HomeMy WebLinkAbout20041449.tiff RESOLUTION
RE: APPROVE TASK ORDER FOR TUBERCULOSIS PROGRAM AND AUTHORIZE CHAIR
TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Task Order for Tuberculosis Program
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment,and the Colorado Department of Public Health and Environment,commencing July 1,
2004, and ending June 30, 2005, with further terms and conditions being as stated in said task
order, and
WHEREAS, after review, the Board deems it advisable to approve said task order, 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 for Tuberculosis Program between the County of Weld,State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Weld County Department of Public Health and Environment,and the Colorado Department of Public
Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said task order.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 19th day of May, A.D., 2004.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY,
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OUNTY,, COLORADO
(1
' 1861 Robert D. Masden, Chair
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1. =.`7 lerk to the Board
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�� i William H rke, Pro-Tern
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Date of signature: S r37-07
2004-1449
HL0031
PO r. Caoalt5) oS_oz0 _6i
Memorandum
age TO: Robert D. Masden, Chair
Board of County Commissioners From: Mark E. Wallace,MD, MPH, Director
COLORADO Department of Public Health and
Environment , Q
DATE: May 17,2004 tIN`4l�5 / J
SUBJECT: Tuberculosis Task Order
Enclosed for Board review and approval is task order between the Colorado Department of
Public Health and Environment and Weld County for the Tuberculosis Program.
Under the provisions of this task order, Weld County Department of Public Health and
Environment (WCDPHE) will provide active TB treatment including directly observed therapy,
ensure contacts to all newly identified infectious TB cases are identified and receive appropriate
evaluation, collect specimens for testing on all persons suspected of having TB, provide for and
interpret chest x-rays, and conduct TB skin test screening programs. Health Department staff
will also follow-up with active patients to ensure they receive appropriate information and
education and they adhere to the completion of their TB therapy.
For providing these services during the time period of July 1, 2004, through June 30, 2005,
WCDPHE will receive an amount not to exceed $52,019.00 plus $12.50 per onsite visit or
$25.00 per field visit for directly observed therapy.
I recommend your approval of this task order.
Enclosure
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2004-1449
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DEPARTMENT OR AGENCY NUMBER
FHA
CONTRACT ROUTING NUMBER
05-00017
TASK ORDER
Tuberculosis Program
This Task Order is made this 21st day of April,2004,by and between:the state of Colorado,acting by and through
the COLORADO 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,the BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY (a
political subdivision of the state of Colorado) whose address or principal place of business is 915 10th Street,
3rd Floor,Greeley,Colorado 80631 for the use and benefit of the Weld County Department of Public Health
and Environment,whose address or principal place of business is 1555 North 17th Avenue,Greeley,Colorado
80631,hereinafter referred to as "the Contractor".
FACTUAL RECITALS
The State,in order: to carry out its lawful powers,duties, and responsibilities under Section,25-4-50,18 C.R.S.,as
amended;and,to effectively utilize legislative appropriations made and provided therefore,in coordination with like
powers,duties,and responsibilities of the Contractor,has determined that public health services are desirable in
WELD COUNTY,Colorado.
'ursuant to 25-4-501, 8 C.R.S.,as amended,the General Assembly has declared that tuberculosis is an infectious
and communicable disease,that it endangers the population of this state,and that the treatment and control of said
disease is a state responsibility and further,pursuant to 25-4-511, 8 C.R.S.,assistance under section 25-4-501,shall
be given to any applicant who is suffering from tuberculosis in any form requiring treatment and is without
sufficient means to obtain such treatment. The State,through the Tuberculosis Program has a mandate to provide
care coordination services for the residents of the State of Colorado.
Pursuant to the Catalog of Federal Domestic Assistance(CFDA)number 93.116,the State has been awarded funds
by the Department of Health and Human Services,Centers for Disease Control(CDC)for tuberculosis control. The
State shall contract with the Contractor to assure that tuberculosis control services are provided for the residents of
the above-mentioned county.
The State has formulated a comprehensive State plan,with associated budgets,to disburse these funds throughout
the state of Colorado. Under this comprehensive State plan,the State shall allocate these funds to qualified entities
to provide certain purchased services to the citizens of the state of Colorado on behalf of the State.
Section 29-1-201, C.R.S.as amended,encourages governments to make the most efficient and effective use of their
powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide
any function,service,or facility lawfully authorized to each of the cooperating or contracting entities. Section 29-1-
201,C.R.S., as amended,further states that all state of Colorado contracts with its political subdivisions are exempt
from the state of Colorado's personnel rules and procurement code.
Page 1 of 11
The Contractor is a political subdivision of the state of Colorado. The State and the Contractor mutually agree that
the most efficient and effective way to provide the above-described services is at the local level. The State and the
Contractor previously entered into a Master Contract with contract routing number 00 FAA 00008. This Task Order
is issued pursuant to the terms and conditions of that Master Contract.
As to the State, authority exists in the Law and Funds have been budgeted,appropriated,and otherwise made
available,and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment
in Fund Code(s)100 Organizational Unit Code(s)4644,4645,and 4648 Appropriation Code(s)386 Program
Code(s)9012,Function Code(s)GFND and Object Code(s)5420 2710 under Contract encumbrance number
PO FHA EPI05000001 and PO FHA EPI0500017. All required approvals,clearances,and coordination have been
accomplished from and with all appropriate agencies.
NOW,THEREFORE,in consideration of their mutual promises to each other,stated below,the parties hereto
agree as follows:
A. PERIOD OF PERFORMANCE AND TERMINATION. The proposed effective date of this Contract is
July 1,2004. However, in accordance with section 24-30-202(1),C.R.S.,as amended,this Contract is not
valid until it has been approved by the State Controller,or an authorized designee thereof. The Contractor
is not authorized to,and shall not,commence performance under this Contract until this Contract has been
approved by the State Controller. 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 Contract. If the State Controller approves this Contract on or before its proposed effective date,then
the Contractor shall commence performance under this Contract on the proposed effective date. If the State
Controller approves this Contract after its proposed effective date,then the Contractor shall only commence
performance under this Contract on that later date. The initial term of this Contract shall commence on the
effective date of this Contract and continue through and including June 30,2005 unless sooner terminated
by the parties pursuant to the terms and conditions of this Contract. In accordance with section 24-103-
503, C.R.S., as amended,and Colorado Procurement Rule R-24-103-503,the total term of this Contract,
including any renewals or extensions hereof, may not exceed five(5)years.
B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR.
1. Funds provided under this Task Order are to assist in supporting tuberculosis(TB)prevention and
control activities as stated in section 25-4-501,et seq.,C.R.S.,as amended,and"Rules and
Regulations Pertaining to Epidemic and Communicable Disease Control"(6-CCR-1009-1,Regulation
4). The Contractor shall provide or coordinate the following services for all individuals within its
service area according to the statutes and regulations listed above and the CDPHE's Tuberculosis
Manual. In no event,however,shall the Contractor provide less duties than those required by the
above-referenced statutes and regulations. The Contractor's use of funds under this Task Order shall
be prioritized as follows: priority 1)fmd all people with active TB in its service area and ensure the
completion of appropriate therapy for those people;priority 2)find and evaluate the contacts of TB
patients and ensure the completion of appropriate therapy,if needed;priority 3)targeted testing of
high-risk persons and ensure the completion of therapy for latent TB infection(LTBI),if needed. If a
patient has medical insurance, then the Contractor shall utilize that patient's medical insurance as the
primary payment source before using funds provided under this Task Order.
a. Suspected or Confirmed Active TB
1. The Contractor shall provide,or arrange for, chest x-rays and interpretations.
Page 2 of 11
2. The Contractor shall collect,or arrange for the collection of,specimens for mycobacteriology
testing on all persons suspected of having tuberculosis. Assure appropriate testing is
performed,e.g.,smears for acid-fast bacilli,(using concentrated fluorescent method),
isolation of mycobacteria(using rapid methods),identification of MTB(using rapid methods),
and susceptibility testing(isoniazid,rifampin,ethambutol,and pyrazinamide)on isolates of
MTB. The CDPHE Laboratory will,at no charge to the Contractor, supply specimen
containers and perform the above testing for the Contractor. The Contractor shall arrange for
the transportation of the specimens to the CDPHE Laboratory for testing.
3. The Contractor shall provide,or arrange for,the placement of patients who require isolation.
The Contractor shall contact CDPHE TB Program for assistance,if needed,and to request
reimbursement from CDPHE for those costs incurred by the Contractor in isolating a patient.
4. The Contractor shall provide,or arrange for,all other necessary laboratory testing and
medical evaluation services.
