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Home My WebLink About20082367.tiff RESOLUTION RE: APPROVE TASK ORDER CONTRACT FOR FAMILY PLANNING 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 for the Family Planning 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 October 20, 2008, and ending June 30, 2009, with further terms and conditions being as stated in said task order contract, and WHEREAS,after review,the Board deems it advisable to approve said task order 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 Family Planning 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 task order contract. The above and foregoing Resolution was,on motion duly made and seconded, adopted by the following vote on the 27th day of August, A.D., 2008. BOARD OF COUNTY COMMISSIONERS ,., WELD COUNTY, COLORADO ATTEST: LI t 1 ,' ` --t..)--, e--l-, ,w, AA _ ;am H. Jerke, Chair Weld ounty Clerk to the B.�d : � p ; 14 4 liai\`t' , l(-> ;berf .. Masden, Pro-Tem Dep1u Clerk the Board W i F. Ga cia APPR AS RM: ,k Foti David E. Long ounty Attorney Dougla Rademac er Date of signature: ` kit% 2008-2367 HL0035 eei ' /tL (: (.1-, , ) ©9//0 O3-- Memorandum 41)- 611 TO: William H. Jerke, Chair Board of County Commissioners FROM: Mark E. Wallace, MD, MPH, Director Department of Pub is Health and Environment 4°8004 A\\ COLORADO DATE: August 25, 2008 SUBJECT: Waiver to Task Order Contract for the Family Planning Program Enclosed for Board review and approval is a waiver to the previously approved Task Order between the Colorado Department of Public Health and Environment(CDPHE) and Weld County for the family planning program. The funding from this waiver is to be used to provide a comprehensive family planning program with an emphasis on increasing the total number of men and women accessing services and increasing utilization of long acting reversible methods of contraception (LARC) among existing clients. For the above services, Weld County will be reimbursed an amount not to exceed $115,692 for the time period October 20, 2008 through June 30, 2009. This funding is being provided entirely by the State of Colorado. I recommend your approval of task order waiver. Enclosure 2008-2367 DHPARTMFNF OF PUBLIC HEALTH AND ENVIRONMENT ROUTING NO.09 FLA 00684 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 915 100 Street Prevention Services Division Greeley, CO 80632-0758 WHS/FP for the use and benefit of the 4300 Cherry Creek Drive South Weld County Department of Public Health Denver,Colorado 80246 and Environment 1555 North 17th Avenue Greeley,CO 80631 TASK ORDER MADE DATE: CONIRAC tOR ENTITY TYPE: 08/15/08 Colorado Political Subdivision PO/SC ENCUMBRANCE NUMBER: PO FLA FPP0900684 TERM. BILLING STATEMENTS RECEIVED: This Task Order shall be effective upon Monthly approval by the State Controller,or designee, or on 10/20/2008,whichever is later. The STATUTORY AUTHORITY: Task Order shall end on 06/30/2009. N/A PRICE STRUCTURE: CONTRACT PRICE NOT 1'O EXCEED: Cost Reimbursement $115,692.00 PROCUREMENT METHOD: FEDERAL.FUNDING DOLLARS- $ Exempt STATE FUNDING DOLLARS: $115,692.00 BID/RI-1/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR: Not Applicable FY09: $115,692.00 LAW SPECIFIED VENDOR STATUTE: Not Applicable SLATE,REPRESENTATIVE CONTRACTOR REPRESENTATIVE: Judith Crotser Weld County Department of Public Health and Department of Public Health and Environment Environment Prevention—WHS/FP 1555 North 17th Avenue 4300 Cherry Creek Drive South Greeley,CO 80631 Denver,CO 80246 SCOPE OF WORK: The contractor will provide a comprehensive family planning program with an emphasis on increasing the total number of men and women accessing services and increasing utilization of long acting reversible methods of contraception(LARC) among existing clients. Page 1 of 4 &eD,- Q3� ; k:xrll Rl'r5: 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- Sample Funding 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 fmancial 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 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;5)the Page 2 of 4 Additional Provisions- Exhibit A,and its attachments if included,to this Task Order Contract;4) 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"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 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. Page 3 of 4 IN WITNESS WHEREOF,the State has executed this Task Order Contract as of 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 and accept personal responsibility for any and all damages the State may incur for any errors in such representation. CONTRACTOR: STATE OF COLORADO: Board of County Commissioners of Weld County BILL RITTER,JR.GOVERNOR e the use and benefit of the Weld County Department of Cont Health and Environment ��L Legal Name Contracting Entity \�.../ate B For Executive Director Department of Public Health and Environment Department Program Approval: Signature of Authorized Officer //�J/� /� ,7`9 William H. Jerke, Chair By (�LtiLGO`T)�t—[ ai4.} Print Name&Title of Authorized Officer AUG 2 7 2008 ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller,or such assistant as he may delegate,has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below,the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: David J.McDermott,CPA By Date l/ t 6 1 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMEN Mark E. Wallace, MD, MPH•Director ' Page 4 of 4 13y c/ akVtV- 2,96; EXHIBIT A ADDITIONAL PROVISIONS To Contract Dated 08/15/2008-Contract Routing Number 09 FLA 00684 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 contractor shall be compensated for services provided in accordance with Attachment A-1 hereto.