HomeMy WebLinkAbout20102363.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR VARIOUS PROGRAMS AND AUTHORIZE
CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with a Task Order Contract for the Maternal and
Child Health (MCH) Program, the Teen Motor Vehicle Safety Program, the DRIVE SMART Weld
County Program, the Tailgate the Safety Way Community Event, the Prevent Alcohol and Risk-
related Trauma in Youth Program (P.A.R.T.Y.), and the Health Care Program for Children with
Special Needs between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment, and the Colorado Department of Public Health and Environment, commencing
October 1, 2010, and ending September 30, 2011, with further terms and conditions being as stated
in said contract, and
WHEREAS, after review, the Board deems it advisable to approve said contract, a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Task Order Contract for the Maternal and Child Health (MCH) Program,
the Teen Motor Vehicle Safety Program,the DRIVE SMART Weld County Program,the Tailgate the
Safety Way Community Event, the Prevent Alcohol and Risk-related Trauma in Youth Program
(P.A.R.T.Y.), and the Health Care Program for Children with Special Needs between the County of
Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on
behalf of the Weld County Department of Public Health and Environment, and the Colorado
Department of Public Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said contract.
Le. iit - P
2010-2363
cvuj4oTck«- /u- -/D //- /p /0 HL L00370037
TASK ORDER CONTRACT FOR VARIOUS PROGRAMS
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 6th day of October, A.D., 2010, nunc pro tunc October 1, 2010.
BOARD OF COUNTY COMMISSIONERS
.,I�/ ELD COUNTY COLORADO
ATTEST: "5i1 r' 00 ti's at..—S 7
gl. Rademacher hair
Weld County Clerk to the Bo.�. 5• _Pin' jr
� rbara Kirkmeyer) Pro-Tem
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Dep Clerk t e Board
Sean . Co
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linty Attorney
David . Long
Date of signature: IL kilt°
2010-2363
HL0037
Memorandum
("t TO: Douglas Rademacher, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH
ODirector, Department of Public44e�l
and Environment \�1 � Q Y
COLORADO DATE: September 13, 2010
SUBJECT: Task Order Contract for the MCH
Prenatal and Adolescent Health & Injury
Prevention Programs and the HCP
Program
Enclosed for Board review and approval is task order contract between the Weld County Board of
Commissioners on behalf of the Department of Public Health and Environment (WCDPHE) and the State of
Colorado through the Colorado Department of Public Health and Environment for the Maternal and Child
Health (MCH) Program, Adolescent Health and Injury Prevention and the Health Care Program for
Children with Special Needs.
The task order issued pursuant to Master Contract made on 1-23-07 is to provide continuation funding to
facilitate the development and enhancement of community-based systems of care.
1. Prenatal $117,235: The task order will be used to address the MCH performance measures for
Weld County and the State of Colorado and to help ensure all families have access to direct care
services. For these services, Weld County will be reimbursed an amount not to exceed $117,235.
This funding is all pass through funding from the federal government.
2. Adolescent Health & Injury Prevention $42,376:
The funding for Adolescent Health is directed to the Teen Motor Vehicle Safety program and the
successful program of DRIVE SMART Weld County to help meet their goal of decreasing deaths
and injuries from motor vehicle crashes. The program will support the DRIVE SMART Weld
County community traffic safety coalition; assist with coordinating the Tailgate the Safety Way (a
community-wide traffic safety event focusing on teens and parents) community event; continue
providing P.A.R.T.Y. (Prevent Alcohol and Risk-related Trauma in Youth) programs to students at
Weld County high schools; provide classes for parents and teens about graduated driver's licensing
laws (GDL); work with student groups to plan and coordinate seat belt pledge drives and no texting
while operating a motor vehicle drives in Weld County High Schools; collaborate with NCMC to
offer car seat installation services for all families of newborns; and offer community wide car seat
installation check points at safety events throughout Weld County. This task order will provide
continuation funding in the amount of$42,376 all of which is attributable to funding from the
federal government.
3. Health Care Program for Children with Special Needs (HCP) $185,903: These funds will be
used to facilitate the development and enhancement of community-based systems of care for
2010-2363
Douglas Rademacher
September 13, 2010
Page 2
children with special health care needs. Some of the services provided will be case finding,
community involvement, and interagency collaboration for children and their families who are
determined eligible for such services. Eligible children are those who have or are at risk for a
chronic physical, developmental, behavioral, or emotional condition. This contract will provide
continuation funding in the amount of$185,903. Of this amount, $46,476 are attributable to a
funding source of the federal government, and $139,427 are attributable to a funding source of the
State of Colorado.
This task order for the total amount of$345, 514, will provide funding for the time period October 1, 2010
through September 30, 2011. I recommend your approval.
Enc.
STATE OF COLORADO
Bill Ritter,Jr.,Governor
Martha E.Rudolph, Executive Director
R ,• 9
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory Services Division
Denver,Colorado 80246-1530 8100 Lowry Blvd.
Phone(303)692-2000 Denver,Colorado 80230-6928 reve,
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
http://www.cdphe.state.co.us and Environment
October 20,2010
Ms. Debbie Drew
Weld County Department of Health& Environment
1555 North 17`"Avenue
Greeley,CO 80631
Dear Ms. Drew:
Enclosed is your copy of the fully executed Colorado Department of Public Health and Environment Task Order listed
below.You may begin work on 10/18/10.
Contractor Name: Weld County Department of Health& Environnment
Task Order: Contract Routing Number 11-FLA-21566
Original Contract Number: N/A
Division: Prevention Services Division(PSD)
Program Name: Maternal& Child Health(MCH)
Project Name: MCH
Reason for Contract: Develop, implement and evaluation
Please contact me with questions or concerns. My contract information is listed below.
Sincerely,
Fiscal Services Unit
Colorado Department of Public Health&Environment
4300 Cherry Creek Drive South
PSD-FSU-A4
Denver,CO 80246
Contracts Manager—Jacqueline O'Bryan
Phone: 303-692-2485
Encl.
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
ROUTING NO.11 FLA 21566
APPROVED TASK ORDER CONTRACT-WAIVER#154
This Task Order Contract is issued pursuant to Master Contract made on 01/23/2007,with routing number 08 FAA 00052
STATE: CONTRACTOR:
State of Colorado for the use&benefit of the Board of County Commissioners of Weld
Department of Public Health and County
Environment for the use and benefit of the
Prevention Services Division,MCH Weld County Department of Public Health
4300 Cherry Creek Drive South and Environment
Denver, Colorado 80246 1555 North 17th Avenue
Greeley,CO 80631
TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE:
08/12/10 Colorado Political Subdivision
PO/SC ENCUMBRANCE NUMBER:
PC) FLA PSD1121566
TERM: BILLING STATEMENTS RECEIVED:
This Task Order shall be effective upon Monthly
approval by the State Controller,or designee,
or on 10/01/2010,whichever is later. The STATUTORY AUTHORITY:
Task Order shall end on 09/30/2011. C.S.R. 25-1,5-101,25-1-709
PRICE STRUCTURE: CONTRACT PRICE NOT TO EXCEED:
Cost Reimbursement $345,514.00
PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS: $206,087.00
Exempt STATE FUNDING DOLLARS: $139,427.00
BID/REP/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR:
Not Applicable FY11: $249,840.00
FY12: $ 95,674.00
LAW SPECIFIED VENDOR STATUTE:
Not Applicable
STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE:
Karen Trierweiler Judy Nero
Department of Public Health and Environment Weld County Department of Public Health and
Prevention Services Division, MCH Environment
4300 Cherry Creek Drive South 1555 North 17th Avenue
Denver,CO 80246 Greeley,CO 80631
SCOPE OF WORE:
Develop,implement and evaluate a comprehensive plan in accordance with state and federal MCH
guidelines,to improve the health and well-being of the MCH population, including children with
special health care needs.
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Yolc--tR3c
EXHIBITS:
The following exhibits are hereby incorporated:
Exhibit A- Additional Provisions (and its attachments if any—e.g.,A-1,A-2,etc.)
Exhibit B- Statement of Work and Budget (and its attachments if any—e.g.,B-1,B-2,etc.)
Exhibit C- Grant Funding Change Letter
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses,the more specific provision shall control.
This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including,but not limited to,Exhibit One thereto. The total term of this Task Order Contract, including
any renewals or extensions,may not exceed five(5)years. The parties intend and agree that all work shall
be performed according to the standards,terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(1),C.R.S.,as amended,this Task Order Contract is not valid until it
has been approved by the State Controller,or an authorized delegee thereof. The Contractor is not
authorized to,and shall not;commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegee. The State shall have no financial obligation
to the Contractor whatsoever for any work or services or,any costs or expenses,incurred by the Contractor
prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order
Contract on or before its proposed effective date,then the Contractor shall commence performance under
this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order
Contract after its proposed effective date,then the Contractor shall only commence performance under this
Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through
and including the date specified on page one of this Task Order Contract,unless sooner terminated by the
parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract.
Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made
a part hereof as if fully set forth herein. Unless otherwise stated,all exhibits and/or attachments to this Task
Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated,
the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event
of conflicts or inconsistencies between the Master Contract and this Task Order Contract(including its exhibits
and/or attachments),or between this Task Order Contract and its exhibits and/or attachments,such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: 1)the
Page 2 of 5 Rev 6/25/09
Special Provisions of the Master Contract;2)the Master Contract(other than the Special Provisions)and its
exhibits and attachments in the order specified in the Master Contract;3)this Task Order Contract;4)the
Additional Provisions-_Exhibit A,and its attachments if included,to this Task Order Contract;5) the
Scope/Statement of Work-Exhibit B,and its attachments if included,to this Task Order Contract;6)other
exhibits/attachments to this Task Order Contract in their order of appearance.
4. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order
Contract,shall perform and complete,in a timely and satisfactory manner,all work items described in the
Statement of Work and Budget,which are incorporated herein by this reference,made a part hereof and
attached hereto as"Exhibit B".
5. The State,with the concurrence of the Contractor,may,among other things,prospectively renew or extend
the term of this Task Order Contract, subject to the limitations set forth in the Master Contract,increase or
decrease the amount payable under this Task Order Contract,or add to,delete from,and/or modify this
Task Order Contract's Statement of Work through a contract amendment. To be effective,the amendment
must be signed by the State and the Contractor,and be approved by the State Controller or an authorized
delegate thereof This contract is subject to such modifications as may be required by changes in Federal
or State law,or their implementing regulations. Any such required modification shall automatically be
incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set
forth herein.
6. The conditions,provisions,and terms of any RFP attached hereto,if applicable,establish the minimum
standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's
Proposal,if attached hereto,or any attachments or exhibits thereto,or the Scope/Statement of Work-
Exhibit B,establishes or creates standards of performance greater than those set forth in the RFP,then the
Contractor shall also meet those standards of performance under this Task Order Contract.
7. STATEWIDE CONTRACT MANAGEMENT SYSTEM[This section shall apply when the Effective
Date is on or after July I, 2009 and the maximum amount payable to Contractor hereunder is$100,000 or
higher]
By entering into this Task Order Contract, Contractor agrees to be governed,and to abide,by the
provisions of CRS §24-102-205,§24-102-206, §24-103-601, §24-103.5-101 and§24-105-102 concerning
the monitoring of vendor performance on state contracts and inclusion of contract performance information
in a statewide contract management system.
Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order
Contract, State law,including CRS §24-103.5-101,and State Fiscal Rules,Policies and Guidance.
Evaluation of Contractor's performance shall be part of the normal contract administration process and
Contractor's performance will be systematically recorded in the statewide Contract Management System.
Areas of review shall include,but shall not be limited to quality, cost and timeliness. Collection of
information relevant to the performance of Contractor's obligations under this Task Order Contract shall be
determined by the specific requirements of such obligations and shall include factors tailored to match the
requirements of the Statement of Project of this Task Order Contract. Such performance information shall
be entered into the statewide Contract Management System at intervals established in the Statement of
Project and a final review and rating shall be rendered within 30 days of the end of the Task Order Contract
term. Contractor shall be notified following each performance and shall address or correct any identified
problem in a timely manner and maintain work progress.
Should the final performance evaluation determine that Contractor demonstrated a gross failure to meet the
performance measures established under the Statement of Project,the Executive Director of the Colorado
Department of Personnel and Administration(Executive Director),upon request by the Colorado
Department of Public Health and Environment and showing of good cause,may debar Contractor and
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prohibit Contractor from bidding on future contracts.Contractor may contest the final evaluation and result
by:(i)filing rebuttal statements,which may result in either removal or correction of the evaluation(CRS
§24-105-102(6)),or(ii)under CRS §24-105-102(6),exercising the debarment protest and appeal rights
provided in CRS§§24-109-106, 107,201 or 202,which may result in the reversal of the debarment and
reinstatement of Contractor,by the Executive Director,upon showing of good cause.
Page 4 of 5 Rev 6/25/09
THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE OF COLORADO:
BOARD OF COUNTY COMMISSIONERS OF BILL RITTER,JR.GOVERNOR
WELD COUNTY for the use and benefit of the
WELD COUNTY DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT,(a political
subdivision of the state of Colorado)
Legal Name of Contracting Entity
By
For Executive Director
Department of Public Health and Environment
Sign ure of Aut orized Officer U V L u t u
Douai ac Rademacher
Print Name of Authorized Officer
Department Program Approval: ��
Chair By `%/jQi, / . e/Le/ e^-'v
Print Title of Authorized Officer
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Contracts.This Contract is not valid until
signed and dated below by the State Controller or delegate.Contractor is not authorized to begin performance until
such time.If Contractor begins performing prior thereto,the State of Colorado is not obligated to pay Contractor
for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER:
David J.McDermott,CPA
Date t / J WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
BY: Cwkc1,) G4h
Mark E, Wallace, MD, MPH-Director
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&o.O
EXHIBIT A
_ADDITIONAL PROVISIONS
To Contract Dated 08/12/2010-Contract Routing Number 11 FLA 21566
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
The revised Statement of Work is effective October 1,2010.
1.The United States Department of Health and Human Services("HHS"),through the Maternal and Child Health
(MCH)Services Block Grant has awarded the State Title V federal funds under Notice of Grant Award("NGA)
number B04MC04248(See,Catalog of Federal Domestic Assistance("CFDA")number 93.994).The State's
Prevention Services Division(PSD)is charged with the administration of funds from the Title V MCH Block Grant
to improve the health and well being of the maternal and child/adolescent populations through assessing population
needs, influencing health policy,engaging in strategic planning and coordinating/implementing best practices and
evidenced-based programs.
The authority for the administration of the Title V MCH Block Grant,including the maternal,child and children
with special health care needs resides in Title V of the Social Security Act, §§ 501-509.
Each state that receives MCH funds from the HHS must demonstrate to the HHS that it has served three(3)distinct
population groups with the MCH funds.These three(3)distinct population groups are:"the perinatal population",
which is defined to include women of childbearing age,pregnant women,and mothers;the"child and youth
population",which is defined to include infants,children,and adolescents from birth through age twenty(20);and,
the"children with special health care needs"population(CSHCN),which is defined as those children who have,or
are at increased risk for a chronic physical,developmental,behavioral,or emotional condition and who also require
health and related services of a type or amount beyond that required by children generally.
The State has formulated a comprehensive statewide plan to carry out a Maternal and Child Health Program, funded
by Title V MCH dollars,and a CSHCN Program,funded by Title V MCH dollars and state general funds. As part of
the comprehensive plan, it is the express intent of the state to support local public health agencies in contributing to
a coordinated,efficient statewide program which focuses on specific MCH performance measures set by the MCH
state and Federal agencies. Local public health agencies,working in partnership with other community
organizations, facilitate the development and enhancement of community-based systems of services and supports for
the maternal and child population.
If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as of the
effective date of that Award,then the State shall reimburse the Contractor for any allowable and allocable expenses
of the Contractor that have been incurred by the Contractor since the proposed effective date of this Contract. If the
underlying Award does not authorize the State to pay all allowable and allocable expenses of a contractor as of the
effective date of that Award,then the State shall only reimburse the Contractor for those allowable and allocable
expenses of the Contractor that are incurred by the Contractor on or after the effective date of this Contract,with
such effective date being the later of the date specified in this Contract or the date the Contract is signed by the State
Controller or delegee.
2. In consideration of those Prenatal and Child/Adolescent services,set forth in Exhibit B satisfactorily and timely
performed by the Contractor under this contract,the State shall cause to be paid to the Contractor a sum not to
exceed ONE HUNDRED FIFTY-NINE THOUSAND,SIX HUNDRED ELEVEN DOLLARS($159,611.001.
Of the financial obligation for the Prenatal and Child/Adolescent services, ONE HUNDRED FIFTY-NINE
THOUSAND,SIX HUNDRED ELEVEN DOLLARS($159,611.001 are identified as attributable to a
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EXHIBIT A
funding source of the federal government and,ZERO DOLLARS,($0.00)are identified as attributable to a funding
source of the state of Colorado.
In consideration of those Health Care Program(HCP) for Children with Special Needs(CSHCN)services, set forth
in Exhibit B satisfactorily and timely performed by the Contractor under this contract,the State shall cause to be
paid to the Contractor a sum not to exceed ONE HUNDRED EIGHTY-FIVE THOUSAND,NINE HUNDRED
THREE DOLLARS($185,903.00). Of the financial obligation for CSHCN services,FORTY-SIX THOUSAND.
FOUR HUNDRED SEVENTY-SIX DOLLARS($46,476.001 are identified as attributable to a funding source of
the federal government and,ONE HUNDRED THIRTY-NINE THOUSAND,FOUR HUNDRED TWENTY-
SEVEN DOLLARS($139,427.00)are identified as attributable to a funding source of the state of Colorado.
3.To receive compensation under this Contract,the Contractor shall submit a signed Monthly Contract
Reimbursement Request in a format acceptable to the State.A separate request must be submitted for each of the
following population groups: Prenatal,Child/Adolescent and CSHCN.The Contractor shall declare the frequency
with which they plan to submit their Contract Reimbursement Request in writing to their MCH Generalist
Consultant by the beginning of the contract period. The Contract Reimbursement Request form is available on
the Colorado MCH web site at www.mchcolorado.org. A Contract Reimbursement Request must be submitted
within sixty(60)calendar days of the end of the billing period for which services were rendered.Contract
Reimbursement Requests must be accompanied by a detailed cost ledger to reflect all purchases being invoiced
under that contract and should include date of payment,payee name and amount,and check or voucher number,
when available.Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B.
