HomeMy WebLinkAbout20071399.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR THE FAMILY PLANNING SERVICES
PROGRAM AND AUTHORIZE CHAIR TO SIGN
WHEREAS,the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with a Task Order Contract for the Family
Planning Services 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 Family Planning Services 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 16th day of May, A.D., 2007.
1 BOARD OF COUNTY COMMISSIONERS
`/ 1( - �� 1) 1 . / /t` EL OUNTY, COLORADO
ATTEST: A��► f I L'li `' ;pv, �, O-A (AYE)
11t61 I( i — id E. Long, Chair
Weld County Clerk to the B.1 . ';s _ /
`:�a ' '- (AYE)
/ e/C ° illiam Je Tem
De� ty Cleiy'to the Board ,1V-' (NAY)
Wi am F. Garcia
APPROV�0 AS : (AYE)
Robert D. Masden
u Attorney .1>••,•.- d�, ,,1,.nr� (AYE)
JI - /D Do�glaa Rademach
of signature: 7
2007-1399
HL0034
g ." //t-6 6 C)6 -iY-0 7
Memorandum
TO: David E. Long, Chair
Board of County Commissioners
IFROM: Mark E. Wallace, MD, MPH, Director
o Department of Public Health and ��, ��
Environment "Imo.AX k a�_" t "s
COLORADO DATE: May 14, 2007 l �
SUBJECT: Task Order Contract for the Family
Planning Program
Enclosed for Board review and approval is a task order contract between the Colorado
Department of Public Health and Environment (CDPHE) and Weld County for continuation of a
comprehensive family planning program.
Under the provisions of this contract, Weld County Department of Public Health and
Environment will provide contraceptive services to both men and women in their reproductive
years. These services will include comprehensive health and social histories, physical
examinations, contraceptive information, and supplies. Education and counseling regarding
family planning, infertility, sterilization, nutrition, sexually transmitted diseases, and follow-up
and/or referral services will also be provided.
For the above services, Weld County will be reimbursed an amount not to exceed $187,537 for
the time period July 1, 2007 through June 30, 2008. Of this amount, $124,627 are federal pass
through funds and $62,910 are from the State of Colorado.
I recommend your approval of this task order.
Enclosure
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2007-1399
DEPARTMENT OP PUBLIC HEALTH AND ENVIRONMENT
ROUTING NO.08 FLA 00081
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
State of Colorado for the use&benefit of the BOARD OF COUNTY COMMISSIONERS OF
Department of Public Health and WELD COUNTY(a political subdivision of the
Environment state of Colorado)
Prevention Services Division 915— 10th Street,3rd Floor
Family Planning Greeley,Colorado 80631
4300 Cherry Creek Drive South for the use and benefit of Weld County Department
Denver,Colorado 80246-1530 of Public Health and Environment
1555 North 17th Avenue
Greeley,Colorado 80631
TASK ORDER MADE DATE CONTRACTOR EN1TTY TYPE:
04/20/2007 Colorado Political Subdivision
PO/SC ENCUMBRANCE NUMBER: CONTRACTOR FEIN OR SOCIAL SECURITY NUMBER:
PO FLA FHS0800081 84-6000813 B
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 06/30/2008. Title X,42 C.F.R,
CFDA #93.217 FP Services
PRICE S IRUCT URE: CONTRACT PRICE NOT TO EXCEED:
Fixed Price $187,537.00
PROCUREMENT METHOD: FEDERAL FINDING DOLLARS: $124,627.00
Exempt STATI'.FUNDING DOLLARS: $62,910.00
BID/APP/LIST PRICE AGREEMENT NUMBER MAXIMUM AMOUNT AVAIL ABLE PER FISCAL YEAR:
Not Applicable FY 08: $187,537.00
LAW SPECIFIED VENDOR STATUTE:
Not Applicable
STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE:
Candace Grosz Judy Nero
Department of Public Health and Environment BOARD OF COUNTY COMMISSIONERS OF
Prevention Services Division WELD COUNTY (a political subdivision of the
Family Planning state of Colorado)
4300 Cherry Creek Drive South 915—10th Street,3rd Floor,Greeley,Colorado 80631
Denver,CO 80246-1530 for the use and benefit of Weld County Department of
Public Health and Environment
1555 North 17th Avenue,Greeley,Colorado 80631
SCOPE OF WORK:
Shall conduct a comprehensive family planning program in accordance with Exhibit B.
