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Home My WebLink About20091182.tiffRESOLUTION RE: APPROVE TASK ORDER CONTRACT FOR TUBERCULOSIS PROGRAM AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Task Order Contract forthe Tuberculosis Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment, commencing July 1, 2009, and ending June 30, 2010, 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 Tuberculosis Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said contract. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 20th day of May, A.D., 2009. BOARD OF COUNTY COMMISSIONERS WELD 0Nc1 OLORADO / ATTEST: Weld County Clerk to't Deputy C -rk to the Board APPROVED AS TO FORM: Air / orh�.11ir4mcvcr ��//-'�� Date of signature it ; //e__ +-i 2009-1182 ©&///G1% HL0036 4a:r4 IIMe COLORADO Memorandum TO: William F. Garcia, Chair Board of County Commissioners FROM: Mark E. Wallace, MD, MPH Director, Department of Public Health and Environmen-t)M A, , DATE: May 5, 2009 SUBJECT: Task Order Contract for the Tuberculosis Program db Enclosed for Board review and approval is a task order contract between Weld County and the Colorado Department of Public Health and Environment for the Tuberculosis Program. Under the provisions of this contract, Weld County Department of Public Health and Environment (WCDPHE) will provide active TB treatment including directly observed therapy, ensure contacts to all newly identified infectious TB cases are identified and receive appropriate evaluation, collect specimens for testing on all persons suspected of having TB, provide for and interpret chest x-rays, and conduct TB skin test screening programs. Health Department staff will also follow-up with active patients to ensure they receive appropriate information and education and they adhere to the completion of their TB therapy. The contract also contains new provisions concerning the monitoring of vendor performance on state contracts and inclusion of contract performance information in a statewide contract management system. For providing these services during the time period of July 1, 2009 through June 30, 2010, WCDPHE will receive an amount not to exceed $70,600 plus $12.50 per onsite visit and $25.00 per field visit for directly observed therapy. I recommend your approval of this contract. Enclosure 2009-1182 DI TARI'MEN'f OF PUBLIC IIEN;fl I AND kNVIRONMEN'P ROUTING NO. 10 FHA 00023 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 of Colorado for the use & benefit of the Department of Public Health and Environment Disease Control and Environmental Epidemiology Tuberculosis Program 4300 Cherry Creek Drive South Denver, Colorado 80246 TASK ORDER MAD' i DAD 4. 04/21/2009 PO/SC ISNCUMBRANC'. NUMBER: PO ELIA EP1000023 I DRNI: This Task Order shall be effective upon approval by the State Controller, or designee, or on 07/01/2009, whichever is later. The Task Order shall end on 06/30/2010. PRici SI'ItUC'R; RE: Cost Reimbursement PRO('LRI'.NuLNT NILE' IOD_ Exempt CON'I'R cioit: Board of County Commissioners of Weld County 915 10th Street Greeley, Colorado 80632-0758 for the use and benefit of the Weld County Department of Public Health and Environment, 1555 North 17th Avenue Greeley, Colorado 80631 CONTRACTOR ENTITY Y'1YPIi. Colorado Political Subdivision BILLING SIAT'4V11 ',NTS ItLGIfDIED: Monthly STATUTE( TRY API! BANDY: Not Applicable CONTRACT PRICY NOT TO IIXCI IIB > $70,600.00 I'' ID'IRAL ITN DI NG DOIJARS: $0.00 STATE FUNDING DOLLARS $70,600.00 BID/REP/IJS'I PRICE AGREEMENT' NUMB' iR. MAXI 11tH AMOUNT AVAILABII. PER FISCAL NTT TAR: Not Applicable LAW SP8CID I!D VENDOR STrYI'U IL: Not Applicable SIAM. rreersI IN I A'1'IVI: Mary Goggin Department of Public Health and Environment Disease Control and Environmental Epidemiology Tuberculosis Program 4300 Cherry Creek Drive South Denver, CO 80246 FY 10: $70,600.00 (Plus a portion of the DOT funding identified in Exhibit A) CONTRACTOR RI'1 RYSDNTATIVI% Judy Nero Weld County Department of Public Health and Environment, 1555 North 17°1' Avenue Greeley, Colorado 80631 SCOPI OI' \\ ORIC The Contractor shall provide or coordinate the Tuberculosis (TB) prevention and control activities for individuals within its service area. Page 1 of 5 Rev 4/3/09 EXI II BITS: 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 - Limited Amendment Template for Task Orders Exhibit D- Grant Funding Letter Exhibit F,- Budget 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. 1. 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. 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 4/3/09 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 and Exhibit E". 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 "Limited Amendment for Task Orders" that is substantially similar to the sample form Limited Amendment that is incorporated herein by this reference and identified as Exhibit C. To be effective, this Limited Amendment must be signed by the State and the Contractor, and be approved by the State Controller or an authorized delegate thereof Upon proper execution and approval, this Limited Amendment shall become a formal amendment to this Task Order Contract. 