These items may include,but are not limited to,the Contractor's salaries,fringe benefits,supplies,travel,operating,
allowable indirect costs,and other allocable expenses related to its performance under this Contract.
Contract Reimbursement Requests shall: 1)reference this Contract by its contract routing number,which the
number is located on page one of this Contract;2)state the applicable performance dates; 3)state the names of
payees;and,4)show the total requested payment. Payment during the term of this Contract shall be conditioned
upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this
Contract. Contract Reimbursement Requests shall be sent via email to:
Attn: Sara Wargo
Maternal and Child Health Program
Prevention Services Division
Colorado Department of Public Health and Environment
PSD-A4—MCH Admin
4300 Cherry Creek Drive South
Denver,CO 80246
cd_phemsmchrevorts@state.co.us
To be considered for payment,billings for payments pursuant to this Contract must be received within a reasonable
time after the period for which payment is requested, but in no event no later than sixty(60)calendar days after
the relevant performance period has passed. Final billings under this Contract must be received by the State
within a reasonable time after the expiration or termination of this Contract;but in no event no later than sixty(60)
calendar days from the effective expiration or termination date of this Contract.Contractors may not receive
payment for billings that exceed sixty(60)the calendar day period.
The State shall reimburse the Contractor for actual indirect costs up to the Prevention Services Divisions maximum
of twenty-five percent(25%)when the Contractor's indirect rate is based on Total Direct Costs,twenty-seven
percent(27%)when the Contractor's indirect rate is based on Total Direct Salaries,or thirty percent(30%)when the
Contractor's indirect rate is based on Total Direct Salaries and Fringe where no other direct costs are charged.
Local Match or in-kind, if any, shall be reported on all contract reimbursement requests. The source of funding for
all local match and in-kind will be reported on the final contract reimbursement request.
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The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved
in writing by the appropriate federalagency.
4.The Contractor is authorized to make transfers of funds from one line item in its Budget to another line item in its
Budget. If a transfer of funds occurs however from the Personnel Budget Category to another Budget Category and
the amount of funds being transferred is greater than 10%of the Budget Category Total,then the Contractor shall
request and receive prior written approval from the MCH Generalist Consultant by completing and submitting a
Budget Revision Request Form,available on the MCH web site at www.mchcolorado.org before the transfer can
be made. Permanent changes in any MCH-funded line item supporting staff positions,require the Contractor to
request and receive prior written approval from the MCH Generalist Consultant by completing and submitting a
Budget Revision Request Form, available on the MCH web site at www.mchcolorado.org. Temporary changes in
any MCH-funded line item funding staff positions in the Contractor's Budget,require the Contractor to notify their
MCH Generalist Consultant in writing.
5. Contractor shall retain and use all revenues generated by the individual MCH Programs(Prenatal,
Child/Adolescent,and HCP)for services in those programs. The revenue cannot be used for other programs or
purposes.
6.Title V,Section 504(b)(6).Title V funds may not be used to pay for any item or service(other than an
emergency item or service)furnished by an individual or entity convicted of a criminal offense under the Medicare
or any State health care program(i.e.,Medicaid, Maternal and Child Health,or Social Services Block Grant
Programs).
7.The Contractor agrees to provide services to all Program participants and employees in a smoke-free environment
in accordance with Public Law 103-227,also known as"the Pro-Children Act of 1994",(Act). Public Law 103-227
requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an
entity and used routinely or regularly for the provision of health,day care,early childhood development services,
education or library services to children under the age of 18, if the services are funded by Federal programs either
directly or through State or local governments,by Federal grant,contract, loan,or loan guarantee.The law also
applies to children's services that are provided in indoor facilities that are constructed,operated,or maintained with
such Federal funds.The law does not apply to children's services provided in private residences;portions of
facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal
funds is Medicare or Medicaid; or facilities where WIC coupons are redeemed. Failure to comply with the provision
of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to$1,000 for each violation
and/or the imposition of an administrative compliance order on the responsible entity. By signing this contract,the
Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking
within any portion of any indoor facility used for the provision of services for children as defined by the Act.The
Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain
provisions for children's services and that all contractors shall sign and agree accordingly.
8.The Contractor certifies,to the best of its knowledge and belief,that no federally appropriated funds have been
paid or will be paid by or on behalf of the Contractor,to any person for influencing or attempting to influence an
officer or employee of any agency,a Member of Congress,an officer or employee of Congress,or an employee of a
Member of Congress in connection with the awarding of this contract,and the extension,continuation,renewal,
amendment,or modification of this contract,or any grant, loan,or other cooperative agreement that utilizes Federal
funds. If any funds other than federally appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency,Member of Congress,an officer or
employee of Congress in connection with this contract, or any other grant, loan,or other cooperative agreement,
then the Contractor shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying" in
accordance with its instructions.The Contractor shall require that the language of this certification be included in the
award documents for subawards at all tiers(including subcontracts,subgrants,and contracts under grants, loans,and
cooperative agreements)and that all subrecipients shall certify and disclose accordingly. This certification is a
material representation of fact upon which reliance was placed when this transaction was made or entered into.This
certification is a prerequisite for making or entering into this transaction imposed by section 1352,title 31,U.S.
Code.Any person who fails to file the required certification shall be subject to a civil penalty of not less than
$10,000 and not more than$100,000 for each such failure.
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EXHIBIT A
9.The Contractor shall not charge for services for those individuals of families at or below the official poverty
guidelines,updated periodically in the Federal Register by the U.S.Department of Health and Human Services
(DHHS)under the authority of 42 U.S.C.9902(2), in accordance with Title V, Section 501 (1)(B)and Section 505
(5)(D).The most current version of this document is available on the DHHS web site at http://aspe.hhs.gov/poverty/
and the Colorado HCP web site: www.hcpcolorado.org. If the State receives new poverty guidelines from the DHHS
during the term of this Contract,then the State shall immediately update the guidelines on the HCP web site.The
Contractor shall use these new poverty guidelines,if any,upon receipt thereof from the State.
10. If any charges are imposed for services to clients who are above the one hundred percent(100%)of poverty
level,such charges must be on a sliding scale which takes into account the client's family size, income and
resources. These charges and the sliding fee scale must be made available to the general public and to a0 clients and
must be based on the agency's usual and customary cost for the service.Clients must understand they shall not be
denied services for inability to pay any of the sliding fee charges.
11.The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are
maintained in accordance with this contract.Except for purposes directly connected with the administration of this
contract,no information about or obtained from,any applicant or recipient shall be disclosed in a form identifiable
with the applicant or recipient without the prior written consent of the applicant or recipient,or the parent or legal
guardian of a minor applicant or recipient with the exception of information protected by Colorado statute as it
applies to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal
guardian must provide consent or,as otherwise properly ordered by a court of competent jurisdiction. The
Contractor shall have written policies governing the access to, and duplication and dissemination of,all such
information. The Contractor shall advise its employees,agents,servants,and subcontractors,if any,that they are
subject to these confidentiality requirements.
12. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried
out.That Act states that"no person in the United States shall on the ground of race,color,or national origin,be
excluded from participation in,be denied the benefits of,or be subjected to discrimination under any program or
activity receiving Federal fmancial assistance."The Office of Civil Rights has concluded that it is the responsibility
of any program which is a recipient of funds from the Department of Health and Human Services to ensure that
clients who do not speak or understand English well,be provided interpretation services to ensure that the service
provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure
that interpretation services are available for clients with Limited English Proficiency and will advise such clients
that an interpreter will be provided for them. If a client has their own interpreter,they shall be advised that the
Contractor will provide an interpreter if the client so chooses.
13. The services or activities under this Contract may be carried out by the Contractor,or through subcontracts with
other providers or,through collaborative partnerships with other community partners. The State authorizes the
Contractor to subcontract some,or all,or the services that are to be performed under this Contract. However,a
subcontractor is subject to all of the terms and conditions of this Contract. Additionally,the contractor remains
ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s)
under this Contract. If the Contractor desires to subcontract some,or all,of the services that are to be
performed under this Contract,the Contractor shall obtain the prior,express,written consent of the State
before entering into any subcontract.The Contractor shall maintain,at a minimum a Memorandum of
Understanding or other binding contractual agreement,and provide a copy fifteen(15)calendar days from the date
the agreement is executed to the State,upon request. The Contractor shall maintain records of any subcontractors for
a minimum of three years.
14.Notwithstanding anything herein to the contrary,the parties understand and agree that all terms and conditions of
this contract and the exhibits and attachments hereto which may require continued performance,compliance or
effect beyond the termination date of this contract shall survive such termination date and shall be enforceable by
the State as provided herein in the event of such failure to perform or comply by the Contractor.
15.The State may require forms attached to this contract and incorporated herein by reference be updated during the
term of this contract.The Contractor will be informed of the new forms as they are developed.Forms may be sent to
To be attached to CDPHE Page 4 of 5 Revised:7/19/10 JC
Version 1.0(4/04)contract template
EXHIBIT A
contractors or will be available on the MCH web site:www.mchcolorado.org or the HCP web site:
www.hcpcolorado.org.__.
16.The State has determined that this contract does not constitute a Business Associate relationship under the
Health Insurance Portability and Accountability Act(HIPAA).
17.The State may increase or decrease funds available under this Contract using a Grant Funding Letter
substantially equivalent to Exhibit C.The Grant Funding Letter is not valid until it has been approved by the State
Controller or designee.
