HomeMy WebLinkAbout20071697.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR TUBERCULOSIS PROGRAM AND
AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with a Task Order Contract forthe Tuberculosis
Program between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment, and the Colorado Department of Public Health and Environment, commencing
July 1, 2007, and ending June 30, 2008, 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 Tuberculosis Program between the County
of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County,
on behalf of the Weld County Department of Public Health and Environment, and the Colorado
Department of Public Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said task order contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 18th day of June, A.D., 2007.
BOARD OF COUNTY COMMISSIONERS
� � WE�� OUNTY, COLORADO
ATTEST: � �" f . ` `� 1 / /• . �: : mss_
�JiNd E. Long, Chair ,
Weld County Clerk to the Bo-1 I' .*"= ` _
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Deputy CBY: lerk to the Board '!/ \ �► �/
Wi '14� la APP D AS TO F \
Robert D. Masden
ty Att rney cs2Yrt�e
Dougla Rademach r
Date of signature: 7-±°7
2007-1697
HL0034
ll� ' lf�1(: ) n7-7/-a 7
Memorandum
TO: David E. Long, Chair
Board of County Commissioners
CFROM: Mark E. Wallace, MD, MPH
ODirector,Department of Publicalt and Environment AfFt o
COLORADO DATE: June 8,2007
SUBJECT: Task Order Contract for the
Tuberculosis Program
Enclosed for Board review and approval is Task Order Contract between Weld County and the
Colorado Department of Public Health and Environment for the Tuberculosis Program.
Under the provisions of this renewal letter, Weld County Department of Public Health and
Environment (WCDPHE) will provide active TB treatment including directly observed therapy,
ensure contacts to all newly identified infectious TB cases are identified and receive appropriate
evaluation, collect specimens for testing on all persons suspected of having TB, provide for and
interpret chest x-rays, and conduct TB skin test screening programs. Health Department staff
will also follow-up with active patients to ensure they receive appropriate information and
education and they adhere to the completion of their TB therapy.
For providing these services during the time period of July 1, 2007 through June 30, 2008,
WCDPHE will receive an amount not to exceed $53,100 plus $12.50 per onsite visit and $25.00
per field visit for directly observed therapy. Of the $53,100, $3,500 is Federal funding and
$49,600 is State of Colorado funding.
I recommend your approval of this task order contract.
Enclosure
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2007-1697
°DEPARTMENT OF PUBLIC I IEACfH AND ENVIRONMENT
ROUTING NO.08 FHA 00037
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
Sl'A"1'E CONTRACTORS.
State of Colorado for the use& benefit of the Board of County Commissioners of Weld
Department of Public Health and County
Environment 1555 North 17th Avenue
Disease Control & Epidemiology Greeley, Colorado 80631
Tuberculosis Program
4300 Cherry Creek Drive South
Denver, Colorado 80127
'CASK ORDER MADE DATE: CONTRACTOR EN7l5Y'TYPE:
04/27/2007 Colorado Political Subdivision
PO/SC ENCUMBRANCE NUMBER: CONTRACTOR PAIN OR SOCIAL SECURITY NUMBER:
PO FI-lA EPI0800037 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 AUTIORrrY
Task Order shall end on 06/30/2008. Not Applicable
muck i S IRUCIL'RE: CONTRACT PRICE NO'I TO EXCEED.
Cost Reimbursement $53,100.00
I'IROCIRIIMt:N'I MEDIOD: FEDERII.FUNDING DOLLARS $3,500.00
Exempt S n 1 FUNDING DO1.'WICS. $49,600.00
BID/RIP/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE Pt-R FISCAL YEAR.
Not Applicable FY 08: $53,100.00
FY XX: $
I SS'SPECIE I ED VENDOR SI.AI UTE: $
FY XX:
Not Applicable FY XX: $
FY XX: $
SI \TE REPRESENT/VI-1W: CONTRACTOR REPRESENTATIVE:
Pam Pergande Board of County Commissioners of Weld
Department of Public Health and Environment County
Disease Control& Epidemiology 1555 North 17th Avenue
-3 Greeley, Colorado 80631
4300 Cherry Creek Drive South
Denver,CO 80127
SCOPI OF WORK:
The Contractor shall assist in supporting tuberculosis prevention and control activities in Weld
County.
Page 1 of 4
o2OO7-/697
txi unrrs.
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
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.
I. 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.
'_. 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: I)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.
CONTRACTOR: STATE OF COLORADO:
Board of County Commissioners of Weld BIL RITTER,.I . GOVERNOR
County
Legal Name of Contracting Entity
For Executive Director
846000813 Department of Public Health and Environment
Social Securi Number or FEIN
O1/41
_ Department Program Approval:
Signature of Authorized Officer
JUN 1 8 007
David E. Long, Chairman By
Print Name&Title of Authorized Officer JJ
GOVERNME TAL ENTITIES:
(An attestor and e r ired/ :tip -
ATTEST:
Weld my Cler to he Board 1861 `P2
Attest(Seal)B- aft v":"
re)
k7C4tvI t$ li t6f 4�[f]j7C re)
De ty Clerk to the oard
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:
Leslie M.Shenefelt
By
Date
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH EN NM T
BY:
Mark E. Wallace, MD, MPH•Director
Page 4 of 4
,2a'2-/99 7
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 04/27/2007 - Contract Routing Number 08 FHA 00037
These provisions are to be read and interpreted in conjunction with the provisions of the
Task Order Contract specified above.
1. The State has determined that this contract does not constitute a Business Associate relationship under
HIPAA.
2. The State, in order: to carry out its lawful powers, duties, and responsibilities under Section, 25-4-501, 8
C.R.S., as amended; and,to effectively utilize legislative appropriations made and provided therefore, in
coordination with like powers,duties,and responsibilities of the Contractor, has determined that public
health services are desirable in WELD COUNTY, Colorado.
3. Pursuant to 25-4-501, 8 C.R.S., as amended,the General Assembly has declared that tuberculosis is an
infectious and communicable disease,that it endangers the population of this state, and that the treatment
and control of said disease is a state responsibility and further, pursuant to 25-4-511, 8 C.R.S., assistance
under section 25-4-501, shall be given to any applicant who is suffering from tuberculosis in any form
requiring treatment and is without sufficient means to obtain such treatment. The State,through the
Tuberculosis Program has a mandate to provide care coordination services for the residents of the State
of Colorado.
4. Pursuant to the Catalog of Federal Domestic Assistance(CFDA)number 93.116,the State has been
awarded funds by the Department of Health and Human Services, Centers for Disease Control (CDC)for
tuberculosis control. The State shall contract with the Contractor to assure that tuberculosis control
services are provided for the residents of the above-mentioned county.
5. The State has formulated a comprehensive State plan,with associated budgets,to disburse these funds
throughout the state of Colorado. Under this comprehensive State plan,the State shall allocate these funds
to qualified entities to provide certain purchased services to the citizens of the state of Colorado on behalf
of the State.
6. In consideration of those services satisfactorily and timely performed by the Contractor under this Task
Order the State shall cause to be paid to the Contractor a sum not to exceed FIFTY THREE THOUSAND
ONE HUNDRED DOLLARS,($53,100.00)for the initial term of this Task Order. Of the total financial
obligation of the State referenced above,$3.500.00 are identified as attributable to a funding source of the
United States government and, $49,600.00 are identified as attributable to a funding source of the state of
Colorado.
