HomeMy WebLinkAbout20111505.tiff RESOLUTION
RE: APPROVE AMENDMENT #3 TO TASK ORDER CONTRACT FOR TUBERCULOSIS
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 Amendment#3 to the Task Order Contract
for the Tuberculosis Program between the County of Weld, State of Colorado, by and through the
Board of County Commissioners of Weld County, on behalf of the Weld County Department of
Public Health and Environment, and the Colorado Department of Public Health and Environment,
commencing July 1, 2011, and ending June 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 #3 to the Task Order Contract for the Tuberculosis Program
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment, and the Colorado Department of Public Health and Environment be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said amendment.
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 ADO
Et
ATTEST ®� /4)4 /UVk��
�♦ Barbara Kirkmey r, hair J
Weld County Clerk to th:Vcb 0 cf45V
�EXCUSED
' i ^ Sean P. Conway, Pro-Tem
BY:
Deputy Clerk to the Boar EXCUSED
m F. Garcia
APP AST M: F
avid E. Long
ounty Attorney O - S cies
Douglas ademach r
Date of signature: 0/2 /
Ov*q Ac X c , Qt./ N'- 2011-1505
t l - ig l I HL0038
86 2 0 . . Memorandum
1TO: Barbara KCounty Co, Chair
Board of County Commissioners
i .
W E L DEC 0 U N T Y FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
Environment
DATE: June 1, 2011
SUBJECT: Amendment for Task Orders #3:
Funding for the Tuberculosis Task Order
Contract
Enclosed for Board review and approval is contract amendment between the Colorado
Department of Health and Environment and the Board of County Commissioners of Weld
County on behalf of the Department of Public Health and Environment(WCDPHE). This
contract is for continuation of the Tuberculosis (TB) Prevention and Control Program.
If approved, the funding for this contract will allow the Department to provide TB prevention
and control activities in Weld County. WCDPIIE staff members will provide active TB
treatment including directly observed therapy, ensure contacts to all newly identified infectious
TB cases receive appropriate evaluation, collect specimens for testing on all persons suspected of
having TB, provide for and interpret chest x-rays, and conduct TB skin test screening program.
Health Department staff will also follow-up with active patients to ensure they receive
appropriate information and education and they adhere to the completion of their TB therapy.
The term of this contract is for one year, ending on June 30, 2012. Funding for this contract
amendment period will not exceed $74,650. Of this amount, $53,400 is from state sources and
$21,250 is from federal sources. This contract includes an additional $17,000 for the purpose of
enhanced testing. The state will also make available to the Contractor a portion of the statewide
funds for the Tuberculosis Direct Observed Therapy for the same one year renewal term. I
recommend your approval of this task order amendment.
Enclosure
2011-1505
STATE OF COLORADO
John W.Hickenlooper,Governor
Christopher E.Urbina, MD, MPH ioF.c.Otop
Executive Director and Chief Medical Officer ye Aso
Dedicated to protecting and improving the health and environment of the people of Colorado i. 9,
4300 Cherry Creek Dr.S. Laboratory Services Division 4 e76
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
7/5/11
Weld County Department of Public Health and Environment
1555 North 17th Avenue
Greeley CO 80631 •
Hi Tanya, •
Enclosed is your copy of the fully executed Colorado Department of Public Health and Environment
Amendment listed below. You may begin work on 7/1/11.
Contractor Name: Weld County Public Health and Environment
Amendment Number: 12 FHA 32078
Original Contract Number: 10 FHA 00023
Division: Disease Control and Environmental Epidemiology/DCEED
Program Name: Tuberculosis Program/TBP
Project Name: Tuberculosis Control and Prevention
Reason for Contract: Renewed Contract
Please contact me with questions or concerns.. My contact information is listed below.
Sincerely,
Jessica K Hubbard
Contracts Administrator
DCEED-A3
4300 Cherry Creek Drive South
Denver, CO 80246
303-692-2702 office
303-782-0904 fax
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DCEED-TB
DEPARTMENT OR AGENCY NUMBER
FHA
CONTRACT ROUTING NUMBER
12-32078
AMENDMENT FOR TASK ORDERS#3
This Amendment is made this 266 day of May, 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),whose
address or principal place of business is 915 10`h Street,Greeley,CO 80632,for the use and benefit of Weld
County Department of Public Health and Environment, whose address or principal place of business is 1555
North 17`h Avenue,Greeley,CO 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
April 21,2009, with contract encumbrance number PO FHA EPI1000023, and contract routing number 10 FHA
00023,as amended by Amendment for Task Orders#1,routing number 10 FHA 16562; Amendment for Task
Orders#2,routing number 11 FHA 24024,c ollectively referred to herein as the"Original Task Order Contract,
whereby the Contractor was to provide to the State the following:
The Contractor shall provide or coordinate the Tuberculosis(TB) prevention and control
activities for individuals within its service area.
The State promises to increase the amount of funds to be paid to the Contractor by Seventy Four Thousand Six
Hundred Fifty Dollars,($74,650.00)for the renewal term of One(1)year,ending on June 30,2012, in exchange
for the promise of the Contractor to perform the increased work described herein.