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 one hundred fifteen thousand six hundred ninety two dollars($115,692.00). 3. To receive compensation under this Contract,the Contractor shall submit a signed Family Planning Initiative Reimbursement Statement monthly. The Reimbursement Statement to be used is attached hereto as Attachment A-2 and incorporated herein by this reference.Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B and in accordance with the allocable expenses outlined in Attachment A-1. 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. Reimbursement Statements shall be sent to: Serafin Diaz Division of Prevention Services Family Planning Intiative Colorado Department of Public Health and Environment PSD-CHFC-A4 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 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 later than sixty(60)calendar days from the effective expiration or termination date of this Contract. 4. The State may require forms attached to this contract and incorporated herein by reference by updated during the term of this contract.The Contractor will be informed of the new forms as they are developed. Forms may be sent to contractors or will be available on the Family Planning Administrative Manual website: http://www.cdphe.state.co.us/DD/womens/famplan.html. 5. The Contractor is not authorized to make transfers of funds from one line item in its Budget to another line item in its Budget without prior,expressed,written consent of the State.Transfer of funds may require the Contractor to enter into an amendment to the Original Task Order Contract with the State,which requires State Controller or delegate approval before the transfer can be made. 6. Contractor agrees to provide services to all Program participants and employees in a smoke-free environment in accordance with Public Law 103-227,also known as"the Pro-Children Act of 1994",(Act). To be attached to CDPHE Page 1 of 2 Revised:4/1/04 Version 1.0(4/04)contract template EXHIBIT A Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health,day care, early childhood development services,education or library services to children under the age of 18,if the services are funded by Federal programs either directly or through State or local governments,by Federal grant,contract,loan,or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed,operated,or maintained with such Federal funds. The law does not apply to children's services provided in private residences;portions of facilities used for inpatient drug or alcohol treatment;service providers whose sole source of applicable Federal funds is Medicare or Medicaid;or facilities where Women Infant and Children(WIC)coupons are redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this Contract,the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. 7. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that"no person in the United States shall on the ground of race,color,or national origin,be excluded from participation in,be denied the benefits of,or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well,be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter,they shall be advised that the Contractor will provide an interpreter if the client so chooses. To be attached to CDPHE Page 2 of 2 Revised:4/1/04 Version 1.0(4/04)contract template EXHIBIT B STATEMENT OF WORK To Contract Dated 08/15/2008-Contract Routing Number 09 FLA 00684 These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above. 1) 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 this approved Statement of Work and incorporated in accordance with the associated Budget,which is attached hereto as Attachment B-1. 2) The Contractor shall continue to conduct a comprehensive family planning program("the program").This program shall comply with section 1001 of the federal Act and all applicable federal regulations, as amended,contained in Title X,42 C.F.R., Subpart A,Part 59,as well as all applicable state regulations. (Federal funding from HHS, CFDA#93.217 FP Services).The program shall offer the following under the Title X family planning program: A. Outreach services and/or other program efforts designed to improve client recruitment. B. Nursing and medical services, which shall include a comprehensive health and social history and physical examination administered in accordance with all applicable Title X regulations and, all applicable nursing-medical policies or procedures which have been,or may be,established by the State's Women's Health Unit(WHU). C. Contraceptive information,education,and supplies regarding all family planning methods. D. Education and counseling services regarding family planning, family planning methods,child spacing, infertility,sterilization,nutrition, sexually transmitted diseases,Human immunodeficiency virus(HIV)/Acquired immunodeficieny syndrome(AIDS),adolescent counseling and other related health issues,as outlined in the Nursing and Administrative Manual. E. Follow-up and/or referral services,as appropriate. 