HomeMy WebLinkAbout20102603.tiff RESOLUTION
RE: APPROVE COLORADO IMMUNIZATION PROGRAM STATEMENT OF WORK FOR TDAP
COCOONING PROJECT EXPANSION 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 Colorado Immunization Program
Statement of Work for the Tdap Cocooning Project Expansion, utilizing American Recovery and
Reinvestment Act(ARRA) Funding, 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,
commencing October 15, 2010, and ending September 30, 2011, with further terms and conditions
being as stated in said statement of work, and
WHEREAS, after review, the Board deems it advisable to approve said statement of work, 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 Colorado Immunization Program Statement of Work for the Tdap
Cocooning Project Expansion, utilizing American Recovery and Reinvestment Act(ARRA) Funding,
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 be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said statement of work.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 1st day of November, A.D., 2010, nunc pro tunc October 15, 2010.
BOARD OF COUNTY COMMISSIONERS
1 - LD COUNTY, •LORADO
C
ATTEST: /� y �ti , J--
X61 +. gl.sRademaiher, 'hair
Weld County Clerk to the -`:r. Ol ��Pr
j \z rbara Kirkme e , Pro-Tem
BY: �1 7/
Deput lerk to tie Board
Sean P. Co
AP FORM: ( //( ( c
Wil ' F. Garcia
County At orney G c. 4—
David E. Long U
Date of signature: I �l��iu VVVV
On 4 I-O 77;4&- ' /4-L - P 2010-2603
/ /_ /- 10 II- I "7- jO HL0037
Memorandum
TO: Douglas Rademacher, Chair
Board of County Commissioners
' C FROM: Mark E. Wallace, MD, MPH, Director Department of Public Health and
Environment
COLORADO DATE: October 28, 2010
SUBJECT: CIP-ARRA Immunization Grant: Tdap
Cocooning Project Statement of Work
Enclosed for Board review and approval is a statement of work for the CIP-ARRA Immunization
Grant between the Colorado Department of Public Health and Environment (CDPHE) and the
Weld County Department of Public Health and Environment(WCDPHE). If approved and
signed, this statement of work will define the services WCDPHE will provide for this project.
The funding will cover public health nurse hours, vaccine administration, promotion and clinic
supplies used to administer Tdap vaccine to parents, grandparents, siblings and other close
caregivers of babies. The intent is to keep babies safe from Pertussis or whooping cough by
vaccinating those who are in close contact with them on regular basis.
The term of the grant is October 15, 2010 through September 30, 2011 for the amount of
$24,000.00. This funding is through the American Recovery and Reinvestment Act (ARRA) as
administered through the Colo9rado Immunization Program (CIP) at the CDPHE. I recommend
your approval of this statement of work.
Enclosure
2010-2603
STATE OF COLORADO
Bill Ritter,Jr.,Governor
Martha E.Rudolph,Executive Director .0! cotoR
Dedicated to protecting and improving the health and environment of the people of Colorado
t.
4300 Cherry Creek Dr.S. Laboratory Services Division
Denver,Colorado 80246-1530 8100 Lowry Blvd. r refs
Phone(303)692-2000 Denver,Colorado 80230-6928
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located In Glendale,Colorado of Public Health
http://www.cdphe.stale.co us and Environment
2010-2011
American Recovery and Reinvestment Act(ARRA)
Colorado Immunization Program (CIP)
Statement of Work
Agency Name: Weld County Department of Public Health and Environment
ARRA-funded Project: Tdap Cocooning Project Expansion
The Colorado Immunization Program (CIP) will incorporate American Recovery and Reinvestment
Act (ARRA) resources to increase the number of children and adults vaccinated against vaccine-
preventable diseases. CIP will utilize the ARRA funds to enhance existing strategies that have been
shown to be effective in raising immunization coverage and reducing vaccine-preventable disease
(VPD) morbidity and mortality. Through local government, community-vaccinators, and partners CIP
will engage in innovative strategies to reach populations not currently being reached.
All programs financed with ARRA funds will be seen as supplemental to existing immunization
programs and will not be allowed to hinder or replace current State operations funded by the VFC and
317 grants.
Grant Information:
Funding period 10/15/10 — 9/30/11
Starting the project Work is not to begin on the proposed project until the grantee receives an
approved contract or purchase order from the CIP.