The State promises to make available to the Contractor a portion of the Thirty Four Thousand Dollars,
($34,000.00)Statewide funds for the Tuberculosis Direct Observed Therapy for the same One(1)year renewal
term, in exchange for the promise of the Contractor to perform the work described herein.
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, 10 FHA 00023,as amended by Amendment for Task Orders#1,
routing number 10 FHA 16562; Amendment for Task Orders#2, routing number 11 FHA 24024,
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,
Page 1 of 4 Rev 3/16/2010
altered,and changed in the following respects only:
A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified
by contract routing number 10 FHA 00023. This Amendment is for the renewal term of July 1.
2011,through and including June 30,2012. The maximum amount payable by the State for the work
to be performed by the Contractor during this renewal term is Seventy Four Thousand Six Hundred
Fifty Dollars,($74,650.00)for an amended total financial obligation of the State of TWO
HUNDRED FIVE THOUSAND FOUR HUNDRED NINETY TWO DOLLARS AND EIGHTY
FOUR CENTS,($205,492.84). This is an increase of Seventy Four Thousand Six Hundred Fifty
Dollars, ($74,650.00)of the amount payable from the previous term. Of the maximum amount for this
renewal term Fifty Three Thousand Four Hundred Dollars,($53,400.00)are attributable to a
funding source of the State of Colorado and Twenty One Thousand Two Hundred Fifty Dollars,
($21,250.00)are attributable to a funding source of the United States Government(see Catalog of
Federal Domestic Assistance(CFDA)number 93.116). Of the amended total financial obligation of
the State referenced above One Hundred Seventy One Thousand Seven Hundred Dollars,
($171,700.00)are attributable to a funding source of the State of Colorado and Thirty Three
Thousand Seven Hundred Ninety Two Dollars and Eighty Four Cents,($33,792.84)are
attributable to a funding source of the United States Government. The revised Statement of Work is
incorporated herein by this reference and identified as"Exhibit C". The revised Budget is
incorporated herein by this reference and identified as"Exhibit H".
B. Payment pursuant to this Amendment shall be made as earned, in whole or in part,from available
State funds encumbered in an amount not to exceed THIRTY FOUR THOUSAND DOLLARS
($34,000.00) Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2012,July
1,2011 through and including June 30,2012. Of the total financial obligation of the State for the
Tuberculosis Direct Observed Therapy, one hundred percent is derived from the State General
Fund.The liability of the State, at any time, for such payments shall be to the unencumbered remaining
balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this
Amendment,then the State, in its sole discretion,may proportionately reduce the funding for this
Amendment or terminate this Amendment in its entirety.
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 July 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.
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 Commisssioners of Weld County
For the use and benefit of STATE OF COLORADO
Weld County Department of Public Health John W. Hickenlooper,Govern r
and Environment
-Q--"(srBy:
Signature of Ad For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT
Barbara Kirkmeyer
Print Name of Authorized Officer
Chair
Print Title of Authorized Officer
JUN 2O 2011
PROGRAM
APPROVAL: o
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.
TATE CONTROLLER
avid J. McDermott,CPA
By:
Date: I
Page 3 of 4 Rev 3/16/2010
C// /5/S
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Page 4 of 4 Rev 3/16/2010
EXHIBIT C
STATEMENT OF WORK
To Amendment for Task Order Dated 05/26/2011 —Contract Routing Number 12 FHA 32078
These provisions are to he read and interpreted in conjunction with the provision of the Task Order Contract specified above.
Funds provided under the Task Order are to assist in supporting tuberculosis (TB)prevention and
control activities as stated in Colorado Revised Statues(CRS)25-4-501-Part 5 Tuberculosis(et
seq)and Rules and Regulations Pertaining to Epidemic and Communicable Disease Control (6-
CCR-1009-1, Regulation 4). Contractor shall provide or coordinate the following services for all
individuals within its service area according to the statutes and regulations listed above and
according to Colorado Department of Public Health and Environment(CDPHE)Tuberculosis
Manual,but in no event less than those duties required by statute and rules(listed above). Use of
funds shall be prioritized as follows: priority I)finding all patients with active TB and ensuring
completion of appropriate therapy,priority 2)finding and evaluating contacts of TB patients and
ensuring completion of appropriate therapy,3)evaluation of newly arrived immigrants and
refugees with Class B TB designation,and priority 4)targeted testing of high-risk persons and
ensuring completion of therapy for latent TB infection(LTBI). If available,use patient's medical
insurance as primary payment source. CDPHE will reimburse for diagnostic_and clinical services
at current Medicaid rate unless prior approval has been given by the CDPHE TB Program.
1. Suspected or confirmed active TB
a. The Contractor shall provide,or arrange for, chest x-rays and interpretations.
b. The Contractor shall collect,or arrange for the collection of,specimens for mycobacteriology
testing on all persons suspected of having TB. Assure appropriate testing is performed,e.g.,
smears for acid-fast bacilli.(using concentrated fluorescent method),isolation of
mycobacteria(using rapid methods), identification of Mycobacterium tuberculosis complex
(MTB)(using rapid methods),and susceptibility testing(isoniazid,rifampin,ethambutol,and
pyrazinamide)on isolates of MTB. Contractor should use the CDPHE Laboratory for testing.