5. The Contractor shall order TB medications through the CDPHE TB Program.
6. The Contractor shall provide the CDPHE with the medical insurance information for those
patients who have medical insurance.
7. The Contract shall provide,or arrange for,the treatment of patients with suspected or
confirmed active TB,including directly observed therapy,and ensure that all patients with
suspected or active TB complete therapy for all reported cases.
8. The Contractor shall provide,or arrange for,a HIV antibody test for all persons diagnosed
with TB disease,regardless of their age or the apparent absence of risk factors for HIV
infection. In accordance with section 25-4-1401,et seq.,C.R.S.,as amended,the Contractor
shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform
those individuals whom refuse testing of the risks associated with HIV/TB co-infection.
9. At least monthly,the Contractor shall monitor and evaluate those persons with suspected or
confirmed active TB.
10. The Contractor shall provide culturally appropriate patient education and information
pertaining to TB treatment and/or follow-up plan.
11. All reports of suspected or confirmed active TB shall include the: reason for initiating,patient
name,date of birth, country of birth,demographics,locating information,provider
information,TB risk factors,results of diagnostic testing,results of mycobacteriology
including susceptibility results,dates of infectious period,treatment information,changes in
patients'status,diagnosis,or any other information as appropriate. The Contractor shall
report to CDPHE when a TB patient completes treatment,moves,or transfers out of the
Contractor's service area. Information may be reported via web-based TB case/contact
management system(TBdb)or via"Tuberculosis Surveillance and Case Management Report"
(TB 17),which is incorporated herein by this reference,made a part hereof,and attached
hereto as"Attachment A". Confirmed cases of TB shall include all data elements identified
in the "Report of Verified Case of Tuberculosis(RVCT)",which is incorporated herein by
this reference,made a part hereof,and attached hereto as"Attachment B"). The CDPHE
shall provide the format and instructions for any additional information requests.
Page 3 of 11
b. Contacts to Newly Identified Infectious TB(smear and/or culture positive pulmonary of laryngeal)
1. The Contractor shall ensure that all contacts to newly identified infectious TB cases are
identified,investigated,and receive appropriate evaluation. Contact investigation and any
follow-up needed as a result of an occupational exposure shall be conducted by the employer.
2. When indicated,the Contractor shall provide,or arrange for,chest x-rays and interpretations.
3. When indicated,the Contractor shall provide,or arrange for,other laboratory testing,and
other necessary medical evaluation services.
4. The Contractor shall provide, or arrange for,the treatment(including directly observed
preventive therapy when appropriate),and ensure the completion of therapy for infected
contacts.
5. The Contractor shall order TB medications through the CDPHE TB Program.
6. The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
7. The Contractor shall provide,or arrange for,an HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401,et
seg.,C.R.S.,as amended,the Contractor shall report all known HIV antibody test results to
the State. The Contractor shall inform all Individuals whom refuse testing of the risks
associated with HIV/TB co-infection.
8. At least monthly,the Contractor shall monitor and evaluate persons with LTBI during
treatment.
9. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan.
10. The Contractor shall submit a preliminary Contact Investigation Report,which is incorporated
herein by this reference,made a part hereof,and attached hereto as"Attachment C")to the
CDPHE TB Program after initiation of each contact investigation. The Contractor shall
submit a final report to CDPHE when a contact investigation is completed.
11. Reports for those persons identified,as part of a contact investigation,with latent TB
infection,or those with suspected latent TB infection requiring treatment recommendations
from the CDPHE shall include:reason for initiating,patient name,date of birth,country of
birth,demographics,locating information,provider information,TB risk factors,results of
diagnostic testing,treatment information,or any other information as appropriate. The
Contractor report to CDPHE when a LTBI patient completes treatment,moves, or transfers
out of the Contractor's service area. Information may be reported via web-based TB
case/contact management system(TBdb)or via"Tuberculosis Surveillance and Case
Management Report" (TB 17). The CDPHE shall provide format and instructions for any
additional information requests.
c. High-Risk Persons with LTBI
1. When indicated,the Contractor shall provide,or arrange for,chest x-rays and interpretations.
2. When indicated,the Contractor shall provide,or arrange for,all other necessary laboratory
testing and medical evaluation services.
Page 4 of 11
3. The Contractor shall provide,or arrange for,the treatment(including directly observed
preventive therapy when appropriate),and ensure the completion of therapy.
4. The Contractor shall order TB medications through the CDPHE TB Program.
5. The Contractor shall provide the CDPHE with the medical insurance information for those
patients that have medical insurance.
6. The Contractor shall provide,or arrange for,a HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401,et
seq.,C.R.S.,as amended,the Contractor shall report all known HIV antibody test results to
the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks
associated with HIV/TB co-infection.
7. At least monthly,the Contractor shall monitor and evaluate persons with LTBI during
treatment.
8. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan.
9. Reports of persons with LTBI shall include the:reason for initiating,patient name,date of
birth,country of birth,demographics,locating information,provider information,TB risk
factors,results of diagnostic testing,treatment information, or any other information as
appropriate. Contractor shall report when a LTBI patient completes treatment,moves,or
transfers out of the jurisdiction. Information may be reported via web-based TB case/contact
management system(TBdb)or via"Tuberculosis Surveillance and Case Management Report"
(TB 17). The CDPHE shall provide format and instructions for any additional information
requests.
10. Tuberculin skin testing,chest x-rays,and chest x-ray interpretations are not eligible for
reimbursement under this Task Order for the following:
i. Correctional facility inmates;
ii. Persons,other than Class A or B TB immigrants,undergoing immigration
medical examinations;
iii. Paid or volunteer employees of health care facilities,long-term care
facilities,drug treatment centers,correctional facilities,shelters,schools,or
child care facilities who undergo skin testing as part of a routine
employment skin testing program.
Page 5 of 11
d. Class A or B TB Immigrants
The CDPHE TB Program shall immediately notify the Contractor of all newly arrived Class A or
B TB immigrants to the county via a CDC 75.17 form,which is incorporated herein by this
reference,made a part hereof, and attached hereto as"Attachment D". Within thirty(30)
calendar days of the Contractor's receipt of written notification from the CDPHE of the arrival of
a Class A or B immigrant,the Contractor shall contact that immigrant and conduct a TB screening
including a tuberculin skin test,provide or arrange for,sputum collection and testing for acid-fast
bacilli x 3,and chest x-ray. The Contractor shall provide appropriate follow-up for an identified
immigrant and, complete and return the CDC 75.17 form for an identified immigrant to the
CDPHE.
e. TB Education and Consultation
As needed,the Contractor shall provide consultation services to providers in its service area
regarding TB reporting,screening,treatment,and follow-up.
f. Reports for contract monitoring
The Contractor shall provide the CDPHE with a semi-annual report on TB activities in its service
area. A sample of the semi-annual report is incorporated herein by this reference,made part
hereof,and attached hereto as"Attachment E".
1. July I,2004,through December 31,2004-due January 31,2005;and,
2. January 1,2005,through June 30,2005-due July 31,2005.
g. Tuberculosis Response Plan
The CDPHE TB Program shall implement a Tuberculosis Response Plan in the event a county
experiences an exceptional TB circumstance(which is described in the Tuberculosis Response
Plan,which is incorporated herein by this reference,made a part hereof,and attached hereto as
"Attachment F". The Tuberculosis Response Plan provides for the assessment of additional TB
response activities, in collaboration with local public health authorities,to ensure comprehensive
and prompt response to the situation.
h. Confidentiality
The Contractor shall maintain internal medical and administrative records in a manner which
ensures the confidentiality and security of those records in accordance with all applicable statutes
including,but not limited to, 25-1-107, C.R.S., as amended.
Page 6 of 11
C. DUTIES AND OBLIGATIONS OF THE STATE.
1. In consideration of those services satisfactorily and timely performed by the Contractor under this
Task Order the State shall cause to be paid to the Contractor a sum not to exceed FIFTY TWO
THOUSAND NINETEEN DOLLARS ($52,019.00)for the initial term of this Task Order. Of
the total fmancial obligation of the State referenced above, $4,358.00 are identified as attributable
to a funding source of the Untied States government and,$47,661.00 are identified as attributable
to a funding source of the state of Colorado.
Payment pursuant to this Task Order shall be made as earned,in whole or in part, from available
State funds encumbered in an amount not to exceed TWENTY FIVE THOUSAND DOLLARS
($25,000.00)Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2005.
Of the total financial obligation of the State referenced above,one hundred percent is derived
from the State General Fund.The liability of the State,at any time, for such payments shall be
limited to the unencumbered remaining balance of such funds. If there is a reduction in the total
funds appropriated for the purposes of this Contract,then the State,in its sole discretion,may
proportionately reduce the funding for this Contract or terminate this Contract in its entirety.
