HomeMy WebLinkAbout20111208.tiff RESOLUTION
RE: APPROVE AMENDMENT#5 TO TASK ORDER CONTRACT FOR COLORADO FAMILY
PLANNING INITIATIVE 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#5 to the Task Order Contract
for the Colorado Family Planning Initiative 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#5 to the Task Order Contract for the Colorado Family Planning
Initiative 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 16th day of May, A.D., 2011.
BOAR OF COUNTY COMMISSIONERS
,/. tz, WEL OUNTY RADO
ATTEST:
r 1861 ( �, sal.` Barbara Kirkmey r, Chair
Weld County Clerk to th.1:o- nOi.��s��
cY 4 Sean P on ay, Pro-Tem
BY:
Deputy Clerk to the Board��►►�'
F. G 'a
AP's D AS cx,A
David E. Long �I
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ou torney — uS
as/Rademacher
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Date of signature ✓/23///
�1 D rAoI��ala (>t: �- P 2011-1208
5- Iu- It x _31 _11 HL0038
18 6 2 0 Memorandum
TO: Barbara Kirkmeyer, Chair
i Board of County Commissioners
WELD--COUNTY FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
Environment
DATE: 4-29-11
SUBJECT: Amendment for Task Orders #5
Colorado Family Planning Initiative
Contract
Enclosed for Board review and approval is contract amendment#5 to a previously approved task
order 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 Colorado Family Planning Initiative
Program (CFPI).
If approved, the funding for this contract will allow the Department to provide comprehensive
family planning services with an emphasis on increasing the total number of men and women
accessing services and increasing utilization of long acting reversible methods of contraception
(LARC) among existing clients. This program compliments the Department's Title X Family
Planning Program.
The term of this contract is for 12 months ending on June 30, 2012. Funding for this amendment
period will not exceed $162,074.00. The funding is provided entirely by a private anonymous
donor through the State of Colorado. I recommend your approval of this contract.
Enclosure
2011-1208
STATE OF COLORADO
John W.Hickenlooper,Governor
Christopher E.Urbina,MD,MPH ,�.oc-cozk
Executive Director and Chief Medical Officer - '?
ya:a
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory Services Division `w
Denver.Colorado 80246-1530 8100 Lowry Blvd. 187s
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
06/13/2011
Weld County Department of Public Health and Environment
1555 North 17th Avenue
Greeley, CO 80631
Hi Ella Soderholm,
Enclosed is your copy of the fully executed Colorado Department of Public Health and Environment
Amendment listed below. You may begin work on 07/01/2011.
Contractor Name: Weld County Department of Public Health and Environment
Task Order Number: 12 FLA 29960
Original Contract Number: 09 I-LA UU684
Division: Prevention Services Division/PSD
Program Name: Colorado Family Planning Initiative/CFPI
Reason for Contract: Family Planning Initiative •
Please contact me with questions or concerns. My contact information is listed below.
Sincerely,
Jacqueline O'Bryan
Contract Manager
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
PSD-A4-FSU
Denver, CO 80246
303-692-2485
•
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
PSD-CFP1
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
12-29960
AMENDMENT FOR TASK ORDERS#5
This Amendment is made this 28th day of March 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), for the use and benefit of the WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND
ENVIRONMENT,whose address or principal place of business is 1555 North 17th 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
November 1,2008, with contract encumbrance number PO FLA FPP09000684,and contract routing number 09-
FLA-00684 as amended by Contract Amendment#1,09-FLA-00869, Grant Funding Change Letter#1, contract
routing number 09-FLA-00930,Contract Amendment#2,contract routing number 10-FLA-00247, Grant Funding
Change Letter#2, contract routing number 10-FLA-11214,Amendment for Task Orders#3,contract routing
number 11-FLA-15919,and Amendment for Task Orders#4,contract routing number 11-FLA-26088,collectively
referred to herein as the"Original Task Order Contract,whereby the Contractor was to provide to the State the
following:
Contractor will provide a comprehensive family planning program with an emphasis on
increasing the total number of men and women accessing services and increasing utilization
of long acting reversible methods of contraception(LARC)among existing clients.
The State promises to pay the Contractor the sum of One Hundred Sixty-Two Thousand,Seventy-Four Dollars,
($162,074.00)in exchange for the promise of the Contractor to continue to perform the work identified in the
Original Task Order Contract for the renewal term of 12 months,ending on June 30,2012.