ARRA-required All ARRA funded projects are required to comply with the Federal and
reporting CDPHE ARRA grant reporting requirements.
Monthly online progress reports are due the last working day of each month
for that month's activities. The online link to the monthly report is:
The online link to the monthly report is:
http://fs8.formsite.com/cohealth/CI PARRAmonthlvreport/index.html
Additional follow-up contact will be made periodically by the CDPHE CIP
contract monitor.
ARRA-required terms All contracts and grants involving the use of ARRA funds must include
and conditions certain provisions. These provisions can be viewed in the attached
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document entitled "State of Colorado Supplemental Provisions for Contracts,
Grants, and Purchase Orders Using Funds Provided under the American
Recovery and Reinvestment Act of 2009 As of 8-21-09".
Project monitoring Throughout the funding period, the CIP will conduct ongoing project
monitoring and provide technical assistance as needed. In the event that
project performance does not meet the agency's stated goals, a follow-up
work plan will be created and additional technical assistance will be
provided. In an extreme situation, and in consultation with the agency, the
CIP reserves the right to reduce or withhold quarterly payments due to poor
project performance.
Required CIIS use All projects will utilize the Colorado Immunization Registry (CIIS) to track
doses administered.
Payments Contractor will invoice the CIP quarterly using the invoice provided (invoice
located at the end of the document).
Project continuation The possibility exists for this project to be continued in future years if funding
allows.
1. Please provide the following information:
Agency name Weld Count% Department of Public Health and Environment
Agency mailing address 1555 N. 17` Ave.
Phone number 970-304-6420
Fax number 970-304-6416
Today's date 09/01/10
2. Who is the contact person for this project?
Name Samantha Orozco
Phone number 970-304-6420 Ext. 2308
Email address sorozco@co.weld.co.us
3. Project Plan:
A. Goal: (intended outcomes of the plan - can be more than one)
B. Objective(s): (events/actions that lead to the goal - clear and measurable)
Write your objectives using the SMART objective process:
Specific: Identifies a specific event/action that will take place
Measurable: Identifies (measures) the amount of change to be achieved
Achievable: The objective is achievable and realistic
Relevant: The objective is logical and relevant to the overall goal
Time-phased: List a time by which the objective will be achieved
C. Steps/Activities to accomplish the objective(s): (outline steps to meet each objective)
D. Measurement of objective accomplishment: (how will you know the objective is
accomplished?)
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Ob'ective #1-1: Tda. vaccine will be offered and administered to clients visitin. the Famil
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Planning clinic, Sunrise Prenatal Program, Southwest Weld County Family
Planning Clinic, Sunrise WIC Program, South County WIC Program, and
Envision. The minimum number of clients to be immunized will be seven per
week.
Steps/Activities 1. Client will visit provider in the Clinic's described in Objective #1-1.
2. Provider will assess client's Tdap immunization status.
3. If Tdap vaccine is recommended for client, provider will contact
immunization coordinator or immunization nurse to administer vaccine.
4. Immunization Coordinator will provide Vaccine Information Statement,
obtain consent, and administer Tdap vaccine the day of the visit.
If the client is pregnant, a voucher will be given to the client to schedule an
appointment for Tdap vaccine after delivery.
How will you know The objective will be met by meeting the goal of immunizing a minimum of seven
the objective is clients per week (364 clients by the end of the grant cycle) with Tdap vaccine.
met?
Objective #1-2: A voucher for Tdap vaccine will be offered to family members of all clients
receiving Tdap vaccine in Family Planning Clinics, Prenatal Clinic, WIC clinics,
and Envision with a focus on those who have regular contact with infants and
children. A minimum of 1000 vouchers will be distributed.
Steps/Activities 1. Immunization Coordinator will ask the client about immunization status of
spouse/partner and other caretakers of children.
2. A voucher will be given to the client to present to family members with
close contact to infants and children.
3. Family members may call and schedule an appointment in immunization
clinic to receive Tdap The vaccine at no cost.
How will you know The objective will be met when all 1000 vouchers or more are distributed. Our
the object is met? objective will be measured by the number of vouchers redeemed and number of
doses of Tdap vaccine administered in immunization clinic, which will be tracked
on a spreadsheet.
