HomeMy WebLinkAbout20043108.tiff RESOLUTION
RE: APPROVE AGREEMENT FOR ASTHMA EDUCATION AND PREVENTION GRANT 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 an Agreement for Asthma Education and
Prevention Grant 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 Environmental Protection Agency, commencing October 1, 2004, and
ending September 31,2005, with further terms and conditions being as stated in said agreement,
and
WHEREAS,after review,the Board deems it advisable to approve said agreement, 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 Agreement for Asthma Education and Prevention Grant 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 agreement.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 27th day of October, A.D., 2004, nunc pro tunc October 1, 2004.
BOARD OF COUNTY COMMISSIONERS
/�� W D COU�1N\\TY��C�OLORADO
ATTEST: ,t;L4/�i/uGLce 1( ` r
Robert D. Masden, Chair
X101 , y Clerk to the Board ��
86 William H. J e, Pro-Tem
BY. n
°' ` p�] rk t the Board
AST c
David . Long
unty Attor ey
Glenn Vaad
Date of signature: k7 "1-i,
2004-3108
H L0031
61O.• ff L 4,1-D9-D6/
KitMemorandum
WagTO: Robert D. Masden, Chair
OBoard of County Commissioners
From: Mark Wallace, M.D., M.P.H., Director,
COLORADO Department of Public Health &
Environment ^W`(' AG 4)
DATE: October 20, 2004
SUBJECT: Agreement for Asthma Education and
Prevention Grant from EPA for the Wee
Wheezers Program.
Enclosed for Board review and approval is an agreement for the Asthma Education and
Prevention grant awarded to the Weld County Department of Public Health and Environment by
the United States Environmental Protection Agency. Also enclosed are four other documents
necessary to complete the administrative requirements for funding.
Funding from this agreement will be used to supplement the asthma education programs
conducted by the STEPS to a Healthier Weld County grant staff. It will also support the Wee
Wheezers bilingual program to educate parents of daycare children on appropriate asthma
management skills.
The grant is in the amount of$13,072 for the funding period of October 1, 2004 through
September 31, 2005. I recommend your approval of this agreement.
Enc.
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vJ
2004-3108
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
REGION VIII
3 999 18th STREET - SUITE 300
%.44,pm, DENVER, COLORADO 80202-2466
http://www.epa.gov/regi on08
OCT 0 6 2004
Ref: 8TMS-G
William H. Jerke, Chair, Pro-Tern
Weld County Department of Public Health
& Environment
1555 North 17th
Greeley, CO 80631
Re: Asthma Education and Prevention
X978028-01
Dear Mr. Jerke:
We are pleased to inform you that we are approving your application for the
Asthma Education and Prevention in the amount of $13,072. This award represents
100% of the amount requested in your FY 2004 application.
Please sign and date all copies of the enclosed award, retain the recipient copy for
your files and return the EPA copy to the Grants, Audit and Procurement Program
Office (8TMS-G).
If you have any questions regarding the administrative requirements, please
contact Tempa Graves at (303) 312-6368 orviaemailatgraves.tempa@epa.gov. If
you have any questions regarding the technical requirements, contact Erin Collard at
(303) 312-6361 or via email at collard.erin@epa.gov.
As a reminder, grant payments for EPA Region 8 recipients has been transferred
to the EPA Las Vegas Finance Center. Please refer to your notification letter for
instructions or contact Bill Pumphrey at (702) 798-2493.
/1
Sincly, /
/11
/r „
ill
2ayn nthofer, Director
Grant , Audit & Procurement
Program Office
Enclosures
cc: Jodi Moore, WCDPH&E
Erin Collard, 8P-AR
Bill Pumphrey, LVFC
9$•
Printed on Recycled Paper
•
•
RECIPIENT COPY
X-97802801 -0 Page 1
ASSISTANCE ID NO.
"00n%.
