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Home My WebLink About20102581.tiff RESOLUTION RE: APPROVE CHRONIC DISEASE SELF MANAGEMENT PROGRAM MASTER TRAINER AGREEMENT AND AUTHORIZE CHAIR TO SIGN - CENTRAL COLORADO AREA HEALTH EDUCATION CENTER 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 Chronic Disease Self Management Program Master Trainer Agreement between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, Area Agency on Aging, and the Central Colorado Area Health Education Center, commencing October 20, 2010, and ending March 31, 2012,with further terms and conditions being as stated in said agreement, and WHEREAS,after review,the Board deems it advisable to approve said agreement, 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 Chronic Disease Self Management Program Master Trainer Agreement between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services,Area Agency on Aging, and the Central Colorado Area Health Education Center, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 27th day of October, A.D., 2010, nunc pro tuns October 20, 2010. BOARD OF COUNTY COMMISSIONERS ELD COUNTY, COLORADO ATTEST: • i� v�T 1861 f-, ■• ._ladC adema. -r Chair Weld County Clerk to the Bo (�� U rbara Kirkmeye,, Pro-Tem BY: l I �B oaI C Dep Clerk t the Board Sean P. Coh APP D ORM: 'am F. Garcia ounty Attorney A 1 jc oh_ David E. Long Date of signature: P� °rig fo /-AD (415 Q_A,'. A5 O 2010-2581 /0/a l/p - D.\_ 11 HR0081 MEMORANDUM ritDATE: October 25, 2010 I TO: Douglas Rademacher, Chair, Board of County Commis loners ` FROM: Judy A. Griego, Director, Human Services D artmeit4XD} - COLORADO RE: Chronic Disease Self Management Program Master Trainer Agreement between the Weld County Department of Human Services' Area Agency on Aging and the Central Colorado Area Health Education Center (AHEC) Enclosed for Board approval is a Chronic Disease Self Management Program Master Trainer Agreement between the Weld County Department of Human Services' Area Agency on Aging and the Central Colorado Area Health Education Center(AHEC). This Agreement was presented at the Board's October 25, 2010, Work Session. This Agreement will allow the AAA Master Trainers to provide fidelity site visits for evidence based classes that are being taught by our training partners. The Department will be reimbursed $125.00 per fidelity visit. The term of this agreement is October 20, 2010 through March 31, 2012. If you have questions, please give me a call at extension 6510. 2010-2581 Developing Community-Academic Partnerships to Promote Healthier Colorado Residents /!. y & Con do r- Chronic Disease Self Management Program Master Trainer Agreement By this written agreement entered into on October 20, 2010, Central CO AHEC (CC AHEC) and Weld County Area Agency on Aging (Independent Contractor) agree to provide Chronic Disease Self Management Program(CDSMP) session fidelity checks to ensure fidelity of workshop sessions to the Stanford Chronic Disease Self Management Program based on these agreements: Section I - Scope of Work: *Contract signed by Independent Contractor and CC AHEC. *Independent Contractor form completed and Notarized, W-9 Form Completed. *Background check on Independent Contractor employee(s) that will be conducting fidelity check(s). Background check conducted by CC AHEC is found satisfactory. * Independent Contractor employee(s) that will be conducting fidelity check(s) will provide to CC AHEC a copy of certificate that states that employee is certified by Stanford University as a Master Trainer in the Chronic Disease Self Management Program. * Independent Contractor employee(s) that will be conducting fidelity check(s) will submit a resume/CV to CC AHEC with demonstration of current training experience with CDSMP workshop sessions. *Independent Contractor will complete fidelity check(s)of the CDSMP workshop session(s) as specified by CC AHEC, with dates agreed upon with workshop leaders and CC AHEC. * Independent Contractor will use the approved "Be Well Colorado Leader Fidelity Checklist" as developed by the Colorado Department of Health and Environment and provided by CC AHEC. *Independent Contractor will call CC AHEC contact staff person (Lindsey Blackwelder, 303.724.4399)within 24 hours of completing each fidelity check in order to discuss any concerns. *Independent Contractor will return the "Be Well Colorado Leader Fidelity Checklist"to CC AHEC within three business days of each workshop fidelity check. Section II The time of performance for this contract is from October 20, 2010 to March 31, 2012. Section III The payment will be made based on an amount of$125.00 per fidelity site visit, for completion of deliverables as stated in the scope of work. Payment will be made after the fidelity check is completed and upon satisfaction of all parts of the scope of work. CC AHEC has 30 days after receipt of the request for payment, to make payment for the deliverables. Invoices are made to Central Colorado AHEC, PO Box 6267, Aurora, CO 80045. Section IV Notice of termination shall be given in writing at least 10 days prior to the effective date of termination, by either party. Central Colorado Area Health Education Center(AHEC) 