3) All money received by the Contractor from the State under the Colorado Family Planning Initiative(CFPI) shall be used by the Contractor to provide contraceptive services in accordance with Attachment B-1.The Contractor shall make its program available to men and women in their reproductive years and shall offer the following services under the CFPI: A. Utilize CFPI funding to purchase long acting reversible methods of contraception and contraceptive rings. These are limited to Intrauterine Devices (IUD)Mirena and Paraguard, contraceptive implants and contraceptive rings. B. Utilize CFPI funding to provide the referral process and cover the actual costs of tubal ligation and vasectomy procedures. C. Utilize CFPI funding for Family Planning staff to attend reproductive health related training with preference to those related to long acting reversible methods of contraception. D. Provide comprehensive family planning services to increase the total number of family planning clients receiving services(fertile clients receiving contraceptive services). 4) The services provided by the Contractor to the clients it serves shall be performed pursuant to law in accordance with prevailing medical standard of care for the same or similar medical,nursing and professional services. The services provided shall also comply with applicable Title X regulations,WHU nursing-medical policies and procedures,and any applicable fiscal or administrative policies of the State or To be attached to CDPHE Page 1 of 3 Revised:4/1/04 Version 1.0(4/04)contract template • EXHIBIT B Federal government. Contractor acknowledges that it has received copies of the preceding policies and regulations as of the effective date of this Contract. 5) The Contractor shall provide the State's family planning program consultants and administrators with reasonable access to its operations to perform: periodic site reviews, data reviews, fiscal reviews or other evaluations of the Contractor's family planning program. Evaluations of the Contractor's program shall be based on established standards and policies of the State or the Federal government. The Contractor shall cooperate during all periodic site visits, data reviews, fiscal reviews or other evaluations conducted by the State. 6) If necessary, the Contractor shall comply with all recommendations made by the State's family planning program consultants and/or administrators after a periodic site visit, data review, fiscal review or other evaluations that are necessary to bring its program into compliance with all applicable federal and state laws, policies and regulations. The Contractor shall be in full compliance with a recommendation, if any, within three(3)months of the date a recommendation is made by the State. If the Contractor cannot obtain full compliance within this three (3) month period, then on or before the expiration date of that three (3) month period the Contractor shall present sufficient written evidence to the State: to show that continuing progress is being made towards full compliance; and, the date when full compliance shall occur. In no event, however, shall full compliance with a recommendation occur any later than six(6)months after the date that a recommendation was initially made by the State. Notwithstanding the foregoing provisions,the State may disregard these cure periods and immediately terminate the contract without liability if it has solely determined that Contractor's noncompliance places the health, safety or welfare of persons receiving services in jeopardy. 7) On a monthly basis, the Contractor shall collect and provide to the State, by the fifteenth calendar day of the following month,all pertinent data regarding all services offered,and all family planning clients served, by its program during the preceding month, submitted through the IRIS data system. This data shall be verified on a monthly basis to help assure accuracy. 8) Within thirty (30) calendar days of receipt of a written request from the State, the Contractor shall submit nursing-medical chart audits to the State. 9) The Contractor shall only use program income generated from client fee collections and donations for family planning purposes that further the objectives of the legislation under which this Contract is entered into. In accordance with Title X guidelines, the Contractor shall not charge for any Title X required services provided to clients who are at or below 100% of the official poverty line as defined by the Office of Management and Budget (OMB). A copy of this guideline has been provided to the Contractor by the State as of the effective date of this Contract. If the State receives new poverty guidelines from the OMB during the term of this Contract, then the State shall immediately forward those new poverty guidelines to the Contractor. The Contractor shall use these new poverty guidelines, if any, upon receipt thereof from the State. 