approved budget up to
a maximum 20%of the total cost of Personnel,Operating/Supplies, Travel, and
Contract/Subcontract totals submitted for the month.
4. Funding levels within the Budget, attached to this Task Order Contract, may be modified as follows:
• Up to ten percent(10%)of funds originally set forth in each major budget category(e.g.,
Personal Services,Operating, Travel, Contractual, and Other Costs)may be transferred to
other budget categories with prior approval by completing the budget revision form and
attaching a revised budget narrative and obtaining approval from the Contract Monitor.
• Fund transfers between line items within the same budget category are allowable and
require a completed budget revision form and a revised budget narrative with the
proposed changes highlighted. Submit the request to your Contract monitor for review
and approval.
• The deadline for budget revision requests is May I-.
5. Time Limit for Acceptance of Deliverables.
a. Evaluation Period. The State shall have thirty(30)calendar days from the date a deliverable is
delivered to the State by the Contractor to evaluate that deliverable, except for those deliverables
that have a different time negotiated by the State and the Contractor.
b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design
specifications for that particular deliverable,or is otherwise deficient, then the State shall notify
the Contractor of the failure or deficiencies, in writing, within thirty(30)calendar days of: 1)the
date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or
deficiency at the time of delivery; or 2)the date the State becomes aware of the failure or
To be attached to CDPHE Page 2 of 3 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT A
deficiency. The above time frame shall apply to all deliverables except for those deliverables that
have a different time negotiated by the State and the Contractor in writing pursuant to the State's
fiscal rules.
c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed
deliverable,the Contractor shall have a reasonable period of time, not to exceed thirty(30)
calendar days,to correct the noted deficiencies. If the Contractor fails to correct such deficiencies
within thirty(30)calendar days,the Contractor shall be in default of its obligations under this
Task Order Contract and the State, at its option, may elect to terminate this Task Order Contract.
To be attached to CDPHE Page 3 of 3 Revised: 12/19/06
Task Order v1.0(11/05)contract template
•
Attachment A-1
Health Disparities Grant Program Contract Reimbursement Statement
To: From:
Colorado Dept. of Public Health& Environment Agency
Office of Health Disparities AFSD-OHD-C1 Office or Program Name
4300 Cherry Creek Drive South C-1 Address
Denver, CO 80246-1530 City, State,Zip
Fiscal Contact Name:
Attn: Contract Monitor Name Phone:
Contract Number:
Final Billing?
Yes No
FROM: TO:
Date of Expenditures:
PROJECT TITLE: GRANT PROJECT NAME
Description Category
Total
PERSONNEL EXPENSES
OPERATING/SUPPLIES EXPENSES
TRAVEL EXPENSES
CONTRACTS/SUBCONTRACTS
INDIRECT COSTS
ITEMIZED EQUIPMENT
LIMITED FACILITY RENOVATON
TOTAL INVOICE AMOUNT $0.00
I/We affirm the claimed expenses comply with the budget provisions of the contract and are reasonable and necessary,that all
relevant progress or other reports have been timely filed and all contract milestones and/or tasks related to the billing period
have been achieved.
CONTRACTOR SIGNATURE: Date:
I certify that the claimed expenses have been reviewed by me for compliance with requirements of the funding source&State of
Colorado Fiscal Rules, and are charged to the appropriate funding source.
CDPHE Fiscal Officer/Delegate: Date:
I affirm that I or my staff have reviewed the contractor's invoice and supporting documentation(as required), progress reports
and other communications with the contractor,and believe to the best of my knowledge that the contractor is in compliance
with all contract provisions.
CDPHE Contract Monitor:
Instructions: Enter individual expenses on page 2, and category totals in the table above. Please sign and date
at the bottom of this form and submit to your contract monitor along with page 2 and back up documentation.
Please ensure that the charges listed on this reimbursement statement are for the corresponding month.
Page 1 of 2
Health Disparities Grant Program Contract Reimbursement Statement
Individual Expense Detail (Page 2)
From: Agency Name
Contract Number
PROJECT TITLE: GRANT PROJECT NAME
Date of Expenditures: FROM: TO:
Description Reimbursement Supporting
Requested Documentation?
PERSONNEL EXPENSES _.
Personnel Total: $ -
OPERATING/SUPPLIES _.
Operating Total: $ -
TRAVEL EXPENSES
Travel Total: $ -
Contracts/Subcontracts _.
$
Contracts/Subcontracts Total: $ -
Indirect Costs
(Total personnel,operating,travel,contracts X approved%)
Indirect Cost Total: $ -
Itemized Equipment
Itemized Equipment Total: $ -
Limited Facility Renovation
Limited Facility Renovation Total $ -
INVOICE TOTAL -
Instructions: List individual expenses in appropriate category area and enter the individual amounts.
Check that your category totals and invoice totals match on page 1 and page 2.
