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HomeMy WebLinkAbout20071443.tiff RESOLUTION RE: APPROVE TASK ORDER CONTRACT FOR TOBACCO EDUCATION AND PREVENTION 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 Tobacco Education and Prevention 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, 2007, and ending June 30, 2010, 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 Tobacco Education and Prevention 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 21st day of May, A.D., 2007. BO' ' u OF COUNTY COMMISSIONERS E,L�� WEL OUNTY, COLOFj ,DO ATTEST: 1444, avid E. Long, Chair Weld County Clerk to the pa + �� • Wil is/ . Je r em De• ty CI_r to the Boa d `mss William F. Garcia AP OVED AS Toys EXCUSED Robert D. Masden ou y Attorney Douglas ademacher Date of signature: (01501 2007-1443 HL0034 o Memorandum rset\ TO: David E. Long, Chair Board of County Commissioners imag FROM: Mark E. Wallace, MD, MPH, Director C Department of Public Health and gyp, �� Environment --1MO.Ad2 t 100012—Qcti J COLORADO DATE: May 17, 2007 � 5.1I SUBJECT: Task Order Contract for the Tobacco Education and Prevention Program Enclosed for Board review and approval is the Task Order Contract between the Colorado Department of Public Health and Environment and Weld County for the State Tobacco Education and Prevention Program (STEPP). This task order contract will support the continued efforts of 3.25 FTE Health Promotion staff members who will conduct activities to prevent youth from using tobacco, reduce tobacco use, help people who use tobacco to quit, assist in the reduction of exposure to secondhand smoke and reduce tobacco use among groups that are disproportionately affected and/or at high risk for disease. For these activities, Weld County will receive a sum not to exceed $247,912 for the time period July 1,2007 through June 30, 2008. I recommend approval of this task order contract. Enc. 03n03a38 SttVI:301 S HI1O3 a13 AM 2007-1443 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ROUTING NO.08 FLA 00166 APPROVED TASK ORDER CONTRACT-WAIVER#154 This Task Order Contract is issued pursuant to Master Contract made on 12/19/2006,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 1555 N. 17th Street Prevention Services Division Greeley,CO 80631 STEPP 4300 Cherry Creek Drive South Denver,Colorado 80127 TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE: 04/20/2007 Colorado Political Subdivision PO/SC ENCUMBRANCE NUMBER: CONTRACTOR FEIN OR SOCIAL SECURITY NUMBER PO FLA PPG0800166 846000813 TERM BILLING STATEMENTS RECEIVED: This Task Order shall be effective upon Monthly approval by the State Controller,or designee, or on 07/01/2007,whichever is later. The STATUTORY AUTHORITY: Task Order shall end on 06/30/2010. Not Applicable PRICE STRUCTURE: CONTRACT PRICE NOT TO EXCEED: Cost Reimbursement $247,912.00 PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS: $ Exempt STATE FUNDING DOLLARS: $247,912.00 BID/RFP/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR: Not Applicable FY 08: $247,912.00 FY XX: $ LAW SPECIFIED VENDOR STATUTE FY XX: $ Not Applicable FY XX: $ FY XX: $ STATE REPRESENTATIVE CONTRACTOR REPRESENTATIVE: Heather Tolby Joe Fleming Department of Public Health and Environment 1555 N. 17th Street Prevention Services Division Greeley,CO 80631 STEPP 4300 Cherry Creek Drive South Denver,CO 80127 SCOPE OF WORK: The Contractor will conduct activities to prevent youth from using tobacco,reduce tobacco use,help people who use tobacco to quit,assist in the reduction of exposure to secondhand smoke and reduce tobacco use among groups that are disproportionately affected and/or at high risk for disease. Page 1 of 4 EXHIBITS: The following exhibits are hereby incorporated: Exhibit A- Additional Provisions (and its attachments if any—e.g.,A-1,A-2,etc.) Exhibit B- Statement of Work and Budget(and its attachments if any—e.g.,B-1,B-2,etc.) Exhibit C- Limited Amendment Template for Task Orders Exhibit D- 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. 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 Contact 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. CONTRACTOR STATE OF COLORADO: BILL R,JR.pOVERNOR Board of County Commissioners of Weld County 1( Legal Name of Contracting Entity ,--� By1 For Executive Director 846000813 Department of Public Health and Environment Social Security Number or FEIN C� Department Program Approval: Signature of Authorized Officer MAY 1 2007 David E. Long, Chair By 0. /11/01- 151N/A Print Name&Title of Authorized Officer GOVERNMENTAL ENTITIES: (An attestation and seal are required) '" f 41/7/ •' f E Attest(Seal)By 47 /-741,G7/ "� ` z� . w� it (Town/City/County Cler i r Equivalent) s , . .�(Place government seal here) t. TO U _ , CATTESTING0MMISSI0NERB0ARD SIGNAT0fURESC0 0NNTY-LY ,,�, ALL CONTRACTS MUST BEA?PRO D 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: Leslie M.Shenefelt Byez'e Date 6/4 c 7 WELD COUNTY DEPARTMENT OF Pl13LiC HEALTH AND ENVIRONMENT BY: .1MG.n S Mark E. Wallace, MD, DirectorMPH- ,�^ Page 4 of 4 r.&0o7-/95?3 EXHIBIT A ADDITIONAL PROVISIONS To Task Order Contract Dated 04/20/2007- Contract Routing Number 00166 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 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. To receive compensation under this Contract,the Contractor shall submit a signed monthly Invoice/Cost Reimbursement Statement. An Invoice/Cost Reimbursement Statement must be submitted within sixty (60)calendar days of the end of the billing period for which services were rendered. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B,and with the work requirements outlined in Attachment B-1,and the Approved Budget attached hereto as Exhibit D and incorporated herein. These items may include,but are not limited to,the Contractor's actual time spent on the project based on the applicable hourly rate,fringe benefits,supplies,travel,operating,indirect costs which are allowable,and other allocable expenses related to its performance under this Contract. All expenditures must be reasonable and necessary for the performance of the grant,and must comply with The State of Colorado,specifically the Colorado Department of Public Health and Environment,fiscal guidelines and rules. Invoice/Cost Reimbursement Statements shall: 1)reference this Contract by its contract routing number, which number is located on page one of this Task Order Contract;2)state the applicable performance dates;3)include allowable costs incurred by line item as approved in the budget;4)include a brief description of the work performed during this performance period;and,5)show the total requested payment in a format either provided or approved by the State. Payment during the initial,and any renewal or extension,term of this Task Order Contract shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order Contract. Invoice/Cost Reimbursement Statements shall be sent to: Colorado Department of Public Health and Environment PSD-STEPP-A5 4300 Cherry Creek Drive South Denver,CO 80246 To be considered for payment,billings for payments pursuant to this Task Order 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 Task Order Contract must be received by the State within a reasonable time after the expiration or termination of this Contract;but in no event no later than sixty(60)calendar days from the effective expiration or termination date of this Contract. The Budget,which is attached hereto as Exhibit D,shall govern the expenditure of funds by the Contractor under this Task Order Contract as well as subsequent reimbursement by the State. Failure to submit contract reimbursement statements in accordance with budget and the above time frames may result in a delay or denial of the reimbursement request. 3. Time Limit For Acceptance Of Deliverables. To be attached to CDPHE Page 1 of 4 Revised: 12/19/06 Task Order v1.0(11/05)contract template EXHIBIT A a. Evaluation Period. The State shall have fifteen(15)calendar days from the date a deliverable is delivered to the State by the Contractor to evaluate that deliverable,except for those deliverables that have a different time negotiated by the State and the Contractor. b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design specifications for that particular deliverable,or is otherwise deficient,then the State shall notify the Contractor of the failure or deficiencies,in writing,within twenty(20)calendar days of: 1)the date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or deficiency at the time of delivery;or 2)the date the State becomes aware of the failure or deficiency. The above time frame shall apply to all deliverables except for those deliverables that have a different time negotiated by the State and the Contractor in writing pursuant to the State's fiscal rules. c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed deliverable,the Contractor shall have a reasonable period of time,not to exceed ten(10)calendar days,to correct the noted deficiencies. If the Contractor fails to correct such deficiencies within ten(10)calendar days,the Contractor shall be in default of its obligations under this Task Order Contract and the State,at its option,may elect to terminate this Task Order Contract or the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract. 4. The Contractor shall not use funds provided under this Contract for the purpose of lobbying as defined in C.R. S.24-6-301(3.5)(a). 5. The Contractor shall support,cooperate and partner with other STEPP contractors. 6. The State of Colorado,specifically the Department of Public Health and Environment,shall be the owner of all equipment,including but not limited to computers,printers,projectors,software and office furniture, purchased with funding under this Contract and that if requested,shall be returned to the State at the end of this or any subsequent Contract funded by tobacco program funds. 7. If the Contractor intends to subcontract any or all of its performance under this Contract,then the Contractor shall provide to the State,a copy of any proposed subcontract between the Contractor and a subcontractor.All subcontractors are subject to all the terms and conditions of this Contract.The Contractor remains ultimately responsible for any work performed by a subcontractor. 8. The contractor must notify STEPP within 30 days of a staff change of those employees performing work under this contract. 9. STEPP requires a disclosure of affiliation or contractual relationships,direct and indirect,with tobacco companies,owners,affiliate,subsidiaries,holding companies or companies involved in any way in the production,processing,distribution,promotion,sales,or use of tobacco.Companies or individuals affiliated with or receiving funds from any tobacco company or subsidiary are not eligible for funding under this proposal.Any and all subcontractors must also adhere to this policy. 10. The Contractor is required to meet all training requirements as outlined in the STEPP Capacity Building Requirements. • 11. Newly hired staff of the Contractor may begin performing work under this Contract;however,participation in orientation training conducted by the State and completion of the STEPP learning modules within six(6) months of the commencement date of employment must be accomplished. 12. Work Plan specifications,attached to this Contract,may be modified by way of a contract amendment as • outlined and described within paragraph 16,page 8,of the Contract. Contractor shall submit all requested changes to its approved Work Plan in writing to the State as needed during the contract term. The State To be attached to CDPHE Page 2 of Revised: 12/19/06 Task Order v1.0(11/05)contract template EXHIBIT A will then develop the necessary contract amendment. Contractor must submit revisions at least thirty(30) calendar days prior to the proposed work plan modification date. However,regardless of the date submitted Contractor understands that the revised Work Plan will not become effective until the associated contract amendment has been fully approved in accordance with the State's Fiscal Rules. 