The CDPHE Laboratory will,at no charge to the Contractor, supply specimen containers and
perform the above testing for the Contractor. The Contractor shall arrange for the
transportation of the specimens to the CDPHE Laboratory for testing.
c. The Contractor shall provide,or arrange for,the placement of patients who require isolation.
The Contractor shall contact CDPHE TB Program for assistance, if needed,and to request
reimbursement from CDPHE for those costs incurred by the Contractor in isolating a patient.
d. The Contractor shall provide,or arrange for,all other necessary laboratory testing and
medical evaluation services.
e. The Contractor shall order TB medications through the CDPHE TB Program.
I. The Contractor shall provide the CDPHE with the medical insurance information for those
patients who have medical insurance.
g. The Contractor shall provide,or arrange for,the treatment of patients with suspected or
confirmed active TB, including directly observed therapy, and ensure adherence to treatment.
h. The Contractor shall provide, or arrange for,a HIV antibody test for all persons diagnosed
with TB disease, regardless of their age or the apparent absence of risk factors for HIV
infection. In accordance with section 25-4-1401,e1 seq.,C.R.S.,as amended,the Contractor
shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform
those individuals whom refuse testing of the risks associated with HIV/TB co-infection.
To be attached to CDPHE Page 1 of 5 Revised 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT C
i. At least monthly,the Contractor shall monitor and evaluate those persons with suspected or
confirmed active TB.
j. The Contractor shall provide culturally appropriate patient education and information
pertaining to TB treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
k. All reports of suspected or confirmed active TB shall include: reason for initiating,patient
name,date of birth,country of birth,date arrived in U.S., demographic information, locating
information,provider information,TB risk factors,results of diagnostic testing,results of
mycobacteriology including susceptibility results,dates of infectious period,treatment
information,changes in patients'status,diagnosis,or any other information as appropriate.
The Contractor shall report to CDPHE when a TB patient completes treatment, moves,or
transfers out of the Contractor's service area. Information may be reported via web-based TB
case/contact management system(TBdb)or via"Tuberculosis Surveillance and Case
Management Report"(TB 17), which is incorporated herein by this reference,made a part
hereof,and referenced in the Original Contract as"Attachment B-1". Confirmed cases of TB
shall include all data elements identified in the"Report of Verified Case of Tuberculosis
(RVCT)", which is incorporated herein by this reference,made a part hereof,and
incorporated herein to as"Attachment G-1"which replaces"Attachment B-2"of the
Original Contract. The CDPHE shall provide the format and instructions for any additional
information requests. Report forms are subject to revision and Contractor agrees to use most
recent version.
2. Contacts to newly identified infectious TB (smear and/or culture positive pulmonary or laryngeal)
a. The Contractor shall ensure that all contacts to newly identified infectious TB cases are
identified, investigated,and receive appropriate evaluation. Contact investigation and any
follow-up needed as a result of an occupational exposure shall be conducted by the employer.
b. When indicated,the Contractor shall provide,or arrange for,chest x-rays and interpretations.
c. When indicated,the Contractor shall provide, or arrange for, other laboratory testing,and
other necessary medical evaluation services.
d. The Contractor shall provide,or arrange for,the treatment of patient(including directly
observed preventive therapy when appropriate),and ensure the completion of therapy for
infected contacts.
e. The Contractor shall order TB medications through the CDPHE TB Program.
f. The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
g. The Contractor shall provide,or arrange for,an HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401,et
seq.,C.R.S.,as amended,the Contractor shall report all known HIV antibody test results to
the State. The Contractor shall inform all individuals whom refuse testing of the risks
associated with HIV/TB co-infection.
h. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during
treatment.
To be attached to CDPHE Page 2 of 5 Revised 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT G
i. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTB1 treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
j. The Contractor shall submit a preliminary Tuberculosis Contact Investigation Record,(which
is incorporated herein by this reference, made a part hereof,and referenced in the Original
Contract as"Attachment B-3"to the CDPHE TB Program after initiation of each contact
investigation. The Contractor shall submit a final report to CDPHE when a contact
investigation is completed. Report forms are subject to revision and Contractor agrees to use
most recent version.
k. For those persons identified,as part of a contact investigation,with latent TB infection,or
those with suspected latent TB infection requiring treatment recommendations from CDPHE,
the Contractor shall report reason for initiating,patient name,date of birth,country of birth,
date arrived in U.S.,demographic information, locating information,provider information,
TB risk factors, results of diagnostic testing,treatment information,or any other information
as appropriate. The Contractor shall report to CDPHE when a patient completes treatment,
moves,or transfers out of the Contractor's service area. Information may be reported via
web-based TB case/contact management system(TBdb)or via"Tuberculosis Surveillance
and Case Management Report"(TB 17). The CDPHE shall provide format and instructions
for any additional information requests. Report forms are subject to revision and contractor
agrees to use most recent version.