0£r4TF.4 U.S. ENVIRONMENTAL PRG I DOC ID IAMENDit DATE OF AWARD
PROTECTION AGENCY x - 97802801 - 0 SEP 2 9C 2004
TYPE OF ACTION �GOD 6004 New t�
4L � Grant Agreement Reimbursement
METHOD:of ACH#
RECIPIENT TYPE: Send Payment Request to:
County Las Vegas Financial Center-
LVFC
RECIPIENT: PAYEE:
Weld County Depart.of Public Health&Environment Weld County Dept.of Public Health&Environment
1555 North 17th 1555 North 17th
Greeley,CO 80631 Greeley,CO 80631
EIN: 84-6000813
PROJECT MANAGER EPA PROJECT OFFICER EPA GRANT SPECIALIST
Jodi Moore Erin Collard Tempa Graves
1555 North 17th 999 18th Street,Suite 300,8P-AR Grants,8TMS-G
Greeley,CO 80631 Denver,CO 80202-2466 E-Mail: Graves.Tempa@epa.gov
E-Mail: E-Mail: Collard.Erin@epa.gov Phone: 303-312-6368
Phone: (970)304-6410 Phone:303-312-6361
PROJECT TITLE AND DESCRIPTION
Weld County/FY04 Indoor Air
Asthma education and prevention for preschooler asthmatic patients and their parents
BUDGET PERIOD PROJECT PERIOD TOTAL BUDGET PERIOD COST TOTAL PROJECT PERIOD COST
10/01/2004 - 09/30/2005 10/01/2004 - 09/30/2005 $13,072.00 $13,072.00
NOTE: The Agreement must be completed in duplicate and the Original returned to the appropriate Grants Management Office listed below,
within 3 calendar weeks after receipt or within any extension of time as may be granted by EPA Receipt of a written refusal or
failure to return the properly executed document within the prescribed time,may result in the withdrawal of the offer by the Agency
Any change to the Agreement by the Recipient subsequent to the document being signed by the EPA Award Official,which the
Award Official determines to materially alter the Agreement,shall void the Agreement
OFFER AND ACCEPTANCE
The United States,acting by and through the U.S.Environmental Protection Agency(EPA),hereby offers
Assistance/Amendment to the Weld County Depart.of Public Health&Environment for 100.00 %of all
approved costs incurred up to and not exceeding $13,072 for the support of approved budget period effort described
in application(including all application modifications)cited in the Project Title and Description above,signed 06/02/2004
Included herein by reference.
ISSUING OFFICE(GRANTS MANAGEMENT OFFICE) AWARD APPROVAL OFFICE
ORGANIZATION/ADDRESS ORGANIZATION/ADDRESS
Environmental Prote tion A ency, Region 8 U.S. EPA, Region 8
999 18th Street,Su' 300 8P-AR
Denver,CO 80202- 66 999 18th Street,Suite 300
Denver,CO 80202-2466
• H ED STATES OF AMERICA BY THE US.ENVIRONMENTAL PROTECTION AGENCY S���1 2004 SIGNATURE! V L TYPED NAME AND TITLE S T
Wayne Anthofer,Director
This ag ent is subject to applicable U.S.Environmental Protection Agency statutory provisions and assistance regulations In
accepti g this award or amendment and any payments made pursuant thereto,(1)the undersigned represents that he is duly
authorized to act on behalf of the recipient organization,and(2)the recipient agrees(a)that the award is subject to the applicable
provisions of 40 CFR Chapter 1,Subchapter B and of the provisions of this agreement(and all attachments),and(b)that
acceptance of any payments constitutes an agreement by the payee that the amounts,if any found by EPA to have been overpaid
will be refunded or credited in full to EPA.
