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Home My WebLink About20071398.tiff RESOLUTION RE: APPROVE TASK ORDER CONTRACT FOR COLORADO WOMEN'S CANCER CONTROL INITIATIVE 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 Colorado Women's Cancer Control Initiative 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 June 30, 2007,and ending June 29,2008,with furthar 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 Colorado Women's Cancer Control Initiative 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. ` BOARD OF COUNTY COMMISSIONERS iWELD UNTY, COLORA O ATTEST: G� /�! _r% ® a,. ism (r, t )1452 David . ong, Chair / Weld County Clerk to t B• '= „� �I ll ( / w, William H erk Tem BY: , cal 1Val ; -� ��e c De ty Cle to the Boar5 C/CY . William F. Garcia n�1 \J APPR V ' AS TO F Robert D. Masden ounty Attorney o (a,,5 <Q7„ �-,ur Date of signature: SII lie,1 Rademacher I 2007-1398 HL0034 41 ,% Iae 5 ) eolvtic-/-n7 Memorandum restr‘- „, TO: David E. Long, Chair Board of County Commissioners ' FROM: Mark E. Wallace, MD, MPH, Director O Department of Public Health and Environment COLORADO DATE: May 14, 2007 SUBJECT: Task Order Contract for the CWCCI Program Enclosed for Board review and approval is a task order contract between the Colorado Department of Public Health and Environment(CDPHE) and the Weld County Board of County Commissioners on behalf of the Weld County Department of Public Health and Environment (WCDPHE) for the Colorado Women's Cancer Control Initiative (CWCCI). The task order will provide funding for WCDPHE to improve the system of clinical and essential support services for breast and cervical cancer screening and diagnosis in twelve northeastern Colorado counties including Weld, Larimer, Morgan, Logan, Sedgwick, Phillips, Washington, Yuma, Cheyenne, Elbert, Kit Carson, and Lincoln. WCDPHE will recruit women for cervical cancer screening who are rarely or never screened and women for breast cancer screening who are between the ages of 50 and 64. The Health Department will provide culturally appropriate and linguistically correct recruitment materials to non-English speaking populations and refer eligible women to a CWCCI contracted provider. The Health Department will also support partnerships of community groups and the CWCCI. For the above services, CDPHE will reimburse Weld County an amount not to exceed $123,000 for the time period of June 30, 2007 through June 29, 2008. This reimbursement, which is identified as Federal funding, will be for personnel expenses, operating expenses including travel costs, and indirect costs. The additional funds received this year will be used to hire a .5 FTE Outreach Specialist to assist the program coordinator and cover other operating expenses. I recommend your approval of this task order contract. Enclosure a :U o n '-< 3 MI m rcnc-� < y oc m zz C7 ,9 ; 2007-1398 DEPARTMENT OF PUBLIC HEAL'I'II AND ENVIRONMENT ROUTING NO.08 FLA 00255 APPROVED TASK ORDER CONTRACT—WAIVER#154 This Task Order Contract is issued pursuant to Master Contract made on 12/19/2006,with routing number 08 FAA 00052 STATE: CONTRACTOR State of Colorado for the use&benefit of the Board of County Commissioners of Weld Department of Public Health and County(a political subdivision of the State of Environment Colorado)for the use and benefit of the Weld Prevention Services Divisions County Department of Public Health and CWCCI Program Environment 4300 Cherry Creek Drive South 1555 North 17th Avenue Denver,Colorado 80127 Greeley, CO 80631 TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE: May 2,2007 Colorado Political Subdivision PO/SC ENCUMBRANCE NUMBER: CONTRACTOR FEIN OR SOCIAL SECURITY NUMBER: PO FLA PPG0800255 846000813 TERM: BILLING STATEMENTS RECEIVED: This Task Order shall be effective upon Monthly approval by the State Controller,or designee, or on 06/30/2007,whichever is later, The ST'ATUT'ORY AUTHORITY: Task Order shall end on 06/29/2007. Not Applicable PRICE STRUCTURE: CONTRACT PRICE NOT TO EXCEED: Cost Reimbursement $123,000.00 PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS: $123,000.00 Exempt STATE FUNDING DOLLARS: $0.00 BID/REP/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR Not Applicable FY 08: $123,000.00 FY XX: $ LAW SPECIFIED VENDOR STATUTE: FY XX: $ Not Applicable FY XX: $ FY XX: $ STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE: Marti Wood Judy Nero Department of Public Health and Environment Weld County Department of Public Health and Prevention Services Division Environment CWCCI 1555 North 17th Avenue 4300 Cherry Creek Drive South Greeley,CO 80631 Denver,CO 80127 SCOPE OF WORK: Increase number of women who will receive breast and cervical cancer screening services per 2008 Scope of Work. 