3. Newly arrived immigrants and refugees with Class B TB designation
a. The CDPHE TB Program will notify the Contractor of all newly arrived Class B TB
immigrants/refugees via a CDC 75.17 form which is incorporated herein by this reference,
made a part hereof,and referenced in the Original Contract as"Attachment B-4"or Follow-up
worksheet which is incorporated herein by this reference,made a part hereof,and referenced
in the Original Contract as"Attachment B-5". Report forms are subject to revision and
contractor agrees to use most recent version.
b. Within thirty (30) calendar days of the Contractor's receipt of written notification from the
State of the arrival of a Class B immigrant/refugee,the Contractor shall contact that
immigrant and conduct,or arrange for,a TB screening that includes medical evaluation,
tuberculin skin test or whole blood interferon y assay,chest radiograph, and three spontaneous
sputum specimens for AFB smear and culture collected on consecutive days.
c. Upon completion of testing and examination,the Contractor shall fill out,sign,and date the
CDC 75.17 form or Follow-up worksheet,and return it within 90 days to:
Colorado Department of Public Health and Environment
Tuberculosis Program
Attn: Class B Coordinator
4300 Cherry Creek Drive South
Denver,CO 80246
d. The Contractor shall,when indicated,provide,or arrange for,treatment and ensure
completion of therapy.
e. The Contractor shall order TB medications through the CDPHE TB Program.
f. The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
To be attached to CDPHE Page 3 of 5 Revised 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT G
g. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
h. For those persons identified with LTBI or active TB,the Contractor shall report patient name,
date of birth,country of birth; date arrived in U.S.,demographic information, locating
information,provider information,TB risk factors,and results of diagnostic testing,treatment
information,or any other information as appropriate. Contractor will report when a patient
completes treatment,moves,or transfers out of the jurisdiction. Information may be reported
via web-based TB case/contact management system(TBdb)or via"Tuberculosis Surveillance
and Case Management Report"(TB 17). The State shall provide format and instructions for
any additional information requests. Report forms are subject to revision and Contractor
agrees to use most recent version.
4. Other high-risk persons with LTBI
a. When indicated,the Contractor shall provide,or arrange for,chest x-rays and interpretations.
b. When indicated,the Contractor shall provide,or arrange for,all other necessary laboratory
testing and medical evaluation services.
c. The Contractor shall provide,or arrange for,the treatment of patient and ensure the
completion of therapy.
d. The Contractor shall order TB medications through the CDPHE TB Program.
e. The Contractor shall provide the CDPHE with the medical insurance information for those
patients that have medical insurance.
f. The Contractor shall provide,or arrange for,a HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401,et
seq.,C.R.S.,as amended,the Contractor shall report all known HIV antibody test results to
the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks
associated with HIV/TB co-infection.
g. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during
treatment.
h. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
i. For persons with LTBI,the Contractor shall report reason for initiating,patient name,date of
birth,country of birth,date arrived in U.S.,demographic information, locating information,
provider information,TB risk factors, results of diagnostic testing,treatment information,or
any other information as appropriate. Contractor shall report when a LTBI patient completes
treatment, moves, or transfers out of the jurisdiction. Information may be reported via web-
based TB case/contact management system(TBdb)or via"Tuberculosis Surveillance and
Case Management Report"(TB 17). The CDPHE shall provide format and instructions for
any additional information requests. Report forms are subject to revision and Contractor
agrees to use most recent version.
To be attached to CDPHE Page 4 of 5 Revised 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT G
j. Tuberculin skin testing,chest radiographs,chest radiograph interpretations,other diagnostic
testing,and medical evaluations are not eligible for reimbursement under this Task Order for
the following:
i. Correctional facility inmates;
ii. Persons,other than Class B TB immigrants/refugees, undergoing
immigration medical examinations;
iii. Paid or volunteer employees of health care facilities, long-term care
facilities,drug treatment centers,correctional facilities, shelters,schools,or
child care facilities that undergo skin testing as part of a routine
employment skin testing program.
5. TB education and consultation
As needed,the Contractor shall provide consultation services to providers in its service area
regarding TB reporting,screening,treatment,and follow-up.
6. Reports for contract monitoring
The Contractor shall provide CDPHE with a Tuberculosis Semi-Annual Progress Report on TB
activities in its service area. A sample of the Tuberculosis Semi-Annual Progress Report is
incorporated herein by this reference,made part hereof,and referenced in the Original Contract as
"Attachment 8-6". Report forms are subject to revision and contractor agrees to use most recent
version or submit a similar type of report. The Contractor shall submit report within two months
after funding period ends.
7. Confidentiality
The Contractor shall maintain internal medical and administrative records in a manner which
ensures the confidentiality and security of those records in accordance with all applicable statutes
including,but not limited to,25-1-107,C.R.S.,as amended.
8. Monitoring
CDPHE's monitoring of this contract for compliance with performance requirements will be
conducted throughout the contract period by the TB Program's Assistant Manager. Methods used
will include review of documentation reflective of performance including progress reports,site
visits,and review of electronic data. The Contractor's performance will be evaluated at set
intervals and communicated to the contractor. A Final Contractor Performance Evaluation will be
conducted at the end of the life of the contract.
9. Remedies for issues of non-compliance
The contractor will be notified by email within 14 calendar days of discovery of a
compliance issue. Within 30 calendar days of discovery, the Contractor and
CDPHE will collaborate, when appropriate,to determine the action(s) necessary to rectify the
compliance issue and determine when the action(s) must be completed. The action(s) and time
line for completion will be documented by email and agreed to by both parties. If extenuating
circumstances arise that requires an extension to the time line,the Contractor must email a request
to the Assistant TB Program Manager and receive approval for a new due date. CDPHE will
oversee the completion/implementation of the action(s)to ensure time lines are met and the
issue(s)resolved. If the Contractor demonstrates inaction or disregard for the agreed upon
compliance resolution plan,CDPHE may exercise its rights under the Remedies section of this
contract.