NOW THEREFORE, in consideration of their mutual promises to each other,stated below,the parties hereto agree
as follows:
1. Consideration for this Amendment to the Original Task Order Contract consists of the payments and
services that shall be made pursuant to this Amendment, and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order
Contract,contract routing number 09-FLA-00684,as amended by Contract Amendment#1,09-FLA-
00869, Grant Funding Change Letter#1,contract routing number 09-FLA-00930,Contract Amendment
#2,contract routing number 10-FLA-00247, Grant Funding Change Letter#2,contract routing number 10-
FLA-11214,Amendment for Task Orders#3,contract routing number 11-FLA-15919,and Amendment
for Task Orders#4,contract routing number 11-FLA-26088,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
Page 1 of 5 Rev 3/16/2010
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:
A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified
by contract routing number 09-FLA-00684. 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 he performed by the Contractor during this renewal term is One Hundred Sixty-Two
Thousand,Seventy-Four Dollars,($162,074.00) for an amended total financial obligation of the
State of EIGHT HUNDRED FORTY-THREE THOUSAND,FOUR DOLLARS,
f$843,004.00). This is an increase of One Hundred Sixty-Two Thousand,Seventy-Four
Dollars,($162,074.00)of the amount payable from the previous term.The revised Additional
Provisions is incorporated herein by this reference and identified as"Exhibit L." The revised
Statement of Work is incorporated herein by this reference and identified as"Exhibit M". The
revised Budget is incorporated herein by this reference and identified as"Attachment M-1".
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.
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Page 3 of 5 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 COI NT) COMMISSIONERS OF STATE OF COLORADO
VNFLD COI-NTY(a political subdivision John W. H ickenlooper,Governor
of the state of Colorado)ti.r the use and benefit
of the MELD COI-\II DEPARTMENT OF
PI-BI.I( FIE ALTII \ND EN\-IRONNIF:N'1'
79--)By:
Signature of thorized fficer For the Executive Director
MAY 1 f COf1 DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT
Barbara Kirkmeyer
Print Name of Authorized Officer
Chair
Print Title of Authorized Officer
PROGRAM APPROVAL:
By: v
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.McD ott,C
2
By. WELD COUNTY DEPARTMENT OF
PUBLIC NEALTIH AND ENVIRONMENT
Date: /� BY: Y2 Zv65 t(
Mark E. Wallace, MD, MPH-Director
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Page 5 of 5 Rev 3/16/2010
EXHIBIT L
ADDITIONAL PROVISIONS
To Contract Dated 03/28/2011 -Contract Routing Number 12 FLA 29960
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified
above.
The revised Additional Provisions are effective July 1,2011.
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
Colorado Family Planning Initiative(CFPI)Cost Reimbursement Statement in a format acceptable to the
State. A CFPI Cost Reimbursement Statement is incorporated and made part hereof by reference.This
document is located at:
http://www.cdphestate.co.us/pp/womens,FPNursingConsntsForms.hnnl?colt=open. A Cost
Reimbursement Statement must be submitted within sixty(60) calendar days of the end of the billing
period for which services were rendered. CFPI Cost Reimbursement Statements must be accompanied by
detailed cost ledger to reflect all purchases being invoiced under that contract and should include date of
payment,payee name and amount,and check or voucher number,when available.Expenditures shall be in
accordance with the CFPI Budget,Budget Narrative and FY12 Estimated Funding Amounts attached
hereto as Attachment M-1 and the Statement of Work attached hereto as Exhibit M. These items may
include,but are not limited to,the Contractor's salaries, fringe benefits,supplies,travel,operating,
administrative costs which are allowable,and other allocable expenses related to its performance under this
Task Order Contract.
CFPI Cost Reimbursement Statements shall: 1)reference this Task Order Contract by its contract routing
number,which 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; and, 5)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.
CFP1 Cost Reimbursement Statements shall be sent to:
Fiscal Officer
Family Planning Program
Prevention Services Division
Colorado Department of Public Health and Environment
PSD-A4
4300 Cherry Creek Drive South
Denver,CO 80246
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 sixty (60)calendar
days from the effective expiration or termination date of this Task Order Contract.
4. The Contractor is authorized to make limited transfers of funds from one line item in its Budget to another
line item in its Budget but must notify the Program Director by email prior to the transfer. A transfer from
one line item to another line item may not exceed ten percent(10%)or One Thousand Dollars($1000),
which ever amount is more, of the total amount of the line item from which the transfer is made unless
prior written approval is received from the Program Director. If the Contractor desires to transfer more
than ten percent(10%)or One Thousand Dollars($1000),which ever amount is more, from one line item
in its budget to another line item in its budget then the Contractor shall request and receive prior written
approval from the Program Director by completing and submitting a Budget Revision Request Form,
To be attached to CDPHE Pagel of 3 Revised:4/1/04
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EXHIBIT L
incorporated and made part hereof by reference.This document is located at:
http:/'www.cdphe.state.co.us/pp/womens/FPNursingConsntsForms.hunl?col?—open.