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 Payment Terms (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. 1. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract including,but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including any renewals or extensions, may not exceed five(5)years. The parties intend and agree that all work shall be performed according to the standards,terms and conditions set forth in the Master Contract. 2. In accordance with section 24-30-202(1),C.R.S.,as amended,this Task Order Contract is not valid until it has been approved by the State Controller,or an authorized delegee thereof. The Contractor is not authorized to,and shall not;commence performance under this Task Order Contract until this Task Order Contract has been approved by the State Controller or delegee. The State shall have no financial obligation to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order Contract on or before its proposed effective date,then the Contractor shall commence performance under this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order Contract after its proposed effective date,then the Contractor shall only commence performance under this Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through and including the date specified on page one of this Task Order Contract,unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract. Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of the terms and conditions of this Task Order Contract. 3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made a part hereof as if fully set forth herein. Unless otherwise stated,all exhibits and/or attachments to this Task Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated, the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event of conflicts or inconsistencies between the Master Contract and this Task Order Contract(including its exhibits and/or attachments),or between this Task Order Contract and its exhibits and/or attachments,such conflicts or inconsistencies shall be resolved by reference to the documents in the following order of priority: 1)the Page 2 of 4 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 Weld County BILL RITTER,JR GOVERNOR for the use and benefit of the Weld County Department of Public Health& _ Environment Legal Name of Contracting Entity By For Executive Director 846000813 Department of Public Health and Environment Social Security Number or FEIN FV Department Program Approval: Signature of Authorized Officer AY 1 6 2001 David E. Long, Chair gy ti 4 VYlatltaAk. Print Name&Title of Authorized Officer GOVERNMENTAL ENTITIES: (An attes n a a e uir ) Ipn La Attest(Seal)B / � - le}"f Ise trio (Town/City/County erk of uivalent) v I e) 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 ' DO W LD E COUNTY DEPARiTMENT OF UBL;C i�TGn c 1RONMENT BY: v Mark E. Wallace, M0, MPH-Directot�� Page 4 of 4 ,?re9-X39cF EXHIBIT A ADDITIONAL PROVISIONS To Contract Dated 05/02/2007-Contract Routing Number 08 FLA 00255 These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above. 1. This contract contains federal funds(see Catalog of Federal Domestic Assistance(CFDA)number 93.283) 2. The United State Department of Health and Human Services("USDHHS"),through the Centers for Disease Control("CDC")has awarded federal funds under Notice of Cooperative Agreement Award, hereinafter"NCAA",number U55/CCU821947-01,to perform the following—breast cancer screening, cervical cancer screening and diagnostic services. The intent of the Cooperative Agreement is to increase screening and diagnosis among low income older women who are uninsured or under insured, including those who are racial,ethnic, and cultural minorities,such as American Indians,African Americans, Hispanics, Asian/Pacific Islanders,Lesbians, women with disabilities, and women who live in hard to reach communities in urban and rural areas. If the underlying Notice of Cooperative Agreement Award"NCAA"authorizes the State to pay all allowable and allocable expenses of a contractor as of the effective date of that NCAA,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 Contract. If the underlying NCAA does not authorize the State to pay all allowable and allocable expenses of a contractor as of the effective date of that NCAA,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 Contract, with such effective date being the later of the date specified in this contract or the date the contract is signed by the State Controller or delegee. 