Payment pursuant to this Task Order shall be made as earned, in whole or in part, from available State
funds encumbered in an amount not to exceed THIRTY TWO THOUSAND DOLLARS($32,000.00)
Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2008. Of the total financial
obligation of the State referenced above,one hundred percent is derived from the State General Fund.
The liability of the State,at any time, for such payments shall be limited to the unencumbered remaining
balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this
Contract,then the State, in its sole discretion,may proportionately reduce the funding for this Contract or
terminate this Contract in its entirety.
To be attached to CDPHE Page 1 of 2 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT A
Description Funding Source Amount
Tuberculosis Control and Outreach State $49,600.00
Tuberculosis Control and Outreach Federal $3,500.00
Direct Observed Therapy State As Administered
($12.50 per onsite visit)
($25.00 per field visit)
TOTAL $53,100.00
To receive compensation under this Task Order Contract,the Contractor shall submit a signed monthly
Invoice/Cost Reimbursement Statement in a format acceptable to the State. A sample Invoice/Cost
Reimbursement Statement is attached hereto as Attachment A-1 and incorporated herein by this reference.
An Invoice/Cost Reimbursement Statement must be submitted within Thirty(30)calendar days of the end
of the billing period for which services were rendered. Expenditures shall be in accordance with the
Statement of Work attached hereto as Exhibit B and incorporated herein. These items may include, but are
not limited to,the Contractor's salaries, fringe benefits, supplies,travel, operating, indirect costs which are
allowable,and other allocable expenses related to its performance under this Task Order Contract.
Invoice/Cost Reimbursement Statements shall: 1)reference this Task Order 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)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 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:
Barb Stone
Tuberculosis Program
Colorado Department of Public Health and Environment
DCEED A-3
4300 Cherry Creek Drive South
Denver, CO 80246
To be considered for payment,billings for payments pursuant to this 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
thirty(30)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 Task Order Contract;but in no event no later than thirty(30)calendar days from the effective
expiration or termination date of this Task Order Contract.
Unless otherwise provided for in this Task Order Contract,"Local Match", if any,shall be included on all
billing statements as required by the funding source.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
To be attached to CDPHE Page 2 of 2 Revised: 12/19/06
Task Order v1.0(11/05)contract template
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EXHIBIT B
STATEMENT OF WORK
To Task Order Contract Dated 04/27/2007-Contract Routing Number 08 FHA 00037
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above.
A. Funds provided under the Task Order are to assist in supporting tuberculosis(TB)prevention and control
activities as stated in Colorado Revised Statues(CRS)25-4-501-Part 5 Tuberculosis(et seq)and Rules and
Regulations Pertaining to Epidemic and Communicable Disease Control(6-CCR-1009-I, Regulation 4).
Contractor shall provide or coordinate the following services for all individuals within its service area
according to the statutes and regulations listed above and according to CDPHE Tuberculosis Manual, but in
no event less than those duties required by statute and rules(listed above). Use of funds shall be prioritized
as follows: priority I)finding all patients with active TB and ensuring completion of appropriate therapy,
priority 2) finding and evaluating contacts of TB patients and ensuring completion of appropriate therapy,
3)evaluation of newly arrived immigrants and refugees with Class B TB designation,and priority 4)
targeted testing of high-risk persons and ensuring completion of therapy for latent TB infection(LTBI). If
available, use patient's medical insurance as primary payment source. CDPHE will reimburse for
diagnostic and clinical services at current Medicaid rate unless prior approval has been given by the
CDPHE TB Program.
I. Suspected or confirmed active TB
a. The Contractor shall provide, or arrange for, chest x-rays and interpretations.
b. The Contractor shall collect, or arrange for the collection of, specimens for mycobacteriology
testing on all persons suspected of having TB. Assure appropriate testing is performed, e.g.,
smears for acid-fast bacilli, (using concentrated fluorescent method), isolation of
mycobacteria(using rapid methods), identification of Mycobacterium tuberculosis complex
(MTB)(using rapid methods), and susceptibility testing(isoniazid, rifampin,ethambutol, and
pyrazinamide) on isolates of MTB. Contractor should use the CDPHE Laboratory for testing.
The CDPHE Laboratory will, at no charge to the Contractor, supply specimen containers and
perform the above testing for the Contractor. The Contractor shall arrange for the
transportation of the specimens to the CDPHE Laboratory for testing.
c. The Contractor shall provide, or arrange for, the placement of patients who require isolation.
The Contractor shall contact CDPHE TB Program for assistance, if needed, and to request
reimbursement from CDPHE for those costs incurred by the Contractor in isolating a patient.
d. The Contractor shall provide, or arrange for,all other necessary laboratory testing and
medical evaluation services.
e. The Contractor shall order TB medications through the CDPHE TB Program.
f. The Contractor shall provide the CDPHE with the medical insurance information for those
patients who have medical insurance.
g. The Contract shall provide, or arrange for, the treatment of patients with suspected or
confirmed active TB, including directly observed therapy, and ensure adherence to treatment.
h. The Contractor shall provide, or arrange for, a HIV antibody test for all persons diagnosed
with TB disease, regardless of their age or the apparent absence of risk factors for HIV
infection. In accordance with section 25-4-1401, et seq., C.R.S., as amended,the Contractor
shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform
those individuals whom refuse testing of the risks associated with HIV/TB co-infection.
To be attached to CDPHE Page 1 of 5 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT B
i. At least monthly, the Contractor shall monitor and evaluate those persons with suspected or
confirmed active TB.
j. The Contractor shall provide culturally appropriate patient education and information
pertaining to TB treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
k. All reports of suspected or confirmed active TB shall include: reason for initiating,patient
name, date of birth, country of birth, date arrived in U.S.,demographic information, locating
information, provider information, TB risk factors, results of diagnostic testing, results of
mycobacteriology including susceptibility results, dates of infectious period, treatment
information, changes in patients' status, diagnosis, or any other information as appropriate.
The Contractor shall report to CDPHE when a TB patient completes treatment, moves, or
transfers out of the Contractor's service area. Information may be reported via web-based TB
case/contact management system (TBdb)or via"Tuberculosis Surveillance and Case
Management Report"(TB 17), which is incorporated herein by this reference, made a part
hereof, and attached hereto as"Attachment B-1". Confirmed cases of TB shall include all
data elements identified in the "Report of Verified Case of Tuberculosis(RVCT)", which is
incorporated herein by this reference, made a part hereof, and attached hereto as"Attachment
B-2". The CDPHE shall provide the format and instructions for any additional information
requests. Report forms are subject to revision and Contractor agrees to use most recent
version.