5. The services or activities under this Contract may be carried out by the Contractor,or through subcontracts
with other providers or,through collaborative partnerships with other community partners. The State
authorizes the Contractor to subcontract some,or all, or the services that are to be performed under this
Contract. However,a subcontractor is subject to all of the terms and conditions of this Contract.
Additionally,the contractor remains ultimately responsible for the timely and satisfactory completion of all
work performed by any subcontractor(s)under this Contract. The Contractor shall maintain,at a minimum
a Memorandum of Understanding or other binding contractual agreement.The Contractor shall provide a
list of all current family planning subcontractors to the Family Planning Program Director within 15 days
of executing this Contract and any new subcontractors at least 15 calendar days prior to an agreement being
executed. The Contractor shall maintain records of any subcontractors for a minimum of three years.
6. Contractor agrees to provide services to all Program participants and employees in a smoke-free
environment in accordance with Public Law 103-227,also known as"the Pro-Children Act of 1994",(Act).
Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or
leased or contracted for by an entity and used routinely or regularly for the provision of health,day care,
early childhood development services,education or library services to children under the age of 18, if the
services are funded by Federal programs either directly or through State or local governments,by Federal
grant,contract,loan,or loan guarantee. The law also applies to children's services that are provided in
indoor facilities that are constructed,operated,or maintained with such Federal funds. The law does not
apply to children's services provided in private residences;portions of facilities used for inpatient drug or
alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or
Medicaid;or facilities where Women Infant and Children (WIC)coupons are redeemed. Failure to comply
with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to
$1,000 for each violation and/or the imposition of an administrative compliance order on the responsible
entity. By signing this Contract,the Contractor certifies that the Contractor will comply with the
requirements of the Act and will not allow smoking within any portion of any indoor facility used for the
provision of services for children as defined by the Act. The Contractor agrees that it will require that the
language of the Act be included in any subcontracts which contain provisions for children's services and
that all contractors shall sign and agree accordingly.
7. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are
carried out. That Act states that"no person in the United States shall on the ground of race, color,or
national origin, be excluded from participation in, be denied the benefits of,or be subjected to
discrimination under any program or activity receiving Federal financial assistance." The Office of Civil
Rights has concluded that it is the responsibility of any program which is a recipient of funds from the
Department of Health and Human Services to ensure that clients who do not speak or understand English
well,be provided interpretation services to ensure that the service provider and the client can communicate
effectively. The Contractor shall have policies and procedures to ensure that interpretation services are
available for clients with Limited English Proficiency and will advise such clients that an interpreter will be
provided for them. If a client has their own interpreter,they shall be advised that the Contractor will
provide an interpreter if the client so chooses.
8. The State may require forms attached to this contract and incorporated herein by reference by updated
during the term of this contract.The Contractor will be informed of the new forms as they are developed.
Forms may be sent to contractors or will be available on the Family Planning website:
httpahvww.cdphe.state.co.us/pp/womens Tam plan.htm1.
9. Notwithstanding anything herein to the contrary,the parties understand and agree that all terms and
conditions of this Task Order Contract and the exhibits and attachments hereto which may require
continued performance,compliance or effect beyond the termination date of this Task Order Contract shall
survive such termination date and shall be enforceable by the State as provided herein in the event of such
failure to perform or comply by the Contractor.
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EXHIBIT L
Funding adjustments may be made during the term of this contract.The State makes funding adjustments
on this contract using a Funding Letter substantially equivalent to Exhibit D of Original Contract and
bearing the approval of the State Controller or his designee;the funding letter shall not be deemed valid
until the State Controller or his designee has approved it.
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EXHIBIT M
STATEMENT OF WORK
To Contract Dated 03/28/2011 -Contract Routing Number 12 FLA 29960
I) The Contractor shall conduct a comprehensive family planning program("the program") in Weld county. This
program shall comply with section 1001 of the federal Act and all applicable federal regulations,as amended,
contained in Title X,42 C.F.R.,Subpart A, Part 59, as well as all applicable state regulations. (Federal funding
from HHS,CFDA#93.217 FP Services). The funding for this program will be spent in accordance with the
CFPI Budget,Budget Narrative and FY12 Estimated Funding Amounts attached hereto and referred to as
Attachment M-1.