Description Funding Source Amount
Tuberculosis Control and Outreach State $43,461.00
Tuberculosis Control and Outreach Federal $ 4,358.00
Chest X-Ray State $ 3,600.00
Medical Consultation State $ 600.00
Direct Observed Therapy State As Administered
($12.50 per onsite visit)
($25.00 per field visit)
TOTAL $52,019.00
2. Payments under this Task Order shall be made either through the State's Electronic Fund Transfer
system or,upon the Contractor's periodic submission of a duplicate"Task Order Reimbursement
Statement".
3. If this Task Order requires the Contractor submit a"Task Order Reimbursement Statement",then
the Contractor shall submit a signed, duplicate monthly Task Order Reimbursement Statement
within thirty(30)calendar days of the end of the billing period for which services were rendered.
A sample Task Order Reimbursement Statement is incorporated herein by reference,made a part
hereof,and attached hereto as"Attachment G". Expenditures shall be in accordance with those
items identified in above. These items may include,but are not limited to: the Contractor's
salaries,fringe benefits, supplies,travel,operating, and indirect costs which are allowable and
allocable expenses related to its performance under this Task Order.
Page 7 of 11
Each Task Order Reimbursement Statement shall reference the related Master Contract by its
contract routing number and this Task Order by their respective contract routing numbers. The
contract routing numbers are located on page one of these documents. Each Task Order
Reimbursement Statement shall also indicate the applicable performance dates,the names of
payees;a brief description of the services performed during the relevant performance dates;all
expenditures incurred;and,the total reimbursement requested. Reimbursement during the initial,
or any renewal,term of this Task Order shall be conditioned upon affirmation by the State that all
services were rendered by the Contractor in accordance with the terms of this Task Order. Each
Task Order Reimbursement Statement shall be sent to:
Barb Stone
Tuberculosis Program
Colorado Department of Public Health and Environment
DCEED-A3
4300 Cherry Creek Drive South
Denver,CO 80246
4. The State may prospectively increase or decrease the amount payable under this Task Order
through a"Task Order Change Order Letter"that is substantially similar to the sample Task Order
Change Order Letter that is incorporated herein by this reference,made a part hereof, and attached
hereto as"Attachment H". To be effective,a Task Order Change Order Letter must be:signed
by the State and the Contractor;and,approved by the State Controller or an authorized designee
thereof. Additionally,a Task Order Change Order Letter shall include the following information:
A. Identification of the related Master Contract and this Task Order by their respective
contract routing numbers and affected paragraph number(s);
B. The type(s)of service(s)or program(s)increased or decreased and the new level of each
service or program;
C. The amount of the increase or decrease in the level of funding for each service or
program and the new total financial obligation;
D. A provision stating that the Task Order Change Order Letter is effective upon approval
by the State Controller,or designee,or its proposed effective date,whichever is later.
Upon proper execution and approval,a Task Order Change Order Letter shall become an
amendment to this Task Order. Except for the General and Special Provisions of the Master
Contract,and the Additional Provisions of the Task Order,if any,the Task Order Change Order
Letter shall supersede this Task Order in the event of a conflict between the two. It is expressly
understood and agreed to by the parties that the task order change order letter process may be used
only for increased or decreased levels of funding,corresponding adjustments to service or program
levels,and any related budget line items. Any other changes to this Task Order, other than those
authorized by the task order option to renew letter process described below,shall be made by a
formal amendment to this Task Order executed in accordance with the Fiscal Rules of the state of
Colorado.
If the Contractor agrees to and accepts a proposed Task Order Change Order Letter,then the
Contractor shall execute and return that Task Order Change Order Letter to the State by the date
indicated in that Task Order Change Order Letter. If the Contractor does not agree to and accept a
proposed Task Order Change Order Letter,or fails to timely return a partially executed Task Order
Change Order Letter by the date indicated in that Task Order Change Order Letter,then the State
may,upon written notice to the Contractor,terminate this Task Order no sooner than thirty(30)
Page 8 of 11
calendar days after the return date indicated in the Task Order Change Order Letter has passed.
This written notice shall specify the effective date of termination of that Task Order. If a Task
Order is terminated under this clause,then the parties shall not be relieved of their respective
duties and obligations under that Task Order until the effective date of termination has passed.
Increases or decreases in the level of contractual funding made through the task order change
order letter process during the initial, or renewal,term of a Task Order may only be made under
the following circumstances:
E. If necessary to fully utilize appropriations of the state of Colorado and/or non-
appropriated federal grant awards;
F. Adjustments to reflect current year expenditures;
G. Supplemental appropriations,or non-appropriated federal funding changes resulting in an
increase or decrease in the amounts originally budgeted and available for the purposes of
a Task Order;
H. Closure of programs and/or termination of related contracts or task orders;
I. Delay or difficulty in implementing new programs or services;and,
J. Other special circumstances as deemed appropriate by the State.
5. The State may renew a Task Order through a"Task Order Option to Renew Letter"substantially
similar to the sample Task Order Option to Renew Letter that is incorporated herein by this
reference,made a part hereof,and attached hereto as"Attachment I". To be effective,a Task
Order Option to Renew Letter must be: signed by the State and the Contractor;and, approved by
the State Controller or an authorized designee thereof. Additionally,a Task Order Option to
Renew Letter shall include the following information:
A. Identification of the related Master Contract and that Task Order by their respective
contract routing numbers and affected paragraph number(s);
B. The type(s)of service(s)or program(s),if any,increased or decreased and the new level
of each service or program for the renewal term;
C. The amount of the increase or decrease,if any,in the level of funding for each service or
program and the new total financial obligation;
D. A provision stating that the Task Order Option to Renew Letter is effective upon
approval by the State Controller,or designee,or its proposed effective date,whichever is
later.
Upon proper execution and approval,a Task Order Option to Renew Letter shall become an
amendment to this Task Order. Except for the General and Special Provisions of the Master
Contract, and the Additional Provisions,if any of that Task Order,a Task Order Option to Renew
Letter shall supersede that Task Order in the event of a conflict between the two. It is expressly
understood and agreed to by the parties that the task order option to renew letter process may be
used only to:renew a Task Order;increase or decrease levels of funding related to that renewal;
make corresponding adjustments to service or program levels,and,adjust any related budget line
items. Any other changes to a Task Order,other than those authorized by the task order change
order letter process described above,shall be made by a formal amendment to a Task Order
executed in accordance with the Fiscal Rules of the state of Colorado.
Page 9 of 11
If the Contractor agrees to and accepts a proposed Task Order Option to Renew Letter,then the
Contractor shall execute and return that Task Order Option to Renew Letter to the State by the
date indicated in that Task Order Option to Renew Letter. If the Contractor does not agree to and
accept the proposed renewal term,or fails to timely return a partially executed Task Order Option
to Renew Letter by the date indicated in that Task Order Option to Renew Letter,then the State
may,upon written notice to the Contractor,terminate this Task Order no sooner than thirty(30)
calendar days after the return date indicated in the Task Order Option to Renew Letter has passed.
This written notice shall specify the effective date of termination of that Task Order. If a Task
Order is terminated under this clause,then the parties shall not be relieved of their respective
duties and obligations under that Task Order until the effective date of termination has passed.
6. All Attachments or exhibits to this Task Order are incorporated herein by this reference and made
a part hereof as if fully set forth herein. If a conflict or inconsistency is found to exist between the
terms and conditions of this Task Order and those of any Attachment or exhibit hereto,then the
terms and conditions of this Task Order shall control.
Page 10 of II
IN WITNESS WHEREOF, the parties hereto have executed this Task Order as of
the day first above written.