2. Contacts to newly identified infectious TB (smear and/or culture positive pulmonary or laryngeal)
a. The Contractor shall ensure that all contacts to newly identified infectious TB cases are
identified, investigated, and receive appropriate evaluation. Contact investigation and any
follow-up needed as a result of an occupational exposure shall be conducted by the employer.
b. When indicated,the Contractor shall provide, or arrange for, chest x-rays and interpretations.
c. When indicated, the Contractor shall provide, or arrange for, other laboratory testing, and
other necessary medical evaluation services.
d. The Contractor shall provide, or arrange for, the treatment of patient(including directly
observed preventive therapy when appropriate), and ensure the completion of therapy for
infected contacts.
e. The Contractor shall order TB medications through the CDPHE TB Program.
f The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
g. The Contractor shall provide, or arrange for, an HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et
seq.,C.R.S., as amended,the Contractor shall report all known HIV antibody test results to
the State. The Contractor shall inform all Individuals whom refuse testing of the risks
associated with HIV/TB co-infection.
h. At least monthly,the Contractor shall monitor and evaluate persons with LTB1 during
treatment.
i. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
To be attached to CDPHE Page 2 of 5 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT B
patient's language using medical interpretation resources such as AT&T language line as
needed.
j. The Contractor shall submit a preliminary Contact Investigation Report,(which is
incorporated herein by this reference, made a part hereof, and attached hereto as"Attachment
B-3"to the CDPHE TB Program after initiation of each contact investigation. The Contractor
shall submit a final report to CDPHE when a contact investigation is completed. Report
forms are subject to revision and Contractor agrees to use most recent version.
k. For those persons identified, as pan of a contact investigation, with latent TB infection, or
those with suspected latent TB infection requiring treatment recommendations from CDPHE,
the Contractor shall report reason for initiating, patient name, date of birth, country of birth,
date arrived in U.S., demographic information, locating information, provider information,
TB risk factors, results of diagnostic testing, treatment information, or any other information
as appropriate. The Contractor shall report to CDPHE when_a patient completes treatment,
moves, or transfers out of the Contractor's service area. Information may be reported via
web-based TB case/contact management system (TBdb)or via "Tuberculosis Surveillance
and Case Management Report" (TB 17). The CDPHE shall provide format and instructions
for any additional information requests. Report forms are subject to revision and contractor
agrees to use most recent version.
3. Newly arrived immigrants and refugees with Class,B TB designation
a. The CDPHE TB Program will notify the Contractor of all newly arrived Class B TB
immigrants/refugees via a CDC 75.17 form which is incorporated herein by this reference,
made a part hereof,attached hereto as"Attachment B-4"or Follow-up worksheet which is
incorporated herein by this reference, made a part hereof,attached hereto as"Attachment B-
5". Report forms are subject to revision and contractor agrees to use most recent version.
b. Within thirty (30)calendar days of the Contractor's receipt of written notification from the
State of the arrival of a Class B immigrant/refugee,the Contractor shall contact that
immigrant and conduct, or arrange for, a TB screening that includes medical evaluation,
tuberculin skin test or whole blood interferon y assay,chest radiograph, and three spontaneous
sputum specimens for AFB smear and culture collected on consecutive days.
c. Upon completion of testing and examination, the Contractor shall fill out, sign, and date the
CDC 75.17 form or Follow-up worksheet, and return it within 90 days to:
Colorado Department of Public Health and Environment
Tuberculosis Program
Attn: Class B Coordinator
4300 Cherry Creek Drive South
Denver, CO 80246
d. The Contractor shall, when indicated,provide, or arrange for, treatment and ensure
completion of therapy.
e. The Contractor shall order TB medications through the CDPFIE TB Program.
f. The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
g. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
To be attached to CDPHE Page 3 of 5
Task Order v1.0(11/05)contract template Revised: 12/19/06
EXHIBIT B
h. For those persons identified with LTBI or active TB,the Contractor shall report patient name,
date of birth, country of birth, date arrived in U.S., demographic information, locating
information, provider information, TB risk factors, results of diagnostic testing, treatment
information, or any other information as appropriate. Contractor will report when a patient
completes treatment, moves, or transfers out of the jurisdiction. Information may be reported
via web-based TB case/contact management system (TBdb)or via"Tuberculosis Surveillance
and Case Management Report"(TB 17). The State shall provide format and instructions for
any additional information requests. Report forms are subject to revision and Contractor
agrees to use most recent version.
4. Other high-risk persons with LTBI
a. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations.
b. When indicated, the Contractor shall provide, or arrange for, all other necessary laboratory
testing and medical evaluation services.
c. The Contractor shall provide, or arrange for, the treatment of patient and ensure the
completion of therapy.
d. The Contractor shall order TB medications through the CDPHE TB Program.
e. The Contractor shall provide the CDPHE with the medical insurance information for those
patients that have medical insurance.
f The Contractor shall provide, or arrange for, a HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et
seq., C.R.S., as amended, the Contractor shall report all known HIV antibody test results to
the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks
associated with HIV/TB co-infection.
g. At least monthly,the Contractor shall monitor and evaluate persons with LTBI during
treatment.
h. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
i. For persons with LTBI, the Contractor shall report reason for initiating, patient name, date of
birth, country of birth, date arrived in U.S., demographic information, locating information,
provider information, TB risk factors, results of diagnostic testing, treatment information, or
any other information as appropriate. Contractor shall report when a LTBI patient completes
treatment, moves, or transfers out of the jurisdiction. Information may be reported via web-
based TB case/contact management system(TBdb)or via"Tuberculosis Surveillance and
Case Management Report"(TB 17). The CDPHE shall provide format and instructions for
any additional information requests. Report forms are subject to revision and Contractor
agrees to use most recent version.
To be attached to CDPHE Page 4 of 5 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT B
j. Tuberculin skin testing, chest radiographs,chest radiograph interpretations, other diagnostic
testing, and medical evaluations are not eligible for reimbursement under this Task Order for
the following:
i. Correctional facility inmates;
ii. Persons, other than Class B TB immigrants/refugees, undergoing
immigration medical examinations;
iii. Paid or volunteer employees of health care facilities, long-term care
facilities, drug treatment centers, correctional facilities, shelters, schools, or
child care facilities who undergo skin testing as part of a routine
employment skin testing program.
5. TB education and consultation
As needed, the Contractor shall provide consultation services to providers in its service area
regarding TB reporting, screening, treatment,and follow-up.
6. Reports for contract monitoring
The Contractor shall provide the CDPHE with an annual report on TB activities in its service area.
A sample of the annual report is incorporated herein by this reference, made pan hereof, and
attached hereto as "Attachment B-6". Report forms are subject to revision and contractor agrees
to use most recent version or submit a similar type of report. The Contractor shall submit report
within two months after funding period ends.
7. Confidentiality
The Contractor shall maintain internal medical and administrative records in a manner which
ensures the confidentiality and security of those records in accordance with all applicable statutes
including, but not limited to, 25-1-107, C.R.S., as amended.