To be attached to CDPHE Page 5 of 5 Revised:7/19/10 JC
Version 1.0(4/04)contract template
EXHIBIT B
STATEMENT 9_F_ORiC_..___
To Contract Dated 08/12/2010-Contract Routing Number 11 FLA 21566
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
The revised Statement of Work is effective October 1,2010.
The Contractor, in accordance with the terms and conditions of this contract,shall perform and complete, in a timely
and satisfactory manner,all activities described in the approved Statement of Work provided herein and
incorporated in accordance with the associated Budgets which are attached hereto as Attachment B-1 Prenatal,
Attachment B-2 CASH,and Attachment B-3 CSHCN,and incorporated herein.
This Statement of Work is for the maternal and child health(MCH)population:Prenatal, Child/Adolescent, and
Children with Special Health Care Needs (CSHCN), birth to age 21.
1. The Contractor shall perform in accordance with the MCH Guidelines and shall follow the policies and
procedures detailed in the MCH Guidelines. The MCH Guidelines are incorporated and made part hereof
by reference,and are located on the Colorado MCH web site: www.mchcolorado.org.
2. The MCH Guidelines are periodically updated and the contractor will be notified by email when
updates/revisions are made. The contractor is responsible for complying with any updates/revisions.
Revised MCH Guidelines would be posted to the MCH web site: www.mchcolorado.org.
3. The Prenatal,Child/Adolescent,and Health Care Program for Children with Special Needs(HCP)
Operational Plans are to be based on a community planning process that includes a review of the health
status needs of the targeted population and of the health system resources of a community.These plans are
further designed to:
a) Contribute to the accomplishment of the MCH National and State priorities,performance
measures,and outcome measures,as identified in the MCH Guidelines;
b) Provide for the continuation of the core public health services of assessment,assurance,and policy
development on behalf of the maternal and child health populations and in implementing the 10
essential services for this population in partnership with the State,as identified in the MCH
Guidelines, located on the MCH web site: www.mchcolorado.org;
c) Work with public and private community partners to plan for the development and maintenance of
resources that assure access to direct care and services for all vulnerable women,children,
adolescents, and CSHCN, including those who are low-income,uninsured,underinsured,or who
live in rural or underserved areas or who are from ethnic or cultural minority communities and
may experience language or cultural barriers and have increased difficulty using services;
d) Refer and provide information to families participating in agency's Prenatal,Child/Adolescent,
and HCP programs to other public health programs,such as the Special Supplemental Nutrition
Program for Women,Infants and Children(WIC);Early and Periodic Screening,Diagnosis and
Treatment(EPSDT); Immunization Clinics;Family Planning;Nutrition Services;Public Health
Nursing;and to appropriate enabling and direct care service programs in the community, including
resources for accessing public insurance programs. The Contractor shall provide all individuals
seeking reproductive health services with information about pregnancy planning,the
consequences of unintended pregnancies, and referrals to comprehensive family planning services.
All pregnant women in need of resources for prenatal medical care shall be provided with
information about programs such as Prenatal Plus,Nurse Family Partnership,WIC, etc.,as
needed.
e) Provide leadership, in coordination with public and private community partners,to plan for the
development, implementation and evaluation of population-based approaches for addressing MCH
performance measures and priority issues for women,children,adolescents,and CHSCN.
yr i.rf11)-1;i1 Page 1 of 4 Revised:7/19/10 JC
m-1. e 1A v' tea;eto Y tE91 :
EXHIBIT B
4. The Contractor shall implement and evaluate the Prenatal,Child/Adolescent,and HCP Operational Plan for
FY11 during the course of this contract._
5. The State shall provide guidance and technical assistance to the contractor to support the implementation
and evaluation of the Contractor's Prenatal,Child/Adolescent,and HCP Operational Plans for FY11.
6. The Contractor shall submit,but not limited to,the following reports, incorporated by reference. These
documents,including instructions for completion and submission are available in the MCH Guidelines,
located on the MCH web site:www.mchcolorado.org.
a) MCH Annual Operational Plan Report for FY10&FY11
b) HCP Annual Performance Measure Report for FY10&FYI I
c) MCH Core Services Final Report for FY10&FY11
d) Numbers Served by Title V Report for FY10&FY11—Tables I&II
e) MCH Final Operational Plan Report for FY8-10&FY9-11, if applicable
7. The Contractor shall revise or develop,according to the MCH Guidelines,the Contractor's Prenatal,
Child/Adolescent,and HCP Operational Plans for FYI 1 or FY12,and an Operational Plan for each year of
renewal.The MCH Guidelines are located on the MCH web site: www.mchcolorado.org.
8. The State shall provide guidance and technical assistance to the Contractor to support the revision or
development,according to the MCH Guidelines,of the Contractor's Prenatal,Child/Adolescent,and HCP
Plan for FY11 or FY12.The MCH Guidelines are located on the MCH web site: www.mchcolorado.org.
9. The Contractor shall cooperate with the State and provide all requested records regarding services provided
under this contract.
10. The Contractor shall provide MCH Generalist Consultants and other State administrators with reasonable
access to its operations to perform: periodic site visits,data reviews, fiscal reviews or other evaluations of
the contractor's program. The contractor shall cooperate during all periodic site visits,data reviews, fiscal
reviews and other evaluations or audits conducted by the State.
II. The Contractor shall notify the State of programmatic changes that might affect the viability,effectiveness
or productivity of the programs,including but not limited to:changes in personnel;physical facilities in
which services are provided; scope of services that deviates from those proposed by the Contractor;sources
of funding and support as declared in the Contractor's submitted proposal for funding;and local
interagency or political circumstances that might impact the MCH Program and HCP.Notification shall be
in writing within fifteen(15)business days of the said change.
12. If the State believes in good faith that an activity or service fails to meet the standard for a particular
activity or service,or is otherwise deficient,then the State shall notify the Contractor of the failure or
deficiencies in writing. Corrective action shall be addressed through a Performance Improvement Plan
(PIP)or some other method defined by the State. Due dates for completion of activities listed in a PIP will
be negotiated on a case-by-case basis. If the Contractor fails to correct such deficiencies,the Contractor
shall be in default of its obligations under this Contract and the State, at its option,may elect to withhold
payment or terminate this Contract.
This Statement of Work is for the maternal and child health(MCH)population: Children with Special Health Care
Needs(CSHCN), birth to age 21, ONLY.
1. The Contractor shall perform in accordance with the HCP Policy and Guidelines and HCP Colorado Health
Information and Reporting and Planning(CHIRP)User Manual and shall follow the policies and
procedures detailed in these documents. The HCP Policy and Guidelines and the CHIRP User Manual are
incorporated and made part hereof by reference,and are located on the Colorado CSHCN Unit web site:
www.hcpcolorado.org.
t'OP:i Page 2 of 4 Revised:7/19/10 JC
fill!(ltr.,'
EXHIBIT B
2. The HCP PolicyaMi Cuideliiles,.and the CHIRP User Manual are periodically updated and the contractor
will be notified by email when updates/revisions are made.The contractor is responsible for complying
with any updates/revisions. Revised HCP Policy and Guidelines and the CHIRP User Manual would be
posted to the CSCHN web site: www.hcpcolorado.org.
3. The Contractor shall work collaboratively with the State for consultation,technical assistance, oversight
and training on using the CHIRP database for documentation of HCP services.
4. The Contractor shall adhere to the CDPHE Security Policy and Procedures and use the Secure External
User ID forms according to the MCP Policy and Guidelines,located on the CSHCN web site:
www.hcpcolorado.org.
5. The Contractor shall attend monthly HCP Regional Office teleconferences,the HCP Team Leader Meeting,
the HCP Spring Meeting,and state training to promote learning and increase skills for HCP practitioners as
referenced in the HCP Policy and Guidelines. The HCP Policy and Guidelines are located on the CSHCN
web site: www.hcpcolorado.org.
6. The Contractor shall provide orientation,technical assistance and ongoing training for the HCP agency and
regional staff by referencing the HCP Policy and Guidelines,the HCP Orientation,the CHIRP User
Manual,and Local HCP Resources, located on the CSHCN web site: www.hcpcolorado.org.
7. The Contractor shall provide HCP Care Coordination to ensure a medical home approach for CSHCN
residing in the counties the agency is contracted to serve according to the HCP Care Coordination Policy
and Guidelines,located on the CSHCN web site: www.hcpcolorado.org.
8. The Contractor shall collaborate with community partners to identify service and systems barriers to
improve ease of service use for families of CSHCN by referencing HCP Policy and Guidelines, located on
the CSHCN web site:www.hcpcolorado.org.
9. The Contractor shall utilize CSHCN and their families as the consumer voice when serving the CSHCN
population according to the HCP Policy and Guidelines and by referencing the Colorado MCH Medical
Home Action Guide. Both documents can be found on the CSHCN web site: www.hcpcolorado.org.
10. The Contractor shall report on family participation activities by completing the family participation
questions in the HCP Annual Performance Measure Report.This report is available on the MCH web site:
www.mchcolorado.org.
This Statement of Work is for the maternal and child health(MCH)population: Children with Special Health
Care Needs(CSHCN), birth to age 21, Specialty Clinics ONLY:
1. The Contractor agrees to schedule and facilitate regional HCP Specialty Clinics in collaboration with the
state HCP staff and specialty providers according to the HCP Specialty Clinic Policy and Guidelines and
HCP Specialty Clinic Provider Handbook, located on the CSHCN web site:www.hcpcolorado.org.