((('''��� BY AND ON BEHALF OF THE DESIGNATED RECIPIENT ORGANIZATION
�c SIGNATURE `- , (\ A A, TYPED NAME AND TITLE DATE
0�( ,J Robert D. Masden, chair 10/27/2001
.3/tg
EPA Funding Information x-97602801 -0 Page2
FUNDS FORMER AWARD THIS ACTION AMENDED TOTAL
EPA Amount This Action $ $ 13,072 $ 13,072
EPA In-Kind Amount $ $ $ 0
Unexpended Prior Year Balance $ $ $0
Other Federal Funds $ $ $0
Recipient Contribution $ $ $0
State Contribution $ $ $0
Local Contribution $ $ $0
Other Contribution $ $ $0
Allowable Project Cost $0 $13,072 $13,072
Assistance Program(CFDA) Statutory Authority Regulatory Authority
66.034- Clean Air Act:Sec. 103 40 CFR PART 31
Surveys-Studies-Investigations-Demonstrations
and Special Purpose Activities relating to the
Clean Air Act
Fiscal
Site Name DCN FY Approp. Budget PRC Object Site/Project Cost Obligation I
Code Organization Class Organization Deobligation
- KPG115 0405 13 08K 102A74E 4183 - - 13,072
13,072
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X-97802801 -0 Page 3
Budget Summary Page
Table A-Object Class Category Total Approved Allowable
(Non-construction) _ Budget Period Cost
1.Personnel $4,000
2. Fringe Benefits $0
3.Travel $300
4.Equipment $0
5.Supplies $6,940
6.Contractual $0
7.Construction $0
8.Other $0
9.Total Direct Charges $11240
10.Indirect Costs: % Base $1.832
11.Total(Share: Recipient % Federal 100.00 5'..) $13,072
12.Total Approved Assistance Amount $13,072
13.Program Income $0
X-97802801 -0 Page 4
Administrative Conditions
1. The recipient will comply with the following: (1)all applicable provisions of 40 CFR Parts 29, 31,
34, and 35(if applicable), OMB Circulars A-87, A-102, and A-133 and (2)any terms and conditions set
forth in this assistance agreement or any assistance agreement.
2. The Project Work Plan is the work plan for this award. Performance will be evaluated consistent
with the Policy on Performance Based Assistance dated May 31, 1985.
3. The recipient agrees to ensure that all requisitions for conference, meeting, convention, or training
space funded in whole or in part with Federal funds comply with the Hotel and Motel Fire Safety Act of
• 1990.
4. The recipient must submit an annual Financial Status Report within 90 days after the grant year,
and must submit a final report within 90 days after the expiration or termination of grant support in
accordance with 40 CFR Part 31.41(b).
5. In accordance with OMB Circular A-21, A-87, or A-122, as appropriate, the recipient agrees that it
will not use project funds, including the Federal and non-Federal share, to engage in lobbying the Federal
Government or in litigation against the United States. The recipient also agrees to provide the information
mandated by EPA's annual appropriations acts for fiscal year 2000, 2001 and fiscal year 2002 (PL 106-74,
§426, PL 106-377, §424 and PL 107-73, §424 respectively)which require as follows: 'A chief executive
officer of any entity receiving funds under this Act shall certify that none of these funds have been used to
engage in the lobbying of the Federal Government or in litigation against the United States unless
authorized under existing law.' The recipient may satisfy this certification requirement in any reasonable
manner. The certification must be submitted to EPA after all grant funds have been expended.
6. In accordance with EPA Order 1000.25 and Executive Order 13101, Greening the Government Through
Waste Prevention, Recycling, and Federal Acquisition ,the recipient agrees to use recycled paper for all reports
which are prepared as a part of this agreement and delivered to EPA. This requirement does not apply to reports
prepared on forms supplied by EPA,or to Standard Forms,which are printed on recycled paper and are available
through the General Services Administration. Please note that Section 901 of E.O. 13101, dated September 14,
1998, revoked E.O. 12873, Federal Acquisition, Recycling, and Waste Prevention in its entirety.
Any State agency or agency of a political subdivision of a State which is using appropriated Federal funds shall
comply with the requirements set forth in Section 6002 of the Resource Conservation and Recovery Act(RCRA)(42
U.S.C. 6962). Regulations issued under RCRA Section 6002 apply to any acquisition of an item where the purchase
price exceeds$10,000 or where the quantity of such items acquired in the course of the preceding fiscal year was
$10,000 or more. RCRA Section 6002 requires that preference be given in procurement programs to the purchase
of specific products containing recycled materials identified in guidelines developed by EPA. These guidelines are
listed in 40 CFR 247.
7. Recipient shall fully comply wi.th Subpart C of 40 CFR Part 32, entitled"Responsibilities
of Participants Regarding Transactions." Recipient is responsible for ensuring that any lower tier
covered transaction, as described in Subpart B of 40 CFR Part 32, entitled "Covered
Transactions," includes a term or condition requiring compliance with Subpart C. Recipient is
responsible for further requiring the inclusion of a similar term or condition in any subsequent
lower tier covered transactions. Recipient acknowledges that failing to disclose the information
required under 40 CFR 32.335 may result in the delay or negation of this assistance agreement,
or pursuance of legal remedies, including suspension and debarment.