CONTRACTOR: STATE:
BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO
OF WELD COUNTY Bill Owens,Governor
(a political subdivision of the state of Colorado)
for the use and benefit of
WELD COUNTY DEPARTMETN OF PUBLIC
HEALTH AND ENVIRONMENT`By: eta 1 J D By: 1
Name: R bert D. Masden For the Executive Dir or
Title: Chair DEPARTMENT OF LIC HEALTH
FEIN: 846000813 AND ENVIRONME
Date: 05 1' t t �ra�.r Date: L -(A-0°I
Zia
Mai❑Ij •�< •:'us � PROGRAM APPROVAL:
�l
By: / A�®_ �_\ By: ((-
r i •`c a c
City,City and ounty, �T•••r�� U
Special District,or Town Clerk or ivalent
APPROVALS:
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:
Arthur L.Barnhart
WELD COUNTY DEPARTMENT OF
P ,C UEAI TH 4Ni ENVIRO'iMENQ By: A/�✓/�� Q
BY: Otat Date: G —7 ,o 7
Maik E. Wallace. M%. MPH-Director
Page 11 of 11
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT
Colorado Department of Public Health and Environment
6(1F Tuberculosis Program
*
4300 Cherry Creek Drive South
M: DCEED-TB-A3
y
k.,,,rp'. Denver,Colorado 80248-1530 ATTACHMENT#
"!et"c�` (303)692-2638 phone (303)691-7749 fax
DEMOGRAPHICS LOCATING INFORMATION
Last Name First Name MI Current Home Address (Number&Street Name) Apt#
/ / Gender: O Male
Date of Birth O Female
City State Zip Code County
Race:O American Ethnicity: O Not Hispanic/Latino
Indian/Alaskan ❑ Hispanic/Latino
O Asian
O Black/African Country O United States Other Address (Number&Street Name) Specify Type
American of Birth: O Mexico
O Native O
Hawaiian/Other Specify other
Pacific Is. Date City State Zip Code County
❑ White Arrived in US: /
❑ Unknown Month/Year
( ) ( )
Home Phone Number Other Phone Number Specify Type
Employer
Occupation: O Health care worker O Unknown ( )
❑ Corrections employee O Other Work Phone Number
❑ Migrant farm worker
❑ Unemployed past 24 months Specify other
CASE INFORMATION
Current — No TB exposure, not infected ■ TB,clinically active
/ / / / Classification: O TB exposure, no evidence of infection ❑ TB, not clinically active
Date Initiated Date Reported O Latent TB infection, no disease O TB suspect
Local Health Agency(LHA) PCP/Clinic Name
LHA Address (Number&Street Name) PCP/Clinic Address (Number&Street Name)
LHA City LHA State LHA Zip Code PCP City PCP State PCP Zip Code
( ) ( )
LHA Phone Number PCP Phone Number
TUBERCULIN SKIN TEST(TST)
TST Type: • Mantoux-Tubersol Reason NB notification-immigrant • Source case investigation
❑ Mantoux-Aplisol For Test: O NB notification-refugee O Suspect case
❑ Mantoux-Unspecified O NB notification-status change O Symptomatic
O Tine ❑ Administrative O Targeted testing-individual
❑ Not done O Contact investigation O Targeted testing-specific project
❑ Unknown O Culture positive O Transfer case/suspect
❑ Employment O Unknown
/ / Reading mm O Known active
Date Given Result
Criteria: O No risk factors for TB O HIV Positive
/ / TST Result: O Positive ❑ Recent arrival high prevalence cntry O Recent contact to TB case
Date Read O Negative O Injection drug user O Fibrotic changes on CXR
O Unknown O Resident/employee high risk setting consistent with old TB
❑ Mycobacteriological lab setting O Immunosuppressed patients
/ / O High-risk clinical conditions O Other
Date last Reading mm ❑ Child exposed to adult in high-risk
negative TST category
G:\TBFORMS\Original Forms\TB17 Form.xls revised 2/24/04
' / /
. Patient Last Name First Name MI Date of Birth
X-RAY FINDINGS
/ / CXR Results ❑ Cavitation ❑ Non-TB abnormality
Date Taken: ❑ Infiltrates El Normal
❑ Pleural disease El Other
MEDICAL HISTORY
Symptoms❑ None Alcohol ❑ Yes HIV ❑ Yes
&Length: El Cough Abuse: El No Test: ❑ No
❑ Hemoptysis O Unknown O Unknown Allergies:
❑ Chest pain
El Weight loss Drug ❑ Injecting HIV O Positive
El Night sweats Abuse: ❑ Noninjecting Result: ❑ Negative Medications:
❑ Urinary ❑ No ❑ Not done
❑ Fever El Unknown El Unknown
❑ Other(specify) / /
HIV Test Date
RISKS AND SPECIAL CONDITIONS
Exposure ❑ None ❑ Resident of long Medical ❑ None O Silicosis
Risks: ❑ Homeless term care facility Risks: O Heart disease ❑ Immunosuppressive
❑ Resident of (if Yes check one) ❑ Diabetes mellitus therapy
correctional facility ❑ Nursing home O Weight loss> 10 lbs ❑ Cancer
(if Yes check one) O Hospital El Gastrectomy El Hepatitis
El Federal prison ❑ Residential O Jejunoileal bypass ❑ Renal failure
❑ State prison O Mental health
❑ Local jail El Alcohol/drug treatment Special ❑ Pregnant EDC / /
❑ Juvenile ❑ Other Conditions: ❑ Postpartum breast feeding
❑ Other ❑ Unknown O Other special conditions
❑ Unknown El TST conversion in last 2 years
TREATMENT
❑ Current treatment / / / /
❑ Past treatment Therapy Start Date Therapy End Date
Treatment Isoniazid mg Reason Therapy O Died
Plan: Rifampin mg Stopped: El Lost to follow-up
Pyrazinamide mg El Moved
Ethambutol mg ❑ Adverse treatment event
Other O Course completed
(Specify) mg El Uncooperative/refused
(Specify) mg ❑ Unknown
El Other
CASE COMPLETION SOURCE INFORMATION
If the person is a contact to an active case
complete information on the source case
Final Case Status: O Closed
❑ Moved away
❑ Lost contact Last Name First Name
❑ Died
O Pending
Current Home Address (Number&Street Name)
If Moved New Address (Number&Street Name) City State Zip Code
/ / to / /
City State Zip Code Relation to Source Exposure Dates
COMMENTS
/ /
Person completing Corm Date
G:\TBFORMS\Original Forms\TB17 Form.xls revised 2/24/04
• ATTACHMENT# j5
A
Patient's Name: REPORT OF VERIFIED CASE
Bean (Finn IM.LI OF TUBERCULOSIS
Street Address:
(Number.Street,City,Stetel Zip Code)
CDC DEPARTMENT OF HEALTH a EAN SERVICES
PUBLIC HEALTH SERVICE
REPORT OF VERIFIED CASE OF TUBERCULOSIS CENTERS FOR DISEASE EA SERVICE
AND PREVENTION(CDC)
(£xlsm FCR M3Faas wNfRtt ATLANTA,GEORGIA 30333
ant FPEVEmWN FORM APPROVED OMB HO.0920-0025 Exp.Date 1131/01
i SOUNDER i [ 1.State Reporting: 2
State Case
Specify: Number:
Alpha State Code City/County
Case Number:
)
3.Date Submitted: By: 4.Address for Case Counting:
Mo. Da y Yr.
Cily
II�II�II Within City Limits 1 L Yes 20 No
5.Month-Year Reported: 6.Month-Year Counted: County
Mo. Yr. Mo. Yr.