2. The contractor shall provide clinic coordination for all CSHCN attending Specialty Clinics according to the
HCP Care Coordination Policy and Guidelines and HCP Specialty Clinic Policy and Guidelines, located on
the CSHCN web site: www.hcpcolorado.org.
3. The Contractor shall retain and use all HCP Specialty Clinic revenues generated by the Contractor to
support CSHCN and HCP activities according to the HCP Specialty Clinic Policy and Guidelines and the
Federal Poverty Level Guidelines located on the CSHCN web site:www.hcpcolorado.org.
• z ^•s•=l•=•t _ Page 3 of4 Revised:7/19/10 JC
EXHIBIT B
This Statement of Work is for the maternal and child health(MCH)population: Children with Special Health
Care Needs(CSHCN), birth to ea], Multi-County Regional Office ONLY:
1. If the HCP Multi-county Regional Office staff believes in good faith that HCP services provided by
contractors in Local Public Health Agencies within the HCP Region fail to meet the standard for a
particular activity or service,or is otherwise deficient,then the Regional Office shall notify the State HCP
Director of failure or deficiencies in writing.The HCP Policy and Guidelines are located on the CSHCN
web site: www.hcpcolorado.org
2. The Contractor shall provide orientation,consultation,technical assistance and ongoing training as a Multi-
County Regional Office for staff in regional Local Public Health Agencies. The contractor shall reference
the HCP Policy and Guidelines,the HCP Orientation,the CHIRP User Manual,and Local HCP Resources,
located on the CSHCN web site: www.hcpcolorado.org.
3. The Contractor,as a multi-county regional office, shall provide one HCP Regional Meeting to include HCP
staff from all counties within the Region and invited state MCH/HCP staff to provide networking,training,
and HCP updates as part of the HCP Policy and Guidelines, located on the CSHCN web site:
www.hcpcolorado.org.
;- t Page 4 of 4 Revised:7/19/10 JC
Attachment B-1 Prenatal
#e.
Agent x--Weld-Coon ; ctment-of-publie4leafth4-€nvirenment -Date Completed: — June-29-4010------ ----------.- _ __--
Name: Debbie Drew Name:Judy Nero
Title: Director, Public Health Services Title: Coordinator,Administrative Services
Phone: 970-304-6410, Ext.2304 Phone: 970-304-6410, Ext.2122
Email: ddrev@co.weid.co.us Email: jnerogpco.weld.co.us
Due Date: July 1,2010
(for the period of Oct. 1,2010 through Sept.30,2011)
Instructions: Refer to instructions for completion of this form in the MCH Guidelines. Enter numbers in yellow highlighted areas below.
Total columns will calculate automatically.
n C• HILDREN AND ADOLESCENT POPULATION
n P• RENATAL POPULATION
n C• HILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATION
,I .. 1. „
PERSONNEL SERVICES(Names&Titles):
Kristin Dodge, Health Comm.Spec.II $53,408.28 0 90 'y" `r r ' $48,067.45
Margaret Herrfeldt,Health Comm S rg pet. I $44,062.08 0 t5 •• xs 5 $6,609.31
Cindy Kronague,Health Data Specialist $73,470.08 0.075 , $5,510.26
Mary Lloyd-Cumley,PHS Supervisor $64,787.93 0,30 r r r $7,620.80 $11,815.58
Debbie Drew,Director,PHS $92,738.52 0.30 , e_ $27,821.56
SUBTOTAL --- -- $107 444.96 $35,442.36 $72,002.60
Fringe Benefits: Rate= 35.54% N/A ttJ� N/A �`�`yy $12,596.21 $25,589.72
""FF 5E
OPERATING EXPENSES(which are not part of indirect)
Supplies $2,000.00 $500.00 $1,500.00
Media $4,000.00 $4,000.00
TRAVEL EXPENSES $1,600.00 $400.00 $1,200.00
CONTRACTUAL EXPENSES
Er °el(r..... ".:,x:...,>�a �(,4 _.._ `3 � ,",'aE
rc r 1r >�:t1r��' ®}.-�f;�- it `i 1[ e '✓!ti'f 7'� .::; s _..
✓ , r,r ...:1....�ll.�.-6�a�o-.{ml�S..�E{�.-�Lal:+. ... ..r"..a. :i°..... _ . .._eM...a..�.�'a(a•. ' <_ ,::a�,7ze�`}� .,..},...f. w'X
INDIRECT COST: Rate= 12.41% $19,015.95 $6,073.28 $12,942.68
fang .-`iT.SEI9f31"` -
ource or unding or"• her"(Match or In-kind)
Loca9County Funding: $55,011.85 Methodology used for reporting"Source of Funds"
Medicaid(will not be used to match):
Patient Fees: Method A n
All Other:
INNEDWAINNIIIMISMAI Method B
Can NON-FEDERAL funds be used as a match? Yes ' 1 No pi
Page 1 of 4
Attachment B-1 Prenatal
Maternal and Child Health (MCH)
Budget Narrative FY11
Agency: Weld County Department of Public Date Completed: May 28, 2010
Health and Environment
Program Contact Person Fiscal Contact Person
Name: Debbie Drew Name: Judy Nero
Title: Director of Public Health Services Title: Business Manager
Phone: 970-304-6420 x 2304 Phone: 970-304-6410 Ext. 2122
Email: ddrew@co.weld.co.us Email: jnero@co.weld.co.us
Population Group
Check the appropriate box below to indicate the population group that applies to this budget
narrative. Complete a separate budget narrative for each population group budget.
❑ Children and Adolescent Population
® Prenatal Population
❑ Children with Special Health Care Needs Population
Due Date: July 1, 2010
General Instructions:
The purpose of the Budget Narrative is:
> To describe how each line item included the proposed planning budget relates to your
agency's MCH plan and
> To explain how you arrived at each cost.
The Budget Narrative should provide a clear and reasonable rationale for the costs associated
with implementing your proposed MCH plan. The MCH plan, planning budget, and budget
narrative should all be aligned. Be sure to describe how you arrived at each line item amount
by providing detailed and specific information for EACH line item. The Budget Narrative should
reflect the MCH plan period from October 1, 2010 through September 30, 2011. Please provide
narrative for each cost category in the spaces below. Examples are included for each budget
category. Additional examples are available in the FY11 MCH Guidelines.
Personnel Services: List the name and title of each staff member (employed by your
agency),annual salary and Full Time Equivalent(FTE) that the staff member will commit to the
MCH plan. Briefly describe the role of the staff member in the MCH Plan and identify the
components of the Plan that this person will be responsible for completing.
Example: Susan Johnson, Registered Dietitian, salary at$50,000/year, .5 FTE (50%)to implement the
Healthy Baby campaign on prenatal weight gain and smoking cessation, Objective 2.
Kristin Dodge, MPH, Prenatal Education Coordinator, salary at $53,408.28/yr, .9 FTE (36
hours/week) to coordinate and provide activities related to Healthy Baby Program, (Objectives
1, 2, 3, and 4).
Debbie Drew, RN,NP, Director of Public Health Services, salary $92,738.52/yr, .3 FTE, with no
funding requested from from CDPHE. Provides leadership and infrastructure support to all
Maternal Child Health activites provided at WCDPHE. Division Director for Public Health
Services, and supervises all staff in Division. Assists with planning and development of program
Page 2 of 4
Attachment B-1 Prenatal
activities (Objective 4).
Mary Lloyd-Cumley, RN,NP, Clinical Services Manager, salary at$64,787.93/yr, .3 FTE, (the
amount requested from CDPHE is $11,815.58 and remainder of FTE is from other sources).
Directly supervises Kristin Dodge, program development, plan development, and execution.
Provides support and assists with planning and development of program activities, (Objectives
1, 2, 3, and 4).
Cindy Kronauge, MPH, Health Data Analyst, $73,470.08 salary/yr, 0.08 FTE (3 hours/week).
Participates in WC Healthy Baby Evaluation Team, provides support and assists with the
planning, implementation, and evaluation of program activities through data analysis and
development of evaluation tools, (Objective 3 and 4).
Margaret Herrfeldt, Registered Dietician (RD), Health Communications Specialist I, salary at
$44,062.08/yr, 0.15 FTE (6 hours/week). Assist with coordination of prenatal nutrition classes,
outreach to community partners, nutrition education, and assisting Health Data Analyst with
outcomes data collection and analysis, (Objectives 1, 2, 3, and 4).
Operating Expenses: Include expenses that are not included in the indirect rate for your
agency. Examples: office supplies, copies, postage, telephone,computer network fees, project
supplies and materials, professional development and training registrations. Include funding for
equipment, including computers and software.
Provide a brief explanation to justify the need for each line item for the MCH Plan and identify
the objective in the MCH Plan for any line items over $1,000.
Example: $1,500 will provide a new computer for S.Johnson,R.D.,who will Implement the Healthy Baby
campaign,Objective 2.
*Operating expenses for supplies are needed to accomplish: Objective 1 and 2 (including office
supplies, project supplies and materials, printing of meeting agendas and program materials,
presentation supplies, printing of class flyers and posters to promote campaign and educational
classes, and prenatal nutrition education training materials). Objective 3 office supplies include
printing consent forms, pre/post class surveys, client satisfaction surveys, and outcomes
reports. The supply costs are estimated at $2,000.00 with $1,500.00 requested from CDPHE.