To be attached to CDPHE Page 5 of 5 Revised 12/19/06
Task Order v1.0(11/05)contract template
Attachment G-1
Patient's Name REPORT OF VERIFIED CASE
Lash first) taco OF TUBERCULOSIS
Street Address PIR CODE)
U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES-
II4FORM APPROVED OMB NO.seta-was Epp.Date 05/31/2011
1����`� � REPORT OF VERIFIED CASE OF TUBERCULOSIS
1.Date Reported 3.Case Numbers
Year Reported(YYYY) State Code Locally Assigned Identification Number
Month Day Year State
Case Number -
,- - City/County
Case Number
2.Date Submitted Reason.
Linking State I ❑
Month Day Year Case Number L
Linking State En
Case Number
4.Reporting Address for Case Counting 8.Date of Birth
Month Day Year
City
Within City Limits(select one) ❑Yes ❑No
--i I 9.Sex at Birth(select one) 11.Race(select one or more)
County d ❑American Indian or
El Male 0 Female Alaska Native
— 10.Ethnicity(select one) ❑Asian:Specify
ZIP CODE ❑Black or African American
0 Hispanic or Latino ❑Native Hawaiian or
5.Count Status(select one) 6.Date Counted Other Pacific Islander:
Month Day Year Not Hispanic
Countable TB Case ❑or Latino Specify
El White
Count as a TB case
Noncountable TB Case 7.Previous Diagnosis of TB Disease(select one) 12.Country of Birth
"U.S.-born"(or born abroad to a parent who was a U.S.citizen)
Verified Case:Counted by (Set one) ❑Yes ❑No
another U.S.area(e.g.,county,state) ❑Yes ❑No
Country of birth:Specify
Verified Case:TB treatment
initiated in another country If YES,enter year of previous TB disease diagnosis: 13.Month-Year Arrived in U.S.
Specify Month Year
I_1 Verified Case:Recurrent TB within 12
months after completion of therapy
14.Pediatric TB Patients(<15 years old) 16.Site of TB Disease(select all that apply)
Country of Birth for Primary Guardian(s):Specify
Guardian 1 ❑Pulmonary ❑Bone and/or Joint
Guardian 2 0 Pleural El Genitourinary
Patient lived outside U.S.for>2 months? ❑Yes 0 No ❑Unknown El Lymphatic:Cervical ❑Meningeal
(select one)
If YES,list countries,specify: ❑Lymphatic:Intrathoracic CIPeritoneal
1
❑Lymphatic:Axillary ❑Other.Enter anatomic codes)
15.Status at TB Diagnosis(select one) (see list):
CI Lymphatic:Other 0 Site not stated 2
❑Alive ❑Deed Month Day Year
Cl Lymphatic:Unknown
3
If DEAD,enter date of death: ❑Laryngeal
If DEAD.was TB a cause of death?(select one)
❑Yes ❑No ❑Unknown
Public reporting burden of this collection of information is estimated to average 35 minutes per response,including the time for reviewing Instructions,saucing existing data sources.gathering and main-
taining the data needed and completing and reviewing the collection of information.An agency may not conduct or sponsor,arid a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number.Send comments regarding this burden estimate or'any other aspect of this collection of information,including suggestions to reducing this burden to CDC,
Protect Clearance Officer 1600 Clifton Road,MS D-74,Atlanta,GA 30333,ATTN:PRA(0920-0026).Do not send the completed form to this address.
Information contained on this form which would permit Identification of any Individual has been collected with a guarantee that it will be new in strict confidence,will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d)of the Public Health Service Act(42 U.S.C.242m).