To be attached to CDPHE Page 5 of 5 Revised: 12/19/06
Task Order v1.0(11/05)contract template
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT
- - Colorado Department of Public Health and Environment
A. --. ,-.k1>'. Tuberculosis Program
M 4300 Cherry Creek Drive South
r
DCEED-TB-A3 ATTACHMENT B-1
+� Denver,Colorado 80246-1530
\\;:j1;vs f (303)692-2638 phone (303)691-7749 fax
DEMOGRAPHICS LOCATING INFORMATION
Last Name First Name MI Current Home Address (Number&Street Name) Apt#
/ / Gender: ❑ Male
Date of Birth ❑ Female
City State Zip Code County
Race: ❑ American Ethnicity: ❑ Not Hispanic/Latino
Indian/Alaskan ❑ Hispanic/Latino
❑ Asian
❑ Black/African Country ❑ United States Other Address (Number&Street Name) Specify Type
American of Birth: ❑ Mexico -
❑ Native ❑
Hawaiian/Other Specify other
Pacific Is. Date City State Zip Code County
ElWhite Arrived in US: / - - -
❑ Unknown Month/Year
( ) ( )
Home Phone Number Other Phone Number Specify Type
Employer
Occupation: ❑ Health care worker ❑ Unknown ( )
❑ Corrections employee ❑ Other Work Phone Number
❑ Migrant farm worker
❑ Unemployed past 24 months Specify other
CASE INFORMATION
Current No TB exposure, not infected ■ TB, clinically active
/ / / / Classification: ❑ TB exposure, no evidence of infection ❑ TB, not clinically active
Date Initiated Date Reported ❑ Latent TB infection, no disease ❑ TB suspect
Local Health Agency (LHA) PCP/Clinic Name
LHA Address (Number& Street Name) PCP/Clinic Address (Number&Street Name)
LHA City LHA State LHA Zip Code PCP City PCP State PCP Zip Code
( ) ( )
LHA Phone Number PCP Phone Number
TUBERCULIN SKIN TEST (TST)
TST Type: • Mantoux-Tubersol Reason ■ NB notification-immigrant • Source case investigation
❑ Mantoux-Aplisol For Test: ❑ NB notification-refugee ❑ Suspect case
❑ Mantoux- Unspecified ❑ NB notification-status change ❑ Symptomatic
❑ Tine ❑ Administrative ❑ Targeted testing- individual
❑ Not done ❑ Contact investigation ❑ Targeted testing-specific project
❑ Unknown ❑ Culture positive ❑ Transfer case/suspect
❑ Employment ❑ Unknown
/ / Reading mm ❑ Known active
Date Given Result ------_. ----------_.__—_ '___ --.-----
Criteria: ❑ No risk factors for TB ❑ HIV Positive
/ / TST Result: ❑ Positive ❑ Recent arrival high prevalence cntry ❑ Recent contact to TB case
Date Read ❑ Negative ❑ Injection drug user ❑ Fibrotic changes on CXR
❑ Unknown ❑ Resident/employee high risk setting consistent with old TB
❑ Mycobacteriological lab setting ❑ Immunosuppressed patients
/ / ❑ High-risk clinical conditions ❑ Other
Date last Reading mm ❑ Child exposed to adult in high-risk
negative TST category
C\TBFORMS\Original Forms\7817 Form.xls revised 11/04 -
/ /
Patient Last Name First Name MI Date of Birth
X-RAY FINDINGS
/ / CXR Results. ❑ Cavitation ❑ Non-TB abnormality ATTACHMENT B-1
Date Taken: ❑ Infiltrates ❑ Normal
❑ Pleural disease ❑ Other
MEDICAL HISTORY
Symptoms❑ None Alcohol ❑ Yes HIV ❑ Yes
& Length: Cl Cough Abuse: ❑ No Test: ❑ No Allergies:
❑ Hemoptysis ❑ Unknown ❑ Unknown
❑ Chest pain
Cl Weight loss Drug ❑ Injecting HIV ❑ Positive Medications:
❑ Night sweats Abuse: ❑ Noninjecting Result: ❑ Negative
❑ Urinary ❑ No ❑ Not done
❑ Fever ❑ Unknown ❑ Unknown Weight:
❑ Other(specify) / /
HIV Test Date
RISKS AND SPECIAL CONDITIONS
Exposure ❑ None ❑ Resident of long Medical ❑ None ❑ silicosis
Risks: ❑ Homeless term care facility Risks: ❑ Heart disease ❑ Immunosuppressive
❑ Resident of - (if Yes check one) ❑ Diabetes mellitus therapy
correctional facility ❑ Nursing home ❑ Weight loss > 10 lbs ❑ Cancer
(if Yes check one) ❑ Hospital ❑ Gastrectomy ❑ Hepatitis
❑ Federal prison ❑ Residential ❑ Jejunoileal bypass ❑ Renal failure
Cl State prison ❑ Mental health
❑ Local jail ❑ Alcohol/drug treatment Special ❑ Pregnant EDC / /
❑ Juvenile ❑ Other Conditions: ❑ Postpartum breast feeding
❑ Other ❑ Unknown Cl Other special conditions
❑ Unknown ❑ TST conversion in last 2 years
TREATMENT
❑ Current treatment / / / /
❑ Past treatment Therapy Start Date Therapy End Date
Treatment Isoniazid mg Reason Therapy ❑ Died
Plan: Rifampin mg Stopped: ❑ Lost to follow-up
Pyrazinamide mg ❑ Moved
Ethambutol mg ❑ Adverse treatment event
Other ❑ Course completed
(Specify) mg ❑ Uncooperative/refused
(Specify) mg ❑ Unknown
❑ Other
CASE COMPLETION SOURCE INFORMATION
If the person is a contact to an active case
complete information on the source case
Final Case Status: ❑ Closed
❑ Moved away
❑ Lost contact Last Name First Name
❑ Died
❑ Pending
Current Home Address (Number&Street Name)
If Moved New Address (Number& Street Name) City State Zip Code
/ / to / /
City State Zip Code Relation to Source Exposure Dates
COMMENTS
/ /
Person completing form Date
G:\TBFORMS\Orioinal Forms\TB17 Form.xls revised 11/04
f11lfbnnlLr.rRP-- 1
Patient's Name: _ REPORT OF VERIFIED CASE
uese (Firs') IM.iI
Street Address: OF TUBERCULOSIS
INember,sireei,coy.stele zip code]
CT DEPARTMENT OF HEALTH&HUMAN SERVICES
■■L`A/``I PUBLIC HEALTH SERVICES
REPORT OF VERIFIED CASE OF TUBERCULOSIS CENTERSFORDISEALTHSERROL
AND PREVENTION(CDC)
csx AND varvsxnoc05050/
ATLANTA.GEORGIA 30333
FORM APPROVED OMB NO.0920-0026 Erp.Dare lo1311O1
C SOUNDEX State Reporting 2
L Specify: State Case
Number:
Alpha State Code City/County
Case Number:
3.Date Submitted: By: 4.Address for Case Counting:
Mo Day Yr. ��
City
Within City Limits I❑ Yes 29 No
5. Month-Year Reported: 6.Month-Year Counted: • County
__Mo. Yr Mo Yr. _
__L Zip Code — I
7. Date of Birth: - 8.Sex: 9. Race:
Mo Day Yr 1
Li Male
rr 1❑ White 2L.1 Black 3❑ American Indian or Alaskan Native
1 2l_ Female
4❑ Asian or Pacific Islander:Specify(Optional) _
10. Ethnic Origin: 11.Country of Origin: 12. Month-Year Arrived in U.S.: 13.Status at Diagnosis of TB:
I{❑ Hispanic It U.S., check here U I Mo Yr.