*Operating expenses for media costs are needed to accomplish: Objective 2 (including media
costs for newspaper ads, radio ads, tv station ads, advertising on billboards and bus benches,
and the development of class flyers and posters for local media campaigns. These funds are for
internal development of the media plan approaches. The media request from CDPHE is
$4,000.00.
Travel Costs:, Travel costs to be incurred while implementing the MCH Plan and/or travel to
attend trainings. -Note:It is required that the LHA includes the cost for one LHA MCH staff
person to attend a one-day, state MCH meeting in the Metro Denver area.
Example:Travel costs are reimbursed at 32 cents/mile per agency policy. Costs of$1,144 are estimated
to provide transportation, lodging,and meal costs to send 2 staff working on the MCH Plan to the
Preconception Summit in September 2009,
Travel costs are currently reimbursed at 48.0 cents/mile per Weld County policy. Costs of
$1,600.00, with $1,200.00 requested from CDPHE, are estimated to provide mileage
reimbursement for traveling throughout the county to various health care facilities and
community-based organizations for meetings, outreach activities, presentations, teaching
Page 3 of 4
Maternal and Child Health (MCH) Attachment B-t Prenatal
Planning Budget Narrative
classes, and follow-up visits (Objectives 1 and 2). It will also cover the cost of at least one staff
- -person ti amt end fug day MCH conference in Denver. (Objective 4).
Contractual Services: Describe costs for contractors (person or company not employed by
your agency) working on the MCH Plan. Briefly describe the role of each contractor in
completing the MCH Plan and identify the objectives of the work plan that this contractor will be
accomplishing.
Example: Robert Brown,Health Educator, contracted at$13,000/year, ($50/hour x 5 hours/week x 52
weeks=$13,000)to provide training to healthcare providers regarding prenatal smoking cessation,
Objective 2.
Example: Media coverage for$10,000 will air TV ads and radio spots for the Healthy Baby campaign
using ads that are already developed, adding information re: the local health agency.
n/a
Indirect Costs: Provide your indirect rate. An indirect rate cap will be applied. The caps are
as follows per CDPHE agreement: 25% of total direct costs; 27% of total direct salaries and/or
fringe; 30% of total direct salaries and fringe where no other direct costs are charged. If your
rate exceeds the indirect rate caps, identify those indirect costs above the allowed rate as
match or in-kind contributions.
Example: Your indirect rate is 34.93%of total direct Salaries/Fringe. 27%can be recognized in your
request and 7.93% must be recognized as match or in-kind.
Example:Your indirect rate is 19%of total direct costs. The rate is within the 25%cap; 19%can be
recognized in your request.
Indirect rate is 12.41% of the total direct cost.
Other Funding Costs: Additional funding that supports MCH in general and/or the MCH Plan
may be included in the proposed budget. This may include the contribution of program
administrators'time (i.e., an Executive Director, Nursing Director or Program Manager's time) or
it may be other funding that supports the salaries of MCH staff. It is not necessary to
include budget narrative information for"Other"funding.
Other funding for salaries, fringe benefits, travel expenses, supplies and indirect costs is
provided by Weld County.
Page 4 of 4
Revised 5/102010
Attachment B-2 CASH1
Px bf-Ir Is'1 V6 g ('iIt1 la c t' tf�'y !' le}T i r c'1
s�
It_ c:lb:r. tick a fa'1 a •:-.7.5eitetkir
ir.
•MG WEIDCOUNTYDEP7 OFP�Bt.UC}iEALIAJIEN1L_.__DatsCompleted:.—._.___
Name: Gaye Monson Name: Judy Nero
Title: Director,Health Communications,Education and Planning Title: Business Manager
Phone: 970-304-6470 ext 2380 Phone: 970-304-6410 ext 2122
Email: gmonison@co.weld.co.us Email: jnero@co.weld.co.us
Due Date: July 1,2009
(for the period of Oct.1,2009 through Sept.30,2010)
instructions: Refer to instructions for completion of this form in the MCH Guidelines.Enter numbers in yellow highlighted areas below.
Total columns will calculate automatically.
in CHILDREN AND ADOLESCENT POPULATION
PRENATAL POPULATION
n CHILDREN WITH SPECIAL HEALTH CARE pNEEDS POPULATION
'a�tJi(}
. f... ' Y L__ 'Y r t "m ged....;i
PERSONNEL SERVICES(Names&Titles):
Kelly'mug,Health Comm.Specialist II $51,866.52 0.25 $440.63 $12,526.00
Cindy Kronauge,Health Data Socialist $73,193.40 0.05 IT. "...I; $124.67 $3,535.00
Marjorie Hanson,Office Technician II $34,212.29 0.25 A, $290.07 $8,263.00
SUBTOTAL — — 26 179 37 — —
Fringe Benefits: Rate= 35.54% N/A N/A $30475 $8,644.00
TlffrattttaEfeseaNNE14�1=RaRaes�a� pR¢ .:+:,t:tssgegaisisolao
OPERATING EXPENSES(which are not part of indirect)
Printing $1,034.00 $14.00 $1,020.00
Meeting Expenses $400.00 $14.00 $386.00
Incentives for high school students in traffic safety programs $400.00 $14.00 $386.00
kM V4 >
TRAVEL EXPENSES
Local travel in county(avg.118 miles/month) $750.00 $26.00 $724.00
CONTRACTUAL EXPENSES
Contract with Marketing Professional to recruit programs in North/South Weld County $3,122.00 $121.70 $3,000.00
TOMAGTOMMINAPAXRP45:!74!..i., F"T'0
INTER-DISCIPLINARY TEAM EXPENSES(HCP Only)
.... ......c��.:..L.:".l..a.T�. .,.. • �: .r.
aeYi_ie t-1k s 4t} {1 s i ..rF •
e,� CrT"i%" y� s {/ ,✓i
_....... ......•..r...a;.. M..u..:.. - - .., S ;a`.$ (..., •kin v • ..•t.}' .�Lec
INDIRECT COST: Rate= 10.31% ~- �� _...-._
$4,028.95 $136.96 $3,892.00
:{e}!n'r,„rr}.i 1r:%ee E. •-•-- ___..._ yf..:..p
Source or funding for"Other"(Match or In-kind)
LocaVCounty Funding: $1,493.04 Methodology used for reporting"Source of Funds"
Medicaid(will not be used to match):
Patient Fees: Method A ' 1
All Other:
ltk6&# Method B n
Can NON-FEDERAL funds be used as a match? Yes n No n
Page 1 of 4
Attachment B-2 CASH2
Maternal and Child Health (MCH)
Planning Budget Narrative FY10
Agency: Weld County Department of Public Date Completed: 06/22/10, Rev. 7/23/10
Health and Environment
Prepared by Fiscal/Budget Approval
Name: Gaye Morrison Name: Judy Nero
Title: Division Director, Health Title: Business Manager
Communications, Education and Planning
Phone: 970-304-6470 ext 2380 Phone: 970-304-6410 ext 2122
Email: gmorrison@co.weld.co.us Email: jnero@co.weld.co.us
Population Group
Check the appropriate box below to indicate the population group that applies to this budget
narrative. Complete a separate budget narrative for each population group budget.
® Children and Adolescent Population
❑ Prenatal Population
❑ Children with Special Health Care Needs Population
Due Date: July 1, 2009 (for the period Oct. 1, 2009 through Sept. 30, 2010)
General Instructions: The purpose of the Planning Budget and Planning Budget Narrative is
to explain how your agency plans to use the MCH funds. Budget requests, staffing, and
objectives described in the MCH Plan need to be aligned and provide a consistent, logical
picture of what is to be accomplished, by whom, and the associated costs. In the event that
this alignment does not occur, applicants will be contacted with requests for clarifications and
modifications.
A detailed budget narrative helps with understanding your request. The Budget Narrative
needs to justify the need for each line to accomplish the MCH Plan for the time period, October
1, 2009 through Septem ber 30, 2010. Please provide narrative for each cost category in the
spaces below.
Personnel Services: List the name and title of each staff member (employed by your
agency), annual salary and Full Time Equivalent(FEE) that the staff member will commit to the
MCH plan. Briefly describe the rote of the staff member in the MCH Plan and identify the
components of the Plan that this person will be responsible for completing.
For example:Susan Johnson, Registered Dietitian, salary,at$50,000/year, .5 FIE (50%)to implement
the Healthy Baby campaign on prenatal weight gain and smoking,cessation, Objective 2.
Kelly Imus, Health Education Specialist, salary at $51,866.52/yr, .25 FIE (25%) to coordinate
activities related to DRIVE SMART Weld County and the teen motor vehicle activities, Objectives
1,2,3,&4.
Cindy Kronauge, Data Analyst, salary at $73,193.40/yr., .05FIE (2hrs/wk) will develop pre-post
surveys and will do data analysis for evaluation of programs, Objectives 2 &3.
Marjorie Hanson, Office Tehnician, salary at $33,415.80/yr from October 1, 2009 through
December 15, 2009 with a salary increase to $34,421.88/yr effective December 15, 2009
through September 30, 2010, .25FTE (25%) to provide clerical support and coordination for
DRIVE SMART Weld County and the teen motor vehicle activities, Objectives 1,2,3,&4.