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 REP 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 1, 2009 and the maximum amount payable to Contractor hereunder is 5100, 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 ofthe 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 Page 3 of 5 Rev 4/3/09 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 4/3/09 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: Board of County Commissioners of Weld County for the use and benefit of the Weld County Department of Public Health and Environment Legal Name of Contracting Entity Signature of Authorized Officer MAY 2 0 1009 STATE OF COLORADO: BILL RITTER, JR. GOVERNOR For Executive Director Department of Public Health and Environment Signatory avers to the State Controller or delegate that Contractor has not begun performance or that a Statutory William F. Garcia Violation waiver has been requested under Fiscal Rules Print Name of Authorized Officer Chair Print Title of Authorized Officer Depanment Prygram Appro � fi By ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. By Date STATE CONTROLLER: vid J. McDermott, CPA Page 5 of 5 B WELD COUNTY DEPARTMENT OF BLIC HEALTH A 'D ENVIRON p4& ' as Mark E. Wallace, MD, MPH -Dire v 4/3/09 .a19- //t2 EXHIBIT A ADDITIONAL PROVISIONS To Task Order Contract Dated 04/21/2009 - Contract Routing Number 10 FHA 00023 These provisions are to be read and interpreted in conjunction with the provisions of the Contract specified above. 1. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The State has determined that this contract does not constitute a Business Associate relationship under HIPAA. 2. The State, in order: to carry out its lawful powers, duties, and responsibilities under Section, 25-4-501, 8 C.R.S., as amended; and, to effectively utilize legislative appropriations made and provided therefore, in coordination with like powers, duties, and responsibilities of the Contractor, has determined that public health services are desirable in WELD COUNTY Colorado. 3. Pursuant to 25-4-501, 8 C.R.S., as amended, the General Assembly has declared that tuberculosis is an infectious and communicable disease, that it endangers the population of this state, and that the treatment and control of said disease is a state responsibility and further, pursuant to 25-4-511, 8 C.R.S., assistance under section 25-4-501, shall be given to any applicant who is suffering from tuberculosis in any form requiring treatment and is without sufficient means to obtain such treatment. The State, through the Tuberculosis Program has a mandate to provide care coordination services for the residents of the State of Colorado. 4. Pursuant to the Catalog of Federal Domestic Assistance (CFDA) number 93.116, the State has been awarded funds by the Department of Health and Human Services, Centers for Disease Control (CDC) for tuberculosis control. The State shall contract with the Contractor to assure that tuberculosis control services are provided for the residents of the above -mentioned county. 5. The State has formulated a comprehensive State plan, with associated budgets, to disburse these funds throughout the state of Colorado. Under this comprehensive State plan, the State shall allocate these funds to qualified entities to provide certain purchased services to the citizens of the state of Colorado on behalf of the State. 6. In consideration of those services 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 SEVENTY THOUSAND, SIX HUNDRED DOLLARS ($70,600.00) for the initial term of this Contract. Of the total financial obligation of the State referenced above, $70,600.00 is identified as attributable to a funding source of the state of Colorado. Payment pursuant to this Contract shall be made as earned, in whole or in part, from available State funds encumbered in an amount not to exceed THIRTY FIVE THOUSAND TWO HUNDRED DOLLARS ($35,200.00) Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2010. Of the total financial obligation of the State referenced above, one hundred percent is derived from the State General Fund. The liability of the State, at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or terminate this Contract in its entirety. To receive compensation under this Contract, the Contractor shall submit a signed monthly Invoice/Cost Reimbursement Statement in a format acceptable to the State. A sample Invoice/Cost Reimbursement Statement is attached hereto as Attachment A-1 and incorporated herein by this reference. An Invoice/Cost Reimbursement Statement must be submitted within Thirty (30) calendar days of the end of the billing period for which services were rendered. Expenditures shall be in accordance with the To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 1 oft Revised: 12/19/06 EXHIBIT A Statement of Work attached hereto as Exhibit B and incorporated herein. These items may include, but are not limited to, the Contractor's salaries, fringe benefits, supplies, travel, operating, indirect costs which are allowable, and other allocable expenses related to its performance under this Contract. Invoice/Cost Reimbursement Statements shall: 1) reference this Contract by its contract routing number, which number is located on page one of this Contract; 2) state the applicable performance dates; 3) state the names of payees; 4) include a brief description of the services performed during the relevant performance dates; 5) describe the incurred expenditures if reimbursement is allowed and requested; and, 6) show the total requested payment. Payment during the initial, and any renewal or extension, 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. Invoice/Cost Reimbursement Statements shall be sent to: Mary Goggin Tuberculosis Program Colorado Department of Public Health and Environment DCEED A-3 4300 Cherry Creek Drive South Denver, CO 80246 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 thirty (30) 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 thirty (30) calendar days from the effective expiration or termination date of this Contract. Unless otherwise provided for in this Contract, "Local Match", if any, shall be included on all billing statements as required by the funding source. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. 