If not U.S., enter count
I Alive
2 Not Hispanic try code (see list) DI 2I 1 Dead
14. Previous Diagnosis 15.Major Site of Disease:
of Tuberculosis: So❑ Miliary 'Ii site is-Other-,
enter anatomic
ODD Pulmonary 23[ Lymphatic:Other son Meningeal code (see Ilse
I i Yes I o❑ Pleural 291 Lymphatic.Unknown 70H Peritoneal Eri
2 L No 21[i Lymphatic.Cervical 3011 Bone and/or Joint ap❑ Other
�� 22 L�1 Lymphatic.Intrathoracic 4 0 L 1 Genitourinary ao 1 Site not Stated
II yes, list year of
19
previous diagnosis 16.Additional Site of Disease: ,--
It site is "Other-,
00 ] Pulmonary 2 3[ Lymphatic Other set I Miliary enter anatomicscede
ce hart
1 pl- I Pleural 29I Lymphatic:Unknown 60❑ Meningeal
If more than one previous _
episode,check here 211 1 Lymphatic:Cervical 30 L I Bone and/or Joint T0❑ Peritoneal
II more than one
22E I Lymphatic'. Intrathoracic 4 0 Genitourinary B.E Other additional sire, C,et
check here
17.Sputum Smear: 18.Sputum Culture: 19.Microscopic Exam of Tissue and Other Body Fluids:
i❑ Positive a H Not Done t❑ Positive 3 Li Not Done I❑ Positive 3❑ Not Done If positive, enter
anatomic code(s)
2E Negative 9❑ Unknown 2❑ Negative 9 E Unknown 2❑ Negative 9 L Unknown (see list)
20.Culture of Tissue and Other Body Fluids: 21.Chest X-Ray:
t❑ Positive a❑ Not Done If positive,enter I L. Normal 2❑ Abnormal 3❑ Not Done aj I Unknown
anatomic code(s)
2{i Negative 9❑ Unknown (see list)
IS Abnormal
22.Tuberculin(Margaux)Skin Test at Diagnosis: (check one) I❑Cavitary 2❑ Noncavitary 3❑ Noncavitary
Consistent Not Consistent
with TB with TB
,E Positive 3❑ Not Done Millimeters(mm)of
Induration M '
2❑ Negative 9E Unknown II Abnormal i❑ Stable 3❑ Improving
(check one)
II Negative,was patient anergic? I❑ Yes 2❑ No 9❑ Unknown 2
•
❑ Worsening g❑ Unknown
Pudic�t^atigDtl l this collection th Ill1 I' b tt A I tdl average 30 minutes per response,includig h rvng instructions Se pg 1gtlt ,gIn comm q gE iqe G0 y cy Oy not conduct or sponsor a d a parses' p d spend t0 a collecl0 I I in
It
d'plast
y gathering Od IdrOMegctoe/rol he esmberedSeed
PRA(0920-0026. Do rwr send Ilie completed term Io the address.c Ilecl on of nbrmalron dud ng suesesl0 s for retluc ng INs burden to CDC Pr j ct Clearance OH'ce,i6D0 Cliton Road M3 D34,Ailanla GA 30333.ATTN
orlrreleased without ICe con eei at t 1ekndvldualpin a[modaooeawith Seclen 30a(d10111ie Public HeathhService qtl(42 D.S c 242Im)e held in strict COnlitlence,will be used only for surveillance purposes,and wilt not be disclosed
CDC 72.9A REV 12/98 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page I ol 2
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
23. HIV Status: o Negative an Refused 9❑ Unknown 20. Homeless Within Past Year:
I❑ Positive an Not Offered on No
2❑ Indeterminate 5 C i Test Done,Results Unknown I[J Yes
9❑ Unknown
If Positive,Based on: II J Medical Documentation 2 L Patient History 9 r Unknown
If Positive,List: CDC AIDS Patient Number (II AIDS Reported before 1993)
Stale HIV/AIDS Patient Number III AIDS Reported 1993 or Later)
Clly/County HIV/AIDS Patient Number LL (II AIDS Reported 1993 or Later)
25. Resident of Correctional Facility at Time of Diagnosis: or I No t❑ Yes 9❑ Unknown
If Yes, ri
I I_' Federal Prison 3 Local Jail s Other Correctional Facility
2❑ State Prison 4'H'Juvenile
�'Correctional Facility 9 Li Unknown
26. Resident of Long-Term Care Facility at Time of Diagnosis: o I No t i J Yes v❑ Unknown
If Yes. I❑ Nursing Home a I Mental Health Residential Facility 6 Other Long-Term Caro Facility
2 Hospital-Based Facility sl I Alcohol or Drug Treatment Facility all Unknown
an Residential Facility
27.Initial Drug Regimen:
NO YES UNK NO YES UNK NO YES URN
Isoniazid 0LI iLI 9'., Ethionamide oL i 1 L 9LI Amlkacin of t❑ 9❑
Rilampin 0❑ II_I 9 .j Kanamycin of, IIJ 9[J Rilabutine 0❑ Ijll 9❑
Pyrazinamide 0❑ it l 9[1 Cycloserine 0❑ t❑ 9L_l Ciprollosacin or I iL l 9❑
❑ ❑ J ❑ H ❑
Ethdm bU10 0� j ti 9 Coe,6o myem 0 I 9 � Olloxacin Or I 9
Streptomycin c LI if 9Ii Para-Amino 0H 'n a❑ Other 0D I❑ aLI
Salicylic Acid
28. Date Therapy Started: 29. Injecting Drug Use Within Past Year:
Mo. Day FT
0 No I❑ Yes 9❑ Unknown
30. Non-Injecting Drug Use Within Past Year: 31. Excess Alcohol Use Within Past Year:
on No i❑ Yes 9❑ Unknown of i No t❑ Yes 9 E Unknown
32. Occupation (Check all that apply within the past 24 months):
i❑ Health Care Worker 2 H Correctional Employee a❑ Migratory Agricultural Worker 5❑ Not Employed within Past 24 Months
4 Fi Other Occupation 9❑ Unknown
..]
Comments:
CDC 72.9A REV 12/98 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2 of 2
/
Patient's Name:
--- — - -- - -- -- - --- REPORT OF VERIFIED CASE
Kest) IFisit IMSI
Street Address: OF TUBERCULOSIS(Number.Sireel.GTE.Stale) zip coact
CDC DEPARTMENT OF HEALTH R HUMAN SERVICES
PUBLIC HEALTH SERVICE
REPORT OF VERIFIED CASE OF TUBERCULOSIS CENTERS FOR E CONTROL
(COG)
AND PREVENTION(CDC)
CENTERS CONTROL ATLANTA.GEORGIA 30333
1u0 eREvervnpn FORM APPROVED OMB NO.0920-0036 Exp.['vie 12/31/01
Initial Drug Susceptibility Report (Follow Up Report — 1)
SOUNDEX i [ State Reporting:
Year
rI I I Counted: State Case
I �LJ Specify•
--._ -- - _ Number:
Alpha Slate Code City/County
Case Number: ri-
Submit this report for all culture-positive cases.
33. Initial Drug Susceptibility Results:
Was Drug Susceptibility Testing Done- 01 I No IL..; Yes sl -I Unknown
If answer is No or Unknown, do not complete rest of report.
If Yes, M0. Day vr.
Enter Date First Isolate Collected
for Which Drug Susceptibility Was Done?