13. The Contractor shall participate in state-level evaluation efforts as requested by the State to include but not be limited to quarterly reports on the implementation and accomplishments of its approved Work Plan,to be due 15 days after the each calendar quarter.Calendar quarters shall be July-September,October- December,January-March,April-June,as applicable. Failure to submit quarterly reports in accordance with the above time frames may result in a delay or denial of the reimbursement request for those periods. 14. Within thirty(30)calendar days after the expiration of the term of this Contract,the Contractor shall submit a written report to the State that describes its key accomplishments in implementing its approved Work Plan, including qualitative and quantitative data collected about smoking prevalence and tobacco control in their communities. The report shall also describe all measurable objectives and the Contractor's overall achievement of its Plan. 15. Unless otherwise provided for,all data collected or produced or derived exclusively from the Contractor's or subcontractor's work under this Contract shall remain the sole property of STEPP,whether in individual, aggregate, identified or de-identified form or any other form required by STEPP. To facilitate follow-up, research,surveillance and evaluation,any such data collected,used or acquired shall be made available in any form required by STEPP,to STEPP and any other contractor designated by STEPP. My such data collected,used or acquired shall be used solely for the purposes of this Contract.The Contractor and its subcontractors agree not to release,divulge,publish,transfer,sell,or otherwise make known any such data to unauthorized persons without the express prior written consent of STEPP or as otherwise required by law.This includes a prior written request by the Contractor to STEPP for submission of abstracts or reports to conferences,which utilize data collected under this Contract. Notwithstanding the foregoing,the Contractor shall be entitled to retain a set of any such data collected or work papers necessary to perform its duties under the Contract and in accordance with professional standards. 16. The State of Colorado,specifically the Department of Public Health and Environment,shall be the owner of all printed materials,graphic representations,educational materials,audio-visual products,or any other media, in whatever form,created under this Contract.All such materials created under this Contract must be pre-approved by the STEPP Marketing Director and Contract Manager in the development phase.A minimum often(10)business days is required for the review and approval process.The State reserves the right to require the CDPHE logo,the STEPP logo,or other wording on any material,representation, product or other media form created under this contract. Any material,representation,product or other media form that will use the Colorado QuitLine,Colorado QuitNet or STEPP logo or information must be pre-approved by the STEPP Media Specialist.A minimum of ten(10)business days is required for the review and approval process. This requirement applies,but is not limited to,any brochure,flyer,presentation,billboard,radio spot, website,banner advertisement,etc. 17. Funds provided under this Contract may not be used to:supplant funding for any existing programs/models;develop new cessation programs/models;develop curricula for youth or adults not reviewed and approved by STEPP;pay for individual cessation aids or nicotine replacement therapy;fund capital improvements;or fund costs of enforcement of state or local laws and ordinances. To be attached to CDPHE Page 3 of 4 Revised: 12/19/06 Task Order v1.0(11/05)contract template EXHIBIT A 18. The Contractor is required to comply with all policies as outlined in the STEPP policy manual. The STEPP Policy Manual and any revisions to those policies made in the STEPP policy manual shall supersede. Failure to comply with such policies may result in a delay or denial of reimbursements to the Contractor. In addition,continuation of the contract and future funding requests will be evaluated. 19. Funding levels within the Budget,attached to this Contract, may be modified as follows: a. Up to ten percent(10%)of the total funds originally set forth in each major budget category(e.g., Personal Services,Operating, Travel,Contractual and Indirect) may be transferred to other major budget categories without prior approval by the State; b. Greater than ten percent(10%)of the total funds originally set forth in each major budget category can be transferred to other major budget categories only after written notice has been given to the State and the State has approved such transfer; c. Where the contract not-to-exceed amount is increased or decreased,the parties shall execute a contract amendment in accordance with paragraph 5,page 3 of this Contract prior to any such budget modification;and d. In all instances described in 19a and 19b above,the Contractor shall submit a revised budget to the State that shows: the original amount(s),the modification(s) made, and the new amount(s)within thirty(30)calendar days of the date the modification(s)is being requested. However, with regard to paragraph 19c above, in no case shall the transfers become effective until the associated contract amendment has been fully approved in accordance with the State's Fiscal Rules. 