Recipient may access the Excluded Parties List System at http://epls.arnet.gov.
8. In accordance with EPA's Program for Utilization of Small, Minority and Women's Business
Enterprises in procurement under assistance programs, the recipient agrees to:
(a) Accept the applicable FY 2003"fair share"goals negotiated with EPA by the Colorado
Department of Public Health and Environment as follows:
MBE WBE
Construction 6.1% 6.6%
Supplies 6.1% 6.6%
Services 6.1% 6.6%
Equipment 6.1% 6.6%
If the recipient does not want to rely on the applicable State's MBE/WBE goals, the recipient agrees
to submit proposed MBE/WBE goals based on availability of qualified minority and women-owned
businesses to do work in the relevant market for construction, services, supplies and equipment.
"Fair share"objectives must be submitted to Maurice Velasquez within 30 days of award and
approved by EPA no later than 30 days thereafter.
(b) Ensure to the fullest extent possible that at least the FY1999/2000 "fair share"objective of
Federal funds for prime contractors or subcontracts for supplies, construction, equipment or services
are made available to organizations owned or controlled by socially and economically disadvantaged
individuals, women and historically black colleges and universities.
(c) Include in bid documents"fair share"objectives of 1999/2000 fair share percentage [see a)
above] and require all of its prime contractors to include in their bid documents for subcontracts the
negotiated fair share percentages.
(d) Follow the six affirmative steps stated in 40 CFR 30.44(b)40 CFR 31.36(e), 35.3145(d), or
35.6580, as appropriate.
(e) For assistance awards for continuing environmental programs and assistance awards with
institutions of higher education, hospitals and other non-profit organizations, submit an EPA Form
5700-52A, "MBE/WBE Utilization Under Federal Grants, Cooperative Agreements and Interagency
Agreements"to the EPA Award Official by October 30 of each year. Other program reports must be
submitted to the award official within 30 days of the end of the Federal fiscal quarter(January 30,
April, July 30 and October 30).
(f)In the event race and/or gender neutral efforts prove to be inadequate to achieve a fair share
objective for MBE/WBEs, the recipient agrees to notify EPA in advance of any race and/or gender
conscious action it plans to take to more closely achieve the fair share objective.
Programmatic Conditions
1. The recipient must submit an annual Performance/Progress Report within 90 days after the reporting
period and a final report within 90 days after the expiration or termination of grant support in accordance
with 40 CFR Part 31.40 (b) (2).
Ff United States
\ � Environmental Protection Agency
• EPA Project Control Number
•
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS,
LOANS. AND COOPERATIVE AGREEMENTS
the undenigued certifies, .,the best of his or her knowledge and he lief, that:
(I) No Federal appropriated funds have been paid or will be paid,by or on behalf of the
undersigned,to any person for influencing or attempting to influence an oft cer or
employee of any agency,a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant,the making of anyFederal loan.the
entering into of any cooperative agreement, and the extension,continuation.renewal,
amendment,or modification of any Federal contract, grant, loan,or cooperative
agreem ent.
• (2) If any funds other than Federal appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any
agency, a Member of Congress in connection with this Federal contract, grant, loan.or
cooperative agreement.the undersigned shall complete and submit Standard Form-
LLL."Disclosure Form to Report Lobbying." in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the
award documents for all sub-awards at all tiers (including sub-contracts, sub-grants.
and contracts under grants, loans.and cooperative agreements) and that all sub-
recipients shall certify and disclose acc ordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for
•
making or entering into this transaction imposed by section 1352. title 31 U.S. Code. Any
person who fails to file the required certification shall be subject to a civil penalty of not less
than SI0,000 and not more than 5100,000 for each such failure.