Zip Code —
7.Date of Birth: 8.Sex: 9.Race:
Mo. Day Yr. I❑Male
t❑White 2❑ Black 3❑American Indian or Alaskan Native
2 Female
4❑Asian or Pacific Islander:Specify(Optional)
10.Ethnic Origin: 11.Country of Origin: 12.Month-Year Arrived in U.S.: 13.Status at Diagnosis of TB:
If U.S.,check here ❑ ❑
I❑Hispanic Mo.Yr. I Alive
If not U.S.,enter coun-
2❑ Not Hispanic try code(see list) 2 Dead
14. Previous Diagnosis 15.Major Site of Disease: •If site is"Other',
son Miliary
of Tuberculosis: enter anatomic
00 Pulmonary 23❑ Lymphatic:Other 60❑ Meningeal code(see list)
i❑Yes i o❑ Pleural 29❑ Lymphatic:Unknown ?on Peritoneal
2❑ No 21❑Lymphatic:Cervical 30❑ Bone and/or Joint eo❑ Other
22❑ Lymphatic:Intrathoracic 4 o Genitourinary ao❑ Site not Stated
'9 If yes,list year of
previous diagnosis 16.Additional Site of Disease: 'If site is'Other',
enter anatomic
oo❑ Pulmonary 23❑Lymphatic:Other 5 O Miliary s code
(see list)
ion Pleural 29❑Lymphatic:Unknown 60❑ Meningeal
❑ If more than one previous
1 episode,check here 21 p Lymphatic:Cervical 30❑ Bone and/or Joint 7D❑ Peritoneal
If more Than one
2 2 Lymphatic:Intrathoracic 4 O Genitourinary eo❑ Otheradditional site, ❑ae
check here
17.Sputum Smear: 18.Sputum Culture: 19.Microscopic Exam of Tissue and Other Body Fluids:
1❑ Positive 3❑ Not Done i❑ Positive 3❑ Not Done t❑ Positive 3❑ Not Done If positive,enter
2❑ Negative 9❑Unknown 2 Negative a anatomic code(s)
❑ ❑ Unknown 2❑Negative e❑ Unknown (see list)
20.Culture of Tissue and Other Body Fluids: 21.Chest X-Ray:
t❑Positive 3❑Not Done If positive,enter - t❑Normal 2❑Abnormal 3❑Not Done 9❑ Unknown
anatomic code(s)
2❑ Negative 9[11 Unknown (see list)
If Abnormal I❑Cavitary 2❑ Noncavitary 3111] Noncavitary
22.Tuberculin(Mantoux)Skin Test at Diagnosis: (check one) Consistent Not Consistent
with TB with TB
41] Positive 3❑Not Done Millimeters(mm)of
Induration I❑Stable 3 Improving
2 Negative 9❑Unknown If Abnormal
(check one)
If Negative,was patient anergic? I❑ Yes 2 No 9 Unknown 2❑Worsening e❑ Unknown
Pubic reponinq burden of the collection of information is eabmated to average 30 minutes per resp nse,including the time for reviewing bwtructlns,searching existing data sources,gathering and maintavling the data needed d
cmrpl ting anoo0aarrdd 9 Me cdtMgn of inazbrnmetiwl.Ana ey not conduct or in d a person is not required to respo d to a CDC,Project
of intlrmance unless t diH a a R Road,y vD- OMB conbtl number. Send
PRA(092 regarding h .seMnMe male ored rorma 10 Hluec of is collection of intorma ion,including suggestions for reducing this made,.to CDC,Project Clearance Officer.1600 ct,,DOn Ms D24,Atlanta,GA 30333.ATTN:
Intormaon containeedoon this torn'wheh would per it identhication of any ltiWdual has been selected xis a guarantee that it sea be held n strict confidence,will be used only for surveillance purposes,and will not be dacbsed
or released without the consent of the hidividuel n aacccordance with Section 308(d)of the Public Health San's Act(42 U.S.C.242m).
CDC 72.9A REV 12/98 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page I ol 2
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
23. HIV Status: 0❑ Negative 3 Refused 9❑ Unknown 24. Homeless Within Past Year:
1❑ Positive 4❑ Not Offered on No
2❑Indeterminate 5❑Test Done,Results Unknown 1❑Yes
9 Unknown
If Positive,Based on: 1❑Medical Documentation 2❑ Patient History 9❑Unknown
If Positive,List: CDC AIDS Patient Number (II AIDS Reported before 1993)
State HIV/AIDS Patient Number (If AIDS Reported 1993 or Later)
City/County HIV/AIDS Patient Number (If AIDS Reported 1993 or Later)
25. Resident of Correctional Facility at Time of Diagnosis: 0❑No 1❑Yes 9 Unknown
If Yes, 1 Federal Prison 3❑ ❑Local Jail 5 Other Correctional Facility
2❑State Prison 4 Juvencile
Corretional Facility 9❑ Unknown
26. Resident of Long-Term Care Facility at Time of Diagnosis: o No 1❑ Yes 9 Unknown
It Yes, 1❑Nursing Home 4❑ Mental Health Residential Facility 8 Other Long-Term Care Facility
2❑Hospital-Based Facility 5 Alcohol or Drug Treatment Facility 9❑Unknown
3❑ Residential Facility
27.Initial Drug Regimen:
NO YES UNK. NO YES UNK. NO YES UNK.
Isoniazid o❑ t❑ 9❑ Ethionamide o❑ 1❑ 9 Amikacin o❑ 1❑ 9❑
Rifampin o❑ 1 s❑ Kanamycin 9❑ 1 9❑ Rifabutine o❑ 1 E 9 E
Pyrazinamide o❑ 1❑ 9 E Cycloserine o❑ 1 L 9❑ Ciprofloxacin o❑ 1❑ 9❑
Ethambutol o❑ 1❑ 9 Capreomycin o❑ 1❑ 9❑ Ofloxacin o❑ 1 E 9
Streptomycin 0❑ 1 9 Para-Amino on in 9 Other o❑ t❑ 9 E
Salicylic Acid
28. Date Therapy Started: 29. Injecting Drug Use Within Past Year:
Mo. Day Yr.
Fri o❑No 1❑ Yes 9❑ Unknown
30. Non-Injecting Drug Use Within Past Year: 31. Excess Alcohol Use Within Past Year:
op No 1❑Yes 9❑Unknown al]No 1D Yes 9[1 Unknown
32. Occupation (Check all that apply within the past 24 months):
1❑ Health Care Worker z❑Correctional Employee 3❑Migratory Agricultural Worker 5❑Not Employed within Past 24 Months
4❑Other Occupation 9❑ Unknown
Comments:
[
CDC T2.9A REV 12/98 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2 of 2
Patients Name: REPORT OF VERIFIED CASE
(Lab) (Fir.q OF TUBERCULOSIS
Street Address:
(Number.Street,City,Stele) zip Cade)
DEPARTMENT OF HEALTH&HUMAN SERVICES
CDC PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL
REPORT OF VERIFIED CASE OF TUBERCULOSIS AND PREVENTION(CDC)
CEereRSFOR DISEASE C fad ATLANTA,GEORGIA 30333
.VIOPAEVENRON
FORM APPROVED OMB NO.0920.0020 Exp.Deb 12/31/01
Initial Drug Susceptibility Report (Follow Up Report — 1)
C SOUNDE% ) [ State Reporting: Year
Counted: State Case
Specify: Number:
Alpha State Code City/County
Case Number:
Submit this report for all culture-positive cases.
33. Initial Drug Susceptibility Results:
Was Drug Susceptibility Testing Done: D❑No 1❑Yes a❑Unknown
If answer is No or Unknown, do not complete rest of report.
It Yes, Mo. Da W.
Enter Date First Isolate Collected
for Which Drug Susceptibility Was Done?
34. Susceptibility Results:
Resistant Susceptible Not Done Unknown
Isoniazid in 2 3❑ 9
Rifampin t❑ 2❑ 3D an
Pyrazinamide 3❑ 2D 3❑ 9
Ethambutol 1❑ 2D an an
Streptomycin in 2D 3❑ 9
Ethionamide 1❑ 2❑ 3❑ 9
Kanamycin in 2❑ 3 9❑
Cycloserine in 2❑ 3❑ an
Capreomycin 1❑ 2❑ 3❑ 9
Para-Amino 1❑ 2❑ 3❑ a❑
Salicylic Acid
Amikacin 1❑ 2 3 9
Rifabutine in 2D 3❑ 9
Ciprofioxacin in 2❑ 3 9❑
Ofloxacin t❑ 2❑ 3D e❑
Other t 2❑ 3❑ 9
Comments:
]
Public reporting burden nof this collection of Mormation is estimated to avenge 30 minutes perresponse,including the limo for reviewing instructions,searching eusiirg data sources,gathering and maintaining the ala needed aria
compleiing and r i the collection of information.An a9 ssy y not conduct or sponsor, d a persons.not required to respond to a collection 01 inbrmaaon unless d d la e.currently valid OMB control number. $end
con,`enls reoard rig N'n n omplete ny other aspect of tit's colbctron of inbrmetion wowing suggestions rot reducing M®GUNen to GDC.Pnpct Clearance Officer.I6p0INtoan Road.MS 0-24,Atlanta.GA 30333.ATnN:
PRA 0920-0628.Oo torn,b sus aadless.
Iniormadon contained on this torn,which W WM permit identificatgn of any inigoi al has been collected wth a guarantee that ft will be held in atria confidence,will be used only br surrnaance purposes,and will not be disclosed
or released without the conxM of the ndividual ul accordance with Section 206(d)of the Public Health Service Act(42 U S.C 242m).
CDC 72.96 REV 12/98 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-I
Patient's Name: REPORT OF VERIFIED CASE
(Last) (First) (Mil OF TUBERCULOSIS
Street Address:
(Number,Street.City,Slate) Zip Code)
DEPARTMENT OF HEALTH a HUMAN SERVICES
CDC PUBLIC HEALTH SERVICE
REPORT OF VERIFIED CASE OF TUBERCULOSIS CENTERS FOR DISEASE
AND PREVENTION CDC
CENree FLP DISEASE LLMNCI
ATLANTA,GEORGIA 30333
.coo mEVEmgv FORM APPROVED OMB NO.0920-0020 Exp.Date M ON D(
Case Completion Report (Follow Up Report - 2)
C SOUNDEX ) [ State Reporting: Year
Counted: State Case
Specify: Number:
Alpha State Code City/County
Case Number:
35. Sputum Culture If Yes,Date Specimen Collected If Yes,Date Specimen Collected on
Conversion Documented: on Initial Positive Sputum Culture: First Consistently Negative Culture:
Mo. Dray Yr. Mo. Da Yr.