20. The list of acronyms below could be referred to throughout the contract, work plan and budget. ACS-American Cancer Society ADA-Americans with Disabilities Act ADAD-Alcohol and Drug Abuse Division AHA-American Heart Association ALA(C)-American Lung Association(of Colorado) AMCHP-Association of Maternal Child Health Programs ANR-Americans for Non-Smokers'Rights ASSIST—American Stop Smoking Intervention Study ASTHO-Association of State and Territorial Health Office BACCHUS-BACCHUS Peer Education Network BOH-Board of Health BRFSS-Behavioral Risk Factor Surveillance System CB—Community-based System CBO-Community-based Organization CCGC-Colorado Clinical Guidelines Collaborative CCPD—Cancer,Cardiovascular,and Pulmonary Disease CCIAA—Colorado Clean Indoor Air Act CDC-Centers for Disease Control CDE-Colorado Department of Education CDPHE-Colorado Department of Public Health and Environment CFFC-Colorado Foundation for Families and Children CNS-County Nursing Service COPAN-Colorado Physical Activity and Nutrition Program CPHA-Colorado Public Health Association CSAP-Colorado Student Assessment Program CTEPA-Colorado Tobacco Education and Prevention Alliance CTFK-Campaign for Tobacco-Free Kids CTRP-Colorado Tobacco Research Program CWCCI—Colorado Women's Cancer Control Initiative DASH-Division of Adolescent& School Health (CDC) DHS—Department of Human Services DOR-Department of Revenue EPA-Environmental Protection Agency ETS-Environmental Tobacco Smoke(a.k.a.secondhand smoke) FDA—Food and Drug Administration To be attached to CDPHE Page 4 of 5 Revised: 12/19/06 Task Order v1.0(11/05)contract template EXHIBIT A GASO-Great American Smokeout GASP CO-Group to Alleviate Smoking Pollution of Colorado Get R!EAL(GR)-Resistl Expose Advertising Lies(Youth Empowerment Program) GLBT—Gay,Lesbian,Bisexual,and Transgender LBW—Low Birth Weight LHA-Local Health Agency LHD-Local Health Department LRPC-Latino/a Research and Policy Center MCRC-Media Campaign Resource Center—CDC MOU—Memorandum of Understanding MPH-Master of Public Health MSA—Master Settlement Agreement NACR—Native American Cancer Research NAQC-North American Quitline Consortium NCI-National Cancer Institute NIDA-National Institute on Drug Abuse NIH-National Institute of Health NJH-National Jewish Medical and Research Center N-O-T-Not-on-Tobacco,(ALA's Youth Smoking Cessation Program) NRT-Nicotine Replacement Therapy OSH-Office on Smoking or Health (CDC) PSD-Prevention Services Division PIO-Public Information Officer PRAMS-Pregnancy Risk Assessment and Monitoring Survey TRC-Tobacco Education And Prevention and Cessation Program Review Committee RFA-Request for Applications RFP-Request For Proposals RMC-Rocky Mountain Center for Health Promotion&Education SB-School-based System SBHC-School-Based Health Centers SES-Socio-Economic Status SEW-School Employee Wellness SGR—Surgeon General's Report SHI-School Health Index SHS-Secondhand Smoke SIDS-Sudden Infant Death Syndrome STEPP-State Tobacco Education and Prevention Partnership STW-Straight-to-Work TA-Technical Assistance TABS-Tobacco Attitudes and Behavior Survey TAG-Technical Advisory Group(for evaluation&TPEG) TCP-Tobacco Control Partners TFS-Tobacco-Free Schools TFS Law-Tobacco-Free Schools Law TDG-Tobacco Disparities Grant TGYS-Tony Grampsas Youth Services TPEG-Tobacco Program Evaluation Group TTI-Tony Grampsas Tobacco Initiative UCD-University of Colorado—Denver UCDHSC-Heath Sciences Center at UCD(sometimes abr.UCHSC) UCDHSC-University of Colorado at Denver and Health Sciences Center Well COA—Wellness Councils of America YE-Youth Empowerment YRBS-Youth Risk Behavior Survey YPH-Youth Partnership for Health YTS-Youth Tobacco Survey 5 A's—Ask,Advise,Assess,Assist,Arrange To be attached to CDPHE Page 5 of 5 Revised: 12/19/06 Task Order v1.0 O1/05)contract template EXHIBIT B STATEMENT OF WORK • To Task Order Contract Dated 04/20/2007-Contract Routing Number 00166 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. 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'3 V 3 a°Ji �c „ V U n c V ti `�` G C ?.il. O v O ^Ct S ,�,, y O p w o a s >3 " ° c U '..' 3 v o" 3 y c � '� 's ° a a � a o a. "� p P. oil VI 'N N N N V1 C M t4) car) Cr -er I I .. 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), 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, ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the [choose one and delete the other] increased/decreased work under the Original Task Order Contract. Page 1 of 5 The State promises to pay the Contractor the sum of********** Dollars, ($*.**) 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 [identify 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. 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 FEIN: AND ENVIRONMENT ATTEST: PROGRAM APPROVAL: Because the Contractor is a governmental entity, an attestation is required By: (Seal, required) By: City, City and County,County, Special District,or Town Clerk or Equivalent [Delete inapplicable language.] 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 Leslie M. Shenefelt By: Date: Page 5 of 5 APPLICANT: Single Site Form FOR THE PERIOD: Check only one: O Year 1(July 1,2007-June 30.2008) ❑Year 2(July 1,2008-June 30.2009) ❑Year 3(July 1,2009-June 30.2010) Exhibit-D Requested Other Source' Other Source' 4k1P1 :' ._ Sautes I Source 2 PERSONAL SERVICES ` Total Personal Services $ 210,561 $ - $ - DIRECT OPERATING COSTS - Total Direct Operating Costs $ 13,285 $ $ - TRAVEL • Total Travel $ 4,912 $ - $ - CONTRACTUAL Total Contractual $ - $ - $ - OTHER COSTS _ Total Other Costs $ 600 ,$ - $ - INDIRECT . Total Indirect $ 18,554 $ - $ - TOTAL PROJECT COSTS 1 $ 247,912 !$ - $ .. . - "Source of Funding for"Applicant and Other"(in•kind) Foundation Grants $ - Other State Funds(list) $ - Cash Fees $ - _ocal Funds $ - Dther $ - Fotal Applicant and Other $ - Signature of Director or Authorized Representative Date Gt. APPLICATION BUDGET FORM State Tobacco Education&Prevention Grants Program FY2007-08 Check only one: El yen 1(Juy 1,2007-in 30.102) PPPUCANT: Weld County Department of Public Health and Environment ❑Mar 1(July I,2009-Julie 30.i009) PROJECT TITLE: Wad County Tobacco Promo ❑year J(July 1,2009-in 30.2010) STRATEGIC INITLATIVE 8: Capacity Building SOURCE OF FUNDS Requested Other Source' Other Source' COME Sancti ;Stint 2:: PERSONAL SERVICES FTE Monthly Monthly Si of Enter name hom a Enter name here if Name Positon Salary Benefits Months aPPtcable applicable Jae Fleming Caatlinaa 0.0%7 4344.783 1447.881 2500 134.135 0.000 0.030 Joe Fleming Coadnfl 0.030 4477720 1491976 1000 537273 0.000 0.000 Joe Fleming Cardnelm 0.030 4634.440 1514.195 6.500 1204.634 0000 0.000 Cassie Kauffman Health Educator 0045 3917700 1305.108 5.500 1292741 0.000 0004 Castle Kauffman Health Educator 0.045 4054.910 1351.096 