7. Notwithstanding the terms and conditions contained in paragraph 16, page 7, General Provisions, of this contract, the parties agree to add a new subparagraph c., which states the following: "c. Funding Letter. The State may increase or decrease funds available under this Contract using a Grant Funding Letter substantially equivalent to "Exhibit D." The Grant Funding Letter is not valid until it has been approved by the State Controller or designee. To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 2 of 2 Revised: 12/19/06 ATTACHMENT A-1 INVOICE NUMBER REIMBURSEMENT STATEMENT artment of Public Health and Environment Colorado De O 4300 Cherry Creek Drive South DCEED/TB/A3 Denver, CO 80246 i>"])z ❑ ❑ FEDERAL ID ( 303 ) 691.7749 DATE OF EXPENDITURE: NUMBER: ro 0 0 0 0 O O U L F O W E- a F n. o ne F Requested Reimbursement Amount Description of Expenditure ITB Control Personal Services N nu g L.]. N a O V Equipment Travel Other (please specify) _ U i- 5 Directly -Observed Therapy 'Diagnostic Services GRAND TOTAL and we are requesting reimbursement for the same. This is to certify that the above expenses were incurred per Contract # W W F F Q Q Q Q SIGNATURE (CONTRACTOR): AUTHORIZED DESIGNEE (ST O a) O) co a EXHIBIT B STATEMENT OF WORK To Task Order Contract Dated 04/21/2009 — Contract Routing Number 10 FHA 00023 These provisions are to be read and interpreted in conjunction with the provision of the Task Order Contract specified above. Funds provided under the Task Order are to assist in supporting tuberculosis (TB) prevention and control activities as stated in Colorado Revised Statues (CRS) 25 -4 -501 -Part 5 Tuberculosis (et seq) and Rules and Regulations Pertaining to Epidemic and Communicable Disease Control (6-CCR-1009-1, Regulation 4). Contractor shall provide or coordinate the following services for all individuals within its service area according to the statutes and regulations listed above and according to Colorado Department of Public Health and Environment (CDPHE) Tuberculosis Manual, but in no event less than those duties required by statute and rules (listed above). Use of funds shall be prioritized as follows: priority 1) finding all patients with active TB and ensuring completion of appropriate therapy, priority 2) finding and evaluating contacts of TB patients and ensuring completion of appropriate therapy, 3) evaluation of newly arrived immigrants and refugees with Class B TB designation, and priority 4) targeted testing of high -risk persons and ensuring completion of therapy for latent TB infection (LTBI). If available, use patient's medical insurance as primary payment source. CDPHE will reimburse for diagnostic and clinical services at current Medicaid rate unless prior approval has been given by the CDPHE TB Program. 1. Suspected or confirmed active TB a. The Contractor shall provide, or arrange for, chest x-rays and interpretations. b. The Contractor shall collect, or arrange for the collection of, specimens for mycobacteriology testing on all persons suspected of having TB. Assure appropriate testing is performed, e.g., smears for acid -fast bacilli, (using concentrated fluorescent method), isolation of mycobacteria (using rapid methods), identification of Mycobacterium tuberculosis complex (MTB) (using rapid methods), and susceptibility testing (isoniazid, rifampin, ethambutol, and pyrazinamide) on isolates of MTB. Contractor should use the CDPHE Laboratory for testing. The CDPHE Laboratory will, at no charge to the Contractor, supply specimen containers and perform the above testing for the Contractor. The Contractor shall arrange for the transportation of the specimens to the CDPHE Laboratory for testing. c. The Contractor shall provide, or arrange for, the placement of patients who require isolation. The Contractor shall contact CDPHE TB Program for assistance, if needed, and to request reimbursement from CDPHE for those costs incurred by the Contractor in isolating a patient. d. The Contractor shall provide, or arrange for, all other necessary laboratory testing and medical evaluation services. e. The Contractor shall order TB medications through the CDPHE TB Program. f. The Contractor shall provide the CDPHE with the medical insurance information for those patients who have medical insurance. g. The Contract shall provide, or arrange for, the treatment of patients with suspected or confirmed active TB, including directly observed therapy, and ensure adherence to treatment. h. The Contractor shall provide, or arrange for, a HIV antibody test for all persons diagnosed with TB disease, regardless of their age or the apparent absence of risk factors for HIV infection. In accordance with section 25-4-1401, et seq., C.R.S., as amended, the Contractor shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks associated with HIV/TB co -infection. To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 1 of 5 Revised 12/19/06 EXHIBIT B i. At least monthly, the Contractor shall monitor and evaluate those persons with suspected or confirmed active TB. j. The Contractor shall provide culturally appropriate patient education and information pertaining to TB treatment and/or follow-up plan. The Contractor shall provide services in patient's language using medical interpretation resources such as AT&T language line as needed. k. All reports of suspected or confirmed active TB shall include: reason for initiating, patient name, date of birth, country of birth, date arrived in U.S., demographic information, locating information, provider information, TB risk factors, results of diagnostic testing, results of mycobacteriology including susceptibility results, dates of infectious period, treatment information, changes in patients' status, diagnosis, or any other information as appropriate. The Contractor shall report to CDPHE when a TB patient completes treatment, moves, or transfers out of the Contractor's service area. Information may be reported via web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and Case Management Report" (TB 17), which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment B -I". Confirmed cases of TB shall include all data elements identified in the "Report of Verified Case of Tuberculosis (RVCT)", which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment B-2". The CDPHE shall provide the format and instructions for any additional information requests. Report forms are subject to revision and Contractor agrees to use most recent version. Contacts to newly identified infectious TB (smear and/or culture positive pulmonary or laryngeal) a. The Contractor shall ensure that all contacts to newly identified infectious TB cases are identified, investigated, and receive appropriate evaluation. Contact investigation and any follow-up needed as a result of an occupational exposure shall be conducted by the employer. b. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations. c. When indicated, the Contractor shall provide, or arrange for, other laboratory testing, and other necessary medical evaluation services. d. The Contractor shall provide, or arrange for, the treatment of patient (including directly observed preventive therapy when appropriate), and ensure the completion of therapy for infected contacts. e. The Contractor shall order TB medications through the CDPHE TB Program. f. The Contractor shall provide CDPHE with the medical insurance information for those patients that have medical insurance. g. The Contractor shall provide, or arrange for, an HIV antibody test to all persons with LTBI with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, el seq. C.R.S., as amended, the Contractor shall report all known HIV antibody test results to the State. The Contractor shall inform all individuals whom refuse testing of the risks associated with HIV/TB co -infection. h. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during treatment. i. The Contractor shall provide culturally appropriate patient education and information pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 2 of 5 Revised 12/19/06 EXHIBIT B patient's language using medical interpretation resources such as AT&T language line as needed. J The Contractor shall submit a preliminary Tuberculosis Contact Investigation Record, (which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment B-3" to the CDPHE TB Program after initiation of each contact investigation. The Contractor shall submit a final report to CDPHE when a contact investigation is completed. Report forms are subject to revision and Contractor agrees to use most recent version. k. For those persons identified, as part of a contact investigation, with latent TB infection, or those with suspected latent TB infection requiring treatment recommendations from CDPHE, the Contractor shall report reason for initiating, patient name, date of birth, country of birth, date arrived in U.S., demographic information, locating information, provider information, TB risk factors, results of diagnostic testing, treatment information, or any other information as appropriate. The Contractor shall report to CDPHE when a patient completes treatment, moves, or transfers out of the Contractor's service area. Information may be reported via web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and Case Management Report" (TB 17). The CDPHE shall provide format and instructions for any additional information requests. Report forms are subject to revision and contractor agrees to use most recent version. 3. Newly arrived immigrants and refugees with Class B TB designation a. The CDPHE TB Program will notify the Contractor of all newly arrived Class B TB immigrants/refugees via a CDC 75.17 form which is incorporated herein by this reference, made a part hereof, attached hereto as "Attachment B-4" or Tuberculosis Follow-up worksheet which is incorporated herein by this reference, made a part hereof, attached hereto as "Attachment B-5". Report forms are subject to revision and contractor agrees to use most recent version. b. Within thirty (30) calendar days of the Contractor's receipt of written notification from the State of the arrival of a Class B immigrant/refugee, the Contractor shall contact that immigrant and conduct, or arrange for, a TB screening that includes medical evaluation, tuberculin skin test or whole blood interferon y assay, chest radiograph, and three spontaneous sputum specimens for AFB smear and culture collected on consecutive days. c. Upon completion of testing and examination, the Contractor shall fill out, sign, and date the CDC 75.17 form or Follow-up worksheet, and return it within 90 days to: Colorado Department of Public Health and Environment Tuberculosis Program Attn: Class B Coordinator 4300 Cherry Creek Drive South Denver, CO 80246 d. The Contractor shall, when indicated, provide, or arrange for, treatment and ensure completion of therapy. e. The Contractor shall order TB medications through the CDPHE TB Program. f The Contractor shall provide CDPHE with the medical insurance information for those patients that have medical insurance. g. The Contractor shall provide culturally appropriate patient education and information pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 3 of 5 Revised 12/19/06 EXHIBIT B patient's language using medical interpretation resources such as AT&T language line as needed. h. For those persons identified with LTBI or active TB, the Contractor shall report patient name, date of birth, country of birth, date arrived in U.S., demographic information, locating information, provider information, TB risk factors, results of diagnostic testing, treatment information, or any other information as appropriate. Contractor will report when a patient completes treatment, moves, or transfers out of the jurisdiction. Information may be reported via web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and Case Management Report" (TB 17). The State shall provide format and instructions for any additional information requests. Report forms are subject to revision and Contractor agrees to use most recent version. 