Objective #1-3: Tdap vaccine will be offered and administered to parents/legal guardians of
children under age 2 during the children's routine immunization visits at the
Health Department (North and Southwest Weld County sites), as well as
family planning visits. A minimum of seven doses of Tdap vaccine will be
administered per week (364 doses by the end of the grant cycle) at no cost.
Steps/Activities 1. Parent or legal guardian visits immunization clinic with child or children
under age 2.
2. Immunization nurse will assess Tdap immunization status of parents/legal
guardian along with immunization status of child.
3. If Tdap is recommended, VIS will be given, consent will be obtained,
immunization nurse will administer Tdap vaccine during the visit at no cost
to the adult(s) accompanying child.
4. Parent or legal guardian visits family planning clinic. Nurse practitioner will
contact on-call nurse to assess Tdap immunization status
5. If Tdap is recommended, VIS will be given, consent will be obtained,
immunization nurse will administer Tdap vaccine during the visit at no cost
to the adult.
How will you know A minimum of seven doses of Tdap per week will be administered to parents of
the objective is children under the age of two in immunization clinic.
met?
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a �� eisttie We Pneumococcal vaccine, along with Tdap vaccine,
Objective#2-1: Meningococcal, HPV4, and will
be offered and administered to adult client visiting the Family Planning Clinic,
Southwest Weld County Family Planning Clinic, and Adult Immunization Clinic.
The minimum number of clients to be immunized will be seven per week.
Steps/Activities 1. Client will visit provider in the Clinic's described in Objective #2-1.
2. Provider will assess client's Meningococcal, HPV4, and Pneumococcal
(PPSV23) immunization status based on ACIP recommendations.
3. If Meningococcal, HPV4, and Pneumococcal vaccine is recommended for
client, provider will contact immunization coordinator or immunization
nurse to administer vaccine.
4. Immunization Coordinator will provide Vaccine Information Statement,
obtain consent, and administer Meningococcal, HPV4, and Pneumococcal
vaccine, along with Tdap, the day of the visit.
If the client is pregnant, a voucher will be given to the client to schedule an
appointment for Meningococcal, HPV4, and Pneumococcal vaccine, as well as
Tdap, after delivery.
How will you know The objective will be met by meeting the goal of immunizing a minimum of seven
the objective is clients per week (364 clients by the end of the grant cycle) with Meningococcal,
met? HPV4, and Pneumococcal, along with Tdap vaccine at no cost.
Objective #2-2: A voucher for Meningococcal, HPV4, and Pneumococcal vaccine will be created
and distributed to the Adult population receiving Meningococcal, HPV4, and
Pneumococcal vaccine in Family Planning Clinics, Adult Immunization clinics,
and Envision, with a focus on adults who have risk factors indicating need for
vaccination. Tdap will also be incorporated with the voucher. A minimum of
1000 vouchers will be distributed.
Steps/Activities 1. Immunization Coordinator will ask the client about immunization status of
spouse/partner and other relatives/friends.
2. A voucher will be given to the client to present to family/friends that have
risk factors indicating need for vaccination.
3. Adults at risk may call and schedule an appointment in immunization clinic
to receive Meningococcal, HPV4, and Pneumococcal vaccines, along with
Tdap. Each vaccine at no cost.
How will you know The objective will be met when all 1000 vouchers or more are distributed. Our
the object is met? objective will be measured by the number of vouchers redeemed and number of
doses of Meningococcal, HPV4, and Pneumococcal vaccines, along with Tdap
administered in immunization clinic, which will be tracked on a spreadsheet.
4. Timeline: List the monthly activities your agency plans to complete to meet your goal(s) for this
project.
Description of the planned activities Additional comments
Oct 2010 Tdap, Meningococcal, HPV4, and Pneumococcal Vouchers October is generally a busy time for
will be ordered and printed in English and Spanish, a kit Immunization clinics.
containing consents, VIS and vouchers will be assembled for
Clients. Tdap,Meningococcal, HPV4, and Pneumococcal
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vaccine will be ordered and in stock. We will then begin
assessing need and offering Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine to clients visiting the Health
Department. A monthly tally will be obtained with the number
of doses of Tdap, Meningococcal, HPV4, and Pneumococcal
vaccine administered for each objective.