Please label your back up documentation and note the ID in the"Supporting Documentation"column.
Page x of 2
EXHIBIT B
STATEMENT OF WORK
To Task Order Contract Dated 05/09/2011 -Contract Routing Number 12 FAA 31515
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above.
1. The Contractor, in accordance with the terms and conditions of this contract, shall perform and complete, in
a timely and satisfactory manner,all activities described in work plan that is attached hereto as Attachment
B-I and incorporated in accordance with the associated Budget which is attached hereto as Exhibit D and
incorporated herein.
2. The Contractor shall perform the activities outlined in the work plan for the term of July 1, 2011 through
June 30,2012. The Contract, based upon the approval of Colorado Department of Health and Environment
(CDPHE)and the Board of Health, may be renewed for one additional year beginning July 1,2012.
3. The Contractor will be required to participate in meeting or trainings provided by the Health Disparities
Grant program, and coordinate media plans, media purchases,evaluation activities and training activities
with the program at the request of the program director.
4. The Contractor will be required to submit quarterly progress reports and an annual report which will be due
within thirty(30)days after the expiration of the term of this contract.
To be attached to CDPHE Page 1 of 1 Revised: 12/19/06
Task Order v1.0(11/05)contract template
•
Exhibit C
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
ADD DIVISION-PROGRAM ACRONYMS
DEPARTMENT OR AGENCY NUMBER
***
CONTRACT ROUTING NUMBER
ELIMINATE ALL INFORMATION APPEARING IN RED
AMENDMENT FOR TASK ORDERS#*
This Amendment is made this **** day of*********,20**,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, LEGAL NAME OF ENTITY,(legal type of entity),whose address or principal place of business is Street
Address,City,State& Zip Code,hereinafter referred to as the"Contractor".
FACTUAL RECITALS
The parties entered into a Master Contract, dated ******** **, ****,with contract routing number** *** *****.
Pursuant to the terms and conditions of the Master Contract,the parties entered into a Task Order Contract,dated
******** **, ****, with contract encumbrance number PO *** **********,and contract routing number** ***
***** [insert the following if previous amendment(s),change order(s), renewal(s)have been processed: as
amended by] [include all previous amendment(s),change order(s), renewal(s)and their routing numbers!,
insert the following if previous amendment(s),change order(s), renewal(s) have been processed: collectively!
referred to herein as the"Original Task Order Contract, whereby the Contractor was to provide to the State the
following:
Briefly describe what the Contractor was to do under the Original Task Order Contract—
indent this paragraph!
[Please choose one of the following four options and delete the other three options not selected!
The State promises to [choose one and delete the other] increase/decrease the amount of funds to be paid to the
Contractor by********** Dollars,($*.**)during the current term of the Original Task Order Contract in exchange
for the promise of the Contractor to perform the [choose one and delete the other! increased/decreased work
under the Original Task Order Contract.
The State promises to pay the Contractor the sum of********** Dollars, ($*.**)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**** years/months, ending on******** **, ****.
The State promises to [choose one and delete the other! increase/decrease the amount of funds to be paid to the
Contractor by ********** Dollars, ($*.**)for the renewal term of**** !choose one and delete the other)
years/months,ending on ******** **,****, in exchange for the promise of the Contractor to perform the !choose
one and delete the other! increased/decreased work described herein.
The State hereby exercises a"no cost"change to the [choose those that apply and delete those that don't apply]
budget,specifications within the Statement of Work, project management/manager identification,notice
address or notification personnel,or performance period within the!choose one and delete the other] current
term of the Original Task Order Contract or renewal term of the Original Task Order Contract.
Page 1 of 6 Rev 3/16/2010
•
Exhibit C
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** *** *****, 'insert the following language here if previous
amendment(s),change order(s),renewal(s)have been processed'as amended by 'include all previous
amendment(s),change order(s), renewal(s)and their routing numbers', 'insert the following word if
previous amendment(s),change order(s), renewal(s) have been processed,otherwise delete
"collectively"'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:
'Please delete this option if it does not apply'
A. The Contractor's address in the Original Task Order Contract,contract routing number** ***
*****,dated********* **,****, is hereby changed from**** ******* ******,***********,
Colorado,*****to the Contractor's new address of**** ******* ******,***********,
Colorado,*****. The Contractor's name and FEIN remain the same as they were in the Original
Task Order Contract.
'Please choose one of the following three options and delete the two options not selected]
JIf you delete item A.above be sure to change the option you choose below from B.to A.'