4. Other high -risk persons with LTBI a. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations. b. When indicated, the Contractor shall provide, or arrange for, all other necessary laboratory testing and medical evaluation services. c. The Contractor shall provide, or arrange for, the treatment of patient and ensure the completion of therapy. d. The Contractor shall order TB medications through the CDPHE TB Program. e. The Contractor shall provide the CDPHE with the medical insurance information for those patients that have medical insurance. f The Contractor shall provide, or arrange for, a HIV antibody test to all persons with LTBI with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et seq., C.R.S., as amended, the Contractor shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks associated with HIV/TB co -infection. g. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during treatment. h. The Contractor shall provide culturally appropriate patient education and information pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in patient's language using medical interpretation resources such as AT&T language line as needed. i. For persons with LTBI, the Contractor shall report reason for initiating, patient name, date of birth, country of birth, date arrived in U.S., demographic information, locating information, provider information, TB risk factors, results of diagnostic testing, treatment information, or any other information as appropriate. Contractor shall report when a LTBI patient completes treatment, moves, or transfers out of the jurisdiction. Information may be reported via web - based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and Case Management Report" (TB 17). The CDPHE shall provide format and instructions for any additional information requests. Report forms are subject to revision and Contractor agrees to use most recent version. J• Tuberculin skin testing, chest radiographs, chest radiograph interpretations, other diagnostic testing, and medical evaluations are not eligible for reimbursement under this Task Order for the following: To be attached to CDPHE Task Order vl.0 (11/05) contract template Page 4 of 5 Revised 12/19/06 EXHIBIT B Correctional facility inmates; ii. Persons, other than Class B TB immigrants/refugees, undergoing immigration medical examinations; iii. Paid or volunteer employees of health care facilities, long-term care facilities, drug treatment centers, correctional facilities, shelters, schools, or child care facilities who undergo skin testing as part of a routine employment skin testing program. 5. TB education and consultation As needed, the Contractor shall provide consultation services to providers in its service area regarding TB reporting, screening, treatment, and follow-up. 6. Reports for contract monitoring The Contractor shall provide the CDPHE with a Semi-annual progress report on TB activities in its service area. A sample of the semi-annual progress report is incorporated herein by this reference, made part hereof, and attached hereto as "Attachment B-6". Report forms are subject to revision and contractor agrees to use most recent version or submit a similar type of report. The Contractor shall submit report within two months after funding period ends. 7. Confidentiality The Contractor shall maintain internal medical and administrative records in a manner which ensures the confidentiality and security of those records in accordance with all applicable statutes including, but not limited to, 25-1-107, C.R.S., as amended. To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 5 of 5 Revised 12/19/06 TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT Last Name Colorado Department of Public Health and Environment Tuberculosis Program Attachment B-1 4300 Cherry Creek Drive South DCEED-TB-A3 Denver, Colorado 80246-1530 (303) 692-2638 phone (303) 691-7749 fax DEMOGRAPHICS LOCATING INFORMATION Date of Birth Race: ❑ American Indian/Alaskan Asian Black/African American ❑ Native Hawaiian/Other Pacific Is. ❑ White ❑ Unknown Occupation: First Name Gender: ❑ Ethnicity: ❑ Country ❑ of Birth: ❑ Date Arrived in US: MI Male Female Not Hispanic/Latino Hispanic/Latino United States Mexico Specify other Month/Year New health care worker Current health care worker (HAS patient contact) Current health care worker (NO patient contact) Corrections employee Migrant farm worker ❑ Unknown Unemployed past 24 months ❑ Other Employer Specify other ■ Current Home Address (Number & Street Name) Apt # City State Zip Code County Other Address (Number & Street Name) Specify Type City State ( ) ( ) Home Phone Number Other Phone Number Specify Type Zip Code County ( ) Work Phone Number TUBERCULIN SKIN TEST (TST) ■ Current Mantoux- Tubersol Reason TST Type: ❑ Mantoux- Aplisol For Test: ❑ ❑ Mantoux- Unspecified ❑ ❑ Not done ❑ ❑ Unknawn ❑ Name of Clinic/Local Health Agency Placing TST ❑ Current / / / / TST Date Given Date Read Reading Current TST Result ❑ Negative ❑ TST positive at 5 mm or greater HIV positive person Recent, close contact to active TB Has fibrotic lesions on CXR consistent with old TB disease ❑ Patients with organ transplants or other immunosuppressed patients QuantiFERON (QFT) / / Collection Date QFT Results mm Admin'strative Class B TB Notification Contact investigation Employment Immigration status change Known active Source case investigation ■ Suspect case Symptomatic Targeted testing- individual Targeted testing- pregnancy Targeted testing- specific project Transfer case/suspect Unknown Previous / / TST Date Positive (please select criteria below) ❑ Not read Positive Negative Testing Laboratory ❑ Indeterminate ❑ Unknown mm Reading TST positive at 10 mm or greater TST positive at 15 mm or greater ❑ Recent arrival from a country with ❑ No known risk factors for TB a high prevelance of TB Injection drug user Resident of high risk congregate setting Employee of