Page 2 of 4
Page 1 of 3
Revised 224/)9
Maternal and Child Health (MCH) Attachment B-2 CASH3
Planning Budget Narrative
Operating Expenses: Include expenses that are not included in the indirect rate for your
agency. Examples: office supplies, copies, postage, telephone, computer network fees, project
supplies and materials, professional development and training registrations. Include funding for
equipment, including computers and software.
Provide a brief explanation to justify the need for each line item for the MCH Plan and identify
the objective in the MCH Plan for any line items over $1,000.
Example: $1,500 will provide a new computer for S. Johnson, R.D., who will implement the Healthy Baby
campaign, Objective 2.
Printing, $1020. To print pre/post surveys for P.A.R.T.Y. (Preventing Alcohol and Risk-related
Trauma in Youth) programs to 700 students. Also printing for Evaluation forms for Parent of
Teen Driver classes and printing for Parent of Teen Driver Manuals (30 page bounded manua I) .
Meeting expenses: $400 will purchase refreshments (water/juice/cookies) for students
attending the day long P.A.R.T.Y. programs and for the parents and teens attending the Parent
of Teen Driver classes.
Incentives for high school students in traffic safety programs: $400 to buy items selected by
the student groups at the high schools to use as incentives for teens who sign seat belt pledges
and/or participate in traffic safety activities. Examples include bracelets, lip balm, or key chains
with traffic safety logos.
Travel Costs: Travel costs to be incurred while implementing the MCI-I Plan and/or travel to
attend trainings. Note:It is required mat the LHA Includes the°test far one LHA MCH staff
person to attend a one-day, state MCH meet/no In the Metro Denver area.
Example: Travel costs are reimbursed at 32 cents/mile per agency policy. Costs of$1,144 are estimated
to provide transportation, lodging, and meal costs to send 2 staff working on the MCH Plan to the
Preconception Summit in September 2009.
Local Travel: $750 per year. This equals about 112 miles per month @ $0.565 per mile for
Health Education Specialist and Office Technician to drive to high schools and other locations
for P.A.R.T.Y. programs, Parent of Teen Driver classes, and other trips related to DRIVE SMART
Weld County activities.
Contractual Services: Describe costs for contractors(person or company not employed by
your agency) working on the MCH Plan. Briefly,describe the role of each contractor in
completing the MCH Plan and identify the objectives of the work plan that this contractor will be
accomplishing.
Example: Robert Brown, Health Educator,contracted at$13,000/year, ($50/hour x 5 hours/week x 52
weeks—$13,000)to provide training to healthcare providers regarding prenatal smoking cessation,
Objective 2.
Example: Media coverage for$10,000 will air TV ads and radio spots for the Healthy Baby campaign
using ads that are already developed, adding information re: the local health agency.
Marketing Contract: $3000.00 willl be used to contract with a marketing specialist to recruit
new high schools in rural South and North Weld County to implement the P.A.R.T.Y. program.
The Marketing Specialist will also work with South and North Weld County insura nce agents to
implement parent/teen driving agreements to promote safe and responsible teen drivers.
Additionally, Marketing Specialist will initiate a South Weld County Teen Traffic Safety Coaltion
consisting of emergency personnel and concerned citizens to participate in South Weld County
Teen Traffic Safety programming.
HCP Inter-Disciplinary Team Costs: (HCP Only) Describe how you will spend the funds in
the line item budgets included in your CSHCN contract. Briefly describe the role of each person
or operating expense for the HCP Inter-Disciplinary Team and identify the objectives in the MCH
Page 3 of 4
Page 2 of 3
Revised 224/09
Maternal and Child Health (MCH) Attachment B-2 CASH4
Planning Budget Narrative
Plan related to this expense.
amofe: 1Na Lamb, Audiologist,
ryog st, provides training for hospital and home birth providers on newborn
hearing screening methods and requirements; $50/hour for 50 hours per year, $2,500.
Example:Team Leader attendance at 2 HCP semi-annual meetings @$500/meeting or$1,000 for year.
Indirect Costs: Provide your indirect rate. An indirect rate cap will be applied. The caps are
as follows per CDPHE agreement 25% of total direct costs; 27% of total direct salaries and/or
fringe; 30% of total direct salaries and fringe where no other direct costs are charged. If your
rate exceeds the indirect rate caps, identify those indirect costs above the allowed rate as
match or in-kind contributions.
gxample: Your Indirect rate is 34.93%of total direct Salaries/Fringe. 27%can be recognized in your
request and 7.93% must be recognized as match or in-kind.
Example: Your Indirect rate is 19% of total direct costs.The rate is within the 25%cap; 19%can be
recognized in your request.
Indirect costs: $ (6.96% of total direct costs)
Other Funding Costs: Additional funding that supports MCH in general and/or the MCH Plan
may be included in the proposed budget. This may include the contribution of program
administrators'time (i.e., an Executive Director, Nursing Director or Program Manager's time) or
it may be other funding that supports the salaries of MCH staff. It is not necessary to
include budget narrative information for"Other"funding.
Other funding for salries is provided by Weld County. Other funding for DRIVE SMART Weld
County activities is provided by small grants from the Colorado Department of Transportation,
State Farm INsurance, Allstate Insurance and local citizens interested in traffic safety.
Page 4 of 4
Page 3 of 3 Revised 224/09
„.. . Attachment B-3
ayV.� : p-ISnr�"t 'I.',, c I y ; ljc&t': •r
Agony:--Weld-Coup --Jane-29)-20W
u e ”- ....... ___.: ,. . .
- - -_-- Agency: -DepertmenFd-Weld &CnvrconmeM Dete�ompktad . .. -�rme-2-49-2678ilEg -
e:.= . !.tik1-r«te),I)Y.. ..__n I4;:, -". °'.'-' ? t'&.rrff'. +-ii.:?
Name: Debbie Drew Name:Judy Nero
Title: Director,Public Health Services Title: Coordinator Administrative Services
Phone: 970-304-6420, Ext 2304 Phone: 970-304-6410, Ext.2122
Email: ddrew(thco.weld.co.us Email: jnero@co.weld.co.us
Due Date: my 1,2010
(for the period of Oct.1,2010 through Sept.30,2011)
Instructions: Refer to instructions for completion of this form in the MCH Guidelines. Enter numbers in yellow highlighted areas below.
Total columns will calculate automatically.
In CHILDREN AND ADOLESCENT POPULATION
n PRENATAL POPULATION
n CHILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATION
PERSONNEL SERVICES(Names&Titles):
Amy Antuna,PHN III $57,346.08 085 r •-s $32,847.4
7
ae
Bev Early,PHN II $54,745.68 0.60i. ;tt' '
t $32,847.41 Samantha Orozco,PHN I $49,120.68 080 ':5:7c1-:',17.:, $39,286.54
Aurora Cura,Social Worker $54,207.48 0.80k ,._ _f;{jf}_..;i9` $24,613.51 $18,752.47
Sara Torres,OT III $33,960.76 0.60). -, - $20,376.46
Mayra Ruiz,OT III $31,748.28 0.30; - ""``.?P
Sue Kerbs, Family Coordinator $24,960.00 0.75. .:RZ. $8,524.48
Debbie Drew,Director,PHS $92,738.52 0.10$ 'I t .;4 r t, $18,720.00
..r_•<;+.::.. $9,273.85
SUBTOTAL -- $222 148.89 $103,084.84 $119,064.05
Fringe Benefits: Rate= 35.54% N/A N/A ' :P' ''' $36,636.35 $42,315.36
TL 5. $ .
OPERATING EXPENSES(which are not part of indirect)
Supplies $3,500.00 $3,500.00
Services $3,890.00 $3,890.00
$D
TRAVEL EXPENSES $4,000.00 $4,000.00
CONTRACTUAL EXPENSES
Rose Thompson OT/PT $1,000.00 $1,000.00
Regional Coordinator Training $3,000.00 $3,000.00
4gYt°X id C.. ., l'77.73-17. 7,47P0777.7.C; 77. leKr'Agr-s,� r ..
o-?7 1�°rt2G !L �°S :II a[ -r1k liTn , aE Y i ` .f... #6x i Rr '1.
INDIRECT COST: Rate= 12.41% $39,276.49 $18752.90 $20,523.59
- E ( Ire 1 s Po Cfr,T-
� s.^.�u� 1 5'P" .,,,..y. i FL}Lk{ k 0k agitXY q - ,±T:1T'.4,
Source
ce r,.._ . .,( atch r.n._ d.
Source for funding for"Other"(Match or In-kind)
LocalCounty Funding: $169,864.10 Methodology used for reporting"Source of Funds"
Medicaid(will not be used to match):
Patient Fees: Method A nX
All Other:
X8 }41) Method B n
Can NON-FEDERAL funds be used as a match? Yes In No El
Page 1 of 4
Attachment B-3
MaternaLand Child_Health_(MCH)
Budget Narrative FY11
Agency: Weld County Department of Public Date Completed: June 18, 2010
Health and Environment
Program Contact Person Fiscal Contact Person
Name: Debbie Drew Name: Judy Nero
Title: Director of Public Health Services Title: Business Manager
Phone: 970-304-6420 Ext. 2304 Phone: 970-304-6420 Ext. 2122
Email: ddrew@co.weld.co.us Email: jnero@co.weld.co.us
Population Group
Check the appropriate box below to indicate the population group that applies to this budget
narrative. Complete a separate budget narrative for each population group budget.