2) The Contractor shall make its program available to men and women in their reproductive years and shall offer
the following services under the Title X family planning program:
A. Outreach services and/or other program efforts designed to improve client recruitment.
B. Nursing and medical services,which shall include a comprehensive health and social history and
physical examination administered in accordance with all applicable Title X regulations and,all
applicable nursing-medical policies or procedures which have been,or may be,established by the
State's Women's Health Unit(WHU).
C. Contraceptive information, education,and supplies regarding all family planning methods.
D. Education and counseling services regarding family planning, family planning methods,child
spacing, infertility, sterilization,nutrition, sexually transmitted diseases,Human immunodeficiency
virus(HIV)/Acquired immunodeficiency syndrome(AIDS),adolescent counseling and other related
health issues,as outlined in the Nursing and Administrative Manual.
E. Follow-up and/or referral services,as appropriate.
3) All money received by the Contractor from the State under the Colorado Family Planning Initiative(CFPI)shall
be used by the Contractor to provide contraceptive services. The Contractor shall make its program available to
men and women in their reproductive years and shall offer the following services under the CFPI:
A. Utilize CFPI funding to purchase long acting reversible methods of contraception and contraceptive
rings. These are limited to Intrauterine Devices (IUD) Mirena and Paraguard, contraceptive implants and
contraceptive rings.
B. Utilize CFPI funding to provide the referral process and cover the actual costs of tubal ligation and
vasectomy procedures.
C. Utilize CFPI funding for Family Planning staff to attend reproductive health related training with
preference to those related to long acting reversible methods of contraception.
D. Provide comprehensive family planning services to sustain the total number of qualifying family
planning clients (fertile clients receiving contraceptive services) receiving services, 2,208 clients, in
FY12; Pre-approved activities to include 1) Sustaining capacity; 2)Outreach; 3) Media and Marketing;
4) Training and Education; 5) Information Technology and Data Management; 6.) Third Party Billing
and Coding Resources; and 7)Other approved activities.
4) The services provided by the Contractor to the clients it serves shall be performed pursuant to law in accordance
with prevailing medical standard of care for the same or similar medical,nursing and professional services. The
services provided shall also comply with applicable Title X regulations,WHU nursing-medical policies and
To be attached to CDPHE Page 1 of 3 Revised:4/1/04
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EXHIBIT M
procedures,and any applicable fiscal or administrative policies of the State or Federal government which can be
located at http://www.cdphe.state.co.us/pp/womens/famplan.html?cot_"'=open. Contractor acknowledges that it
has reviewed these policies and procedures.
5) The Contractor shall provide the State's family planning program consultants and administrators with
reasonable access to its operations to perform: periodic site reviews,data reviews, fiscal reviews or other
evaluations of the Contractor's family planning program. Evaluations of the Contractor's program shall be
based on established standards and policies of the State or the Federal government. The Contractor shall
cooperate during all periodic site visits,data reviews,fiscal reviews or other evaluations conducted by the State.
The established standards and policies for the Family Planning Program can be located in the Family Planning
Administrative Manual and the Family Planning Nursing Manual located on the Family Planning website at
http://www.cdphc.state.co.us/pphvomens/famplan.html.
6) If necessary,the Contractor shall comply with all recommendations, including development and implementation
of a Performance Improvement Plan, made by the State's family planning program consultants and/or
administrators after a periodic site visit,data review, fiscal review or other evaluations that are necessary to
bring its program into compliance with all program requirements and applicable federal and state laws,policies
and regulations. The Contractor shall be in full compliance with a recommendation, if any,within three(3)
months of the date a recommendation is made by the State. If the Contractor cannot obtain full compliance
within this three(3)month period,then on or before the expiration date of that three(3)month period the
Contractor shall present sufficient written evidence to the State:to show that continuing progress is being made
towards full compliance;and,the date when full compliance shall occur. In no event,however,shall full
compliance with a recommendation occur any later than six (6) months after the date that a recommendation
was initially made by the State. Notwithstanding the foregoing provisions,the State may disregard these cure
periods and immediately terminate the contract without liability if it has solely determined that Contractor's
noncompliance places the health,safety or welfare of persons receiving services in jeopardy.