high risk congregate setting Mycobacteriology laboratory personnel High risk clinical conditions Child < 4 years old, or child or adolescent exposed to adult in high risk category Current CXR / / X-RAY FINDINGS • Cavitation ■ ❑ Infiltrates ❑ Results: Date Taken ❑ Pleural disease ❑ Previous CXR / / ❑ Cavitation ❑ Results: Date Taken ❑ Infiltrates ❑ ❑ Pleural disease ❑ Non -TB abnormality Normal Other Non -TB abnormality Normal Other Patient Last Name First Name MI Date of Birth Page 1 of 2 MEDICAL HISTORY Srptoms: None ❑ Cough > 3 wks ❑ Productive cough Hemoptysis Chest pain Weight loss Night sweats Urinary Fever Other (specify) ❑❑❑❑❑❑❑ Symptom Length: Alcohol ❑ Yes HIV ❑ Yes Abuse: ❑ No Test: ❑ No ❑ Unknown ❑ Unknown Drug ❑ Injecting HIV ❑ Positive Abuse: ❑ Noninjecting Result: ❑ Negative ❑ No ❑ Not done ❑ Unknown ❑ Unknown Previous ❑ Yes / / TB ❑ No HIV Test Date DiagnosiLl Unknown Allergies: Attachment B-1 Medications: Weight: RISKS AND SPECIAL CONDITIONS Exposure ❑ Risks: ❑ None ❑ Homeless Resident of correctional facility (if Yes check one) Federal prison State prison Local jail Juvenile Other Unknown Resident of long term care facility (if Yes check one) Nursing home Hospital Residential Mental health Alcohol/drug treatment Special Other Conditions: Unknown Medical Risks: ❑ TST conversion in last 2 years None Heart disease Diabetes mellitus Weight loss > 10 lbs Gastrectomy Jejunoileal bypass Pregnant EDC / Postpartum breast feeding Other special conditions Silicosis Immunosuppressive therapy Cancer Hepatitis Renal failure TREATMENT ❑ Current treatment ❑ Past treatment Isoniazid Rifampin Pyrazinamide Ethambutol Therapy Start Date mg mg mg mg Other Other Other mg mg mg Therapy End Date Reason ❑ Died ❑ Stopped: ❑ Lost to follow-up ❑ ❑ Moved ❑ ❑ Adverse reaction ❑ Course completed Uncooperative/refuse( Unknown Other CASE COMPLETION SOURCE INFORMATION Final Case Status: ❑ Closed ❑ Died ❑ Moved away ❑ Not determined ❑ Lost contact If Moved New Address (Number & Street Name) City State Zip Code If the person is a contact to an active case complete information on the source case Last Name Relation to Source First Name to / / Exposure Dates PROVIDER INFORMATION Local Health Agency (LHA) ( ) LHA Phone Number LHA Fax Number Nurse PCP/Clinic Name PCP/Clinic Address PCP City PCP State ( ) PCP Phone Number PCP Fax Number PCP Zip Code COMMENTS Person completing form / / Date Page 2 of 2 SOUNGEX I r etie:ire; came: Street Address: '.r�ri_xY�.• 1:.-4:J3 E,+4S i t, State Repo,,^.eny: I.., °tit:: Ccc,. Attachment 8-2 REPORT OF 'WSW ED CASE ac TUEERCULOSIti Utf'MiTME:NT G: it_ -A1.111 8 ,1URtAti S£RviCES ;•EMIR A:•4:::41.t.:WI: \!S. L13:.l•9ti tat. Cato Di:it:i J'° State Case Number CltyiCou:rty Cosa Nu?r:trirr• . • j. / 3. ts"atc Suosr.tted: 5. Mcerth•Yca: Reported: S. Memil•Vear Ceunred: a. Etrsn;eity' I 4. Addro t;.s for Carr Counting: ::; .. ct..... ...!.... .:. i Y. Date of chit.. 11. Country et Origin. If US.::3 5. Sea. 15. Race: t3. Statu . at Dia lr enia 01r @: t2. Month -Yee/ Arrived in t:,S. ft4. Previous Diagnosis 1 If. Wa;•:r Site of 3i4e=.s::• of Tubcrcutca?s: j 1 • !t :.::f - :'•:a: .. •'t :.• LEY', • 1-5. Add tit•nal Site l:t tiis:asrr . ..... .u3 :: t•'t'!'. t".. .. .t^,. !^n:' .f 71 l�.__ r _ rOr,-n _• 17. Spcau!n Srreaf• 'F. �G+aetn" r;u ire: r':itttt.:E • N0E;;,,, <• Y.' tA7:. t9. Microscopic c.e i of r Isere zed Other Bony F. :eas: d 2C. Cutluru of fie e:ir, .:ncf Other Body tIui. •b sr 22. Tuba rcuiin (M Icut) Siren :weer. ,yh L• eta.• :. .��„�+'t i•., <.. tsa�...�1'.w:t Y•.{!1 P: :... �:r::' ne<:':•..i; :-- ..~^..f•`M'•t `.t .::, :�. .. .. 21. Chest X -Ray if 4bt:cr'trot t,1. tut::. • 4. n^.: it Abncrraa! tire. • :........ tit r, a ast Copy Page 1 of 4 Attachment B-2 REPORT OF VERIFIED CASE OF TUSERCULOSIS REPORT OF VERIFIED CASE OF TUBERCULOSIS 1223. HIV Status. ..� FCilWr �l Ot Offe'rhi IF Positive. tia%ott •:n: • • F::ci:�:::! 1'l::r:;.•::.•::iL:a': i'. Pr: ;live. Lint: .']P. ;- .._.. ' r {:r;. :!r..'t Jtri;' Yd: Ste:'': •,...-. R :n:'r• it::• 25. `'osidtrrt of Carrr.ctier.: ; `-aci'ity ::t Time ci C aan:;sfn• J(� Sla a • Le, a 2E, 'rcmclest. Within PPM Year: 1 26. Resident:If Lor...7lrrs Cent Facility Y ctTir.e et TJiapnosis: ..., h�_ Yog ARr;la f•t o't'' ?e•: dr., .' ty { 27. talttaf fl:trg Regrin •at:. tt F - K:1"tt:rp::r. 2a. Date Thersoy Startrd: ..,1...-_.. 1. • 2P. inject%r;i 3rt:y Use W'thin ParluYear fi .:ri•Iniecteti%t Ding Use Within Past Year: 31. Excess A:ceha:t !.,c• iV;itifr• Pat.i ...,,w:, Page 2 of 4 Attachment 8-2 Patient's Name: . Street Address - REPORT OF VERIFIED CASE OF TUBERCULOSIS Initial Drug Susceptibility Report SOU N DEX {State. Recorrng REPORT OF VERIFiED CASE OF TUBERCiilO8is .1rP4]'MCN; Cr' ;1_,ii,'+; & •iJMAN SEA'CEZ5 SE. •L•eN :J•vsove:': *ten YO. Oi.:.,::4 E EiC• �:•'• oi•.ia.'i: ]' (Follow Up Report - 1) State Case Number. CityrCeuuty Case Number Submit this report for all culture -positive cases. I- 33. Ir tiol Drug Susceptibility .Results: if .-rnsvier is IV(, c" res; Of rgrs. Lr'Et ' Date F, .fat :..:, 14z: c::r:a:yE.n. ... :1'• ::n ;i+:., 5: a::y3t�L : l.: via: 34. Susccptibii!ty Results: ..4(jo, !X'r?:"-h: .rci rPaer. +1�L^; ;L%:114_•..`.'r>t:Yr^•4:r. A.: MMnr.f a' -q 'k •+annr• .a. s•vrc :.. t� z. wy;. •n: ;t Cnoy Page 3 of 4 Attachment (3-2 t 35. Soutt:nt Cultu; • r,*:•onvr.r ion Dot: ereen•{^r• 35. Oz.It^TRerapy Stopped. aLcn,'t fimmp: Street Ai•33srs• r3F.'PC(T Or VERIFIED CASE OF TUBERCULOSIS GEFA.t;Tte ti' o: isCA•: Yrt 3 -IVMAN 5t i v ce e ,: 4„ -'i ..4 L.t.a. ON i.3ri 3.::+'.^ E EPORT.0F VERIFIED CASE OF TUBERCULOSIS. Case Completion Report 1 .-. iP,'W.VIt:: .7V C t^ 4!2;•i,.:e �. . f: r,;♦ ^Y.L s.Stf.! (Follow Up Report -• 2) Yasr j Counted EI State Crt+:e Number. Cltr•CvL 0114 Ci•T4 'Fr Submit this report for all cases in which the patient was alive ai diagnosis. e• '' ' I 3? c)•: Thepy Stopped: 3a Tyr. ct Health Care P: 39 DS,roctiy Oasct'ved Tticrany Sc.,1 Artiti,n,5t.p,a; t' -vim .. _ •: r r3pr,.r I 4C'. Fitsi Drug S::yiC:=tiitif;ty Re.sult. • . ,j%rS:f?t. ,r P,`C. .,.... ;C::;.., ftn rr ... •Ipi.t .. `R C! :. 