Mark E. Wallace, MD, MPH, Director
Typed Name&Titlmf Authorizedr ���Repre^^^sern .ve
I n �/ \\/) (D ) L 0 t(
Signature o(Authorized Representative Date
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OMB Approval No.0346-0040
ASSURANCES - NON-CONSTRUCTION PROGRAMS
blic reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
ions, searching existing data sources, gathering and maintaining the data needed,and completing and reviewing the collection of
„ation. Seno comments regarding the buroen estimate or any other aspect of this collection of information, including suggestions for
ucing this burden,to the Office of Management and Budget, Paperwork Reduction Project (0346-0040),Washington,DC 20503.
_EASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
END IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
awarding agency. Further, certain Feoeral awarding agencies may require applicants to certify to additional assurances. If such
is the case,you will be notified.
the duly authorized representative of the applicant, I certify that the applicant:
1. Has the legal authority to apply for Federal assistance
Act of 1973, as amended (29 U.S.C. §794), which
and the institutional, managerial and financial capability prohibits discrimination on the basis of handicaps; (d)
the Age Discrimination Act of 1975, as amended (42
of p project funds nsure to pay the nng management an share U.S.C. §§6101-6107), which prohibits discrimination
of cost) 10 ensure piupef planning, Office arid and completion of the project described in this on the basis of age; (e) the Drug Abuse ---
application.
Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug
2. Will give the awarding agency, the Comptroller General
abuse; (f) the Comprehensive Alcohol Abuse and
of the United Stales and, if appropriate, the Elate, Alcoholism Prevention, Treatment and Rehabilitation
through any authorized representative, access to ant Act of 1970 (P.L. 91-616), as amended, relating to
the right to examine all records, books, papers, or nondiscrimination on the basis of alcohol abuse or
documents related to the award; and will establish a alcoholism; (g) §&523 and 527 of the Public Health
proper accounting system in accordance with generally Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee
3), as amended, relating to confidentiality of alcohol
accepter accounting standards or agency directives. and drug abuse patient records: (h) Title VIII of the
a. Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
Will esteblish safeguards to prohibit employees from amended, relating to nondiscrimination in the sale,
using their positions for a purpose that constitutes or other
presents the appearance of personal or organizational rental or financing of housing; (i) any
conflict of interest, or personal gain. nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
mace; and, (j) the requirements of any other
4. Will initiate and complete the work within the applicable nondiscrimination statute(s) which may apply to the
time
frame after receipt of approval of the awarding
agency. application.
Will comply with the Intergovernmental Personnel Act of 7. Will comply, or has already complied, with the
1970 (42 U.S.C. §§472E-4763) relating to prescribec requirements of Titles II and III of the Uniform
standares for merit systems for programs funded under Relocation Assistance and Real Property Acquisition
one of the 19 statutes or regulations specified in Policies Act of 1970 (P.L. 91-646) which provide for
Appendix A of OPM's Standards for a Merit System of fair and equitable treatment of persons displaced or
Personnel Aoministration(5 C.F.R. 900, Subpart Fl. whose propeny is acquired as a result of Federal or
federally-assisted programs. These requirements apply
to all interests in real property acquired for project
6. Will n comply with all Feouderal bustt
e o:to regardless of Federal participation in
nondiscrimination. These include but are not limited wc: purposes
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) purchases.
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education 6. Will comply, as applicable, with provisions of the
Amenaments of 1972, as amended (20 U.S.C. §§1661- Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328)
1683, and 1685-1686),which prohibits discrimination on which limit the political activities of employees whose
the basis of sex; (c)Section 504 of the Rehabilitation principal employment activities are funded in whole or
in part with Federal funds. •
Standard Form 474E(Rev.7.97)
aides Edition Usable
Authorized for Local Reproduction Prescribed by OMB Circular A-102
•
9. Will comply, as applicable, with the provisions of the Davis- 12. Will comply with the Wild and Scenic Rivers Act of
Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act 1968 (16 U.S.C. §§1271 et seq.) related to protecting
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract components or potential components of the national
Work Hours and Safety Standards Act (40 U.S.C. §§327- wild and scenic rivers system.