34. Susceptibility Results:
Resistant Susceptible Not Done Unknown
Isoniazid 3❑ 2❑ 3❑ 9❑
Rilampin II---i 2❑ 3❑ r l
Pyrazinamide IL 2❑ 311 9❑
Ethambutol Il 2❑ 3❑ I. I
Streptomycin IL.1 2[H 3H 91
Ethionamide I 2❑ 3E1 9[
Kanamycln I 2LI 3❑ 9
Cycloserine t❑ 2❑ 3 9❑
Capreomycin I❑ 2 3 r 9❑
Para-Amino
Salicylic Acid 1L.. 2`_ 3[ sl
Amikacin I❑ 2❑ 3❑ 9❑
Rifabutine 1❑ 2❑ 3❑ 9❑
Ciprotloxacin 1❑ 2❑ s❑ e❑
Ofloxacin 1❑ 2[.. j all 9❑
Other I❑ 2❑ all e❑
Comments:
[ - - - -
comic rep ti g b tl hits Ik r l i t 1 ( d l average 30 m nutes penespense includ g tM1 Y b g" t dons s M1 g 'ti g tl 1 g Iber ng tl -Ia dng the dory needed and
mleting ntl e g uM1 II 1 1"1 1 q y Oy not conduct or sponsor d a person- g tl 1 p d 1 Ileclio 1 1 r '1 di pI y , tty lE OMB control number. tend
y tl grh E d t yo1M1 P tth' Ileclon etinformation,including suggest ns for reducing this burden to CDC,Pr Iecl Clearance Officer,ieee Dillon Ro tl MS D-24,Atlanta.GA 30333 ATTN
iniormabon PRA(0920 00261 Oo not send the rompleleo form Io IM1 s address.
ained on thls form ch would or released without the consent of the y individual n accordance with Sectilron of on 3001d0aol las been the Public Hlected with a eallh Service Act 142 U.S C 242m)arantee that it will s held in sieict confidence.will be used only to,surveillance purposes,and will not be disclosed
CDC 72.9B REV 12/98 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-1
Patient's Name: REPORT OF VERIFIED CASE
_. -Rasp - iFirstl -_.IM 1
Street Address: OF TUBERCULOSIS
_ _-
'Number Str Coy.Stale) 2.p Code)
Cry /� DEPARTMENT OF HEALTH&HUMAN SERVICES
■L��\/`/ PUBLIC HEALTH SERVICE
REPORT OF VERIFIED CASE OF TUBERCULOSIS EN ens FOR DISEASE CONTROL
AND PREVENTION(CDC)
ENTER,.nn ntvcrvuom ro ATLANTA,GEORGIA 30333
FORM APPROVED OMB NO.0920-0026 Eep.Dale 13I31IOt
Case Completion Report (Follow Up Report - 2)
[ iiii
SOUNDER State Reporting:
Year
Counted: Stale Case
l Specify Number:
Alpha Slate Code CityCounty
Case Number:
35. Sputum Culture If Yes, Dale Specimen Collected If Yes, Dale Specimen Collected on
Conversion Documen led: on Initial Positive Sputum Culture. First Consistently Negative Culture
•
Mo. pay_ Yr._ Mo. _ Day Yr
or l No 1 F I Yes 9 I Unknown 1I I l r
36. Date Therapy Stopped: 37. Reason Therapy Stopped:
Mo Day yr.-
L_ J 1L iCompleted Therapy a; i Lost s i Not TB ?❑ Other
2 i__ j Moved 4 Uncooperative or Refused e[ -I Died 9❑ Unknown
38. Type of Health Care Provider: 39. Directly Observed Therapy: It Yes, Give Site(s)of Directly Observed Therapy:
. Health Department o` No,Totally Sell-Administered 1 i I In Clinic or Other Facility
2( .1 Private/Other I l )i Yes,Totally Directly Observed 2I I In the Field
3 i '
Both Health Department I Yes, Both Directly Observed
and Private/Other
p3r_I Both in Facility and in the Field
and Self-Administered
9[ Unknown weeks
9 Unknown o
Number of Weeks of Directly Observed Therapy'
40. Final Drug Susceptibility Results: fI Yes, Enter Date Final Isolate
Was Follow-up Drug Susceptibility Testing Done? aLi No t C I Yes 9❑ Unk. Collected for Which Drug Mo Day Yr.
Susceptibility Was Done.
If answer is No or Unknown, do not complete rest of report.
41. Final Susceptibility Pesispanl Susceptible Not Dyne UilknOvail Hesistznl 5 u_c_cYJILLe Del Deng Unknown
Results:
Isonlazid II 1. 2j 1 3I I 9,- ] Capreomycin is I 2 L 3[] I 9:
Rilampin It. I 2] i a❑ 9r� Para-Amino ❑ 2[ J a❑ 9❑
Salicylic Acid 1
Pyrazinamide i1- I 21 I 3l-j 9[_ i Amikacin I❑ 2] l a❑ 9L
Ethambutoi t❑ 21 3❑ 9❑ Ritabutine I❑ 2❑ a❑ 9❑
Streptomycin ri ] 2 L 3I__I 9❑ Ciproftoxacin I❑ 2 11 3r 9❑
Ethionamide 1❑ 2❑ of 9❑ Ofloxacin r❑ s ] 3❑ 9❑
Kanamycin 1❑ 2i 1 3 9❑ Other I❑ 2 L 3 9❑
Cycloserine t❑ 2❑ a❑ 9❑
Comments:
c".„,`",°„127,
om leublic epor g burden of Ibis collection of information is estimated to average 30 minutes per esp n e.ncluding the time for reviewing instructions,searching existing data sources,gathering ale maintaining the data needed and
p ri gand gg yVhe collect oe 01 etsteatenee Ana a cry seas not Conduct or a pars 1 0 -red t0 respond 10 a Collect I' 1 alien Ie55 t displays IIV I'd OMB control number. Send
O nDs not send he completed Forme this admesss c Iledon al nlorm tlTg sang t l tludng lis burtlen t0 CDC.P j t CI ranee O�rcer 600 Cllton Roed MS D 20.A lame.GA JOJ]].ATTN
PRA 10920 0 26
tomanon Contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence,will be used only Mr surveillance purposes,and will not be disclosed
ore leased we bout the consent of lye individual in accordance with Section 300(d)of ihe Public Health Service Act(42 U.6.C.242m).
CDC 72.9C REV 12/90 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-2
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ATTACHMENT B-4
aorta(o.Lonp,Name,Address,Phone): NOTICE OF ARRIVAL OF ALIEN WITH TUBERCULOSIS
STATE HEALTH OFFICER:
Please Forward the Evaluation Copy and Accompanying Report
of Medical Examination Performed Abroad(OF-157),to the
Appropriate Local Health Department,
Upon arrival in the United States this alien was requested to repon
SEX: f ) DATE OF BIRTH(Mo., Day, Yr.) to the Local Health Department at his/her destination. X-ray taken aba
showed findings consistent with tuberculosis. The person may not have
received antituberculosis chemotherapy or chemoprophylaxis:therefore
the Health Department may wish to initiate preventive treatment
The Local Health Department is requested to submit a repon of initial
( I CLASS A erculosis,clinically active.not infectious evaluation by through you to:
I ) CLASS B-2-Tuberculosis,aaan�oott clinically active.not infectious Division of Quarantine,Data Mgr(E031
M Centers for Disease Control and Prevention(CDC)
Atlanta,Georgia 30333
•Military Mll rend 2ren,a the Craven Jm Dirrrve Car"'...?Yr[.rv,m
Tlbs space is provided for you to record we Local Health Depantnent's report,if desired.