B. 'Use this paragraph when changes to the funding level of the Original Task Order Contract
occur during the current term of the Original Task Order Contract'This Amendment is
issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing
number** *** . This Amendment is for the current term of********* **,****,through
and including***********,****. The maximum amount payable by the State for the work to be
performed by the Contractor during this current term is 'choose one and delete the other]
increased/decreased by********** Dollars,($*.**)for an amended financial obligation of the
State for the current term of*********** DOLLARS,($**,***.**)and an amended total
financial obligation of the State of******************* DOLLARS($**,***.**). 'Delete the
following two blue sentences if your amendment does not contain any federal funds. If you
keep both of these sentences change the font color to black before printingJOf the amended
financial obligation for the current term ********** Dollars,($*.**)are attributable to a
funding source of the State of Colorado and ********** Dollars,($*.**)are attributable to a
funding source of the United States Government(see Catalog of Federal Domestic Assistance
(CFDA)number**.***). Of the amended total financial obligation of the State referenced above
********** Dollars,($*.**)are attributable to a funding source of the State of Colorado and
********** Dollars,($*.**)are attributable to a funding source of the United States
Government. 'Delete the following sentence if not applicable in your situation I The revised
Statement of Work is incorporated herein by this reference and identified as 'choose one and
delete the other'"Exhibit*/Attachment*". 'Delete the following sentence if not applicable in
your situation'The revised Budget is incorporated herein by this reference and identified as
'choose one and delete the otherl"Exhibit*/Attachment*".
B. 'Use this paragraph when the Original Task Order Contract will be renewed for another
term' This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract
identified by contract routing number** *** . This Amendment is for the renewal term of
********* **,****,through and including********* **,****. The maximum amount payable
by the State for the work to be performed by the Contractor during this renewal term is
**********Dollars,($*.**)for an amended total financial obligation of the State of
Page 2 of 6 Rev 3/16/2010
Exhibit C
**********DOLLARS,($*.**). This is an (choose one and delete the
otherjincrease/decrease of**********Dollars,($*.**)of the amount payable from the
previous term. (Delete the following two blue sentences if your amendment does not contain
any federal funds. If you keep both of these sentences change the font color to black before
printing]Of the maximum amount for this renewal term********** Dollars,($*.**)are
attributable to a funding source of the State of Colorado and********** Dollars,(5*.**)are
attributable to a funding source of the United States Government(see Catalog of Federal Domestic
Assistance(CFDA)number**.***). Of the amended total financial obligation of the State
referenced above**********Dollars,($*.**)are attributable to a funding source of the State of
Colorado and **********Dollars,($*.**)are attributable to a funding source of the United
States Government. [Delete the following sentence if not applicable in your situation]The
revised Statement of Work is incorporated herein by this reference and identified as"Exhibit*".
[Delete the following sentence if not applicable in your situation)The revised Budget is
incorporated herein by this reference and identified as"Exhibit*".
B. (Use this paragraph when there are"no cost changes" to the Budget.the specifications within the
original Statement of Work,allowable contract provisions as noted,or performance period.)This
Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by
contract routing number** *** . This Amendment[choose those that apply and delete those
that don't[ modifies the Budget in [identify location in contract[,modifies the Statement of Work
in)identify location in contract(,modifies the project management/manager identification in
'identify location in contract(,modifies the notice address or notification personnel in (identify
location in contract],modifies the period of performance in [identify location in contract[ of the
Original Task Order Contract. The revised (choose those that apply and delete those that don't'
Budget,Statement of Work,project management/manager identification,notice address or
notification personnel is incorporated by this reference and identified as Exhibit*or Attachment*-
*. (If you are changing the performance period,choose the following two sentences or delete
both sentences( The period of performance of the (choose one and delete the other[
current/renewal term is hereby 'choose one and delete the other)extended/reduced by*****(*)
months,changing the current ending date from********* ** **** to********* **,****. The
revised period of performance is********* **,****through and including***********,****.
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******** **,****,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.
Page 3 of 6 Rev 3/16/2010
Exhibit C
This page left intentionally blank.
Page 4 of 6 Rev 3/16/2010
Exhibit C
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:
"LEGAL NAME OF CONTRACTOR) STATE OF COLORADO
(Legal type of entity) John W. Hickenlooper,Governor
(DELETE RED TEXT BEFORE PRINTING INCLUDING THE RETURN - Add more spaces for the
contractor's name as needed. Be sure there arc four spaces below(legal type of entity),which MUST be the
last line. Also, make sure everything is aligned properly,e.g.,Governor's name and title MUST be the line
right under STATE OF'COLORADO and make sure Lines for State Controllers signature and date stay on
this page"
By:
Signature of Authorized Officer For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT
Print Name of Authorized Officer
Print Title of Authorized Officer
PROGRAM APPROVAL:
By:
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until
signed and dated below by the State Controller or delegate.Contractor is not authorized to begin
performance until such time. If Contractor begins performing prior thereto,the State of Colorado is not
obligated to pay Contractor for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER
David J.McDermott,CPA
By:
Date:
Page 5 of 6 Rev 3/16/2010
Exhibit C
This page left intentionally blank.