41. r; not St:5cestUt>il.ty ,._....�s.... ^.._:: L�3 '3 :v..._. 4. 'r.t Copy Page 4 of 4 C a, E C O C w C L ctf aD 2 V a O C as d O -O co O V Attachment B-3 0 O U Nw z O I- w z_ I - U h Z O U U) U) O U cc w CO t O O. a) C Preliminary report Name of reporting agency a) E (n Name of index case Date case reported Susceptibilities Infectious period Comments/ Symptoms t M a) m X O I — Diagnosis a) .) a m H J Chest X-ray Results a) ca O PPD Results Retest E E a) as m -c E E a) 111 N w Z M 0 4) ‘1••• 1..- .. 7 w 2 o O J a U.1 0 C .— O m O 1H O U a) 40 C C a, O Contact Name: DOB/Age: Relation to source: Name: DOB/Age: Relation to source: Name: DOB/Age: Relation to source: Name: DOB/Age: Relation to source: Name: DOB/Age: Relation to source: a) o ' U N N 0 C D a) O c co ' N aa0 0 ) 0 0) x u c 0 o O a o a`r a EE O= • a) c jai) m a) co L 2) o — a) T a o co O O U c N 0 G a 0 Ol J (1) N N (n O O) O U aj c Co 3 a) O o 0 Y c a m a) c • U Y 3 a) 2 - N co m s a aa)) C. Le as 0 c Y 0 •m N a) o C N m' E v -C t O O ,S0 .c •� L 3 c C O N a) c N C Y O .N O 'O h E N 3 N N N 4. c Q O 1a Attachment B-4 Page 1 of 1 Attachment B -S • TB Follow -tip Worksheet A. Demographic Information •,.,. lit%:�:.,.:t,tli:,l: ..: ,.::•,,:,1.:'r l';...., l B jurisdictional In`ormation. lit J.S. Evaluiitlon J .:.,it :•!'I:.:ii il�tt :!1: ,., I.: ,.l:i:tl :I,1: !i:. .i .,C:•.,:.: F;, .:: l t) •l.i.•,.: ? . { 3 ..> itt :' .:tl.:. I i I F--7—.;. :Lcelrtis :if O1,..m: s 4: Xi( i r1 ' ,1 . €>,i. i):a:_. .... i)utnl:'ti. (•\R I._ 1 • .,.. I ti+:....... �� I :. I. 1'i�r ti:)+!, XI. 'i ^:k•:'.1i1 :l .::ii i``• G: I T Lj „,:t‘ \ticrnScl•iiv' tklcicriuti • I :VJ • t • f _ • • 1 . fJ I•.... Page 1 of 2 Attachment B-5 i -i TB Fc!1ow-Up Worksheet (Conti Li • t.. tSU!+ryitif.)r3 • • t;�Sis i1=1: L ---'i -. 'I' . ..-..:.......li .1i f`" .........I ..... ,:tl;a:' '':i...5 ,, i ! T r.': .. ., _ i;t;! ... .:si .:{'.t: . t .t....::: I 5 i.._. N -r..:!:. .. !:.. :; I ...:.,t..,. f'""*1 i i - !....n:-:} :<,...,:•.-.1 r • ,: sp: i (L`.! . i:. i.:ti:: • , ! ! -- y • ,.. ..1 •, 1 .. :I i:[; . e _ .. .i':' ( f-.-. i� I•: is . .. I1 .'l :i1 i:::.:12.:s!.!�'. 15,1!.s L._; ....... I ;....... - i - - -. U.S. Treatment . I. S - t t'. 7''J"Y:; •,nts 14. 1.--; •. •• L Page 2 of 2 ATTACHMENT B-6 Tuberculosis Semi -Annual Progress Report Agency/Person Date Submitted Reporting Time Period July 1 - December 31 _ January 1 - June 30 Briefly describe TB activities and accomplishments during reporting period. Describe any challenges/obstacles to providing TB services as specified in the CDPHE TB contract during reporting time period. Page 1 of 1 EXHIBIT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ADD DIVISION -PROGRAM ACRONYMS DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER ELIMINATE ALL INFORMATION APPEARING IN RED LIMITED AMENDMENT FOR TASK ORDERS #* This Limited Amendment is made this **** day of *********, 200*, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY, (legal type of entity), whose address or principal place of business is Street Address, City, State & Zip Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated ******** **, ****, with contract routing number ** *** *****. Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated ******** **, ****, with contract encumbrance number PO *** **********, and contract routing number ** *** *****,'insert the following if previous amendment(s), change order(s), renewal(s) have been processed: as amended by] 'include all previous amendment(s), change order(s), renewal(s) and their routing numbers', 'insert the following if previous amendment(s), change order(s), renewal(s) have been processed: collectively' referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: 'Briefly describe what the Contractor was to do under the Original Task Order Contract — indent this paragraph' 'Please choose one of the following four options and delete the other three options not selected' The State promises to [choose one and delete the other' increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the 'choose one and delete the other) increased/decreased work under the Original Task Order Contract. The State promises to pay the Contractor the sum of ********** Dollars, ($*.**) in exchange for the promise of the Contractor to continue to perform the work identified in the Original Task Order Contract for the renewal term of **** years/months, ending on ******** **, ****. The State promises to 'choose one and delete the other] increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) for the renewal term of**** 'choose one and delete the other' years/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the 'choose one and delete the other' increased/decreased work described herein. The State hereby exercises a "no cost" change to the 'choose those that apply and delete those that don't apply' budget, specifications within the Statement of Work, project management/manager identification, notice address or notification personnel , or performance period within the 'choose one and delete the other' current term of the Original Task Order Contract or renewal term of the Original Task Order Contract. Page I of 4 Rev 4/3/09 EXHIBIT C NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: I. Consideration for this Limited Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the Original Task Order Contract, contract routing number ** *** *****,'insert the following language here if previous amendment(s), change order(s), renewal(s) have been processed] as amended by 'include all previous amendment(s), change order(s), renewal(s) and their routing numbers], (insert the following word if previous amendment(s), change order(s), renewal(s) have been processed, otherwise delete "collectively"'collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Limited Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: ]Please choose one of the following three options and delete the two options not selected] A. 