Nov Tdap,Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children, as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
Dec Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children, as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
Jan 2011 Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children, as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap,Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
Feb Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children, as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
Mar Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children,as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
April Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children, as well
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as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
May Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children, as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
June Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children, as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap,Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
July Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children,as well
as relatives and friends eligible for Meningococcal, HPV4, and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
August Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children,as well
as relatives and friends eligible for Meningococcal, HPV4,and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
Sept Tdap, Meningococcal, HPV4, and Pneumococcal vaccine will
be offered and administered, according to the detailed
objectives, daily and vouchers will be presented to clients to
give to family members with close contact to children,as well
as relatives and friends eligible for Meningococcal, HPV4,and
Pneumococcal vaccine. A monthly tally will be obtained with
the number of doses of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccine administered for each objective.
5. Collaboration: Please list the providers, community groups, networks, agencies, etc. who will
be your collaborators with this project. Indicate the specific role each will play.
6
Care providers in our clinics will assist to identify clients in need of Tdap, Meningococcal, HPV4, and
Pneumococcal vaccines and contact immunization coordinator. The Immunization coordinator will be
the main contact to plan and implement the project. Immunization nurses will administer Tdap,
Meningococcal, HPV4, and Pneumococcal vaccines in immunization clinic. Nursing students from the
University of Northern Colorado will assist with data collection and administering of vaccine under the
supervision of the Immunization Coordinator. The Immunization Coalition of Weld County, WIC, and
Envision will provide support and collaboration with this project by promoting immunizations to all
community members across the lifespan.
6. Barriers: What problems must be solved or obstacles overcome to commence and/or to
complete the project? How do you plan to address them?
1. One potential barrier that may exist will be communication between providers and the
Immunization Coordinator. Due to clinic flow and time constraints, it may be a challenge for
providers to take the time to coordinate Tdap, Meningococcal, HPV4, and Pneumococcal
vaccine administration during their clinic. It will be a change process for their clinic flow.
2. Another potential barrier in immunization clinic will be that the nurse may not have enough time
during the child's visit to immunize both, the parent and the child, or that the parent may refuse
the vaccine.
The Immunization Coordinator will make the process simple for the provider and be available as
needed to administer vaccine. The Immunization Coordinator will educate clinic staff about the
importance of protecting people of all ages from Pertussis, Meningococcal, HPV, and Pneumococcal
diseases. In the event that there is not enough time to administer the vaccine to the adult
accompanying the child, a voucher will be given so that the client can return to the clinic at their
convenience to receive the vaccine.
7. Evaluation: All funded agencies are required to have a detailed evaluation plan in place at the
time of application. A final comprehensive evaluation report will be submitted by the grantee at the
end of the project period, Include your project evaluation plan here and ensure it includes the
following information:
A. What specific aspects of the program will be evaluated when judging project performance?
> We will evaluate the number of doses of Tdap, Meningococcal, HPV4, and Pneumococcal
vaccine administered for the three separate listed objectives under each goal to assess
whether or not the goal was met.
> We will evaluate the effectiveness and convenience of working with other programs in our
facility and within our own children's and adult immunization program to immunize adults
with Tdap, Meningococcal, HPV4, and Pneumococcal vaccines.
> We will evaluate the number of family members/adults with vouchers who visit our clinic for
the Tdap, Meningococcal, HPV4, and Pneumococcal vaccines to assess whether or not
this method is effective.
B. What standards (i.e. type or level of performance) must be reached for the project to be
considered successful (overall target performance measures)?
> By the end of the grant cycle, we will have administered the minimum number of doses
(364 of Tdap and 468 total of Meningococcal, HPV4, and Pneumococcal) of Tdap,
Meningococcal, HPV4, and Pneumococcal vaccines to adults who care for children under
the age of 2 and adults at risk for disease.
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C. Include process measures (description of the extent to which the project was implemented
according to the project plan).
> The doses administered will be tracked and counted to measure progress
D. Conclusions (analyze data/results, interpret results, judgment, recommendations)
> Data results will be presented in a report based on the three primary objectives states in
each goal; each objective will be evaluated and judged for success/failure by the number of
doses administered; recommendations will be made for future planning for the most
effective way to immunize adults with Tdap, Meningococcal, HPV4, and Pneumococcal
vaccines.
E. Ensure use and lessons learned (feedback, follow-up, dissemination)
> Feedback will be obtained from clinic staff regarding the utilization of their clinic time to
administer vaccine. Feedback will be obtained from immunization staff about administering
adult Tdap, Meningococcal, HPV4, and Pneumococcal vaccines during child visits.