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- Contract Automatic Reimbursement Statement
Exhibit E- Expenditure/Revenue Report
Exhibit F- Secure External User ID Form
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses,the more specific provision shall control.
This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including,but not limited to,Exhibit One thereto. The total term of this Task Order Contract,including
any renewals or extensions,may not exceed five(5)years. The parties intend and agree that all work shall
be performed according to the standards,terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(1),C.R.S.,as amended,this Task Order Contract is not valid until it
has been approved by the State Controller,or an authorized delegee thereof. The Contractor is not
authorized to,and shall not;commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegee. The State shall have no 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 @ncluding its exhibits
and/or attachments),or between this Task Order Contract and its exhibits and/or attachments,such conflicts or
Page 2 of 4
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
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 BILL RITTER,JR. VERNOR
WELD COUNTY(a political subdivision of the
state of Colorado) -
Legal Name of Contracting Entity
By JAY-0-1
For Executive Director
84-6000813B Department of Public Health and Environment
Soc. Number or FEIN
c't
c �� Department Program Approval.
Signature of Authorized Officer AY 1 6 2007
David E. Long, Chair By StAtr—
Print Name&Title of Authorized Officer
GOVERNMENTAL ENTITIES: EL pX
(An attestad and a ar r i ed) ,, '4/J`
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•
' 1161 (' S- '
Attest(Seal)B �� 11 ,o
(Town/City/Coup Jerk o quivalent) VD: _may, ;. here)
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 irk
WEELD��C�O�U�N�T�Y DEPARTMENT OF
Ptetigi
BY:
Page 4 of 4 Mark E. Wallace, MD, MPH-Director
am 7--/S99
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 04/20/2007 - Contract Routing Number 08 FLA 00081
These provisions are to be read and interpreted in conjunction with the provisions of the
Task Order Contract specified above.
1. Health Insurance Portability and Accountability Act(HIPAA)Business Associate Determination.
The State has determined that this contract does not constitute a Business Associate relationship under
HIPAA.
2. This Task Order Contract contains federal funds(see Catalog of Federal Domestic Assistance(CFDA)
number 93.217)
3. The United State Department of Health and Human Services("US DHHS"),through the Colorado General
Assembly has awarded federal funds,hereinafter"Award",to perform—a comprehensive family planning
program. 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 comprehensive family planning services to the citizens of the state of
Colorado on behalf of the State.
If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as
of the effective date of that Award,then the State shall reimburse the Contractor for any allowable and
allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective
date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable
and allocable expenses of a contractor as of the effective date of that Award,then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by
the Contractor on or after the effective date of this Task Order Contract,with such effective date being the
later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the
State Controller or delegee.
4. Reimbursement under this Task Order,and any renewal or extension hereof,shall be made to the
Contractor by the State on a monthly basis through automatic payment invoices prepared by the State.The
sample invoice,attached hereto as"Attachment D",is incorporated here by reference,made a part hereof,
and attached hereto,for the contract term.Accordingly,the Contractor shall be paid one twelfth(1/12)of
the State's financial obligation under this Task Order each month.
Upon affirmation by the State that the Contractor has satisfactorily and timely provided the services
described in this contract,the State shall pay the Contractor 1/6th of the total amount of federal funding
of$124,627.00 or$20,771.17 a month for the months of July through December,and 1/6's of the total
amount of state funding of$62,910.00 or$10,485.00 a month for the months of January through
June,inclusive.
5. The Contractor shall comply with section 1001 of the federal Act and all applicable federal regulations,as
amended,contained in Title X,42 C.F.R.,Subpart A,Part 59,as well as all applicable state regulations.
To be attached to CDPHE Page 1 of 1 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT B
STATEMENT OF WORK
To Task Order Contract Dated 04/20/2007-Contract Routing Number 08 FLA 00081
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above.
I. The Contractor shall conduct a comprehensive family planning program ("the program") in Weld County.
This program shall comply with section 1001 of the federal Act and all applicable federal regulations, as
amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all applicable state regulations.
(Federal funding from HHS, CFDA #93.217 FP Services). The funding for this program will be spent in
accordance with Exhibit B-1 attached hereto.