'Use this paragraph when changes to the funding level of the Original Task Order Contract occur during the current term of the Original Task Order Contract] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the current term of ********* **, ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is [choose one and delete the other' increased/decreased by ********** Dollars, ($*.**) for an amended total financial obligation of the State of ********** DOLLARS, ($*.**). 'Delete the following sentence if not applicable in your situation' The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". 'Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. 'Use this paragraph when the Original Task Order Contract will be renewed for another term] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the renewal term of ********* ** ****, through and including ********* ** ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars, iS*.**1 for an amended total financial obligation of the State of ********** DOLLARS, ($*.**). 'Delete the following sentence if not applicable in your situation! The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". [Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. [Use this paragraph when there are "no cost changes" to the Budget, the specifications within the original Statement of Work, allowable contract provisions as noted, or performance period.' This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment [choose those that apply and delete those that don't) modifies the Budget in 'identify location in contract', modifies the Statement of Work in 'identify location in Page 2 of 4 Rev 4/3/09 EXHIBIT C contract], modifies the project management/manager identification in ]identify location in contract], modifies the notice address or notification personnel in [identify location in contract], modifies the period of performance in [identify location in contract] of the Original Task Order Contract. The revised [choose those that apply and delete those that don't] Budget, Statement of Work, project management/manager identification, notice address or notification personnel is incorporated by this reference and identified as Exhibit * or Attachment *-*. [ If you are changing the performance period, choose the following two sentences or delete both sentences] The period of performance of the [choose one and delete the other] current/renewal term is hereby [choose one and delete the other] extended/reduced by ***** (*) months changing the current ending date from ********* ** **** to ********* ** ****. The revised period of performance is ********* ** **** through and including ********* **, ****. The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Limited Amendment is ******** **, ****, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Limited Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Limited Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 3 of 4 Rev 4/3/09 EXHIBIT C IN WITNESS WHEREOF, the parties hereto have executed this Limited Amendment on the day first above written. * Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect. CONTRACTOR: STATE: ]LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (Legal type of entity) Bill Ritter, Jr. Governor By: Signature of Authorized Officer Print Name of Authorized Officer Print Title of Authorized Officer For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Signatory avers to the State Controller or that Contractor has not begun performance or that a Statutory Violation waiver has been requested under Fiscal Rules PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. By: Date: STATE CONTROLLER David J. McDermott, CPA Page 4 of 4 Rev 4/3/09 Exhibit D SAMPLE GRANT FUNDING CHANGE LETTER Date: State Fiscal Year: TO: Insert Grantee's name Grant Funding Change Letter # CLIN Routing # In accordance with Section of the Original Contract routing number between the State of Colorado, Department of Public Health and Environment and Contractor's Name beginning Insert start date and ending on Insert ending date, the undersigned commits the following funds to the Grant: The amount of grant funds available and specified in Section is ❑ increased or ❑ decreased by $amount of change to a new total funds available of $ 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: By: Lisa Ellis, Purchasing & Contracts Unit Director 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 Exhibit E BUDGET To Task Order Contract Dated 04/21/2009 - Contract Routing Number 10 FHA 00023 Weld County Description Funding Source Amount Tuberculosis Control and Outreach State $62,800.00 Federal $7,800.00 Direct Observed Therapy ($12.50 per onsite visit) ($25.00 per field visit) State As Administered GRAND TOTAL $70,600.00 Page 1 of 1 STATE OF COLORADO Bill Ritter, Jr., Governor James B. Martin, Executive Director Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr. S. Denver, Colorado 80246-1530 Phone (303) 692-2000 TDD Line (303) 691-7700 Located in Glendale, Colorado http://www.cdphe.state.co.us Laboratory Services Division 8100 Lowry Blvd. Denver, Colorado 80230-6928 (303) 692-3090 Colorado Department of Public Health and Environment July 6, 2009 Re: Contract Number PO FHA EPI1000023 (routing number 10 FHA 00023) Dear Contractor, Enclosed please find your fully approved contractual documents with the Colorado Department of Public Health and Environment. Please keep these original documents for your records. If you have any questions or require further information, please feel free to contact me. Sincerely, Qk-4 essica Hubbard Contracts Administrator Disease Control Division Phone: (303) 692-2702 Fax: (303) 782-0904 Hello