6.500 1501.257 0.000 0.000 Jody Kugler Health Educator 0036 3917.790 1305.410 5.500 1005.486 0.000 0.060 Jody Kugler Health Educator 0.035 4054.910 1355.100 8.500 1229.867 0.000 0000 01100 0.000 0003 0.000 0.000 0.000 0.004 0.000 0.004 0.000 0.000 0000 0.000 0.000 0.000 0.000 0.000 0000 0.000 0.000 0.000 0.000 0.000 0003 0000 00100 0004 0.000 0.060 0.003 0.030 0.600 0000 0000 0000 Subs: 7265673 0.000 0000 Total Personal SeMas 7285173 0900 9900 DIRECT OPERATING COSTS DESCRIPTION Printing/Copying 60,00 WOO WO p08bgesShppng 1020 *CO 60.00 Office Supplies 60.60 50.0 *0 Telephone,Fax,Internet Access *00 0000 10.00 Rent and libidos 10.00 93.00 $0.00 Computer Equipment 83.00 93.00 09.00 Staff Development Tobacco cc Haab Cant Repsaabn 8400.00 00.0 5000 Other Program Cost 53.00 30.00 6090 Total Operating Costs $40020 6020 6010 TRAVEL DESCRIPTION In-State Only STEPP reguirdeaning 1788.m $.00 30.00 Out of Slate ONy Ott CeveWWM(1 start E Ned Coatings) 1800.00 30.03 50.00 Total Travel Costs 81,565.60 WO 6010 CONTRACTUAL DESCRIPTION Consulted 10.00 93.00 10.00 COnhacTranrsSpeakelS 10.00 0009 W00 Subcontractors 83.0 3000 09.00 Total Contractual Costs 6010 nee OM OTHER COSTS(lit) DESCRIPTION 50.00 10.00 50.00 10.03 10.00 50.00 30.00 60.00 10.00 93.30 M90 MOO M00 M00 WOO Total Other Costs $0.00 MAO $0.50 ' 4'.f2?448 - �6aacei Eaaa@ SUBTOTALS 47425117... WO 5620 Etc OnMde%$or 604nd'Coals .:: .. INDIRECT COSTS: 8% Caed Oasts,Inter COPHE approved roe or 10%) $746.00 INDIRECT COSTS: 0% Slay and Fare,oar CDPHE epxov.d ram or 10%) $0.00 INDIRECT COSTS: 0% Salty only,ardor COPHE approved mho 10%) Total Want Cat(Calcultad on Amount Requested from COPHE Only) 874600 TOTAL AMOUNT REQUESTED FROM CDPHE $9.9913.87 'Other Please instate ddba a await 4 epplabla Signature of Authorized Representative Dm Rot.2107 APPLICATION BUDGET FORM State Tobacco Education and Prevention Grants Program FY2007-08 Check only one: Year 1(July 1,2007-June 30.2008) APPLICANT: Weld County Department of Public Health and Environment_ ❑Year 2(Jury 1,2008-June 30.2009) 3ROJECT TITLE: Weld County Tobacco Program E Year 3(July 1,2009-June 30.2010) STRATEGIC INITIATIVE#: CB-1 SOURCE OF FUNDS Requested Other Source' Other Source' CDPHE Source 1 Source 2 DERSONAL SERVICES FTE Monthly Monthly #of Enter name here if Enter name here if Name Position Salary Benefits Months applicable applicable Joe Fleming Coordinator 0.035 4344.780 1447.680 2.500 506.840 0.000 0.000 Joe Fleming Coordinator 0035 4477.720 1491.970 3.000 626.817 0.000 0.000 Joe Fleming Coordinator 0.035 4634.440 1544195 6.500 1405.639 0.000 0.000 Lassie Kauffman Health Educator 0.200 3917.790 1305.400 5.500 5745.509 0.000 0.000 Cassie Kauffman Health Educator 0.200 4054.910 1351.096 6.500 7027.808 D 000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000_ 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0000 0.000 Subtotals.' 15312.614 0.000 0.000 total Personal Services 15312.614 0.000 0.000 DIRECT OPERATING COSTS DESCRIPTION PrintingiCoPying $0.00 $0.00 $0.00 Postage/Shipping $0.00 $0.00 $0.00 Office Supplies $0.00 $0.00 $0.00 Telephone,Fax,Internet Access Y $0.00 $0.00 $0.00 Rent and Utilities $0.00 $0.00 $0.00 Computer Equipment $0.00 $0.00 £0.00 Staff Development $0.00 $0.00 $0.00 Other Program Cost Meeting costskofiosting of recognition clam $300.00 $0.00 $0.00 Total Operating Costs _ $300.00. $0.00, $0.00 TRAVEL DESCRIPTION In-State Only $0.00 $0.00 50.00 Out of State Only $0.00 $0.00 $0.00 Total Travel Costs $0.00 $0.00 $0.00 CONTRACTUAL DESCRIPTION Consultant 50.00 $0.00 $0.00 Contract Trainers/Speakers $0.00 $0.00 $0.00 Subcontractors $0.00 $0.00 $0.00 Total Contractual Costs • $0.00 S0.00 f0.00 OTHER COSTS(list) DESCRIPTION $0.00 $0.00 $0.00 50.00 $0.00 $0.00 50.00 $0.00 $0.00 50.00 $0.00 $0.00 $0.00 $0.00 $0.00 _ Total Other Cats $0.00 $0.00 $0.00, ;.,... _ yr na,i ;.t •; t t4 a 2 xr rr r! s CDPHE Source 1 .IIIIINSiiiiiiiii2 SUBTOTALS $15,812.51 $0.00 $0.00 I. Enter only one%for lrldrect OoMc ,- . ... ,:I,:.•::,• • -�' . INDIRECT COSTS: 8% Direct Costs,enter CDPHE approved rate or 10%) $1,263.00 INDIRECT COSTS: 0% Salary and Fringe,enter CDPHE approved rate or 10%) $0.00 INDIRECT COSTS: 0% Salary only,enter CDPHE approved rate or 10%) Total Indirect Cost(Calculated on Amount Requested from CDPHE Only) $1,263.00 TOTAL AMOUNT REQUESTED FROM CDPHE 116,875.61 'Other Please indicate additional revenue if applicable. /47? 3i:lCenter for Healthy Living and Chronic Disease PrevlGrants UnIt1STEPP1Blank RFA Budget forrm.STEPP.multi sife.xls /177 1 s—'/' Signature of Authorized Representatnre Date Rev.2.9.07 APPLICATION BUDGET FORM State Tobacco Education and Prevention Grants Program FY2O07-08 Check only one: 0 Year 1(July 5,2007.June 30.z008) APPLICANT: Weld County Department of Public Health and Environment O Year 2(Jul 1,2008-June 30.2009) PROJECT TITLE: Weld County Tobacco Program O Year 3(Jul 1,2009-June 30.2010) STRATEGIC INITIATIVE it: CB-2 SOURCE OF FUNDS Requested Other Source' Other Source' . -'CiWHE --.Saxta1 , Source2:. ... PERSONAL SERVICES FTE Monthly Monthly #of Enter name here if Enter name here if Name Position Salary Benefits Months applicable applicable Joe Fleming Coordinator 0.385 4344.780 1447.681 2.500 5575.243 0.000 0.000 Joe Fleming Coordinator 0.385 4477.720 1491.976 3.000 6894.999 0.000 0.000 Joe Fleming Coordinator 0.385 4634.440 1544.195 6.500 15462.035 0.000 0.000 Cassie Kauffman Health Educator 0.355 3917.790 1305.408 5.500 10198.293 0.000 0.000 Cassie Kauffman Health Educator 0.355 4054.910 1351.096 6.500 12474.359 0.000 0.000 Jody Kugler Health Educator 0.415 3917.790 1305.410 5.500 11921.954 0.000 0.000 Jody Kugler Health Educator 0.415 1054.910 1351.100 8.500 14582.712 0.000 0.000 Penny Duell Office Technician 0.150 2521.470 840.154 5.500 2773.340 0.000 0.000 Penny Duell Office Technician 0.150 2609.720 869.559 6.500 3392.297 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0000 0.000 Subtotals: 83275.232 0.000 0.000 Total Personal Services 83275.232 0.000 0.000 I. . DIRECT OPERATING COSTS DESCRIPTION Printing/Copying $0.00 $0.00 $0.00 