2. The Contractor shall make its program available to men and women in their reproductive years and shall offer
the following services,as appropriate:
A. Outreach services and/or other program efforts designed to improve client recruitment;
B. Nursing and medical services, which shall include a comprehensive health and social history and
physical examination administered in accordance with all applicable Title X regulations and, all
applicable nursing-medical policies or procedures which have been, or may be, established by the
State's Women's Health Unit("WH");
C. Contraceptive information,education,and supplies regarding all family planning methods;
D. Education and counseling services regarding family planning,family planning methods, child spacing,
infertility, sterilization, nutrition, sexually transmitted diseases,HIV/AIDS, adolescent counseling and
other related health issues,as outlined in the Nursing and Administrative Manual;
E. Follow-up and/or referral services,as appropriate.
3. The services provided by the Contractor must be deemed acceptable, in good faith,by WH. For a service to
be "acceptable" it must comply with all applicable: Title X regulations, WH nursing-medical policies and
procedures, and any applicable fiscal and administrative policies and procedures of the State and Federal
government. All applicable Title X regulations, WH nursing-medical policies and procedures, and all
applicable fiscal or administrative policies of the State have been provided to the Contractor by the State as of
the effective date of this Contract.
4. The Contractor shall provide the State's family planning program consultants and administrators with
reasonable access to its operations to perform: periodic site reviews, data reviews, fiscal reviews or other
evaluations of the Contractor's family planning program. Evaluations of the Contractor's program shall be
based on established standards and policies of the State or the Federal government. The Contractor shall
cooperate during all periodic site visits, data reviews, fiscal reviews or other evaluations conducted by the
State.
5. If necessary, the Contractor shall comply with all recommendations made by the State's family planning
program consultants and/or administrators after a periodic site visit, data review, fiscal review or other
evaluations that are necessary to bring its program into compliance with all applicable federal and state laws,
policies and regulations. The Contractor shall be in full compliance with a recommendation, if any, within
three (3) months of the date a recommendation is made by the State. If the Contractor cannot obtain full
compliance within this three (3) month period, then on or before the expiration date of that three (3) month
period the Contractor shall present sufficient written evidence to the State:to show that continuing progress is
being made towards full compliance; and, the date when full compliance shall occur. In no event,however,
To be attached to CDPHE Page 1 of 2 Revised: 12/19/06
Task Order v1.0(11/05)contract template
EXHIBIT B
shall full compliance with a recommendation occur any later than six (6) months after the date that a
recommendation was initially made by the State.
6. On a monthly basis,the Contractor shall collect and provide to the State,by the fifteenth calendar day of the
following month,all pertinent data regarding all services offered,and all family planning clients served,by its
program during the preceding month, submitted through the IRIS data system. This data shall be verified on
a quarterly basis to help assure accuracy. The Contractor must adhere to the Data Security, Use and
Confidentiality Agreement attached hereto in a form substantially equivalent to Exhibit F.
7. Within thirty (30) calendar days of receipt of a written request from the State, the Contractor shall submit
nursing-medical chart audits to the State.
8. The Contractor shall only use program income generated from client fee collections and donations for family
planning purposes that further the objectives of the legislation under which this Contract is entered into. In
accordance with Title X guidelines,the Contractor shall not charge for any Title X required services provided
to clients who are at or below 100%of the official poverty line as defined by the Office of Management and
Budget(OMB). A copy of this guideline has been provided to the Contractor by the State as of the effective
date of this Contract. If the State receives new poverty guidelines from the OMB during the term of this
Contract, then the State shall immediately forward those new poverty guidelines to the Contractor. The
Contractor shall use these new poverty guidelines,if any,upon receipt thereof from the State.
9. The Contractor's charges for services to clients who are above 100% of poverty level shall be based on a
sliding fee scale that takes into account a client's family size and/or individual income. These charges and the
sliding fee scale shall be made available to all clients of the Contractor, the general public, and the State.
This most current version of this document is available on the Family Planning website
(http://www.cdphe.state.co.us/pp/womens/FederalPovertvGuidelines.htm). Charges shall be based upon the
Contractor's actual costs to provide these services as determined by a cost analysis. The Contractor and the
State shall review these costs annually. The Contractor shall insure that all clients understand that they will
not be denied services because of an inability to pay any of the Contractor's sliding fee charges.
10. All money received by the Contractor from the State under this Contract shall be used by the Contractor to
provide contraceptive services to approximately 2,046 target family planning clients (fertile clients
receiving contraceptive services).
11. The Contractor shall either use a cytology laboratory chosen by the State or, a laboratory proposed by the
Contractor and approved by the State.
12. During the term of this Contract, the Contractor agrees to provide the State with the semi-annual Family
Planning Expenditure/Revenue Reports. The required report is incorporated herein by this reference, made
part hereof, and attached hereto in a form substantially equivalent to Exhibit E. The first report is for the
months of July through December will be due no later than February 7; the second report is for the months
of January through June and will be due no later than August 7.