7) On a monthly basis,the Contractor shall collect and provide to the State,by the fifteenth calendar day of the
following month unless otherwise specified by CDPHE,all pertinent data as defined by CDPHE regarding all
services offered,and all family planning clients served, by its program during the preceding month, submitted
through the IRIS data system. This data shall be verified on a quarterly basis to help assure accuracy. The
Contractor must adhere to the Data Security, Use and Confidentiality Agreement(also known as the Secure
External User form),incorporated and made part hereof by reference.This document is located at:
http:/hvww.cdphe.state.co.us/pp/womens/FPNursingConsntsForms.htmI?colt=open. Contractor also agrees to
respond to other data requests required by the program.
8) During the term of this Contract,the Contractor agrees to provide the State with the semi-annual Family
Planning Expenditure/Revenue Reports.The Expenditure/Revenue Report(ERR) is located on pages 19-21 in
the Financial Management Section of the Family Planning Administrative Manual,this information can also be
accessed online on the CDPHE Family Planning website at
http:/'www.cdphe.state.co.us/pp/womens/firmplan.html . Final due dates will be specified by CDPHE.
9) The Contractor shall protect the confidentiality of all client records and other materials that are obtained,
created,or maintained by the Contractor under this contract. Except for purposes directly related to the
administration of this contract, no information about, or obtained from,any client shall be disclosed by the
Contractor in any form that would identify that client without the prior written consent of that client. As of the
acceptance date of this contract by the Contractor,the Contractor shall have written policies governing the
access to and,the duplication and dissemination of,all such information. The Contractor shall advise its
directors,officers,employees, agents, servants, and subcontractors, if any,that they are subject to these
confidentiality requirements.
I O) The services provided by the Contractor must be deemed acceptable, in good faith, by WI-1. For a service to be
"acceptable"it must comply with all applicable:Title X regulations, WH nursing-medical policies and
procedures,and any applicable fiscal and administrative policies and procedures of the State and Federal
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EXHIBIT M
government. All applicable Title X regulations, WH nursing-medical policies and procedures,and all
applicable fiscal or administrative policies of the State have been provided to the Contractor by the State as of
the effective date of this Contract.
II) During the term of this Contract,the Contractor agrees to provide the State with quarterly surveys,an Annual
Family Planning Work Plan and to submit semi-annual work plan progress reports by dates specified by
CDPHE.
12) The Contractor shall require any new family planning coordinator or fiscal staff working on Family Planning
Program services to participate in Fiscal Orientation within forty-five(45)days of employment.
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Attachment M-1
WORKSHEET
APPLICANT: Weld County Department of Public Health & Environmer
Federal Title X June 30, 2011 - June 29, 2012
FOR THE BUDGET PERIOD: State Title X July 1, 2011 - June 29, 2012
CFPI July 1, 2011 - June 30, 2012
Salary % Time CDPHE-WHU NON-CDPHE
Family Planning
JULY 1, 2011 - Program
Funding JULY 1,
PLEASE ROUND ALL FIGURES JUNE 30, 2012 2011 -JUNE 30,
TO THE NEAREST DOLLAR 2012
FTE
CFPI NON-CDPHE
PERSONNEL EXPENSES: (Include name&
title for each employee charged to CDPHE funding.
You do not need to list the name and title for
employees charged only to Non-CDPHE funding)
Office Technician II $21,305 77% $21,305
Office Technician III $50,201 150% $50,201
Medical Assistant $69,917 200% $69,917
MA Supervisor Kathy Dausch $23,224 60% $23,224
Isabelle Vasquez Operations Manager $13,214 25% - $13,214
PHN II Ella Soderholm $47,856 90% "t $47,$56
Laurie Dunn, Nurse Practitioner $82,505 100% :$20,193
Annette O'Dell,Nurse Practitioner $65,040 80% " $17,060
Terri Yetter,NP $76,577 100% $29,098 $45,946
NP Supervisor Cynthia Horn $66,179 70% $66,179
PH Nsg Supervisor Mary Lloyd-Cumley $16,257 25% $16,257
Nursing Director Debbie Drew $9,274 10% $9,274
Sub-total Salary Expenses $29,098 $400,626
Fringe Benefit Rate and Expenses=35.54 $10,341 $142,382
Total Personnel Expenses $39,439 $543,008
CONTRACTUAL: (Independent contractor for tuba) ligation, Essure,vasectomy,
physicians, nurse practitioners,etc. In CFPI portion ONLY,add referral fee in this
section.