Postage/Shipping $0.00 $0.00 $0.00 Office Supplies Supplies allocated$43 per month $520.00 $0.00 $0.00 Telephone,Fax,Internet Access $0.00 50.00 $0.00 Rent and Utilities $0.00 $0.00 $0.00 Computer Equipment $0.00 $0.00 $0.00 Staff Development $0.00 $0.00 $0.00 Other Program Cost Coalition and nelxork meetings(12-15 meetings) $2,000.00 $0.00 $0.00 Total Operating Costs $2,520.00 $0.00 $0.00 TRAVEL DESCRIPTION In-State Only Weld C untynocal travel(80 mleshnonth br three start Q$0.465) $1,340.00 $0.00 $0.00 Out of State Only $0.00 $0.00 $0.00 Total Travel Costs $1,340.00 $0.00 $0.00 CONTRACTUAL DESCRIPTION .. Consultant $0.00 $0.00 $0.00 Contact Trainers/Speakers $0.00 $0.00 $0.00 Subconbadura $0.00 $0.00 $0.00 Total Contractual Costs $0.00 $0.00 $0.00 OTHER COSTS(list) DESCRIPTION $0.00 $0.00 60.00 ' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $010 Total Other Costs $0.00 $0.00 $0.00 SUBTOTALS $87,135.23 $0.00 $0.00 Etwonlyone%ti'IrfkleACasls .,, . . ,. .•r, :, INDIRECT COSTS: 8% Died Costs,at CDPHE approved rate or 10%) $7,049.00 INDIRECT COSTS: 0% Salary and Fringe,Wen CDPHE approved rate or 10%) $0.00 INDIRECT COSTS: 0% Salary only,enter CDPHE approved rate or 10%) Total Indirect Cost(Calculated on Amount Requested from CDPHE Only) $7019.00 TOTAL AMOUNT REQUESTED FROM CDPHE $94,18423 'Other. Please State addbwral revenue 8 applicable. 11 I:\Center for Healthy Living and Chronic Disease Prey\Grants Unh1STEPP\Blank RFA Budget form.STEPP.multi-site.be Z "3 Signature of Authorized Representative Date Rev.2.9.07 APPLICATION BUDGET FORM State Tobacco Education and Prevention Grants Program FY2007-08 Check only one: 0 Year 1(July 1,2007-June 30.2008) APPLICANT: Weld County Department of Public Health and Environment ❑Year 2(July 1,2008-June 30.2009) PROJECT TITLE: Weld County Tobacco Program 0 Year 3(July 1,2009-June 30.2010) STRATEGIC INITIATIVE 1t CB-3 SOURCE OF FUNDS Requested Other Soure Other Source ... >.CDPHE Sooraa# <Sorace2 _. PERSONAL SERVICES FTE Monthly Monthly #of Enter name here if Enter name here if Name Position Salary Benefits Months applicable applicable Joe Fleming Coodnmator 0.45 $4,344.78 $1,447.68 2.5 $6,516.52 $0.00 $0.00 Joe Fleming Coordinator 0.45 $4,477.72 $1,491.98, 3.0 $8,059.09 $0.00 $0.00 Joe Fleming Coordinator 0.45 $4,634.44 $1,544.20 6.5 $18,072.51 $0.00 $0.00 Cassie Kauffman Health Educator 0.35 $3,917.79 $1,305.41 5.5 $10,054.66 $0.00 $0.00 Cassie Kauffman Health Educator 0.35 $4,054.91 $1,351.10 6.5 $12,298.66 $0.00 $0.00 Jody Kugler Health Educator 0.35 $3,917.79 $1,305.41 5.5 $10,054.66 $0.00 $0.00 Jody Kugler Health Educator 0.35 $4,054.91 $1,351.10 6.5 $12,298.67 $0.00 $0.00 Penny Duel! Office Technician 0.10 $2,521.47 $840.15 5.5 $1,848.89 $0.00 $0.00 Penny Duell Office Technician 0.10 $2.609.72 $869.56 6.5 $2,261.53 $0.00 $0.00 0.00 $0.00 $0.00 0.0 50.00 50.00 $0.00 0.00 50.00 $0.00 0.0 50.00 $0.00 $0.00 0.00 $0.00 $0.00 0.0 $0.00 $0.00 $0.00 Subtotals: 581,465.19 $0.00 $0.00 Total Personal Services $81,465.19 $0.00 $0.00 DIRECT OPERATING COSTS DESCRIPTION Prvhtnt#O00yng $0.00 $0.00 $0.00 Postage/Shipping Mailings to business communities $300.00 $0.00 $0.00 Office Supplies Office supplies 100/month prorated $1,200.00 $0.00 $0.03 Telephone,Fax,Internet Access $0.00 $0.00 $0.00 • Rent and Utilities $0.00 $0.00 $0.00 Computer Equipment $0.00 $0.03 $0.00 Staff Development $0.00 $0.00 $0.00 Other Program Cost Meeting expenses-educational materials/Host enforcement education $2,000.00 $0.00 $0.00 Total Operating Costs $3,500.00 $0.00 $0.00 TRAVEL DESCRIPTION In-State Only County/Local travel 110x12xac465 $1,841.00 $0.00 $0.00 Out of State Only $0.00 $0.00 $0.00 Total Travel Costs $1,841.00 $0.00 $0.00 CONTRACTUAL DESCRIPTION Consultant $0.00 $0.00 $0.00 Contract Trsers/Speakers $0.00 $0.00 $0.00 Subcontractors $0.00 $0.00 $0.00 Total Contractual Costs $0.00 $0.00 $0.00 OTHER COSTS(list) DESCRIPTION Memberships GASP,CTEPA,Tobacco-Free Rodeo $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Total Other Costs $600.00 moo $0.00 SUBTOTALS $57,406.19 $0.00 $0.00 Enleratyorrs%>a';hx>hedClxt4 INDIRECT COSTS: 8% Deed Cans,enter CDPHE approved rate or 10%) $7,071.00 INDIRECT COSTS: 0% Salary and Fringe,enter CDPHE approved rate or 10%) $0.00 INDIRECT COSTS: 0% Salary only,ester CDPHE approved rate or 10%) Total Indirect Cost(Calculated on Amount Requested from CDPHE Only) $7,071.00 TOTAL AMOUNT REQUESTED FROM CDPHE $94A77.19 *0ther Please indicate additional revenue it applicable. .. V /3 Signature of Authorized Representative Date Rev.2107 APPLICATION BUDGET FORM State Tobacco Education and Prevention Grants Program FY2007-08 Check only one: EJ Year 1(July 1,2007-June 30.2008) APPLICANT: Weld County Department of Pubilc Health and Environment ❑Year 2(Jul 1,2053-June 30.2009) PROJECT TITLE: Weld County Tobacco Program 0 Year 3(Jury 1,2009-June 30.2010) STRATEGIC INITIATIVE it CB-5 SOURCE OF FUNDS Requested Other Source' Other Source* . COWIE ' Saacet Source2 ,. PERSONAL SERVICES FTE Monthly Monthly #of Enter name here if Enter name here if Name Position Salary Benefits Months applicable applicable Joe Fleming Coordinator 0.100 4344.780 1447.681 2.500 1448.115 0.000 0.000 Joe Fleming Coordinator 0.100 4477.720 1491.976 3.000 1790.909 0.000 0.000 Joe Fleming Coordinator 0.100 4634.440 1544.195 6.500 4016.113 0.000 0.000 Cassie Kauffman Health Educator 0.050 3917.790 1305.408 5.500 1436.379 0.000 0.000 Cassie Kauffman Health Educator 0.050 4054.910 1351.096 6.500 1756.952 0.000 0.000 Jody Kugler Health Educator 0.055 3917.790 1305.410 5.500 1580.018 0.030 0.000 Jody Kugler Health Educator 0.055 4054.910 1351.100 6.500 1932.649 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.030 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 Subtotals: 13961.135 0.000 0.000 Total Personal Services 13961.135 0.000 0.000 DIRECT OPERATING COSTS DESCRIPTION PrmtpglCopying $0.00 $0.00 $0.00 Poslage/Shippkg $0.00 $0.00 $0.00 Office Suppies Media supplies$3ohnath 5360.00 $0.00 $0.00 Telephone,Fax,Internet Access $0.00 $0.00 $0.00 Rent and(Mites ' $0.00 $0.00 $0.00 Computer Equipment Website Development/Promotion $1,500.00 $0.00 $0.00 Staff Development $0.00 $0.00 $0.00 Other Program Cost Billboards and local media placements $4,530.00 $0.00 $0.00 Total Operating Costs $6,390.00 $0.00 $0.00 TRAVEL DESCRIPTION . . In-State Only $0.00 $0.00 $0.00 Out of State Only W00 $0.00 60.00 Total Travel Costs $0.00 $0.00 $0.00 CONTRACTUAL DESCRIPTION Consultant $0.00 $0.00 $0.00 Contract Trainers/Speakers $0.00 $0.00 $0.00 Subcontractors $0.00 $0.00 $0.00 Total Contractual Costs $0.00 $0.00 $0.00 OTHER COSTS(list) DESCRIPTION $0.00 $0.00 $0.00 $0.03 $0.00 $0.00 $0.00 $0.00 $0.