3. 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. 4. Survival of Certain Contract Terms. Notwithstanding anything in this contract to the contrary,the parties understand and agree that all terms and conditions of this contract which may require continued performance,compliance, or effect beyond the termination date of the contract and shall survive such termination date and shall be enforceable by the State as provided herein in the event of failure to perform or comply by the Contractor. To be attached to CDPI-IE Page 1 of 1 Revised:4/1/04 Version 1.0(4/04)contract template EXHIBIT B STATEMENT OF WORK To Task Order Contract Dated 05/02/2007-Contract Routing Number 08 FLA 00255 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. The Contractor, in accordance with the terms and conditions of this contract,shall perform and complete, in a timely and satisfactory manner,all activities described in the approved Work Plan/Scope of Work and Budget that is attached hereto as Attachment B-1 incorporated herein. To be attached to CDPI-IE Page 1 of 1 Revised: 12/19/06 Task Order v1.0(11/05)contract template Attachment B-1 Colorado Women's Cancer Control Initiative (CWCCI) Community Coordinator Scope of Work—Fiscal Year 2007 - 2008 North East Region Contractor/Company Name: Weld County Health Department Project Period: June 29, 2007 through June 28, 2008. Direct Beneficiaries: Colorado Women's Cancer Control Initiative (CWCCI) eligible women lawfully present in Colorado, CWCCI eligible women receiving health care in rural areas, rural health care providers and CWCCI. Project Goal: Increase the number of women who receive breast and cervical cancer screening services by actively referring potentially eligible women to a CWCCI contracted provider site within the Community Coordinator's (CC) catchment area using evidence-based community strategies. Definitions: Catchment Area— The catchment area (Attachment B-1) includes counties within which the CC will meet the objectives. For this scope of work, the catchment area includes Logan, Morgan, Phillips, Sedgwick, Washington, Yuma, Cheyenne, Elbert, Kit Carson, Lincoln, Larimer, Weld Evaluation for Effectiveness—A process used to evaluate recruitment strategies. Evaluation of the strategy may result in either a positive or negative evaluation. For the purposes of this project, specific recruitment strategy results have been identified and are listed under the "Deliverables" section of this scope of work. Recruitment — A planned process aimed at gaining attention of women who are potentially eligible for breast and cervical cancer screening services. Recruitment is directed towards women residing within the catchment area. Recruitment may include individual or a combination of evidence-based activities. Referral — The process by which a program-eligible woman is referred to a CWCCI contracted site in the catchment area. Deliverables: The contractor shall perform the following services: 1. Recruitment of Women for Cervical Cancer Screening who are Rarely or Never Screened (R/NS) and Women for Breast Cancer Screening Age 50-64. a. Utilize marketing materials developed by the Department's media firm. b. Utilize evidence-based strategies to reach program eligible women in the catchment area using program-approved resources, such as the CWCCI Literature Review 1:\CCP\CWCCI\Community Coordinators\Statement of Work v1.0 060506.doc (http://www.edphe.state.co.us/pp/eweci/Providerflandbook/EffOutStratL,itReview .DOC ) and the Guide to Community Preventive Services http://www.thecommunityguide.org). c. Provide culturally appropriate and linguistically correct recruitment materials to non-English speaking populations. d. Evaluate recruitment activities for effectiveness on the monthly report. e. Effective strategies must be evaluated for: 1. Referrals that result in a paid screening to a CWCCI contracted provider site in the catchment area. 2. Attainment of a 20% or greater rate of cervical cancer screening in woman who are rarely or never screened in the catchment area. 3. Attainment of a 75% or greater rate of breast cancer screening of women 4. age 50-64 in the catchment area. f. Obtain program approval: 1. Before the use of the State of Colorado logo on publications and materials. 