CDC 72.9A Rev 09/15/2008 CS121321 1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Paget of 3
Page 1 of 6
Attachment G-1
Patient's Name State Case No. REPORT OF VERIFIED CASE
hash Per cm l.) OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
17.Sputum Smear(select one) Date Collected:
El Positive El Net Done Month Day Year _
❑Negative ❑Unknown
18.Sputum Culture(select one) Date Collected: Date Result Reported:
Month Day Year Month Day Year
❑Positive ❑Not Done
❑Negative ❑Unknown
Reporting Laboratory Type(select one): ❑Public Health rl❑Commercial ❑Other
Laboratory Laboratory
19.Smear/Pathology/Cytology of Tissue and Other Body Fluids(select one)
❑Positive ❑Not Done Date Collected: Enter anatomic code Type of exam(select all that apply)',
(see list):
Month Day Year
❑Smear ❑Pathology/Cytology
El Negative ❑Unknown
20.Culture of Tissue and Other Body Fluids(select one) Enter
anatomic code Date Result Reported:
❑Positive ❑Not Done Date Collected: (see list):
Month Day Year Month Day Year
❑Negative ❑Unknown
Reporting Laboratory Type(select one): ❑Public Health ❑Commercial El Other
Laboratory Laboratory
21.Nucleic Acid Amplification Test Result(select one)
❑Positive ❑Not Done Date Collected: Date Result Reported:
Month Day Year Month Day Year
❑Negative ❑Unknown
❑Indeterminate
Reporting Laboratory Type(select one):
Enter specimen type:❑Sputum ❑Public Health ❑Commercial
OR Laboratory Laboratory ❑Other
If not Sputum,enter anatomic code(see list):
Initial Chest Radiograph and Other Chest Imaging Study
22A.Initial Chest Radiograph ❑Normal ❑Abnormal'(consistent with TB) ❑Not Done ❑Unknown
(select one) ❑Yes ❑No El Unknown
'For ABNORMAL Initial Chest Radiograph: Evidence of a cavity(select one):
Evidence of miliary TB(select one):❑Yes ❑No ❑Unknown
22B.Initial Chest CT Scan or ❑Normal ❑Abnormal'(consistent with TB) ❑Not Done ❑Unknown
Other Chest Imaging ❑Yes ❑No El Unknown
Study(select one) 'For ABNORMAL Initial Chest Radiograph: Evidence of a cavity(select one):
Evidence of miliary TB(select one):❑Yes ❑No ❑Unknown
25.Primary Reason Evaluated for TB Disease
23.Tuberculin(Mantoux)Skin Test (select one)
at Diagnosis(select one)
Date Tuberculin Skin Test(TST)Placed: Millimeters(mm) ❑TB Symptoms
Month Day Year
❑Positive ❑Not Done of induration:
❑Negative ❑Unknown Abnormal Chest Radiograph(consistent with TB)
❑Contact Investigation
❑Targeted Testing
24.Interferon Gamma Release Assay Date Collected:
for Mycobacterium tuberculosis at Diagnosis Month Day Year ❑Health Care Worker
(select one) ❑Employment/Administrative Testing
❑Positive ❑Not Done ❑Immigration Medical Exam
❑Negative ❑Unknown Test type: ❑Incidental Lab Result
❑Indeterminate
Specify ❑Unknown
CDC➢2.9A Rev D9/15/2008 O5121321 1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2 of 3
Page 2 of 6
Attachment G-1
Patient's Name State Case No. REPORT OF VERIFIED CASE
(Last) (First) sail) OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
26.HIV Status at Time of Diagnosis(select one)
❑Negative ❑Indeterminate El Not Offered El Unknown
El Positive El Refused El Test Done,Results Unknown
If POSITIVE,enter:
State HIV/AIDS City/County HIV/AIDS
Patient Number: - Patient Number:
27.Homeless Within Past Year 28.Resident of Correctional Facility at Time of Diagnosis(select one) El No ❑Yes El Unknown
(select one) It YES,(select one): tf YES,under custody of
Immigration and Customs
El No El Yes ❑Unknown El Federal Prison El Local Jail El Other Correctional Facility Enforcement?(select one)
El State Prison ❑Juvenile Correction Facility El Unknown ❑No El Yes
29.Resident of Long-Term Care Facility at Time of Diagnosis(select one) El No El Yes El Unknown
If YES,(select one):
El Nursing Home ❑Residential Facility ❑Alcohol or Drug Treatment Facility El Unknown
El Hospital-Based Facility El Mental Health Residential Facility El Other Long-Term Care Facility
30.Primary Occupation Within the Past Year(select one)
❑Health Care Worker El Migrant/Seasonal Worker ❑Retired El Not Seeking Employment(e.g.student,homemaker,disabled person)
❑Correctional Facility Employee El Other Occupation ❑Unemployed ❑Unknown
31.Injecting Drug Use Within Past Year 32.Non-Injecting Drug Use Within Past Year 33.Excess Alcohol Use Within Past Year
(select one) (select one) (select one)
ID No El Yes ❑Unknown El No ❑Yes ❑Unknown El No El Yes El Unknown
34.Additional TB Risk Factors(select all that apply)
El Contact of MDR-TB Patient(2 years or less) ❑Incomplete LTBI Therapy ❑Diabetes Mellitus ❑Other Spec'&
El Contact of Infectious TB Patient(2 years or less) ❑TNF-a Antagonist Therapy El End-Stage Renal Disease ❑None
El Missed Contact(2 years or less) El Post-organ Transplantation El Immunosuppression(not HIV/AIDS)
35.Immigration Status at First Entry to the U.S.(select one)
El Not Applicable ❑Immigrant Visa ❑Tourist Visa El Asylee or Parolee
• "U.S.-born"(or born abroad to a parent who was a U.S.citizen) ❑Student Visa El Family/Fiance Visa ❑Other Immigration Status
• Born in 1 of the U.S.Territories,U.S.Island Areas,or U.S.Outlying Areas ❑Employment Visa El Refugee El Unknown
36.Date Therapy Started 37.Initial Drug Regimen(select one option for each drug)
No Yes Unk No Yes Unk No Yes Unk
Month Day Year ❑ El
Isoniazitl El ❑ El Ethionamide ❑ El 117Moxifloxacin
Rifampin El ❑ ElAmikacin 111 ❑ ElCycloserine ❑ ❑ ❑
Para-Amino El El
Pyrazinamide El ❑ El Kanamycin El El Salicylic Acid
Ethambutol El ❑ El Capreomycin El ❑ El Other El El ❑
Streptomycin El ❑ El Ciprofloxacin ❑ ❑ El Speciy
Rifabutin ❑ ❑ El Levofloxacin
El ❑ ❑ Other ❑ ❑ El
❑ ❑ ❑ Specify
Ritapentine ❑ El El Ofloxacin
Comments:
CDC 72.9A Rev 09/15/2008 05121321 1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 3 of 3
Page 3 of 6
Attachment 0-1
Patients Name REPORT OF VERIFIED CASE
vase {First) IMII OF TUBERCULOSIS
Street Address _ -
(Number,Street.City.Stale) (ZIP 00051
PITPA
0.5.DEPARTMENT OF ENTERS FOR DIE AN S CONTROL
CHEALTH AND HIUEASE CONTCES
AND PREVENTIOA 3033)REPORT OF VERIFIED CASE OF TUBERCULOSIS AT-D PREVENTION
FORM APPROVED OMB NO.0920-002e Exp.Date 05/51/2011
Initial Drug Susceptibility Report (Follow Up Report-1)
Year Counted State
Case Number
City/County
Case Number J
Submit this report for all culture-positive cases.