❑ Children and Adolescent Population
❑ Prenatal Population
® Children with Special Health Care Needs Population
Due Date: July 1, 2010
General Instructions:
The purpose of the Budget Narrative is:
> To describe how each line item included the proposed planning budget relates to your
agency's MCH plan and
> To explain how you arrived at each cost.
The Budget Narrative should provide a clear and reasonable rationale for the costs associated
with implementing your proposed MCH plan. The MCH plan, planning budget, and budget
narrative should all be aligned. Be sure to describe how you arrived at each line item amount
by providing detailed and specific information for EACH line item. The Budget Narrative should
reflect the MCH plan period from October 1, 2010 through September 30, 2011. Please provide
narrative for each cost category in the spaces below. Examples are included for each budget
category. Additional examples are available in the FY11 MCH Guidelines.
Personnel Services: List the name and title of each staff member(employed by your
agency), annual salary and Full Time Equivalent(FTE) that the staff member will commit to the
MCH plan. Briefly describe the role of the staff member in the MCH Plan and identify the
components of the Plan that this person will be responsible for completing.
Example: Susan Johnson,Registered Dietitian,salary at$50,000/year, .5 FTE(50%) to implement the
Healthy Baby campaign,on prenatal weight gain and smoking cessation, Objective 2.
-Amy Antuna, Registered Nurse/HCP Team Leader, salary at $48,744.17/year, .85 FTE (85%) to
implement and oversee the Weld HCP office activities, Objectives 1, 2, and 3.
-Beverly Earley, Registered Nurse, salary at $32,847.41/year, .6 FEE (60%) to implement Level
I and Level II care coordination services and create an awareness about the HCP program
among community partners/agencies, Objectives 1 and 2.
-Samantha Orozco, Registered Nurse, salary at $39,296.54/year, .8 FIE (80%) to implement
Level I and Level II care coordination services and create an awareness about the HCP program
among community partners/agencies, Objectives 1 and 2.
Page 2 of 4
Attachment B-3
-Aurora Cura, Social Worker, salary at $43,365.98/year, .8 FTE (80%j to implement Level I and
Level II care coordination services with a psychosocial emphasis and create an awareness about
the HCP program among community partners/agencies, Objectives 1 and 2.
-Sara Torres, Office Technician, salary at $20,376.46/year, .6 FTE (60%) to provide
clerical/technical support for HCP clients/staff, Objective 1.
-Mayra Ruiz, Office Technician, salary at $9,524.48/year, .3 FTE (30%) to implement the
CRCSN Alert System and provide clerical/technical support for HCP clients/staff, Objective 1.
-Sue Kerbs, Regional Family Coordinator, salary at $18,720.00/year, $12.00/hour, .75 FTE
(75%) to provide consultation to HCP staff/clients/families, Objective 1.
-Debbie Drew, Registered Nurse-c, Nurse Practitioner/Director of Public Health Services, salary
at $9,273.85/year, .1 FTE (10%) to provide supervision and oversight of Weld HCP program,
Objectives 1, 2, and 3.
Operating Expenses: Include expenses that are not induded in the indirectte for your
agency. Examples: office supplies, copies, postage, telephone, computer network fees, project
supplies and materials, professional development and training registrations. Include funding for
equipment, including computers and software.
Provide a brief explanation to justify the need for each line item for the MCH Plan and identify
the objective in the MCH Plan for any line items over$1,000.
Example:.$1,500 will provide a new computer for S.Johnson, R.D., who will implement the Healthy Baby
campaign, Objective 2.
-Supplies - $3,500.00 will be utilized for postage, office supplies, copies, professional
development, training registrations, home visit supplies, marketing materials (pencils/pens, etc.)
for outreach/marketing/systems building activities, and supplies/refreshments for official HCP
functions (support group and trainings), Objectives 1 and 2.
-Services - $3,890.00 will be utilized for computers, computer software, computer network fees,
printers, phone services, and speaker/facility fees for official HCP functions (support group),
Objectives 1 and 2.
Travel Costs: Travel costs to be incurred while implementing the MCH Plan and/or travel to
attend trainings. Note:It is required that the LHA includes the cost for one LHA MCH staff
person to attend a one-day, state NCH meetina in the Metro Denver area
Example: Travel costs are reimbursed at 32 cents/mile per agency policy. Costs of$1,144 are estimated
to provide transportation,lodging,and meal costs to send 2 staff working on the MCH Plan to the
Preconception Summit in September 2009.
Travel costs are reimbursed at 48 cents/mile per agency policy. Costs of$4000.00 are
estimated to provide mileage reimbursement for travel to trainings, client home visits, and
program outreach with community partners/agencies. It will also cover the estimated costs to
provide transportation, lodging, and meals to send 2 local MCH staff to MCH related
meetings/trainings.
Contractual Services: Describe costs for contractors (person or company not employed by
your agency) working on the MCH Plan. Briefly describe the role of each contractor in
completing the MCH Plan and identify the objectives of the work plan that this contractor will be
accomplishing,
Example: Robert Brown,Health Educator, contracted at$13,000/year, ($50/hour x 5 hours/week x 52
weeks=$13,000)to provide training to healthcare providers regarding prenatal smoking cessation,
Objective 2.
Example: Media coverage for$10,000 will air TV ads and radio spots for the Healthy Baby campaign
using ads that are already developed, adding information re: the local health agency.
Page 3 of 4
Maternal and Child Health (MCH) Attachment B-3
Planning Budget Narrative
HCP Inter-Disciplinary Team Costs:
=Rose Thom son h sica T era (Regional Consultant p y py ( g ) - $1,000.00/year, $24.00/hour, to
provide consultation to HCP staff/clients/families. Objective 1.
-Regional Coordinator Training, $3000.00 in funds is provided to facilitate training opportunities
for Weld HCP Regional Coordinators/staff, Objective 1.
Indirect Costs: Provide your indirect rate. An indirect rate cap will be applied. The caps are
as follows per CDPHE agreement: 25% of total direct costs; 27% of total direct salaries and/or
fringe; 30% of total direct salaries and fringe where no other direct costs are charged. If your
rate exceeds the indirect rate caps, identify those indirect costs above the allowed rate as
match or in-kind contributions.
Example: Your indirect rate is 34.93%of total direct Salaries/Fringe. 27%can be recognized in your
request and 7.93% must be recognized as match or in-kind.
Example: Your indirect rate is 19% of total direct costs.The rate is within the 25% cap; 19%can be
recognized in your request.
Indirect rate is 12.41% of the total direct cost.
Other Funding Costs: Additional funding that supports MCH in general and/or the MCH Plan
may be included in the proposed budget. This may,include the contribution of program
administrators'time (i.e., an Executive Director, Nursing Director or Program Manager's time) or
it may be other funding that supports the salaries of MCH staff. It is not necessary to
include budget narrative information for"Other"funding.
Additional funding that supports HCP activities comes from local County general fund in the
amount of$169,864.10/annually.
Page 4 of 4
Revised 5/10/2010
EXHIBIT C
GRANT FUNDING CHANGE LETTER
Date: State Fiscal Year: Grant Funding Change Letter# CMS Routing#
TO: Insert Grantee's name
In accordance with Section of the Original Contract routing number , [insert the following
language here if previous amendment(s), renewal(s) have been processed] as amended by [include all
previous amendment(s), renewals) and their routing numbers], [insert the following word here if
previous amendment(s), renewal(s) have been processed] between the State of Colorado, Department
of Public Health and Environment and Contractor's Name beginning Insert start date <insert start date of
original contract> and ending on Insert ending date <insert ending date of current contract amendment>,
the undersigned commits the following funds to the Grant:
The amount of grant funds available and specified in Section of<insert contract amendment
number and routing number> is Elincreased or ❑ decreased by$amount of change to a new total
funds available of$ <insert new cumulative total> for the following reason: . Section
is hereby modified accordingly.
This Grant Funding Change Letter does not constitute an order for services under this Grant.
The effective date of hereof is upon approval of the State Controller or , whichever is later.
STATE OF COLORADO
Bill Ritter,Jr. GOVERNOR
Department of Public Health and Environment PROGRAM APPROVAL:
By: Lisa Ellis, Purchasing &Contracts Unit Director. BY:
Date:
ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Grants.This Grant is not valid until signed and dated below by
the State Controller or delegate.Grantee is not authorized to begin performance until such time.if Grantee begins performing prior
thereto,the State of Colorado is not obligated to pay Grantee for such performance or for any goods and/or services provided
hereunder.
STATE CONTROLLER
David J. McDermott, CPA
By:
Donald Rieck
Date:
Page 1 of 1
.:. Effective Date:1/6/09-Rev 8/25/09
404-cti
tWr MEMORANDUM
CTo: Office of Clerk to the Board of Weld County Commissioners
. Date: NOie tin bek 8, 020 10
COLORADO From: ".O I t DeAnq'el t S , Health Department
Subject: nnCl-I / 1.1.CP JrbrrtRocr
Attached to this memo is the finalized contract, amendment to a contract, letter of renewal,
change order letter or other document as listed below.
Please sign and date below in the designated areas indicating you have received the finalized
document and return this signed memo to me in the Administration Division of the Health
Department.
Thank you for your assistance with the processing of this document.
Att. LIaj
Document Name: mCH and HCP PRUA12Q►nm Con'tacr
Resolution Number: dolt - 93623
Finalized Document Received By: %.SO vvv 1 L,_/en&o. 6
Date Received: \\ - C1 1l7
-9 P 3b
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