2. before any alterations to marketing materials as developed by the Department's media firm. g. Report activities on the monthly report. 2. Perform Eligibility and Referral Activities: a. Determine eligibility of women, using CWCCI eligibility guidelines (Attachment B-2). 1. Eligibility guidelines will be updated during the period this scope of work is in effect. When new eligibility guidelines are adopted for implementation by CWCCI, the CC will be notified and is then responsible for implementing necessary changes to their workflow by a date determined by the Department. b. Provide culturally appropriate and linguistically correct eligibility materials to non-English speaking populations. c. Refer eligible women to a CWCCI contracted provider in the catchment area. c. Perform site visits to all CWCCI providers in the catchment area and document encounter on template provided by the Department (Attachment B-3). d. Report activities on the monthly report. 3. Actively Pursue Partnerships between CWCCI and the Catchment Area: a. Support partnerships of community groups that are natural and unnatural partners for CWCCI. I. Within the catchment area, attend meetings and events that support and relate to breast and cervical cancer education, detection and treatment. 2. Identify and provide an active list of partners in the catchment area by September 2007 and updated in March 2008. 3. Attend at least 3 Colorado Cancer Coalition (CCC) (http://www.coloradocancercoalition.orn_/) meetings during the scope of this work. 1:\CCP\CWCCI\Community Coordinator\SOW 041607.doc 2 of 3 1. Increase regional membership of the CCC by 20% by the end of this contract cycle. 2. Support the Breast Cancer Task Force and upcoming Cervical Task Force Activities at the direction of the Department. This may entail attending or supporting meetings of the task forces and activities that come from this groups. b. Report activities on the monthly report. 4. Department Meetings: Attend a minimum of 3 of the 4 quarterly meetings held by Department staff during the contract period. These may be telephone or face-to-face meetings, at the discretion of the Department. 5. Reporting Requirements: a. Monthly reports are due to the Department in electronic format by the 5th day of each month. b. Reports are to be emailed to Sandra Mortensen at Sandra.mortensen@state.co.us or to a staff person at the Department as directed. 1. If the 5th day falls on a Saturday, Sunday, or holiday then the report is due the following business or workday. 2. Reports will be submitted on a template provided by the Department (Attachment B-4). 3. Final report for the contract year is due to the Department by July 5, 2008. Payment Terms: CWCCI will pay $10,250 each month for a total project budget not to exceed $123,000. The contractor agrees to provide the services of one (1.5) full-time equivalent position (FTE) to provide services for this project. CWCCI and the contractor shall confer on the selection of any new employees to ensure that the parties are compatible. This amount will cover all costs for personnel, supplies and other expenses related to this project. Funds paid per this contract are for activities that support the recruitment efforts described in the scope of work. The contractor will also submit the required deliverables listed above in this Scope of Work. If the contractor should fail to staff this project or submit required deliverables, CWCCI has the right to withhold payment. In the event that CWCCI is dissatisfied with the performance of the work of the contractor, CWCCI shall contact the agency to schedule a meeting to discuss the pertinent issues. If differences are not resolved, CWCCI shall provide the contractor written notice of the final actions of the Department, which may include time lines for corrective action of discontinuation of the contract. J\CCP\CWCCI\Community Coordinator\SOW 041607.doc 3 of 3 Billing shall be monthly and submitted on an invoice provided by the Department (Attachment B-5). All invoices are to be submitted by the last day of the month