30.Genotyping Accession Number
Isolate submitted for genotyping(select one): ❑No ❑Yes
If YES,genotyping accession number for episode:
39.Initial Drug Susceptibility Testing
Was drug susceptibility testing done?(select one) ❑No ❑Yes ❑Unknown
If NO or UNKNOWN, do not complete the rest of Follow Up Report-I
If YES,enter date FIRST isolate collected for which drug susceptibility Enter specimen type: ❑Sputum
testing was done: OR
Month Day Year If not Sputum,enter anatomic code(see list):
40.Initial Drug Susceptibility Results(select one option for each drug)
Resistant Susceptible Not Done Unknown Resistant Susceptible Not Done I lnknnwn
Isoniazid ❑ ❑ ❑ ❑ Capreomycin ❑ ❑ ❑ ❑
Rifampin ❑ ❑ ❑ ❑ Ciprofloxacin ❑ ❑ ❑ ❑
Pyrazinamide 0 ❑ ❑ ❑ Levofloxacin ❑ ❑ ❑ ❑
Ethambutol ❑ ❑ ❑ ❑ Ofloxacin ❑ ❑ ❑ ❑
Streptomycin ❑ ❑ ❑ ❑ Moxifloxacin ❑ ❑ ❑ ❑
Rifabutin ❑ ❑ ❑ ❑ Otherouinolones ❑ ❑ ❑ ❑
Rifapentine ❑ ❑ ❑ ❑ Cycloserine ❑ ❑ ❑ ❑
Ethionamide ❑ ❑ ❑ ❑ Para-Amino Salicylic Acid ❑ ❑ ❑ ❑
Amikacin ❑ 0 ❑ ❑ Other ❑ ❑ ❑ ❑
Kanamycin ❑ ❑ ❑ ❑ Specify
Other ❑ ❑ ❑ ❑
Specify
Comments;
•
Public reporting burden of this collection of information is estimated to average 35 minutes per response,including the time for reviewing instructions,searching existing data sources,gathering and main-
taining the data needed and completing and reviewing the collection of information.An agency may not conductor sponsor,and a person is not required to respond to a collection of Information unless it
displays a currently valid OMB control number.Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden to CDC,
Protect Clearance Officer,1600 Clifton Road,MS D-74,Atlanta.GA 30333,ATTN:PRA(0920-0026).Do not send the completed form to this address.
Information contained on this form which would permit identification of any Individual has been collected with a guarantee that it will be held in strict confidence,will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 306(d)of the Public Hearth Service Act(42 U.S.C.242m1.
CDC 72.9B Rev 09/15/2009 CS121321 1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-1/Paget oft
Page 4 of 6
Attachment G-1
Patient's Name REPORT OF VERIFIED CASE
0.zet1 IFrs-tl i) OF TUBERCULOSIS
Street Address (ZIP CODE)
(Number.street,ant Stale)
ul�
U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE
U ERVICEL
I'// 'A AND PREVENTION(CDC)
REPORT OF VERIFIED CASE OF TUBERCULOSIS ORMAPPROVED OMB NO.0 NTAEzp.EDaeGIA30333 0--0
Case Completion Report (Follow Up Report-2)
Year Counted State
Case Number
City/County
Case Number
Submit this report for all cases in which the patient was alive at diagnosis.