333), regarding labor standards for federally-assisted
construction subagreements. 13. Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
0. Will comply, if applicable, with flood insurance purchase Act of 1966, as amended (16 U.S.C. §470), EO 11593
requirements of Section 102(a) of the Flood Disaster (identification and protection of historic properties), and
Protection Act of 1973 (P.L. 93-234) which requires the Archaeological and Historic Preservation Act of
recipients in a special flood hazard area to participate in the 1974 (16 U.S.C. §§469a-1 et seq.).
program and to purchase flood insurance if the total cost of
insurable construction and acquisition is$10,000 or more. 14. Will comply with P.L. 93-346 regarding the protection of
human subjects involved in research, development,and
1. Will comply with environmental standards which may be related activities supported by this award of assistance.
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National 15. Will comply with the Laboratory Animal Welfare Act of
Environmental Policy Act of 1969 (P.L. 91-190) and 1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et
Executive Order (EO) 11514; (b) notification of violating seq.) pertaining to the care, handling, and treatment of
73
facilities pursuant to EO 11736; (c) protection of wetlangs warm blooded animals held for research, ieadiiiny, ui
pursuant to EO 11990; (d) evaluation of flood hazards in other activities supported bythis award of assistance.
floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management -16. Will comply with the Lead-Based Paint Poisoning
program ceveloped under the Coastal Zone Management Prevention Act (42 U.S.C. §§4801 et seq.) which
Act of 1972 (16 U.S.C. §§1451 et seq.); (1) conformity of prohibits the use of lead-based paint in construction or
Federal actions to State (Clean Air) Implementation Plans rehabilitation of residence structures.
under Section 176(c) of the Clean Air Act of 1955, as
amended (42 U.S.C. §§7401 et seq.); (g) protection of 17. Will cause to be perlormed the required financial and
unoerground sources of drinking water under the Sale compliance audits in accordance with the Single Audit
Drinking Water Act of 1974, as amended (P.L. 93-523); .Act Amendments of 1996 and OMB Circular No. A-132,
and, (h) protection of endangered species under the "Audits of States, Local Governments, and Non-Profit
Encangered Species Act of 1973, as amended (P.L. 93- Organizations."
205).
18. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies.
governing this program.
'JURE OF AUTHORIZE CERTIF OFF IAL TITLE
Ij -c / (reth
CANT ORGANIZATION DATE SUBMITTED
Standard Form 4248 (Sew.7-97) Back
•
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Washington,DC 20460 FORM Approved
0% Preaward Compliance Review Report for OMB No.2030-0020
N Al)Applicants Requesting Federal Financial Assistance Expires 12-31-05.
Note: Read instructions before completing form.
1. A. Applicant(Name,City,State) B. Recipient(Name,City,State) C. EPA Project No.
•
Weld County Health Dept. Weld County Health Dept.
1555 N 17th Ave. 1555 N 17th Ave.
Greeley, CO 80631 Greeley, CO 80631
II. Brief description of proposed project,program or activity.
•
Implementation of the Wee Weezer asthma education program for preschools
111. Arc any civil rights lawsuits or complaints pending against applicant and/or recipient? If Yes No
No
yes,list those complaints and the disposition of each complaint.
IV. Have any civil rights compliance reviews of the applicant and/or recipient been conducted
by any Federal spency during the rwo year;prior to this application for activities which would Yes X No
receive EPA assistance? If yes, list those compliance reviews and status of each review: ---'—
V. Is any other Federal financial assistance being applied for or is any other Federal financial
assistance being applied to any portion of this project,program or activity? If yes,list the other X Yes El No
Federal Agency(s),describe the associated work and the dollar amount of assistance.
VI. If entire community under the applicant's jurisdiction is not served under the existing facilitiesiservices,or will not be
served under the proposed plan,give reasons why.
Focus is on the greater Greeley area.
VII Population Characteristics Number of People
•
1. A. Population of Entire Service Area 95,000
B. Minoriry Population of Entire Service Area 28 Of10
2. A. Population Currently Being Served 95,000
B. Minority PopulationCunently Being Served R8 'S00
3. A. Population to be Served by Proieet,Program or Activity 180
_ B. Minority Population to be Served by Project.Program or Activity . 5!
4. A. Population to Remain Without Service 60
B. Minority Population to Remain Without Service 50
VII. Will all new facilities or alterations to existing facilities financed by these.funds be X
designed and constructed to be readily accessible to and usable by handicapped persons? If-no, Yes No
explain how a regulatory exception(40 CFR 7.70)applies.