in which services are provided. Please mail invoices to the following address: Colorado Department of Public Health and Environment Attn: Marti Wood PSD, Chronic Disease, CWCCI, A-5 4300 Cherry Creek Drive South Denver, CO 80246 J:\CCP\CWCCACommunity Coordinator\SOW 041607.doc 4 of 3 Attachment B-1 Attachment B-1 Catchment Area Regions for the contract are based on a map developed by the Colorado Cancer Coalition, February 2007. North East Planning and Management Regions (PMR) 1: Logan, Morgan, Phillips, Sedgwick, Washington, Yuma PMR 5: Cheyenne, Elbert, Kit Carson, Lincoln Central PMR 2: Larimer, Weld J:\CCP\CWCCI\Community Coordinators\Statement of Work v1.0 060506.doc nyt xF Y * }�sa 'ry *."s"*r a v 'a� . _t 1.1:5•1:•:•• "!t ++PQ s r .?'*..per t t ##"+'{�''`t �'a:.14.1111M4114:4::15.4'::, .;::::,..";:i...1". 't + t -i'' d .21'1I.2.21,1"..0.• f rt t"d fsr ,iy.e 1�i 1 eua: vYlC t t ! ad r kt x; nr t,;44ipi a k .gtgt.i.i` +art! ¢yaa p+. t Q • °a419040 '"r 'a I a v sa %A a''k P x } �. .s a �,.;c �w r i t ptc�ra'y'� a,�i�, �y r''�"� y ' .k 7 t y t•\ r 4 a a s {,' ti sa .E✓ t>t v`t4 a'2 $S2Fa • I t " x •! x•+>" 'c°a ma' i u�r Y' • .: rtr .t • 1 a ,a"r e °- < .n° r !<",' w at t''s^u a ' *� s.'1:••••••!::4",i, + f. q'•: p,ao-: .a#�. .t •ar 5 ad A,yti�t�i t ;4;• x s d r tar t �3 S tt A t �i gym: Ctritli %W�`P I 1'dl .? Yom.. { a ' t •• . .•kF F Y s rF iaa•`.Ta { 14' W a_ } sn ' tom„ „... d tt w t a a �. { 9y I t "att wE �` t ,s,rt 4 '+ • s t '.hi t kxa :•14 g>+`'i 'aA t4 `5 n a 11 t� 6� ,`�%AL•I �tt Et § .atwti Fyn! . y N p t' .kv....e_.�;ni3fi E jt i 041 41 kSr > 9r y Z ..{ •* k `: , • ^app 'i,...., ...• ploy g �^ .!L ( y " Yd-24 rtq'ih�• a aro`4•......4-,.,44.,-.4, �s�'li • � '�I t r'C$ tq:{ At. : Y # C w'4 I O :fl3 ""4 E L�y a Ilti , t: 4 Le{ Ifla* y ••••+•;"•;''''.". O ht:', aa'r �# C�tl Ea I x t t. :......41:illi'-" AP ,.., • It. t ;2..4.",":1::".:'.'-'1. ,� O a,. jgt y„ yfl� �y j i t f it d� �{ t rt • t o '� � }s y`; nYt C 5w'• � • - t. I �i t N x{' t '�i�cf uFt} G ' I th SxF"}t .:rc. a A t I� R tt v gyp:•k C Ws: •• r lit � I }� 3I r F • ' • i rr II Fy • Ik c tl7 tFu �tf t • • o t� uMl s# f'�' i�b rt 'r t c .41 t It t o Yat't 3 7 • v .m ro,t a 11,• t ..t o t { t C�J • 4a I„.. a,,� I3, �t�' .fit E y� 4' 9tI ttlr4d I E • • � P w tta'. dl f CL E. � f ,sit. t d t :•:.:4'... .... •' •• V U U Attachment B-1 Attachment B-2 CWCCI Program Eligibility Criteria In order to qualify for free breast and cervical cancer exams under the CWCCI program, women will meet the following criteria: 1. Age 40 to 64 for pap test, pelvic exam and clinical breast exam OR Age 40 to 49 for pap test, pelvic exam, clinical breast exam and **mammogram **a mammogram in this age group is not considered to be a covered service unless the woman presents with risk factors such as; mother, sister or daughter with breast cancer prior to age 50; two or more first degree relatives (mother, sister, daughter) with breast cancer at any age; personal history of breast cancer OR abnormal self-reported or clinical breast exam findings OR Age 50 to 64 for a mammogram and pap test, pelvic exam and clinical breast exam. AND 2. Meet 250% of the DHHS Federal Poverty Guideline* income requirements: Persons in family (Household**) Monthly Annually 1 $ 2127 $ 25,525 2 $ 2852 $ 34,225 3 $ 3577 $ 42,925 4 $ 4302 $ 51,625 5 $ 5027 $ 60,325 6 $ 5752 $ 69,025 7 $ 6477 $ 77,725 8 $ 7202 $ 86,425 Source: Federal Register: January 24, 2007 (Volume 72,Number 15): http://aspe.hhs.gov/poverty/07fedreg.htm * DHHS Federal Poverty Guidelines change every March. ** As defined by the Bureau of the Census for statistical purposes, a household consists of all the persons who occupy a housing unit (house or apartment), whether they are related to each other or not. If a family and an unrelated individual, or two unrelated individuals, are living in the same housing unit, they would constitute two family units, but only one household. J:\CCP\CWCCI\Community Coordinators\Statement of Work vi.0 060506.doc Attachment B-3 CWCCI Provider Site Visit Report Directions: Complete for each provider visit and attach to monthly report. Date/Time: Site Name and Location: Name and Title of Attendees: Discussion Points: ❑ Roles and responsibilities of the CC. ❑ Site hours of operation, staffing, enrollment process, etc. ❑ Referral process between CC and the site. ❑ Resources: discussion of resources available to the site and list of materials left. ❑ Partnership planning: Identification of collaborative projects in the contract year, items and issues needing follow-up visit/contact. Print CC Name: Signature of CC: Region: Date Submitted: J:\CCP\CWCC1\Community Coordinator\SOW 041607.doc 2 of 3 Z a) • 'V M y j (4-. 