41.Sputum Culture Conversion Documented(select one) ❑No ❑Yes ❑Unknown
If YES,enter date specimen collected for FIRST If NO,enter reason for not documenting sputum culture conversion(select one):
consistently negative sputum culture: ❑No Follow-up
Month Day
Year Sputum Despite Induction ❑Patient Refused ❑Patient Lost to Follow-Up
❑No Follow-up Sputum and No Induction ❑Other Specify
❑Died ❑Unknown
42.Moved
Did the patient move during TB therapy?(select one) ❑No ❑Yes
If YES,moved to where(select all that apply):
❑In state,out of jurisdiction(enter city/county)Speciy Specify
❑Out of state(enter state) Specify Specify
❑Out of the U.S.(enter country) Specify Specify
If moved out of the U.S.,transnational referral?(se/ect one) ❑No ❑Yes
43.Date Therapy Stopped 44.Reason Therapy Stopped or Never Started(select one)
❑Completed Therapy ❑Not TB If DIED,indicate cause of death(select one):
Month Day Year
❑Lost ❑Died ❑Related to TB disease ❑Unrelated to TB disease
❑Uncooperative or Refused ❑Other ❑Related to TB therapy ❑Unknown
❑Adverse Treatment Event ❑Unknown
45.Reason Therapy Extended>12 months(select a/I that apply)
❑Rifampin Resistance ❑Non-adherence ❑Clinically Indicated-other reasons
❑Adverse Drug Reaction ❑Failure El Other Specify
46.Type of Outpatient Health Care Provider(select all that apply)
❑Local/State Health Department(HD) ❑IHS,Tribal HD,or Tribal Corporation ❑Inpatient Care Only ❑Unknown
❑Private Outpatient ❑Institutional/Correctional ❑Other
Comments:
Public reporting burden of this collection of information is estimated to average 35 minutes per response,including the time for reviewing instructions,searching existing data sources gathering and main-
taining the data needed and completing and reviewing the collection of information.An agency may not conductor sponsor and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number.Send comments regarding this burden estimate or any other aspect of this collection of information.Including suggestions for reducing this burden to CDC,
Project Clearance Officer.1600 Clifton Road,MS D-74.Atlanta,GA 30333,ATTN:PRA(0920-0026).Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence,will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d)of the Public Health Service Act(42 U.S.C.242m).
CDC 72.9O Rev 09/15/2008 OS121321 1st Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-2/Pagel of 2
Page 5 of 6
Attachment G-1
REPORT OF VERIFIED CASE
Patient's Name
State Case No. OF TUBERCULOSIS
crass wit) IM,q
I�(1,4 U.S.DEPARTMENT OF ENTERS AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
REPORT OF VERIFIED CASE OF TUBERCULOSIS AND PREVENTION GEORGIA
30333
I"//�i ATLANTA,GEORGIA 30331
FORM APPROVED OMB NO.0940 W26 Em.Date 05131/2011
Case Completion Report - Continued (Follow Up Report-2)
47.Directly Observed Therapy(DOT)(select one)
0 No,Totally Self-Administered
❑Yes,Totally Directly Observed
Dyes,Both Directly Observed and Self-Administered
❑Unknown
Number of weeks of directly observed therapy(DOT)
48.Final Drug Susceptibility Testing
Was follow-up drug susceptibility testing done?(select one) ❑No ❑Yes ❑Unknown
//NO or UNKNOWN, do not complete the rest of Follow Up Report-2
If YES,enter date FINAL isolate collected for which drug susceptibility Enter specimen type: ❑Sputum
testing was done: OR
Month Day Year If not Sputum,enter anatomic code(see fist):
49.Final Drug Susceptibility Results(select one option for each drug)
esl t Susceptible Not Done Unknown Resistant susceptible Not Done Unknown
Isoniazid ❑ ❑ ❑ ❑ Capreomycin ❑ ❑ ❑ ❑
Rifampin ❑ ❑ ❑ ❑ Ciprofloxacin ❑ ❑ ❑ ❑
Pyrazinamide ❑ ❑ ❑ ❑ Levofloxacin ❑ ❑ ❑ ❑
Ethambutol ❑ ❑ ❑ ❑ Ofloxacin ❑ ❑ ❑ ❑
Streptomycin ❑ ❑ ❑ ❑ Moxifloxacin ❑ ❑ ❑ ❑
Rifabutin ❑ ❑ ❑ ❑ Other Quinolones ❑ ❑ ❑ ❑
Rifapentine ❑ ❑ ❑ ❑ Cycloserine ❑ ❑ ❑ ❑
Ethionamide ❑ ❑ ❑ ❑ Para-Amino Salicylic Acid ❑ ❑ El
Amikacinaci
❑ ❑ ❑ ❑ Other
❑ ❑ ❑ 0
Kanamycin ❑ ❑ ❑ ❑ Specify
Other ❑ ❑ O ❑
Specify
Comments:
•
Public reporting burden of this collection of information is estimated to average 35 minutes per response,including the time for reviewing Instructions,searching existing data sources,gathering and main-
taining the data needed and completing and reviewing the collection of information.An agency may not conduct or sponsor,and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number.Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden to CDC.
Protect Clearance Officer,1600 Litton Road,MS 0-74,Atlanta.GA 30333,ATTN'.PRA(0920-0026).Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence,will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d)of the Public Health Service Act 142 U S.C.242m).
CDC 72.93 Rev 09/15/2008 0S121321 let Copy REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-2/Page 2 of 2
Page 6 of 6
EXHIBIT H
BUDGET
\Feld County Public Health and Environment
Description, FundingSource Amount
Tuberculosis Control and Prevention State $53,400.00
Tuberculosis Control and Prevention Federal $4,250.00
Direct Observed Therapy State As Administered
($12.50 per onsite visit)
($25.00 per field visit)
Interferon Gamma Release Assay Federal $17,000.00
(1GRA)in select populations
(immigrants,refugees,close contacts,
o )
Totata l $74,650.00
T
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