303-7240335 PO Box 6267 303-724-1548 Fax Aurora, CO 80045 Kriswenzel@CentralCOAHEC.org Developing Community-Academic Partnerships to Promote Healthier Colorado Residents Section V Professional liability insurance errors and omissions or Professional Liability Insurance is recommended for the completion of this contract work. Section VI Address for Notices and Invoices: To Center: Central CO AHEC PO Box 6267 Aurora, CO 80045 Central CO AHEC, Attorney Same as above To Contractor: Weld County Area Agency on Aging 315C N. 11th Avenue P.O. Box 1805 Greeley, CO 80632 Section VII Special Conditions: Agreement to carry out additional locations and trainings requiring fidelity checks can be made in an addendum to this agreement with specific time of performance and with the same consideration noted in Section III. IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the date first written above Independent Contractor' . ks,ile ATTEST: . % BOARD OF COUNTY COMMISSIONERS � � `� ~�� 1%6 !v - J WELD COUNTY, COLORADO Weld County Clerk to the B' A7 -ALA BY: f �' I,,ii� � ►�� jr,�:_ i_ � adeacher eputy CI to the Boar. OCT 2 2010 WELD COUNTY DEPARTMENT CENTRAL COLORADO AHEC OF HUMAN SERVICES Kristina R. Wenzel, Executi e Director Judy riegojDirecto( i �JJ WELD COUNTY AREA AGENCY ON AGING "' Eva M. well, *vision Head Central Colorado Area Health Education Center(AHEC) 303-724-0335 PO Box 6267 303-724-1548 Fax Aurora, CO 80045 Kriswenzel@CentralCOAHEC.org I Declaration of independent Contractor Status Form We certify UNDER PENALTY OF PERJURY that: e d trde name)11)al 4 (to ail A(*, 45e"g e"(y 4j t performing(type of work) �3 m P +rt Ac� i 1y C h e S.J 5 / Social Security or Federal Employer Identification# 84=6000-813 Address:_ Phone: is an independent contractor(IC)an,El is not An employee gqf�the followinnj�policyholder(PH)' A .0 • L Address:)24s 3 1 e_ 11 *el HtA.c O f t J C C) 2CO'1.. olicy# • - ;J Phone: . 0J.;• We also certify,by OUR initials WHERE APPLICABLE,that the above business for which the above individual performs services meet the following criteria: IC l''11 PH. 1. The business DOES NOT require the individual to work ONLY for the business for whom services are performed (except that the individual may DECIDE to work only for the business for a definite period); IC ! V;J PH 2.The business DOES NOT establish a quality standard for the individual(except that the business may provide plans and specifications regarding work but cannot oversee the actual work or instruct the individual as to how work will be performed); IC a',i-)PH 3.The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate; IC*t )PH 4.The business DOES NOT terminate the work or the service provided during the contract period unless the Th individual violates the terms of the contract or fails to produce a result that meets the specifications of the contract; IC L 1` PH 5.The business DOES NOT provide more than minimal training for the individual; IC PH 6.The business DOES NOT provide tools or benefits to the individual(except that materials and equipment may be supplied); IC f.o()PH 7.The business DOES NOT dictate the time of performance(except that a completion schedule and a range of agreeable work hours may be established); IC:- PH 8.The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade or business name of the individual; IC•-•�._ PH 9.The business DOES NOT combine the business operations inc any way with the individual's business operations / instead of maintaining all such operations separately and distinctly. A, CERTIFICATION BY INDEPENDENT CONTRACTOR THE INDEPENDENT CONTRACTOR UNDERSTANDS THAT HEISHE; •WILL NOT BE ENTITLED TQ ANY WORKERS'COMPENSATION BENEFITS IN THE EVENT OF INJURY. •IS OBUGATED TQ PAY ALL FEDERAL AND STATE INCOME TAX OR-ALL MONEY EARNED WHILE PERFORMING SERVICES FOR THg BUSINESS. i i. et.. RE UIRED TO P RKERS'COMPENSA ON INSURANCE FOR ALL WORKERS THAT HEISHE HIRES, Girfr• C' l A Co iir 84-6000-813 d ' O1A� d Contractor gnature Title Social Security# FEIN II i' $ A OF COLORADO,COUNTY OF Weld _ ., 1. � ' ' Sub andcwornl r)by Aou as Rademacher this 27thdayof October , 2010 en.. A s co :'p / -k -e4-__.?, Commission expires: '-/! .. ;�Ly i );rIIet Y P 'I �-.; -ti- •Acceptance of the Independent Contractor named on this form don not change any party's responsibility under the Workers'Compensation Act.If iv cl-jNiA'vls,, ;i1e•- ;Ii.:e.•y lvidnals er rganlaation hued or contracted by the Independent Contracmr are not coveted by other workers'compensation insurance,the policyholder speeil7cd on thi s form wfll he charged premium for coverage of those indlcidaaia or orgnnhations. CERTIFICATION BY BUSINESS Pt,11 .� •.��"�� t I am authorized by the business listed above to state that all of the information on this form is true and accurate.I \ t if the above person does not qualify for independent contractor status,the proper premium can be assessed. •• Signature . j Title I STATE O);Csj ORADO,COUNTY OF LQ`,zjT',..)- J `i2.,'•• 3 Subscribed worn before me by ,,-sk 1•=.r. ,'• .tn-arc.e this .� day of L2/4 2.4_r , --•- G•'// <1 i3X11 2- . .f)'' KGs , Commission expires: 6-,/1 / ti t '•...-'.. i F PUBLIC Page 2 of 2 7AIrerrrno•t pr0-iiR ,.9(/G'.. (.:47-45S/ Hello