0 M 0 tij N Q N H 0 ." I. CU O 40 4.4 o .5 0 O O 0 0 zz z z z z t0 O O O 1. 6 4.4' 6 O el o 0 0 a 5 :° ° a 4 a a o El p" e a a a tm A ❑ z ❑ z ❑ z ❑ z W > c, U c4i 4., c-i .� L-• nih' 8 C4 42. 4D d114 y u ii o U a °' au a li x '<':-,'U c o a, 04 A d i, u O 3 ••••I .4., �. _o .� a El t 4 v 4 V h 6 6 O O 0 et r+ et IS' 'Q q 'o C w •j,,�•' $ to fl .. V 6 � el„ a aGO E °a. 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Y ❑ z cn C) C 5 o � 0 O O.• n'i b O • tY 0 • O 'y O_ C 0 O § c O n I • V 0 C a• Y ti O U N V 'b • LL o U U • 0y • 0 U XI en to, .. z ea § ; 2872 % k � 22 � k / © .0 � m � \ ; to ; 2 J Zia ■ U ° \ t.° 00 0 a, ) § s / � 4. ° = tu en� O ) ( 03 ! —er Eh ) ° ( 2 2 ® / a. ) / } Cl) t I. 0 § C) ] / co \ ^ \ ]te \ N4. / @ 0 © 0 CU ) ) G § � e / / q o � } \ 2.2. 2 j « ) z \ ] ] — @ 4) ] ) ] k \ 0 ) & j \ ) ; \ & - ] C .0 2 t % a \ § 3 as u e © 0 & ] _ / | 0 e g k C J ] \ ) a � ; 0) 7 • to aa ( E § I. - u g © E � \ o \ 5 • Cl)\ = w / / 2 \ ) Cl$ / \ � o § \ & / a t / \ § § § * O 9 0 ® k • _ . $ ) / a 7 7 � ® f] { ] 3J4u / ) m / \ / / \ ) \ EXHIBIT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER ELIMINATE ALL INFORMATION APPEARING IN RED LIMITED AMENDMENT FOR TASK ORDERS #* This Limited Amendment is made this **** day of*********,200*, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South,Denver, Colorado 80246, hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY, (legal type of entity), whose address or principal place of business is Street Address, City, State & Zip Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated ******** **, ****, with contract routing number ** *** ***** "the Master Contract"). Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated ******** **, ****, with contract encumbrance number PO *** ********** and contract routing number ** *** *****, [insert the following if previous amendment(s), change order(s), renewal(s) have been processed: as amended by] (include all previous amendment(s), change order(s), renewal(s) and their routing numbers], [insert the following if previous amendment(s), change order(s), renewal(s) have been processed: collectively] referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: [Briefly describe what the Contractor was to do under the Original Task Order Contract—indent this paragraph] [Please choose one of the following four options and delete the other three options not selected] The State promises to [choose one and delete the other] increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the [choose one and delete the other] increased/decreased work under the Original Task Order Contract. Page 1 of 5 The State promises to pay the Contractor the sum of********** Dollars, ($*.**) in exchange for the promise of the Contractor to continue to perform the work identified in the Original Task Order Contract for the renewal term of**** years/months, ending on ******** **, ****. The State promises to [choose one and delete the other] increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) for the renewal term of**** [choose one and delete the other] years/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the [choose one and delete the other] increased/decreased work described herein. The State hereby exercises a"no cost" change to the [choose those that apply and delete those that don't apply] budget, specifications within the Statement of Work, project management/manager identification, notice address or notification personnel, or performance period within the [choose one and delete the other] current term of the Original Task Order Contract or renewal term of the Original Task Order Contract. NOW THEREFORE, in consideration of their mutual promises to each other, stated below,the parties hereto agree as follows: 1. Consideration for this Limited Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the Original Task Order Contract, contract routing number ** *** *****, [insert the following language here if previous amendment(s), change order(s), renewal(s) have been processed] as amended by [include all previous amendment(s), change order(s), renewal(s) and their routing