P
CDC 75.1'](Rev 12/94) CI S B STATE HEALTH DEPARTMENT COPY
Altos(Aliens. Name. Address. Phone). REPORT ON ALIEN WITH TUBERCULOSIS
I
LOCAL HEALTH OFFICER:
This person recently entered the United States and is referred to you becnue
the X-ray shows findings consistent with tuberculosis.as indicated in the
accompanying repon of medical examination performed abroad. This person
may not have received chemotherapy or chemoprophylaxis and is referred In
you because you may wish to initiate preventative treatment. Your milial
SEX-1 IMI I F DATE OF BIRTH(Mu.. Day. Yr.) evaluation would app timed. Please check the appropriate boxes below
and return this f a to the State Health Officer.•
I 1 CLASS D-I 'Tuberculosis. clinically anlvc, not infectious If the alien does not report by please check here I j and
forward this form to the State th Officer.' Retain for you records
( 1 CLASS B-2-Tuberculosis.not clinically active.not infectious the accompanying re on of s r'on perfocant., id abroad(OF-I571
'MiliuryMll seta done:.elrrC [ue Lonrr.Arve!Nerv.rrrnr
Your Initial Evaluation: E.Has Patient Received Chemotherapy/Prophylaxis eh the past?
A.Direct Smear(in U.S.) C.X-ray (abroad) D.Presumptive Diagnosis
1 I PositiveNormalI I e Yes 1 7 No ) I Unknown
1 1 Negative 1 3 Abnormal I Pulmonary TB Active F.Are youI prescribing Che
1 I Not DoneI Pulmonary TB-Not Active ( 3 Yes I No v/Prvphate of
1 1 Not Done I PulExtr onaryplum na -Activity Undetermined Signature of Physician
D.X-ray(w U.S.) I I Unavailable I Non'p B Abnormality
g Date of Evaluation
I I Normal I Non-TB Abnormality
t AbnormalI No Abnormality Name of Health Deportment
I I Not Done
This lam)is not intended so substitute for normal NOTE TO STATE HEALTH OFFICER:Upon receiving Division of Quarantine.Da gr(E03)
procedures for reporting tuberculosis to the state this completed copy from the Local Health Officer, Centers for Disease Contr Health Department please forward to: d Prevention(CDC
T Atlanta,Georgia 30333
CDC 75.17(Rev. I2/P4) CLASS B LOCAL HEALTH DEPARTMENT COPY
ATTACHMENT B-5
Burmese* Tuberculosis Follow-up Worksheet
A. Demographic
Al Name(Last, First,Middle): A2. Alien#: A3. Visa Type: A4. Initial U.S. Entry Date
A5. Age A6 Gender Al. DOB: A8. TB Class: A9. Class Condition:
A10 Country of Examination All. Country of Birth:
Al2. Port of Arrival: A13 Port Contact Name: A14. Port Contact Phone:
Al5a. Sponsor Name: Al6a. Sponsor Agency Name.
Al5b. Sponsor Phone Al6b. Sponsor Agency Phone:
A15c. Sponsor Address. Al6c. Sponsor Agency Address:
B. Jurisdictional
B1. Destination State: B2. Jurisdiction: B3. Jurisdiction Phone#:
C. U.S.Evaluation
Cl. Date of Initial U.S Medical Evaluation!
C2a. TST Placed: [Yes ❑No ['Unknown
C2b. TST Placement Date:
C2c TST mm:
C2d. TST Interpretation ❑Positive ['Negative ['Unknown
C2e History of Previous Positive TST: ❑
C3a. Quantiferon(QFT)Test: ['Yes ❑No ❑Unknown
C3b. QFT Collection Date:
^C3c OFT Result: ['Positive Negative ❑Intermediate ❑Unknown
_ U.S. Review of Overseas CXR Domestic CXR Comparison
C4 Overseas CXR Available'? C7. U.S. CXR Done?
❑Yes ❑No C11 U.S. CXR
['Yes ❑No ['Not Verifiable C8. Date of U.S. CXR: Comparison to
C5 Interpretation of Overseas CXR: CO. Interpretation of U.S. CXR: Overseas CXR:
❑Normal ['Abnormal ['Poor Quality ❑Unknown [Normal ['Abnormal ['Unknown ['Stable
C6 Overseas CXR Abnormal Findings: C10. U.S. CXR Abnormal Findings: ['Worsening
['Abnormal, not TB ['Cavity El Fibrosis ['Abnormal, not TB ❑Cavity ['Fibrosis ['Improving
❑Infiltrate ❑Granuloma(ta) ❑Adeno ath
p y ❑Infiltrate ❑Granuloma(ta) ❑Adenopathy ['Unknown
['Other(Specify) ['Other(Specify)
C12. U.S. Microscopy/Bacteriology ❑Sputa in U.S. Not Collected
Spec Specimen Date AFB Smear Result Culture Result Drug Resistance
# Source
['Not Done ❑Positive ['Not Done ❑NTM ONODone ❑Mono-RIF
1 ❑Negative ❑Contaminated ['Not DR ❑MDR-TB
[Negative ❑Unknown
❑MTB Complex ['Unknown ❑Mono-INH ❑Other DR
['Not Done ❑NTM ['Not Done ❑Mono-RIF
['Not Done ❑Positive
2 ['Negative ❑Contaminated ❑Not DR ❑MDR-TB '
❑Negative ❑Unknown
❑MTB Complex ❑Unknown ❑Mono-INH ❑Other DR
i
1
Not Done DNTM ❑Not Done ❑Mono-RIF
❑Not Done ❑Positive
3 ['Negative ❑Contaminated ❑Not DR ❑MDR-TB
['Negative ['Unknown
❑MTB Complex ❑Unknown ❑Mono-INH ❑Other DR
Burmese Tuberculosis Follow-up Worksheet (continued) ATTACHMENT B-5
U.S. Review of Overseas Treatment
C13. Overseas Treatment C14. Overseas Treatment Initiated: C15. On Treatment on C16. Completed '
Recommended by Panel Physician. Lives ❑No Unknown Arrival. Treatment Overseas:
rives If Yes: Lives Dyes
['No
❑Patient-Reported ❑N° ❑No
['Unknown DUnknown ['Unknown
['Panel Physician-Documented
❑Both
C17. Overseas Treatment Concerns. Eves ❑No
D. Disposition
D1 Disposition Date:
D2 Evaluation Disposition
Completed Evaluation ❑Initiated Evaluation/Not Completed ❑Did Not Initiate Evaluation •
`—Treatment Recommended [Moved within U.S. ['Not Located
JNo Treatment Recommended ❑Lost To Follow-up ❑Moved within U.S.
['Returned to Country of Origin ['Lost To Follow-up
['Refused Evaluation ❑Returned to Country of Origin
Died ['Refused Evaluation
❑Unknown ❑Died
❑Other, specify. Unknown
❑Other, specify:
D3 Diagnosis.