13. The Contractor shall protect the confidentiality of all client records and other materials that are obtained,
created, or maintained by the Contractor under this contract. Except for purposes directly related to the
administration of this contract, no information about, or obtained from, any client shall be disclosed by the
Contractor in any form that would identify that client without the prior written consent of that client. As of
the acceptance date of this contract by the Contractor,the Contractor shall have written policies governing the
access to and, the duplication and dissemination of, all such information. The Contractor shall advise its
directors, officers, employees, agents, servants, and subcontractors, if any, that they are subject to these
confidentiality requirements.
To be attached to CDPHE Page 2 of 2 Revised: 12/19/06
Task Order v1.0(11/05)contract template
Exhibit B-1
Weld
Title X federal funding from the United States government(HHS CFDA#93.217 FP Services)provides:
$ 114,827.00 for ROUTINE FAMILY PLANNING services
$ - for STERILIZATION services
$ 9,800.00 for CHLAMYDIA TESTING services
$ 124,627.00 Total Title X Funding
All federal funds must be fully expended by December 31,2007.
State of Colorado funding provides:
$ 62,910.00 for ROUTINE FAMILY PLANNING services
$ - for STERILIZATION services
$ 62,910.00 Total State of Colorado Funding
p„ All State funds must be fully expended by June 30,2008.
$ 187,537.00 Total Current Award
Family planning services target clients: 2,046
Exhibit B-1 Page 1 of 1
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), renewals) have been processed: as amended by] [include all previous
amendment(#),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, (5*.**) 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, (S*.**) 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 precious amendment(s),change order(s), renewals) have
been processed] as amended by [include all previous amendment(s),change
order(s),renewal(s) and their routing numbers], [insert the following Nsord 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,(5*.**). [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)
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
By:
City, City and County,County, BY:
Special District, or Town Clerk or Equivalent Mark E. Wallace, MD, MPH-Director
[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
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COLORADO DEPARTMENT of PUBLIC HEALTH and ENVIRONMENT
FAMILY PLANNING EXPENDITURE/REVENUE REPORT
I Exhibit E
AGENCY NAME:
PERIOD:
COMPLETED BY:
DATE:
:.ti.r
Column(A) Column(B) I Column (C)
Family Planning
CDPHE-WHS Program-(Non-
Funding CDPHE funding) Combined Total
Personal Services
-- --
Salary $ - I $ $
Fringe @% I #DIV/0l - I - -
Subtotal Personal Services 5 .:;4:'1. i.- $ S:
Contractual Services
Clinician ' $ - $ - $ -
Lab&X-ray -, - -
Other - - -
x •.i:�y:s;c: rs:
Subtotal Contractual Services •s.r<<t}lt::i:� st,:ig:=�E:`'.....-.,r••-:. •t...,,,='s, -fin . $ i'.... -
Operating Expenses
Supplies $ - $ - $ -
Training - - -
_
Other - - i -
Travel - - -
Equipment - i - -
Subtotal Operating Expenses $ - $ - $ '.. !':.! !'l -
.;1::.„.,LH1.ri;,.ir':,,i•!�.l�CI}.S{tC ;: f , 1
Total Direct Costs r.$.::;:.,.,:, - $ !;i6;r?�°is":>i,='�:,:r•i;���. $ .. � -
Indirect Costs @% $ - rs - s -
TOTAL EXPENDITURES ;'$ .,,Fars 6'; - S :............a.€ 'i<$:=: ... ..,,.... ... ': -
Inkind $ - I $ - I $
TOTAL COSTS i$ s °r'lilitIkv ''ii; $at:;a s, . ,a?: _ g -
r.E:'.° r^ii i ktrc„�.IEi t;. .r'il:ii,g-1.fied'' �'' +t s
: A- REVENUES' ,l' :.v ,
Family Planning
CDPHE-WHS Program-(Non-
Funding CDPHE funding) Combined Total
CDPHE-Women's Health family planning contracts $ - $ - $ -
Patient Fees - - -
Patient Donations - -
Medicaid - ( - -
State Children's Health Ins(CHP+) I - 1 - -
Local government-County and City grants and contracts - - -
Inkind(Other Donations) - - I -
Other public health insurance(TRICAREJCHAMPUS,CHAMPVA) - -
Private Health Insurance - - -
Temporary Assistance for Needy Families(TANF) - - -
Other(specify private grants,fundraising,MCH,Social Service Blodc grant,Medicare,d - - -
TOTAL 5Tiii.•i it t.;#iz i[ft tFiit; r s ': s ['.is' _ i ` ,i;r:;. - $
Unspent Funds-This Period $ - $ - $ -
Unspent Funds-Prior Periods - -Balance Unspent Funds `4 i 4'ii'la i4 i?: P:::.:...:::::.:...::, - S