0 No t❑Yes 9 Unknown II—'rl'�I I ITI
36. Date Therapy Stopped: 37. Reason Therapy Stopped:
Mo. Day Yr.
II—II—II t❑Completed Therapy 3❑Lost 5❑ Not TB T❑Other
2❑Moved s❑ Uncooperative or Refused s❑Died 9❑Unknown
38. Type of Health Care Provider: 39. Directly Observed Therapy: If Yes,Give Site(s)of Directly Observed Therapy:
1❑Health Department on No,Totally Self-Administered i❑ In Clinic or Other Facility
2❑ Private/Other 1❑Yes,Totally Directly Observed 2 In the Field
3❑ Both Health Department Yes,Both Directly Observed
and Private/Other 2El 3❑Both in Facility and in the Field
and Self-Administered
e❑Unknown 9❑ Unknown Weeks
Number of Weeks of Directly Observed Therapy:
40. Final Drug Susceptibility Results: If Yes,Enter Date Final Isolate
Was Follow-up Drug Susceptibility Testing Done? 9 No t❑Yes 9 Unk. Collected for Which Drug Mo. Day Yr.
Susceptibility Was Done: (I III
If answer is No or Unknown, do not complete rest of report.
41. Final Susceptibility Resistant Susceptible NS Done Unknown Resistant Suscentible H41 Done Unknown
Results: isoniazid 1 2❑ 3 9❑ Capreomycin 1 2 3 9
Rifampin 1 j 2 3❑ 9 Para-Amino t❑ 2❑ 3❑ s❑
Salicylic Acid
Pyrazinamide 1 2 3 9 Amikacin 1 2❑ 3 9
Ethambutol 1 2❑ 3 E 9 Rifabutine 1❑ 2 L 3 9
Streptomycin 1 2 3 9 Ciprofloxacin 1 2 3 3
Ethionamide t❑ 2 3 9 Ofloxacin 1 2 3 9
Kanamycin 1❑ 2 3 9 Other 1❑ 2 3 9
Cycloserine 1 2 3 L 3
Comments:
[._
I
Public reportingand bwdennof this collection of information is estimated to average 30 minutes per response,including the tin,.or reviewing insbucliona.searching existing data sources,gathering and maintaining the data needed and
completing 9 the collection of information.Anagency may not conduct or sp w.and a person is not required to respond to a collection oI information unless it diwlays tly lid oMB control nugget. §end
b rd tae Wrden ealimase w a 1M1er aspect of the collection of information, summons for reducing the burden to CDC,Protect Clearance Officer,1600 Clifton Road.MS 0-24.Atlanta,GA 30333,ANT
PRA(0920-0026).Do mt deny the conpletedtorm to Me address,
IInmatron contained an thb form w0kh would permit MBntircalnn of any ntlividsal has been collected with a guarantee that it we be held in strict confidence,will be used only for surveillance purposes,and will not be disclosed
released without the consent of tae vgividwl n accordance with Section 30B(d)of Me Pudk Health Servke Act(42 U.3.G 2<2m).
CDC T2.9C REV 12/98 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-2
Colorado Department of Public Health and Environment
TUBERCULOSIS CONTACT INVESTIGATION RECORD
Name of reporting agency Preliminary report Final report
Name of index case Smear
Date case reported Culture
Infectious period Susceptibilities
Type of Country Date of HIV PPD Results Chest X-ray Diagnosis TX Start Comments/
Contact Last
Contact' of Birth Exposure Status Initial Retest — Date Symptoms
Date mm Date mm
- Date Results LTBI Active
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source: _
Name:
DOB/Age:
Relation to source:
Type of Contact:
close Contact-C: persons who have shared air with a known or suspected TB case for prolonged and frequent periods of time(e.g.household members,work associates-depending on the
type of work/environment)
Other Contact-OC: persons who do not meet the criteria of a close contact,but have limited exposure to a known or suspected TB case. Skin testing for OC's is indicated only when it is likely yin
that transmission to this group has taken place(e.g. significantly large number of close contacts show positive skin tests) �1
k
g:\tbforms\Original Forms Tuberculosis Contact Investigation Record.xls
Revised 01/08/2004
ACHMENT#
Alien(Alieaii,Name,Address,Phone): IMMIGRANT NOTICE OF ARRIVAL OF ALIEN WITH TUBERCULOSIS
A00-000-000 STATE HEALTH OFFICER:
AB,CD Please forward the evaluation copy and accompanying report of
Medical examination performed abroad(OF-157),to the
CIO EF appropriate local health department.
123 Upon arrival in the United States this alien was requested to report to
HOWARD BEACH,NY 11414 (000)000-0000 the Local Health Department at his/her destination-X-ray taken abroad
4/2772004 N showed findings consistent with tuberculosis. The person may not have
— --- received antituberculosis chemotherapy or chemoprophylaxis;therefore,
the Health Department may wish to initiate preventive treatment. The
SEX:[ ]M [X]F Local Health Department is requested to submit a report of initial
evaluation by 5/211120B4 through you t0:'
DATE OF BIRTH(Mo/Day/Yr.): 1/1/1934
Division of Quarantine,Data Mgr(E03)
Centers for Disease Control and Prevention(CDC)
[ ] CLASS B-1-Tubemulosis,clinically active,not infectious Atlanta,CA 30333
(X] CLASS B-2-Tuberculosis,not clinically active,not infectious •Military will send direct to the CDC.
This space is provided for you to record the Local Health Department's report.if desired.
CDC 75A 7(kev.02/99) CLASS B STATE HEALTH DEPAICIMrNT COPY
Alien(Alien*,Name,Address,Phone): IMMIGRANT REPORT ON ALIEN WITH TUBERCULOSIS
A00-000-000 LOCAL HEALTH OFFICER:
AB CD This person recently entered the United States and is referred to you
because the X-ray shows findings consistent with tuberculosis,as
C/0 F.F indicated in the accompanying report of medical examination performed
123 abroad. This person may not have received chemotherapy or
HOWARD BEACH,NY 11414 (000)000-0000 chemoprophylaxis and is referred to you because you may wish to initiate
preventative treatment Your initial evaluation would be appreciated.
4/27/2004 N Please check the appropriate boxes below and return this form to the
State Health Officer.'
Sex:[ ]M [X]F Date of Birth(Mo./Day/Yr.): 1/1/1934 If the alien does not report by 52812004 please check here[ ]anti
forward this form to the State Heakh Officer.' Retain for your records the
[ 3 CLASS B-1-Tuberculosis,clinically active,not infectious accompanying report of examination performed abroad(OF-157].
[X] CLASS 8-2-Tuberculosis,not clinically active,not infectious •Military will rend direct t.the CDC.
Your Initial(valuation:
C.X-ray(abroad) D.Presumptive Diagnosis
A.Direct Smear(in US) B.X-ray(In U.S.) [ ] Normal [ ] Pulmonary 1B-Active
[ ] Positive [ ] Normal [ 3 Abnormal ( ] Pulmonary TB-Not Active
[ ] Negative [ J Abnormal [ ] Not Done [ ] Pulmonary TD•Activity Undetermined
[ ] Not Done [ ] Not Done [ ] Unavailable [ ] Exbaplumonury TB
[ ] Non-TB AbnormalityE.Has patient received chemotherapy/prophytaxls in the past?
[ J No Abnormality[ 3 Yes [ 3 No [ ] Unknown
F.Are you prescribing chetnotherapy/prophylaxis? Signature of-Physician:
[ ] Yes [ ] No
Date of Evaluation:
Name of Health Department:
This form is not intended to substitute for NOTE.TO STATE HEALTH OFFICER: Division of Quarantine,Data Mgr(E03)
normal procedures for reporting tuberculosis Upon receiving this completed copy from Centers fur Disease Control and Prevention(CDC)
to the state Health Deportment. the Local Health Officer,please forward to: Atlanta,GA 30333
CDC 75A 7(Rev.02/99) CLASS B LOCAL HEALTH DEPARTMENT COPY
4TTAGHMENTif E
Tuberculosis
Semi-Annual Progress Report
Agency/Person
Date Submitted
Reporting Time Period _July 1 - December 31 _ January 1 - June 30
Briefly describe TB activities and accomplishments during reporting period.
Describe any challenges/obstacles to providing TB services as specified in the
CDPHE TB contract during reporting time period.