Women's Clinic of Greeley $80,000
Radiology $20,000
WCDPHE
referral fees $4,000
Page 1 of 4
Attachment M-1
Total Contractual Expenses $104,000 $0
OPERATING:
Contraceptive Methods(for CFPI portion ONLY, 10%admin fee can be
included in this line.) $13,191 $38,000
Training costs-which includes registration fees,travel $1,500 ,.$4,000
Chlamydia tests $1,000
Other Lab tests $34,000
;Educational materials(brochures, etc) $2,500
'Clinical supplies ''$31,000
Office operating supplies(papers,charts,pens,etc) $5,000
Office expense(rent, utilities,maintenance)
OTHER(Specify)Mileage $6,000
Electronic Medical Records $75,000
North Colorado Health Alliance membership , ";$10,000
Total Operating Expenses $14,691 , ' $206;500
EQUIPMENT: (Computers, Office furnitures)
Total Equipment Expenses $0 *. ��,N °�: $0
TOTAL DIRECT EXPENSES $158,130 $749,508
INDIRECT:
Indirect rate: 12.63% Indirect Expense
ADMINISTRATIVE (10% CFPI Sustainability Grant. Do NOT calculate the
10%admin rate on one-time expenes, contraceptive methods,training, or
contractors for tubals,Essure, vasectomy, etc) $3,944
ONE-TIME EXPENSE (For CFPI Sustainability Grant only)
TOTAL AMOUNT REQUESTED $162,074 ' $749,508
Page 2 of 4
Attachment M-1
BUD
GET NARRATIVE ... :: :.. ..:: . :: ; .
- FY12 CFPI Methods,Training and Sustainability
APPLICANT: Weld County Department of Public Health & Environment
FOR THE PERIOD: July 1,2011 -June 30,2012
For Personnel category list title of
position
Relationship to project How is the total amount required Total
For all other categories list the line calculated?
item from the budget
PERSONNEL EXPENSES: $39,439.00
Terri Vetter NP Provides Direct care and outreach n, Approx..38 Annual salary of$76,577 $29,098.00
2 sites
Fringe I3enefit rate&expenses .09%unemployment, 2.3%sick 10.49%health insurance $10,341.00
.08%Workman's compensation, 4.61%vacation, 4.23%holiday
11.9%PERA,.39%life insurance 1.45%Medicare,
CONTRACTUAL SERVICES: 4 $104,000.00
Women's Clinic Greeley Provide Essure insertions for our clients 40 insertions @$2,000.00/insertion $80,000.00
Physicians
NCMC HSG's Post Essure HSG testing 40 procedures r $500.00 each $20,000.00
WCDPHE referral fee referral fees for Essure procedures 40 referrals at$100.00 each $4,000.00
OPERATING EXPENSES: - $14,691.00
\R C Purchase Nuvaring $13,191.00
Mirena,Paragard,Implanon
Training NP&RN registration to relevant trainings $300.00/5 staff $1,500.00
ADMINISTRATIVE EXPENSES: $3,944.00
Calculated at 10%of$39,439 3944
ONE-TIME EXPENSES: SO 00
Total Project Costs: $162,074.00
•
Page 3 of 4
Attachment M-1
Colorado Family Planning Initiative (CFPI)
FY12 ESTIMATED FUNDING AMOUNTS
FOR BUDGET WORK SHEET AND BUDGET NARRATIVE
AGENCY NAME: Weld County Department of Public Health and Environment
FUNDING SOURCE AMOUNT FUNDING PERIOD
CFPI Methods, Tubal $117,191 July 1, 201 1 —June 30, 2012
Ligations & Vasectomies
CFPI CFPI Training $ 1,500 July 1, 201 I -June 30, 2012
CFPI Sustainability Grants $43,383 July 1,2011 —June 30, 2012
TOTAL CFPI $162,074
#of Total Clients 2208
Page 4 of 4
1 661 20 1 1 Memorandum
TO: Office of Clerk to the Board to the
Weld County Commissioners
W E L DEC O U N T Y FROM: Administration Division-Department of
Public Health and Environment
DATE: June ao, (90 ) l
SUBJECT: Cr P I Con-iRact
Attached to this memo is the finalized contract that the Health Department has received.
Please sign and date below indicating you have received the finalized contract and return
this signed memo to the Administration Division of the Health Department.
Please send the confirmation receipt to my attention. Thank you for your assistance with
the processing of this document.
ATTN: Li( jQU
Contract Name: COl0Rad0 FQmLIN PI0nnin1LUnL1u11 Vt.
-Amendment ids
Resolution Number: (PO)) J (D0 2S
Finalized Contract Received By:
Date Received: Le -,,-A - VI
Enclosure
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