10) The Contractor's charges for services to clients who are above 100% of poverty level shall be based on a sliding fee scale that takes into account a client's family size and/or individual income. These charges and the sliding fee scale shall be made available to all clients of the Contractor, the general public, and the State. This most current version of this document is available on the Family Planning website: (http://www.cdphe.state.co.us/DD/womens/FederalPovertvGuidelines.htm). Charges shall be based upon the Contractor's actual costs to provide these services as determined by a cost analysis. The Contractor and the State shall review these costs annually. The Contractor shall insure that all clients understand that they will not be denied services because of an inability to pay any of the Contractor's sliding fee charges. I I) The Contractor shall either use a cytology laboratory chosen by the State or, a laboratory proposed by the Contractor and approved by the State. To be attached to CDPHE Page 2 of 3 Revised:4/1/04 Version 1.0(4/04)contract template EXHIBIT B 12) During the term of this Contract,the Contractor agrees to provide the State with the semi-annual Family Planning Expenditure/Revenue Reports. The Expenditure/Revenue Report(ERR)is located on pages 19-21 in the Financial Management Section of the Family Planning Administrative Manual,this information can also be accessed online on the CDPHE Family Planning website at http://www.cdphe.state.co.us/pp/womens/famplan.html.The first report is for the months of October to December will be due no later than February 7. January through June and will be due no later than August 7. 13) The Contractor shall protect the confidentiality of all client records and other materials that are obtained, created, or maintained by the Contractor under this contract. Except for purposes directly related to the administration of this contract, no information about, or obtained from, any client shall be disclosed by the Contractor in any form that would identify that client without the prior written consent of that client. As of the acceptance date of this contract by the Contractor, the Contractor shall have written policies governing the access to and, the duplication and dissemination of, all such information. The Contractor shall advise its directors, officers, employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. 14) Maintenance of Effort(MOE) Colorado Family Planning Initiative funding is expected to provide new funding for providing services to additional family planning clients and increasing the total number of clients utilizing efficacious methods of contraception.This is a temporary funding source,and therefore shall not be used to supplant other traditional funding sources.Therefore,the contractor shall show Maintenance of Effort(MOE)for revenue provided by local government as documented on the required family planning program Expenditure Revenue Reports(ERR),for the three years previous to any year in which funding from the Colorado Family Planning Initiative is received.This revenue,provided by local government(county and city grants and contracts)shall be equal to, or in excess of,90%of the average of the last 3 year's Expenditure Revenue Reports. Definition: Maintenance of Effort(MOE)—A measure intended to preserve funding for the base program.This ensures that fiscal resources are not supplanted and that new funding creates an expansion in the program.MOE shall be determined by averaging the revenue provided by local government in the last 3 years' Expenditure/Revenue Reports(ERR)for the entity's family planning program,and then multiplying by ninety percent(90%).The result is the minimum amount that the entity must spend in order to illustrate MOE.In an instance where there is not three years' data,MOE shall be 90%of previous two years' local government revenues from the ERR,or 95%of the last year's results,as applicable. In the case of an anomaly where local government revenue level from the previous three years' ERR varies more than 30% in any two of the three years,an explanation of the variance must be provided by the Contractor. The Family Planning Director shall use this information to decide if the anomaly should be eliminated from the calculation of the MOE level. In any year in which the Contractor will not attain MOE,according to the formula described in the definition the Contractor shall notify the Family Planning Director. Should MOE not be obtained,in special hardship cases, a Maintenance of Effort Waiver to this clause may be requested from the CDPHE Family Planning Director, in conjunction with the Women's Health Director,attached hereto as Attachment B-2. Should a Maintenance of Effort Waiver not be granted,the Colorado Family Planning Initiative funding may be reduced. 15) 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. 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A L UL • r o N N d y a,0 M on V ti { O O O L U {d r a) le W v u a 4^ b A •' C L a co 0 y O co M v dd to h* 5. � 0 v UaVA W Ox as "S` .. , F, " W Cu w #h"' : W ,,^ 0.1 z H Z .. wC7 wp7 + a t.. t - 7 a a -a F as W 'L c c. 1e‘Iii.....%, .