numbers], [insert the following word if previous amendment(s), change order(s), renewal(s) have been processed, otherwise delete "collectively"]collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Limited Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: [Please choose one of the following three options and delete the two options not selected] A. [Use this paragraph when changes to the funding level of the Original Task Order Contract occur during the current term of the Original Task Order Contract] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the current term of********* ** Page 2 of 5 EXHIBIT C ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is [choose one and delete the other] increased/decreased by ********** Dollars, ($*.**) for an amended total financial obligation of the State of********** DOLLARS, ($*.**). [Delete the following sentence if not applicable in your situation] The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". [Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. [Use this paragraph when the Original Task Order Contract will be renewed for another term] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the renewal term of********* ** ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars, ($*.**) for an amended total financial obligation of the State of********** DOLLARS, ($*.**). [Delete the following sentence if not applicable in your situation] The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". [Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as"Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. [Use this paragraph when there are "no cost changes" to the Budget, the specifications within the original Statement of Work, allowable contract provisions as noted, or performance period.] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment [choose those that apply and delete those that don't] modifies the Budget in [identify location in contract], modifies the Statement of Work in [identify location in contract], modifies the project management/manager identification in [identify location in contract], modifies the notice address or notification personnel in [identify location in contract], modifies the period of performance in [identify location in contract] of the Original Task Order Contract. The revised [choose those that apply and delete those that don't] Budget, Statement of Work, project management/manager identification, notice address or notification personnel, or period of performance is incorporated by this reference and identified as. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Limited Amendment is **/**/****, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. Page 3 of 5 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Limited Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Limited Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 4 of 5 EXHIBIT C IN WITNESS WHEREOF,the parties hereto have executed this Limited Amendment on the day first above written. CONTRACTOR: STATE: [LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (a political subdivision of the State of Colorado) Bill Ritter, Jr. Governor By: By: Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT ATTEST: PROGRAM APPROVAL: Because the Contractor is a governmental entity, an attestation is required By: (Seal, required) By: City, City and County, County, Special District, or Town Clerk or Equivalent [Delete inapplicable language.] ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for goods and/or services provided. STATE CONTROLLER Leslie M. Shenefelt By: Date: Page 5 of 5 STATE OF COLORADO Bill Ritter,Jr.,Governor James B. Martin, Executive Director op•coi� R=` Dedicated to protecting and improving the health and environment of the people of Colorado ye-� o) 4300 Cherry Creek Dr.S. Laboratory Services Division 11\* Denver,Colorado 80246-1530 8100 Lowry Blvd. \ t • Phone(303)692-2000 Denver,Colorado 80230-6928 !a�6� 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 17, 2007 Weld County Department of Public Health and Environment Judy Nero 1555 North 17'h Avenue Greeley CO 80631 Dear Ms. Nero: Enclosed a copy of the executed contract upon between the State of Colorado, CWCCI Program and the Weld County Department of Public Health and Environment. If you have any questions,please contact me at(303)692-2433 Sincerely, Marti Wood Contract Administrator cc: File Hello