Feedback will be obtained from our evaluation results.
> Follow-up plans will take place for continuing/discontinuing use of both clinic time and space
for administering Tdap, Meningococcal, HPV4, and Pneumococcal vaccines and Child
immunization clinic time for administering Tdap, Meningococcal, HPV4, and Pneumococcal
vaccines. Follow-up plans will take place regarding the success of voucher use for clients,
as well.
> Information will be disseminated among all providers and stakeholders involved with the
coordinated Tdap, Meningococcal, HPV4, and Pneumococcal efforts.
F. What is the future plan for using the project process and outcome data to improve immunization
services?
> If the project is successful, and the minimum number of Tdap (364), Meningococcal (209),
HPV4 (209), and Pneumococcal (50) doses as stated in our objectives is administered, our
future planning may include continuing the project beyond the grant cycle if funds are
available to permit continuation. The Pneumococcal vaccine has strict guidelines who is
eligible to receive, including smokers, individuals with asthma, and those with
immunocompromised conditions. The amount of vaccine being requested for
Pneumococcal will be less than the Tdap, Meningococcal, and HPV vaccines.
8. Budget
Expenses Describe in detail Proposed Local Total
funding Budget
In-kind
Personnel Nurse #1- 12 hours per week FTE nurse time $19,973.45
Travel Outreach clinics to two WIC clinics in Evans, $43.47
CO and one outreach clinic to Envision in
Evans, CO
Marketing 0
Incentives In-staff promoting incentives for project. $470
Equipment Immunization supplies-Needles, Bandaids, $300
Cotton balls, Alcohol swabs, sharps cont.
Office General office supplies: $1260
supplies $600 for printing supplies (this includes
brochures and advertisement fliers)
$400 for paper (consent forms, VIS
information, etc.)
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$260 for items including pens, ice, coolers
(for transport purposes), and stickers.
Indirect 13.39% $2952.08
Other
Ta4al `; s� i ,: + ; z f:"o 4,. :*$24,999:00 .titagAtit S . u . ,__
9. Any additional information you'd like to add? None
10. ARRA-specific deliverables:
Proposed # of vaccine types/doses to be administered Tdap: 364
Meningococcal: 200
HPV4: 200
Pneumococcal: 50
Amount of each vaccine type listed above you have 100-Tdap
available from previous ARRA project
Anticipated vaccine need for this project (type/doses) Tdap: 350
Meningococcal: 200
HPV4: 200
Pneumococcal: 50
All administered doses will be tracked in CIIS Yes
Number of FTE/jobs created for the project period
Number of FTE/jobs retained for the project period Nurse 1: 0.3
The number of jobs created/retained can be calculated as:
FTE= Cumulative Hours Worked that were funded by the Recovery Act
Cumulative Hours in a Full-time Schedule
Examples:
A person working full-time for 1 year= 1 FTE.
A person working half-time for 1 year= .5 FTE.
A person working full-time for 3 months = .25 FTE.
LOCAL HEALTH PARTNER ACCEPTANCE OF THE 2010-11 American Recovery and Reinvestment
Act (ARRA) Colorado Immunization Program (CIP) Statement of Work requirements:
] Douglas Rademacher , on behalf of
the Board of Weld County Commissioners
hereby acknowledge that the requirements for the above-named Immunization Service Purchase Order have
been reviewed, and are accepted and agreed to. I further acknowledge that I have the necessary authority to
sign this acceptance on behalf of the entity mentioned above.
�� Our( (Lie Chair 11/01/2010
Signatup�� � Title Date
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2010-11 CIP ARRA Project Invoice
Agency name:
Today's Date:
Invoice #:
Billing period:
TO: Teri Lindsey (teri.lindsey@state.co.us)
Colorado Department of Public Health& Environment/Immunization Program
4300 Cherry Creek Drive South
DCEED-IMM-A3
Denver, CO 80246-1530
303-692-2732 303-691-6118 (fax)
EXPENSES DESCRIPTION AMOUNT
Personnel
Travel
Marketing
Incentives
Equipment
Office Supplies
Indirect
Other TOTAL DUE
Agency name: Weld County Department of Public Health and Environment
Address:
City:
State: Colorado
Zip Code:
Agency Tax ID#:
Name of agency staff authorized to complete this invoice:
Purchase order#/Contract#:
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