IX. Give the schedule for future projects,programs or activities f or of future plans),by which services will be provided to all
beneficiaries within applicant's jurisdiction. If there is no schedule,explain why.
Relies upon future funding
X. I certify'that the statements 1 have made on this corm and all attachments thereto arc true,accurate and complete. 1
acknowledge that any knowingly false or misleading statement may be punishable by fine or imprisonment or both under
applicable law.
A. Signature o horiz f I B. Title of Authorized Official 1 C. Date
r
r.For the U.S.Environmental Protection Agency
9 Approved Disapproved Authorized EPA Official Date
EPA Form 4700-4 (Rev. 1/90)Previous editions are obsolete.
;etructions for EPA FORM 4100-9 (Rev. 1/90) ITEMS
•
General Ih. "Applicant" means any entity that files
an application or unsolicited proposal or
tcipients of Federal financial assistance otherwise reeuests EPA assistance.
iom the U.S. Environmental Protection Agency
'st comply with the following statutes . IE. "Recipient" means any entity, other
than applicant, which will actually
:tae VI of the Civil Rights Acts of 3964 receive EPA assistance.
-ovides that no person in the United States
;all, on the grounds of race, color, or IC. Self-explanatory.
tional origin, be excluded from
rticipation in, be denied the benefits of, II . Self-explanatory.
• be subjected tc discrimination under any
ocram or activity receiving Federal III . "Civil rights lawsuits' means any
nancial assistance. lawsuit or complaint alleging
e Act noes on to explain that the title discrimination on the basis of race,
all not be construed to authorize action color, national origin, sex, age, or
th respect to any employment practice of any handicap pendino against the s licant
and/or pleyer, employment agency, or labor be
aanization (except where the primary entity, which actually if benefits
iective of the Federal financial assistance from the c aapt. For le a city is
tc provide employment) . the named applicant but the grant will
actually benefit the Department of
,- oe _the '972 Amendments Srth. Sewage, civil rights lawsuits involving
ct'°-r both the city and-t_he._nepa.rtment..laf _ __
deral water Pollution Control Act provides Sewage should be listed.
at no person in the United States shall on
e cround of sex, be excluded from. - IV. "Civil richts compliance review" means
rticipation in, be denied the benefits of , any review assessing the .applicant and/or
be subjected tc discrimination under the recipient's compliance with laws
ieral water Pollution Control Act, as prohibiting discrimination on the basis
ended. Employment discrimination on the of race, color, national origin, sex,
?is of sex is prohibited in all such ace, or handicap. If any part of the
'grams or activities . review covered the entity, which will
• actually benefit from the grant, it
-Lion 504 of The Rehabilitation Act of 1971 should be listed.
;vides that no otherwise qualified
'disarmed individual shall solely by reason v. Self-explanatory.
handicap be excluded from participation in,
denied the benefit of, or be subjected tc VI . The word "community" refers to the area
cramination under any prooram or activity under the applicant and/or recipient's
eivino Federal financial assistance . jurisdiction. The "community" might be loyment discrimination on the basis of a university or laboratory campus, or a
dicap is prohibited in all such procrams or community within a large cif If there
ivities. is significant disparity between minority
Ace Discrimination Act of 1975 provider and nonminority populations to receive
P service, not otherwise satisfactorily
t no person on the basis of age shall be explained, the Regional office may
luded from participation under any prooram require a map, which indicates the
activity receiving Federal financia: minority and nonminority population
istance. Employment discrimination is not served by this project, program or
=red. Age discrimination in employment is activity.
aibited by the Age Discrimination in
ioyment Act administered by the VII . This information is required so that
;1 Employment Opportunity Commission. reviewers may determine if a disparity in
the proposed provision of services will
.e IX of the Education Amendments of 197:
exist in the event the application is
rides that no person on the basis of sex approved for funding. Give population of
I be excluded from participation in, be recipient's jurisdiction, broken out by
ed the benefit of, or be subjected tc categories as specified.