ATTACHMENT# F
Colorado Department of Public Health &
Environment
Tuberculosis Response Plan
Revised 4/26/2004
4
Colorado Department of Public Health and Environment
Tuberculosis Response Plan
Table of Contents
I. Introduction 3
Purpose of the Tuberculosis (TB) Response Plan
Defining"Exceptional Circumstances"Requiring Activation of TB Response Plan
II. TB Response Team 4
TB Program Staff
Other DCEED Staff
Centers for Disease Control and Prevention (CDC) staff
III. Activation of TB Response Plan 6
How the TB Response Team Learns of Exceptional TB Circumstances
TB Response Team Evaluation of Exceptional TB Circumstances
Declaration of a TB Response Plan Activation
Internal and External Communications
IV. Responses of the TB Response Team 8
TB Responses
Other Responsibilities
V. Local Public Health Agency Responsibilities 9
Establish Authority
Other Responsibilities
VI. Centers for Disease Control and Prevention (CDC)Notification/Request for Assistance 10
Indications for CDPHE to Notify CDC
How to Report to and Request Assistance From CDC
VII. Activation of Department-wide TB Response Plan 11
VIII. Deactivation of Plan 11
Appendix A-TB Response Report
2
INTRODUCTION
Purpose of the Tuberculosis (TB) Response Plan
The Colorado Department of Public Health and Environment (CDPHE) TB Program is
committed to providing treatment and control of TB in order to protect the public health. The
purpose of this plan is to ensure comprehensive and prompt response to exceptional TB
circumstances, especially in those areas of the state with insufficient staffing, funding, or
expertise to respond quickly without assistance. The plan also provides for tracking and
reporting of TB issues.
Defining "Exceptional Circumstance" Requiring Activation of TB Response Plan
The principle function of the CDPHE TB Program is to support local efforts to discover,
interrupt, and prevent TB transmission. Because of the low incidence of TB in Colorado—fewer
than 3.5 cases per 100,000—the public-health apparatus for finding TB and for investigating
contacts has been reduced to a minimum in many parts of the state. The investigation of a single
case in some counties can quickly exhaust available resources, resulting in "an urgent need for
assistance or relief" Thus, the definition of an"exceptional TB circumstance" in Colorado
depends on the detection of active TB or latent TB infections that meet one or more of the
following criteria:
• Due to the setting, the risk level of the population involved, or the number of cases, active
TB or latent TB infections,pose a serious risk of further TB transmission.
• The capacity of a local public health agency is overwhelmed by the scope of the
comprehensive response necessary to "ascertain the existence of all cases of TB in the
infectious stages and to ascertain the sources of such infections" (C.R.S. 24-4-506).
• The local health authority deems, in consultation with CDPHE, that activation of the
response plan would be in the best interest of the public.
Examples of exceptional TB circumstances that may prompt activation of the TB Response Plan:
• A patient with infectious TB is suspected or known to have Mycobacterium tuberculosis
resistant to isoniazid and rifampin(multidrug-resistant TB/MDR TB).
• Persons with HIV infection or other immune-compromising conditions are suspected or
known to be exposed to a case of infectious TB.
• A child five years of age or less with confirmed TB for which a source of infection is not
discovered after source investigation.
• An increase in the number of cases over time or in a particular area is considered significant
by a local public health worker or by CDPHE personnel.
• A genotype cluster is considered to indicate ongoing transmission.
• Extensive TB transmission is confirmed or suspected. These situations may involve
workplaces, schools, unconventional social networks, or other circumstances in which
screening for TB disease and infection involves large numbers of people or in which multiple
cases are suspected.
• A TB case generates a great deal of public interest or political pressure.
3
THE TB RESPONSE TEAM
All initial TB Response activities are the responsibility of TB Program staff, in collaboration
with local public health authorities. Other Disease Control and Environmental Epidemiology
Division (DCEED) staff may be called upon at the discretion of the Director to assist or provide
additional support to the TB Response Team or local public health agencies. The purpose of the
TB Response Team is to ensure a comprehensive and prompt response to exceptional TB
circumstances, especially in those areas of the state with insufficient staffing, funding, or
expertise.
The following members of the TB Program staff are designated as the TB Response Team.
These positions and duties include:
TB Program Staff
1. Chief Medical Officer(CMO)
a. Provides medical consultation and guidance
b. Maintains communications with Executive Director regarding status of and needs
related to the TB response
c. Makes final decisions with regard to requests for assistance from CDC and activation
of department-wide TB Response Plan
d. In conjunction with the Director of Communications, reviews and approves all
information prior to release to the media
e. Serves as a resource for public speaking during a TB response
2. Director, Disease Control and Environmental Epidemiology Division(DCEED)
a. Provides management and guidance of activities of the TB Response Team
b. Assists in reviewing communications with CDPHE administration, DCEED, local
public health agencies, or other parties involved in a TB response
c. Provides recommendations and assists with final decisions related to TB responses
d. Makes final decisions with regard to onsite assistance for local health agencies, and
recommends requests for assistance from CDC, and activation of department-wide
TB Response Plan
e. Reviews and approves all reports, publications or other documents related to TB
responses prior to use or distribution
3. TB Response Team Leader—Gayle Schack, RN(extension 2635)
a. Facilitates meetings of TB Response Team (scheduling, agendas, conference calls,
etc.)
b. Serves as primary liaison (contact person)with local public health authorities
c. Assists with case management of TB patients and contacts
d. Monitors diagnosis and treatment of TB patients and contacts
e. Provides expert consultation and recommendations regarding appropriate measures to
control the further spread of TB
f. Assists local public health agencies as requested by DCEED Director/Program
Manager
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g. Prepares written reports and documents used related to a TB response
(correspondence,publications, summary reports, final response evaluations, etc.) with
assistance from TB Response Team and obtains approval of the DCEED Director
prior to use or distribution
h. Arranges for annual review of this plan by team and DCEED Director
4. TB Program Nurse Consultant—Barbara Schultz, RN (extension 2647)
a. Assists Team Leader to monitor diagnosis and treatment of TB patients and contacts
b. Assists Team Leader to provide expert consultation and recommendations regarding
appropriate measures to control the further spread of TB
c. Reports newly discovered TB cases or significant findings related to the TB response
to TB Response Team Leader on an ongoing basis
d. Serves as a resource for public speaking during a TB response, in collaboration with
the Division Director and CMO
e. Assists local public health agencies as assigned by DCEED Director/Program
Manager.
f. Trains State and local TB Program staff on this plan
g. Assists Team Leader in preparing written reports and documents used related to a TB
response (correspondence,publications, summary reports, final response evaluations,
etc.)
5. Contact Investigation Coordinator—Juli Bettridge (extension 2675)
a. Consults and/or assists with contact investigations
b. Trains local public health agencies on how to conduct interviews of TB patient and
contacts
c. Tracks contact follow-up activities
d. Assists local public health agencies with contact investigations as requested by
DCEED Director/Program Manager
6. TB Program Manager/Surveillance Coordinator Barb Stone (extension 2656)
a. Assures quality of ongoing TB surveillance
b. Monitors TB activity for exceptional TB circumstances by reviewing TB surveillance
data
c. Assists in procuring funding and resources for activities related to TB response
d. Assists TB Response Team Leader in preparing and compiling written reports and
documents used related to a TB response (correspondence,publications, summary
reports, final response evaluations, etc.)
e. Assigns work activities of TB Program staff
7. TB Response Support Personnel
a. Arranges for acquisition and delivery of additional supplies or services required for
an effective response
b. Provides additional logistical support to TB Response Team as requested
c. Recording of TB Response Team meeting minutes
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Other DCEED Staff
Other DCEED staff may be called upon at the discretion of the DCEED Director to assist or
provide additional support to the TB Response Team or local public health agencies (Fiscal
Officer, Accounts Manager, Epidemiologists, etc.). Duties may include assistance with
procuring additional funding resources, setting up emergency purchase orders, assisting local
public health agencies with contact investigations, patient interviews, translation/interpretation
for persons with limited English proficiency, medication or specimen transport, form completion,
etc.
Centers for Disease Control and Prevention (CDC) Staff
Assistance may be requested from CDC such as in the event of extensive, confirmed or suspect
TB transmission involving workplaces, schools, unconventional social networks, or other
circumstances in which screening for TB disease and infection involves large numbers of people
or in which multiple cases are suspected. The Epidemiology Intelligence Surveillance (EIS)
Officer or other designated CDC health advisors may be needed to provide further consultation
and assistance.