-i .y N M 7 0 cl. ay 2 / o / , \ \ \ 5 / \ vi \ \ \ \ . \ oe cu \ B a. \ bo j \ \\ , \ z Jo co t> ) \ \ a ) \] k \ , i k \ � k \ ch c :o~ \ \ rd Lo ® { ) \ e _ ; \ § g p. ) \ / a _ ; 78 > © \ ) \ k i 2 3 ) 8 # ) § \ k \) ) \ � 2 ) \ 0 ) } ) ) » E t ai E m / @ ( _ 0 jk ( / ( / 0 z • = ® / r # c s 0 2j o 4 7 \ \ E. / © c / / \ \ \ \ \ \ \ \ } \\ \ Attachment B-1 Colorado Family Planning Initiative Budget Weld County Department of Health and Environment October 20, 2008 to June 30, 2009 Description of Expenditure Maximum Allowable Reimbursement Methods: limited to Intrauterine Devices(IUD) Mirena and Paraguard, contraceptive implants and contraceptive rings. Methods may be billed for the purchase amount and up to 10% for shipping and handling expenses. $32,992.00 Tubal Ligations & Vasectomies: The maximum allowable reimbursement cost per procedure $2,500.00 for each tubal ligation and $625.00 for each vasectomy. A referral cost of$100.00 for each tubal ligation and$50.00 for each vasectomy is also allowed in addition to the actual cost for the procedure. $80,700.00 Training: Training related to reproductive health, those related to Long Acting Reversible Contraception(LARC)preferred. Training expenses are limited to the cost of registration,car and air travel,meals and hotels. $2,000.00 Total $115,692.00 1oft Attachment B-2 Colorado Family Planning Initiative Request for Waiver of Maintenance of Effort Maintenance of Effort(MOE)—A measure intended to preserve funding for the base program. This ensures that fiscal resources are not supplanted and that new funding creates an expansion in the program. MOE shall be determined usually by averaging the revenue provided by local government in the last 3 years' Expenditure/Revenue Reports(ERR) for the entity's family planning program,and then multiplying by ninety percent(90%). The result is the minimum amount that the entity must spend in order to illustrate MOE. Agency Name: Agency Address: Name of Requestor of Waiver: Title: Address(if not the same as agency): Phone Number: Email Address: Date of request: Average amount of annual revenue provided by the local government over the past 3 years' Expenditure/Revenue Reports(ERR) for the entity's family planning program. $ /year Please indicate 3-year time period used Amount of anticipated amount annual revenue to be provided by local government for the entity's family planning program. $ /year. Please explain the reason for and the duration of the expected decrease of local government support to the entity's family planning program: Email to cdphe.pswomenshealth(Zistate.co.us, subject line: CFPI Waiver Request;or fax to 303-691-6957 Attention: Family Planning Director. 1of1 EXHIBIT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) 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** *** *****"the Master Contract"). 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), renewals) 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, ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the [choose one and delete the other[ increased/decreased work under the Original Task Order Contract. Page 1 of 5 The State promises to pay the Contractor the sum of********** Dollars, ($*.**) 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. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: 1. 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********* ** Page 2 of 5 EXHIBIT C ****, 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, ($*.**). [Delete the following sentence if not applicable in your situation] The revised Statement of Work is incorporated herein by this reference and identified as"Attachment *". [Delete the following sentence if not applicable in your situation! The revised Budget is incorporated herein by this reference and identified as"Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. [Use this paragraph when the Original Task Order Contract will be renewed for another term] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number** *** *****. This Limited Amendment is for the renewal term of********* ** ****,through and including ********* ** ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars, ($***) 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 lidentify location in contract!, modifies the Statement of Work in [identify location in 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,or period of performance is incorporated by this reference and identified as. 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. Page 3 of 5 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 4 of 5 • 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 and accept personal responsibility for any and all damages the State may incur for any errors in such representation. CONTRACTOR: STATE: [LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (a political subdivision of the State of Colorado) Bill Ritter,Jr. Governor By: By: Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment is not valid until the State Controller,or such assistant as he may delegate,has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below,the State of Colorado may not be obligated to pay for goods and/or services provided. STATE CONTROLLER David J.McDermott,CPA By: Date: Page 5 of 5 Exhibit D SAMPLE GRANT FUNDING LETTER Date: State Fiscal Year: Grant Funding Letter# CLIN Routing# TO: Insert Grantee's name In accordance with Section(s) of the Original Contract routing number between the State of Colorado, Department of Public Health and Environment, and Insert 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 by $amount of change to a new total funds available of$ to satisfy orders under the Grant. Section is hereby modified accordingly. This Grant Funding Letter does not constitute an order for services under this Grant. The effective date of hereof is upon approval of the State Controller or Insert start date, whichever is later. STATE OF COLORADO Bill Ritter,Jr. GOVERNOR Department of Public Health and Environment By: Lisa Ellis, Purchasing and Contracts 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 Revised 7/21/08 Hello