-rimdnation under any education prooram or
vity receiving Federal financial In the event the applicant cannot provide
stance. Employment discrimination on the the requested information because the funds
s of sex is prohibited in all such will be distributed over a wide demographic
ation procrams or activities. Note: ar._ area, which is yet to be determined, .an
ation procram or activity is not limited explanation may be provided on a separate
my those conducted by a formal sheet. For Example, a State applying for a
itution. P capitalization grant under the State Revolving Fund program may not know which
information on this form is required tc cities and counties will apply for, and le the U.S. Environmental Protection receive, SRF loans.
ry to determine whether applicants and
aective recipients are developinc III . Self-explanatory.
ects, programs and activities on a
iscriminatory basis as required
by the IX. "Jurisdiction" means the geographical
statutes. area over which applicant has the ,
t this form with the original and authority to provide service.
•
•
rewired copies of applications, requests for X. Self-explanatory.
extensions, requests for increase of funds, 'Burden Disclosure Statement•
etc. Updates of information are all that are
required after the initial application EPA estimates public reporting burden for the
submission. preparation of this form to average 30 minutes
if any item 1E not relevant to the project for per response. This estimate includes dinad
the time
which assistance is requested, write "NA' revii the datfor a needed
instructions, gathering ha d and
for Not Applicable." mornreviewinc the form. Send comments regarding the
in the event applicant is uncertain about how burden estimate, including suggestions for
to answer certain questions, EPA program reducingr th this
s,burden, tU.Chief, Infor ation
clarifica should be contacted for Policy Protection Agency, 401 M Street, S.W. ,
clarification. Washington, D.C. 20460; and to the Office of
Information and Regulatory Affairs, Office of
Manacement and Eudoet, Washington, D.C. 20E03.
•
Yt =rAa
I A 04. Non-Profit Organization Certification
• zzttia Regarding Internal Revenue Code of 1986
a PnoSEC•`
In order to comply with government-wide restrictions on lobbying activities for
_r.. and educational instintrinnc all non-profit
non-wont u,;�,,..�........ ...... .._...------, -- organizations
who apply for financial assistance with the U.S. Environmental Protection Agency,
Region VD, must cenify the following (check the appropnate block):
❑ It is not a nonprofit organization described in Section 501(c)(4) of the Internal
Revenue Codeof 1986; or
It is a non-profit organization described in Section 501(c)(4) of the
Internal Revenue Code of 1986 but does not, and will not, engage in
lobbying activities as defined in Section 3 of the Lobbying Disclosure
Act of 1995.
El It is anon-profit organization described in Section 501(c)(4) of the
Internal Revenue Code of 1986 who engages in lobbying activities
as defined in Section 3 of the Lobbying Disclosure Act of 1995.
Weld County is a subdivision of the State of Colorado.
Mark E. Wallace, MD, MPH, Director
Typed Name & Title of Authorized Representative
kAA-Cijk- Vl, r C4 (6-1-1—of
Signature of Authorized Representative Date
ADDITIONAL APPLICATION 7ORMATTON
Authorized Repreentstive
Robert Masden
(Name)
Chair, Board of County Commissioners
(Title)
970-"l5Fi-Goon pvt / 'na Fay. 970-357-07L9
(Telephone and FAX Number)
rmacden(cn weld rn ns
(E-Mail Address)
Administrative Contact
Mark Wallace. MD. MPH
.._. ......
(frame)..
Executive Director Weld County Department of Public Health
(Title)
970-3Q4-6419. ext-2102 Fax: 970-304-6412
(Telephone and FAX Number)
mwallare@co.weld.co.us
(E-Mail Address)
Fiscal Contact (Tenon responsible for preparing Financial Status Report & Payment Request)
Tudy Nero
(Name)
Business Manager, Weld County Department of Public Health
(Title)
970-6410. ext. 2122 Fax: 970-304-6412
(Telephone and FAX Number)
jnern@co.weld.co.us
(E-Mail Address)
MBE/NBE (Person responsible for preparing the MBE/ BE Utilization Report (EPA Form 5700-52A)
Anna McConnell
(Name)
STEPS to a Healthier Colorado, Asthma Coordinator
• (Title)
970-304-6420, ext. 2350 Fax: 970-304-6416
(Telephone and FAX Number)
amcconnell@co.weld.co.us
(E-Mall Address)
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