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Total Other Costs $0.00 $0.00 $0.00 SUBTOTALS $20,351.13 $0.00 $0.00 ESonyone%6tM0tectCosts .. `. - .; ... INDIRECT COSTS: 8% Direct Costs,enter CDPHE approved rate or 10%) $1,646.00 INDIRECT COSTS: 0% Salary and Fringe,enter CDPHE approved rate or 10%) $0.00 INDIRECT COSTS: 0% Salary only,enter CDPHE approved rate or 10%) _ Total Indirect Cost(Calculated on Amount Requested tarn CDPHE Only) $1,646.00 TOTAL AMOUNT REQUESTED FROM CDPHE $21,997.13 Other. Please indicate additional revenue if applicable. / Signature of Authorized Representative Date Rev.2.9.07 APPLICATION BUDGET FORM State Tobacco Education and Prevention Grants Program FY2007-08 Check only one: 0 Year 1(July 1,2007-June 30.2008) APPLICANT: Weld County Department of Public Health and Environment O Year 2(July 1,2006-June 30.2009) PROJECT TITLE: Weld County Tobacco Program ❑rear 3(July 1,2009-June 30.2010) STRATEGIC INITIATIVE#: CB-8 SOURCE OF FUNDS Requested Other Source Other Source' . -Cik+HE Soetdei :=.Same2' PERSONAL SERVICES FTE Monthly Monthly #of Enter name here if Enter name here if Name Position Salary Benefits Months applicable applicable Jody Kugler Health Educator 0.145 3917.790 1305.410 5.500 4165.502 0.000 0.000 Jody Kugler Health Educator 0.145 4054.910 1351.100 6.500 5095.164 0.000 0.000 0.000 0.000 0.000 0.000 0.030 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000` 0.000 0.000 0.000 0.000 0.000 0.000 0:000 0.000 0.000 0.000 0.000 Subtotals: 9260.666 0.000 0000 Total Personal Services 9260.666 . 0.000 0.000 DIRECT OPERATING COSTS DESCRIPTION Pri finglCopying $0.00 $0.00 $0.00 POstage/ShppOg $0.00 $0.00 $0.00 Office Supplies 10.00 $0.00 $0.00 Telephone,Fax,Internet Access $0.00 $0.00 $0.00 Read and LABS $0.00 $0.00 $0.00 Computer Equipment $0.00 $0.00 $0.00 Staff Development $0.00 $0.00 $0.00 Other Program Cost Share reception costs for worksite partners event $175.00 $0.00 $0.00 Total Operating Costs $175.00 50.00 $0.00 TRAVEL DESCRIPTION , . . . .. .. . In-State Only CountyAncal Travel 30x12x.465 $165.00 $0.00 $0.00 Out of State Only $0.00 $0.00 $0.00 Total Travel Costs $165.00 woo woo CONTRACTUAL DESCRIPTION Consultant $0.00 $0.00 $0.00 Contract Trainers/Speakers $0.00 $010 $0.00 Subcontractors $0.00 $0.00 $0.00 Total Contractual Costs WOO $0.00 $0.00 OTHER COSTS(fist) DESCRIPTION $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 W00 $0.00 Total Other Costs $0.00 $0.00 WOO .. : �"°C0PE a Sowce1 5aaee2 SUBTOTALS $9,600.67 $0.00 $0.00 INDIRECT COSTS: 8% Direct Costs,enter CDPHE approved rate or 10%) $777.00 INDIRECT COSTS: 0% Salary aid Fringe,enter CDPHE approved rate or 10%) SOHO INDIRECT COSTS: 0% Salary only,enter CDPHE approved rate or 10%) Total Indirect Cost(Calculated on Amount Requested from CDPHE Only) $777.00 TOTAL AMOUNT REQUESTED FROM CDPHE $10,377.67 a { � -Other Please indicate additional revenue if applicable. 1 C Signature ofAu#wr¢ed Representative Date Rev.2.9.07 State Tobacco Education and Prevention partnership Grants Program FY2007-2008 Capacity Building Year 1: July 1,2007 through June 30,2008 PERSONAL SERVICES: Program Coordinator State regional and Tier II Capacity Building requirements, meetings, conference calls and staff development .03 FTE $2,176.54 Health Educator State, regional and Tier II Capacity Building requirements, meetings, conference calls online modules and national conference attendance .045 FTE 2,874.00 Health Educator State, regional and Tier II Capacity Building requirements, meetings, conference calls and online modules. .035 Fit $2,235.33 Total $7,285.87 OPERATING COSTS: Staff Development: 1 staff registration @ Tobacco or Health Conference $400.00 Total $400.00 TRAVEL: In-state State, regional, Tier II trainings for 3 staff: Contractors meeting 2 days @ 140 miles x.465= $130.00 Regional meetings 2 days x 120 x.465=$112.00 Tier II trainings 3 staff x 2 programs x140 miles x.465=$391.00 Trainings could include Cultural Competence, Collaborative Leadership,Public Health 101, and other topics offered to be determined through the training center. Meals/per diem for 3 staff @ trainings $133.00 Total $766.00 Out of State Airfare for 1 staff to Minneapolis,Minnesota- Tobacco or Health Conference 10/2007 $400.00 Lodging 1 staff for 3 nights=$300.00 Per Diem=$100.00 Total $800.00 Total $1566.00 INDIRECT COSTS: 8.09% of total direct costs= $748.00 Total $9,999.87 State Tobacco Education and Prevention partnership Grants Program FY2007-2008 CB-1 Year 1: July 1,2007 through June 30,2008 PERSONAL SERVICES: Program Supervisor Provide general oversight and coordination of initiative. Focus on rural spit tobacco users- information and relationship development. Planning and assessment regarding services/activities for disparate populations in Weld County .035 FTE $2,539.30 Health Educator Staff member is responsible for the majority of initiative activities and objectives. Collect and analyze data. Contact resources, develop relationships and provide information and education to address disparities related to tobacco prevention. Program planning. Program objectives and contacts .20 FTE $12,773.32 Total $15,312.62 OPERATING COSTS: Other Program costs Partners Meetings/Recognition 1 event $300 Total $300.00 INDIRECT COSTS: 8.09% of the total direct costs $1263.00 TOTAL $16,875.61 9 r 3 State Tobacco Education and Prevention partnership Grants Program FY2007-2008 CB-2 Year 1: July 1,2007 through June 30,2008 PERSONAL SERVICES: Program Coordinator Provide program administration/evaluation. Maintain and establish partnerships through systems approach to support comprehensive tobacco control initiatives. Responsible for supervision& community networking .385 FTE $27,933 Health Educator Responsible for program objectives and outcomes in community systems including work with schools, coalition recruitment and work with community based organizations. Link disparity initiative objectives and information into community system approach and to overall program. Coordination of special events. Program planning. Resource contact for university. .355 FTE $22,672.65 Health Educator Responsible for program objectives and outcomes especially with community systems including work with schools,youth organizations, daycares, healthcare providers, overall health care system, networks and community based organizations. Coordination of special events. Program planning. Coalition recruitment. Resource contact for community college. .415 FTE $26,504.66 Office Technician Provide administrative/clerical support to tobacco program. Maintain supplies and records. Organize program meetings including monthly coalition meetings. .150 FTE $6,165.64 Total $83,275.23 OPERATING COSTS: Office Supplies $43 per month= $520.00 Other Program Costs Monthly coalition& system partners meetings $2,000 Total $2,520.00 TRAVEL: In-state Mileage for staff contacting and meeting with community members and system partners to effect tobacco control initiatives. Relationship development. Providing education and information. Covering a 4,000 square mile county 3 staff x 80 miles per month x.465 $1,340.00 Total $1,340.00 INDIRECT COSTS: 8.09% of the total direct costs $7,049.00 Total $94,184.23 State Tobacco Education and Prevention partnership Grants Program FY2007-2008 CB-3 Year 1: July 1,2007 through June 30,2008 PERSONAL SERVICES: Program Supervisor Providing supervisor&policy development .45FTE $32,648.12 Health Educators (2) Tobacco policy- community work @ .35 FTE and .35 FTE $44,706.65 Office Technician Clerical Support, .10 FTE $4110.42 Total $81,465.19 OPERATING COSTS: Postage Mailings to community partners toward Policy initiation- $300.00 Office Supplies $100.00 per month x 12 months= $$1,200.00 Also prorated to CB4-CB-5 and CB8 Other Program Meeting Expenses/Educational Materials Host partners policy meetings $2,000.00 Total $3,500.00 TRAVEL: In-state only Weld County—visitation community partners &businesses 110 miles per month x 3x .465 Total $1,841.00 CON 1'RACTURAL: OTHER COSTS: Memberships CTEPA, GASP, Tobacco Free rodeo $600.00 Total $600.00 INDIRECT COSTS: 8.09% of the total direct costs $7,071.00 TOTAL $94,477.19 11 State Tobacco Education and Prevention partnership Grants Program FY2007-2008 CB-5 Year 1: July 1,2007 through June 30, 2008 PERSONAL SERVICES: Program Coordinator Coordinate media plan with county, region, and state interests and resources. Collaborate with local programs to maximize effects of media. Build relationships with media resources. Backup Public Information Officer. .10 FTE $7,255.13 Health Educators (2) Health educators will place both earned and paid media in a variety of sources based on state needs and local initiatives. Special work and emphasis will be focused on media reaching disparate populations and a large rural population in a large geographical area. 1@ .05 FTE and l@ .055 $6,706.00 Total $13,961.13 OPERATING COSTS: Office Supplies Media Materials $30/month $360.00 Computer Continuing website development/promotion $1,500.00 Other Program Costs Media placement-billboards, signage, radio,television 4,530.00 Media will be coordinated with state strategic initiatives to maximize coverage and to coincide with events (such as the Great America Smokeout, Greeley Stampede, Through with Chew, etc). Continuing efforts will be directed toward media with the Colorado Clean Indoor Act implementation and related issues. Coordinate media placement regionally. Total $6,390.00 INDIRECT COSTS: 8.09% of the total direct costs $1,646.00 TOTAL $21,997.13 Iac� ( 3 State Tobacco Education and Prevention partnership Grants Program FY2007-2008 CB-8 Year 1: July 1,2007 through June 30,2008 PERSONAL SERVICES: Health Educator Provide tobacco control information and education to employers and worksites throughout Weld County. Serve as tobacco resource in support of several worksite initiatives. Assist Steps to Healthier Weld County to ensure tobacco control is included in all worksite wellness initiatives. Coordinate and collaborate with the Greeley Well City Initiative applicants through the Wellness Councils of America to include tobacco control policies and practices. 0.145 FTE $9,260.67 Total $9,260.67 OPERATING COSTS: Other Program Costs Coordinate with community partners and share costs to host employer reception $175.00 Total $175.00 TRAVEL: In-state only County-wide travel to support worksite initiatives 30 miles per month x .465 $165.00 Total $165.00 INDIRECT COSTS: 8.09% of the total direct costs $777.00 Total $777.00 TOTAL $10,377.67 STATE OF COLORADO Bill Ritter,Jr.,Governor James B. Marlin, Executive Director .oF cot Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr.S. Laboratory Services Division Denver,Colorado 80246-1530 8100 Lowry Blvd. \* " Phone(303)692-2000 Denver,Colorado 80230-6928 TDD Line(303)691-7700 (303)692-3090 Located in Glendale,Colorado Colorado Department of Public Health http://www.cdphe.state.co.us and Environment June 25, 2007 Joe Fleming, Project Coordinator Board of County Commissioners of Weld County 1555 N. 17th Street Greely, CO 80631 Dear Mr. Fleming: Enclosed for your records, is a fully executed copy of the Contract with the Colorado Department of Public Health and Environment for the tobacco education and prevention program. The effective date of the contract is July 1, 2007. Please feel free to contact me at(303)692-2579 should you have questions or need further information. Sincerely, t/MelfrLaura Jorstad, Fiscal Officer State Tobacco Education and Prevention Partnership enclosure(s) Hello