Class 0- No TB Exposure, Not Infected ❑Class 2 -TB Infection, No Disease ❑Class 4-TB, Inactive Disease
❑Class 1 -TB Exposure, No Evidence of Infection ['Class 3-TB,Active Disease
D4 RVCT Reported D5 RVCT#
E. U.S.Treatment
El U.S. Treatment Initiated. E2 U.S Treatment Start Date: E3. U.S. Treatment Completed: E4. U.S. Treatment End Date.
No Treatment Eves
(Active Disease DNo
HLTBI ❑Unknown
['Unknown
F. Comments
'Only for Burmese refugees arriving from Thailand
Last modified 12/20/2006
ATTACHMENT B-6
Tuberculosis
Semi-Annual Progress Report
Agency/Person
Date Submitted
Reporting Time Period _ July 1 - December 31 _ January 1 - June 30
Briefly describe TB activities and accomplishments during reporting period.
Describe any challenges/obstacles to providing TB services as specified in the
CDPHE TB contract during reporting time period.
EXHIBIT C
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
(ADD PROGRAM NAME HERE)
DEPARTMENT OR AGENCY NUMBER
***
CONTRACT ROUTING NUMBER
LIMITED AMENDMENT#*
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 contract dated******** ** ****,with contract encumbrance number PO ***
**********,and contract routing number** *** *****,whereby the Contractor was to provide to the State the
following:
briefly describe what the Contractor was to do under the original contract—indent this paragraphs
I Please choose one of the following four options and then delete this heading and the other three options not
selected:I
The State promises to (choose one and delete the otherlincrease/decrease the amount of funds to be paid to the
Contractor by ********** Dollars,($*.**)during the current term of the Original Contract in exchange for the
promise of the Contractor to perform the[choose one and delete the otherlincreased/decreased work under the
Original Contract.
The State promises to pay the Contractor the sum of********** Dollars,($*.**) in exchange for the promise of
the Contractor to continue to perform the work identified in the Original Contract for the renewal term of****
years/months,ending on******** ** ****
,
The State promises to (choose one and delete the otherlincrease/decrease the amount of funds to be paid to the
Contractor by********** Dollars,($*.**)for the renewal term of**** (choose one and delete the
otherlyears/months,ending on******** **,****, in exchange for the promise of the Contractor to perform the
(choose one and delete the otherlincreased/decreased specifications to the Scope of Work described herein.
The State hereby exercises a"no cost"change to the 'insert those that apply and delete those that don'tIbudget,
specifications within the Scope 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 Contract or renewal term of the Original 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 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
Page 1 of 4
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
here if previous amendment(s),change order(s), renewal(s) have been processed(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 Contract is and shall be modified, altered, and
changed in the following respects only:
A. l Use this paragraph when changes to the funding level of the Original Contract occur
during the current term of the Original Contract(This Limited Amendment is issued pursuant
to paragraph_*. of the Original Contract identified by contract routing number** *** *****
This Limited Amendment is for the current term of********* ** ****,through and including
********* ** **** The maximum amount payable by the State for the work to be performed by
the Contractor during this current term is choose one and delete the
otherlincreased/decreased by ********** Dollars,($*.**)for an amended total financial
obligation of the State of********** DOLLARS, ($*.**). 'delete any portion of this sentence
that is not applicableiThe revised specifications to the original Scope of Work and the revised
Budget, if any, are incorporated herein by this reference and identified as"Attachment *"and
"Attachment*". The first sentence in paragraph *_*. of the Original Contract is modified
accordingly. All other terms and conditions of the Original Contract are reaffirmed.
A. (Use this paragraph when the Original Contract will he renewed for another term(This
Limited Amendment is issued pursuant to paragraph *_**. of the Original 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, ($*.**)for an amended total financial obligation of the State of**********
DOLLARS,($*.**). This is an choose one and delete the otherlincrease/decrease of
********** Dollars,($*.**)of the amount payable from the previous term. 'delete any portion
of this sentence that is not applicableiThe revised specifications to the original Scope of Work
and revised Budget, if any, for this renewal term are incorporated herein by this reference and
identified as"Attachment *"and"Attachment *". The first sentence in paragraph_*.of the
Original Contract is modified accordingly. All other terms and conditions of the Original Contract
are reaffirmed.
A. 'Use this paragraph when there are"no cost changes" to the Budget,the specifications
within the original Scope of Work,allowable contract provisions as noted, or performance
period.IThis Limited Amendment is issued pursuant to paragraph *_*. of the Original Contract
identified by contract routing number** *** *****. This Limited Amendment (choose those
that apply and delete those that don't(modiftes the Budget in I identify location in contract(,
modifies the specifications to the Scope 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 contracts of the Original Contract. The revised
(choose those that apply and delete those that don'tiBudget,specifications to the original
Scope of Work,project management/manager identification, notice address or notification
personnel,or period of performance is incorporated herein by this reference and identified as
"Attachment *". All other terms and conditions of the Original Contract are reaffirmed.
4. The effective date of this Amendment is date, or upon approval of the State Controller, or an authorized
delegate thereof,whichever is later.
5. Except for the General Provisions and Special Provisions of the Original Contract, in the event of any
Page 2 of 4
EXHIBIT C
conflict, inconsistency,variance,or contradiction between the terms and provisions of this Amendment and
any of the terms and provisions of the Original Contract,the terms and provisions of this Amendment shall
in all respects supersede,govern,and control. The Special Provisions shall always control over other
provisions of the Original Contract or any subsequent amendments thereto. The representations in the
• Special Provisions to the Original Contract concerning the absence of personal interest of state of Colorado
employees is presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR
ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED,
AND OTHERWISE MADE AVAILABLE.
Page 3 of 4
IN WITNESS WHEREOF,the parties hereto have executed this Form Amendment on the day first above written.
CONTRACTOR: STATE:
• [LEGAL NAME OF CONTRACTOR[ STATE OF COLORADO
(legal type of entity) Bill Ritter,Jr. Governor
By: By:
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
ATTEST: PROGRAM APPROVAL:
If the Contractor is a corporation
or governmental entity,then an attestation By:
is required.
(Seal,if available.)
By:
City,City and County,County,
Special District,or Town Clerk or Equivalent
Corporate Secretary or Equivalent
IDelete 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:
Form: LAT 7-I-04ON
Page 4 of 4
STATE OF COLORADO
Bill Owens,Governor
Douglas H.Benevento,Executive Director ��of c .tp%
Dedicated to protecting and improving the health and environment of the people of Colorado he �c 4300 Cherry Creek Dr.S. Laboratory Services Divisionw*o
Denver,Colorado 80246-1530 8100 Lowry Blvd. y tan
Phone(303)692-2000 Denver,Colorado 80230-6928
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
http://www.cdphe.state.co.us and Environment
July 20, 2007 ') C
Dear Contractor,
Enclosed please find your fully approved contractual document with the Colorado Department of Public
Health and Environment, Disease Control and Environmental Epidemiology Division. Please keep
these original documents for your records.
If you have any questions or require further information, please feel free to contact me.
Sincerely,
CI)
t
Pam Pergande
Accounts Payable Coordinator
Disease Control and Environmental Epidemiology
Phone: (303) 692-2774
Fax: (303) 782-0904
E-mail : pam.pergandegstate.co.us
Hello