Page 6 of 6 Rev 3/16/2010
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Exhibit D
Health Disparities Grant Program - FY 11-12 Application
_ = BUDGET:FORM =
Project Title: Ama Tu Vida, Cuida Tu Corazon
Agency/Organization: Weld County Department of Public Health & Environment
Fiscal Year 11-12 (Year 1)
Personnel Expenses
(including salaries or wages and
fringe benefits) $76,982
Operating/Itemized Supplies
$1,724
In-State Travel Expenses
$1,104
Contracts/Subcontracts
$8,550
Subtotals for Direct Costs:
$ 8$,36Q.00
Indirect Costs*
(Not to exceed 20% of Direct
Costs listed above: Personnel,
Operating, Travel, Contractual/
Subcontracts budget categories) $ 7,308.00
Total Project Cost
$ 95,668.00
List the detailed cost breakdown in Budget Narrative section of the application for each grant
year separately. Please see the Health Disparities Guidelines for detailed budget information.
Signature of Authorized Official:
Print Name of Authorized
Official: Mark Wallace, MD, MPH
Title: Executive Director
Date: 5/4/2011
Page 1 of 3
f
Exhibit D
Budget Narrative
Project Title: Ama Tu Vida, Cuida to Corazon
Agency/Organization Name: Weld County Department of Public Health & Environment
Year 1 FY 11-12 (July 1, 2011 —June 30, 2012)
LINE ITEM NARRATIVE
Personnel Expenses Total for Year 1 = $76,982
Gabrielle Vergara, MPH .50 FTE: Gabrielle will be responsible for managing the day-to-day activities of the
Program Coordinator program, including program implementation,staff supervision,overseeing contracts
(w/sub-contractors), progress monitoring and reports. She will also be responsible for
program outreach and marketing, coordinating referrals with local providers and
service organizations,overseeing promotora training,facilitating the steering group,
securing locations for classes,and assisting with platicas and classes.
$40,857 Annual salary is$60,287 X.50(FTE) _$30,144
Fringe calculated at 35.54%($30,144)=$10,713
Total salary and fringe requested=$40,857
Ofelia Orozco, MA .50 FTE: Ofelia will be the lead educator for the platicas and lifestyle intervention
Health Educator classes. She will also help lead the support group and oversee the promotoras.
Annual salary is$53,305 X.50(FTE)=$26,653
$36,125 Fringe calculated at 35.54%($26,653)=$9,472
Total salary and fringe requested=$36,125
Operating/Supplies Total for Year 1 = $1,724
Office Supplies An annual budget for office supplies needed to implement the program is estimated
at$500 for the year. Example of supplies needed include printer toner,paper,
$500 pens/pencils,file folders,etc. Actual expenses will be charged to the grant as
incurred.
Printing Miscellaneous copying for the program is budgeted at approximately 300 copies per
month at.09 cents/copy. Items to be copied included class handouts, program
flyers,and other outreach materials.
$324 300(copies)X.09(cents)X 12 months=$324
Platica Host Stipends If a Platica is held in someone's home,we would like to be able to provide a$25
dollar gift card to off-set any expenses they may incur as the host. As the host, most
will want to provide refreshments for their quests. We do not want them to have to
$900 cover this expense out-of-pocket.
3 platicas per month @$25 per Platica X 12 months=$900
In-State Travel Total for Year 1 = $1,080
Mileage reimbursement Actual mileage will be charged to the grant as incurred. Mileage will be used by
(for program coordinator and health educator) program staff for travel related to the program including travel to and from sites
where platicas and educational classes will be held as well as any meetings in
$1,104 Denver related to the grant. An annual budget for mileage has been set at$1,350
(estimated 200 miles per month for all staff at.46 cents/mile X 12 months=$1,104
Contracts/Subcontracts Total for Year 1 = $8,550
Promotora Training Either a subcontractor will be hired or a training program will be found to provide
training for three promotoras. It is estimated that the training will cost$500/per
$1,500 promotora for a total of$1,500.
Promotoras Promotoras will be contracted to provide community presentations(platicas),assist
with community outreach, implement physical activity opportunities in their
communities, and provide backup for the lifestyle intervention classes.
$6,750 3 promotoras X 150 hrs./year X$15/hr. =$6,750
Contract Nurse Practitioner or Certified We will contract with a either a Nurse Practitioner or CDE to teach 3 CVD self-
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• Exhibit D
Diabetes Educator(CDE) management class during the grant year. Each class will be for 1 hr.with 1 hr.of
prep time per class.
$300 2 hrs.X 3 classes X$50/hr. _$300
Indirect Costs (based on 8.3%) Total of Personnel+Operating+Travel+Subcontractors=$88,657
$7,332 $88,336 X.083=$7,332
Total Program Cost(Year 1) $95,668
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