Has your agency used Title X funds topurchase any single piece of equipment valued at<$5,000 during this period? _Yes `_No
J:1FiscaPcontracts1FY061Exhibit E-Family Planning Expendenditure-Revenue Report
Magpie Leman 303-692-2485
EXHIBIT F
OF COO
� �o STATE OF COLORADO
tz ° DEPARTMENT OF PUBLIC HEALTH
** * AND ENVIRONMENT
Please fill out online and print, deliver,mail or fax
Secure EXTERNAL User ID Form
Instructions: A letter on agency letterhead,signed by the applicant's supervisor,must accompany
this form. Make certain pages 1 and 2 are completed and signed. Complete the first lines only at
the top of page 3. The department completes the gray area on page 3. The list of program(s) provided
at the top of page 3 is used to determine the applicant's access. An authorizing department staff member
will contact the applicant when a new ID is set up or changes to an ID are completed.
Do you have a user ID for ANY department application? What is it?
Why are you completing this form? New system access Li renewal ❑ change name n other change I
Explain:
PRINT Full Name- C Phone(s)used to contact C E-mail address for general c
including middle name h user about new ID and h communications h
npassword and to reset a
g passwords g g
e e e
d d d
Applicant
( )
Applicant's
Supervisor ( ) -
( ) -
Please PRINT full address clearly. Must include a physical street
address if a P.O. Box is used to receive mail. h
a
n
g
e
d
Agency or Organization
P.O. Box
Street Address(Not P.O. Box)
2" Address: Suite, Floor or Bldg#
City,State and Zip Code
Applicant Signature Title Date
Supervisor Signature Title Date
Page 1 of 4
Applicant Name: Agency Name:
Ermougale
Program(s)applicant requests access for(e.g., Special Needs,Communicable Disease and TB):
Check(-4) box if this is a change. LI
CDPRE Program Use Only
Application Department Authorizing Staff Name Date Phone Email
Name/Role
Print:
( )Role: Sign:
Print: ( ) -
Role: Sign:
Print:
( ) -
Role: Sign:
Department Authorizing Program Use Only (Instructions to ITS and Training Notes)
Indicate any known user ID:
ITS USE ONLY
ITS Staff Person Completing This Set Up:
Assigned User ID:
Confirmation Emailed to
Authorizing Program Staff: Date:
Confirmation ONLY by e-mail
Signature—ITS Staff Title
Notes:
Exhibit F
Page 2 of 4
Renewal User ID Agency Name: wgrellicsiromen
',
err
Data Security,Use and Confidentiality Agreement
In consideration of my access to the Colorado Department of Public Health and Environment secure Web site and
information,I agree to the following.(Initial each statement and sign below.)
I understand that I am responsible for making every effort to prevent unauthorized users from gaining access to or
using my user ID and password.I also agree to make every reasonable effort to prevent use of a computer for illegal
or unethical purposes by all users,authorized or not.
I agree to immediately report any suspected or actual unauthorized access to the Colorado Department of Public
Health and Environment point of contact that manages the information.
I will not share my password with any other person.
I will not leave my password around my computer or where another person might easily locate it.
I will change my password periodically and if I suspect it has been compromised.I will set up my passwords
according to department guidelines for length and content.
I understand that this is a"shared fate"environment. My fellow users and patients may be affected or
confidentiality compromised by the activities of other users. Preventing such activity is the shared responsibility of
all users.
I agree to access only the information I need to do my job and not to access or attempt to access files that I am not
authorized to use. I will not"browse"or otherwise use files or programs that exceed what is the minimum necessary
to do my job. My use and disclosures of information will be consistent with those permitted by the federal Health
Insurance Portability and Accountability Act of 1996(HIPAA)and other applicable laws and rules.
I agree not to discuss confidential information or to provide copies of confidential reports,regardless of how or
where acquired,to family members,friends,professional colleagues,other employees, other clients or any other
person unless such person has been authorized to have access to that information. If unsure who is authorized to
access the information,I will check with my supervisor or the department point of contact who manages the
information.
I understand that my access is granted for the purposes of public health and environmental protection. I will not use
or disclose any data for any purpose or end inconsistent with the purposes of the system(s)for which access is
granted. If I am unsure if any use or disclosure is permitted,I will discuss the issue with my supervisor and/or
contact appropriate department program staff for further clarification.
I will take precautions to protect confidential data displayed on my screen from viewing by others. This may mean
re-positioning my computer screen, adding a device to limit other's view,turning off the computer when leaving the
area or enabling password—protected screen savers. I will take reasonable and appropriate steps taking into account
the staff and public access to my area and the nature of the data on the system.
I understand that files I access may be protected from distribution by copyright or other applicable laws. The
department has exclusive copyrights in all original works of authorship created by its employees or contractors.
This applies to both published and unpublished works,and includes,but is not limited to,written documents,charts,
graphs,imagery and maps. Other entities' copyrighted works also may be accessible on this Web site. I will not
reproduce,distribute or display these works without permission from the department or another copyright owner.
I understand that for audit or system security purposes,the department may monitor all my activity.
I understand that the department may revoke my access at any time,with or without cause.
I understand that any violation of federal,state, local or the program's confidentiality requirements or this
Agreement will be considered a breach of my obligations and may result in disciplinary action,up to and including
termination of employment,termination of contractual relationship and other remedies allowed by law during or
after my employment or work with these data systems. For the department and other state employees,discipline
will be per the State of Colorado Personnel Rules.
I understand that information contained in the department's information systems is highly confidential and is
protected from improper use and disclosure by applicable federal and state laws. I agree not to disclose confidential
information in violation of this agreement or applicable confidentiality laws.
Applicant Printed Name Applicant Signature Date
Supervisor Name Signature Date
Exhibit F
Page 3 of 4
User Agency Letterhead
Colorado Department of Public Health and Environment
Program Name and Mail Code
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Date
To Whom It May Concern:
The employee(s) listed below require(s) access to the Colorado Department of Public Health data
collection and reporting system indicated.
As supervisor of the employee(s) I understand that if the employee(s) indicated should no longer
be employed or should no longer require access to the data system indicated to conduct their job,
I will request that access be disabled immediately. I also understand that if I have any questions
about the status of the access, I can contact the owner of the data system indicated at the
Department of Public Health and Environment at(303)692-2000 or 1-800-886-7689 (In-state.)
Sincerely
Supervisor Name
Title
Agency
Employee Name:
Employee Name:
Employee Name:
Employee Name:
Please indicate which data system(s)you are requesting access to.
❑ Colorado Women's Cancer Control Initiative (CWCCI): eCaST
(1 HCP: CHIRP
n Family Planning: IRIS
n Prenatal Plus: IRIS
Exhibit F
Page 4 of 4
STATE OF COLORADO
Bill Ritter,Jr.,Governor
James 8.Martin,Executive Director Rw,oP C
iutes
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. 'te16 s
Phone(303)692-2000 Denver,Colorado 80230-6928
TDD Line(303)691.7700 (303)692-3090 Colorado Department
Located In Glendale,Colorado of Public Heald'
httpJfwww.cdphe.state.co.us and Environment
July 10, 2007
Weld County Department of Public Health and Environment
Judy Nero
1555 North 17th Avenue
Greeley, CO 80631
RE: Nurse Home Visitor Program (NHVP)Task Order Contract
Contract Routing Number 08 FLA 00184
Family Planning Program (FPP)Task Order Contract
Contract Routing Number 08 FLA 00081
Dear Ms. Nero,
Enclosed please find fully executed copies of each of the above referenced Contracts for your files.
The FPP Task Order Contract covers the period from July 1,2007 through and Including
June 30, 2008.
The NHVP Task Order Contract covers the period from July 4,2007 through and including
June 30, 2008.
If you have any questions regarding these Contracts please contact me, Deb Polk, Contract Specialist at 303-
692-2492 or by email at deb.pollgastate.co.us or the individual program managers:
Candace Grosz, FPP Manager—303-692-2482 or by email at candace.orosz(Wstate.co.us
Esperanza Ybarra, NHVP Manager-303-692-2482 or by email at esoeranza.ybarraailstate.co.us
Sincerely,
1
Deb Polk
Contract Specialist, Fiscal Services Unit
Center for Healthy Families and Communities, Prevention Services Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, Colorado 80246
Phone: 303-692-2492
Fax: 303-753-9249
Deb.00lkastate.co.us
Enclosure
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