ACTIVATION OF TB RESPONSE PLAN
CDPHE TB Program staff will review information as reported from an outside source(after
review by local public health authorities) or as reported directly by local public health
authorities. The TB Program staff will then meet to evaluate the suspected cluster or reported
crisis to determine if the event meets the"exceptional TB circumstance"criteria specified above.
If so, the CDPHE TB Program staff, in consultation with DCEED Director, local public health
authorities, and other TB experts (as needed),will make a final determination of"exceptional TB
circumstance"status and the TB Response Plan will be activated.
How the TB Response Team Learns of Exceptional TB Circumstances
The TB Program conducts ongoing surveillance of reported TB cases. Analysis of routine TB
surveillance data and discussions at weekly case management meetings may reveal a suspected
cluster or a situation that poses a serious risk of further TB transmission. Additionally, the local
public health agency may identify an urgent need for assistance or relief and request assistance
from the TB Response Team.
When an exceptional TB circumstance is discovered or reported to the TB Program, a"TB
Response Report" (Appendix A) will be completed by the person receiving the information. The
report will be given immediately to the TB Response Team Leader for further review.
Additional information may need to be obtained from the local public health agency staff to
assist with evaluation of the TB situation. Communications with the local public health agency
staff will be initiated by the TB Response Team Leader, in collaboration with the DCEED
Director.
TB Response Team Evaluates Exceptional TB Circumstances
The Team Leader will inform the TB Response Team of an exceptional TB circumstance.
Details regarding the situation will be shared with TB Response Team members and reviewed to
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determine whether it meets the definition of an exceptional TB circumstance. If so, the TB
Response Team will initiate a request for activation of the TB Response Plan.
Declaration of a TB Response Plan Activation
The DCEED Director will be responsible for declaring the need to activate the TB Response
Plan as appropriate. Depending upon the type of response needed, duties will be assigned
consistent with predetermined responsibilities of the team.
Internal and External Communications
The DCEED Director will be responsible for informing the CMO (303) 692-2662 and the
Director of Office of Communications (303) 692-2013 of new or updated information, as
appropriate. The Office of Communications will be responsible for preparing news articles and
for arranging TV interviews, radio interviews, and other public announcements. The TB
Response Team members may be asked to assist by providing general information as requested.
Once the plan is activated, the TB Response Team will meet on a regularly scheduled basis, at a
frequency determined at the initial evaluation meeting, in order to maintain internal
communications with regard to the status of all TB response activities. The TB Response Team
Leader will be responsible for ensuring that meeting notices, locations and times are distributed
to all team members, with assistance by TB Response Team support personnel. Each team
member will have an opportunity at each meeting to report on his/her progress, new findings, or
to ask questions.
Each TB circumstance will be evaluated by the TB Response Team on a case-by-case basis to
determine whether a special "hotline"should be activated at CDPHE to enhance external
customer communications. A hotline can be used to provide pre-recorded information and/or
serve as a devoted telephone line for callers seeking information specific to an exceptional TB
circumstance. If it is determined that a hotline is needed, the DCEED Director will obtain
approval for the hotline and assist in developing a pre-recorded telephone message. The
Telecommunications Manager at (303) 692-2117 can assist in setting up a local telephone line in
approximately 30 minutes or a wide area telephone system (WATS) line in two days. Local
telephone lines include:
• "Call-in line"primarily used for short,pre-recorded messages. Customers can leave a
voicemail message if they have further questions.
• "Call box" for longer,pre-recorded messages and a telephone tree that directs the caller to
other extensions for additional information. A call box can also track the number of calls
made to that number.
The hotline pre-recorded message will be reviewed at least weekly by TB Response Team and
revised/updated as needed.
TB Response Team members will maintain open communications with public health agencies
and private providers, in collaboration with the DCEED Director. This includes routine
telephone consultation or conference call on an "as-needed"basis. All information received by
the TB Program from outside sources, should be channeled through local health agencies.
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The Team Leader will discuss exceptional TB circumstances with the TB Elimination
Cooperative Agreement Project Officer at CDC, Division of TB Elimination (404) 639-8126.
The TB Response Team will provide recommendations with regard to guidance or assistance
needed by CDC and relay these requests to the TB Response Team Leader.
RESPONSES OF TB RESPONSE TEAM
TB Responses
Each exceptional TB circumstance must be individually evaluated to determine the scope of
assistance needed by the TB Response Team. Not every response will require the same actions.
Possible responses include:
• Monitor events through the Team Leader and Public Health Nurse Consultant
• Request additional information from the local agency through the Team Leader or designee
• Designate a team member to provide telephone consultation to the agency involved
• Establish authority, in collaboration with local public health agencies, for implementing
interventions and strategic programmatic changes (see "Responsibilities of Local Public
Health Agency")
• Provide prompt internal and external communications to the extent needed in each situation
• Provide weekly TB epidemiological analysis reports
• Ensure availability of appropriate laboratory testing, including DNA fingerprinting and
specimen transport, for purposes of prompt diagnosis and epidemiological investigation
• Provide documentation and written reports with regard to TB Response Team activities as
needed and as requested by DCEED Director, or CDPHE senior management
• Provide onsite assistance and consultation to the local public health agency, as resources
allow. This includes, but is not limited to, assigning one or more members of the TB
Response Team to investigate contacts, conduct intensified surveillance, collect and/or
transport specimens, apply TB skin tests, assist with implementing appropriate engineering
controls, occupational hazard evaluation, etc.
• Provide public speaker(s) to address affected citizens' groups (e.g. parents, employees,
employers, schools, organizations)
• Assist local public health agencies arrange for resources needed at the local level (e.g.
personal protection supplies, interpreters, translated patient education materials, quarantine
facilities, laboratory resources,packaging and distribution of mass drug orders) as resources
allow
• Request emergency supplemental funding from CDC or attempt to find additional funding
resources needed for TB response activities
• Other actions as recommended by CDC
• No further action
All activities will be conducted in compliance with state statues (C.R.S. 25-4-501-513) and may
require additional assistance from other DCEED staff. If so, the DCEED Director will authorize
specific staff and duties needed for the TB response.
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Other persons involved in the TB response (e.g. Epidemiology Intelligence Surveillance (EIS)
Officer, if one is available at CDPHE) may be included in all TB Response Team meetings and
activities.
Other Responsibilities
The TB Response Team will review and update the TB Response Plan on an annual basis and
update/revise as needed. Other DCEED staff maybe required to provide TB response assistance
and will receive training as needed.
LOCAL PUBLIC HEALTH AGENCY RESPONSIBILITIES
Establish Authority
It is the responsibility of the CMO and local public health agencies in Colorado to conduct
activities in order to discover, interrupt, and prevent TB transmission in their counties, through
contractual agreements with the TB Program at CDPHE. In the event of an exceptional TB
circumstance,however, authority for local TB control efforts must be established, based on
availability and ability of the local resources to implement interventions and strategic
programmatic changes needed to interrupt TB transmission. Such decisions will be made in
collaboration with local public health authorities. Authority may remain solely with the local
public health agency, other persons designated to direct activities at the local level (e.g. EIS
Officer), or to a member of the TB Response Team.
All counties in Colorado have designated persons who should be contacted in the event of an
exceptional TB circumstance. Such persons have agreed to be responsible for sharing
information to others in their agencies or communities, as appropriate.
Other Responsibilities
Local Public Health Agencies involved with an exceptional TB circumstance can assist the TB
Response Team by:
• Building consensus with state and other TB control advisors regarding investigative strategy
• Establishing accountable systems of communication, evaluation, response and tracking of TB
cases
• Notifying appropriate local officials
• Providing a list of available personnel and their skills
• Providing a list of available quarantine resources if needed, including a list and location of
negative air flow rooms available in the county
• Designating one person to communicate with TB Response Team Leader on an agreed-upon
schedule, in coordination with other media relations
• Adjusting investigation strategies based on new information obtained during TB response
efforts
• Designating a person to communicate with local media relations
• Recommending the type of written publications and reports needed to assist them in TB
response efforts
• Additional assistance offered by local public health agency
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CENTERS FOR DISEASE CONTROL AND PREVENTION(CDC)
NOTIFICATION/REQUEST FOR ASSISTANCE
Indications for CDPHE to Notify CDC
CDC requests the following instances of TB transmission be reported:
1. Infectious source patient with high-risk exposures and there is at least one of the
following circumstances:
a. The source patient is suspected or known to have Mycobacterium tuberculosis
resistant to isoniazid and/or rifampin,with or without resistance to other drugs.
b. The exposure involves contacts with HIV infection or other immune-compromising
condition.
c. The exposure involves contacts in high-risk settings.
2. A child five years of age or less with confirmed TB for which a source of infection is not
discovered after source investigation.
3. A cluster of cases in place and time. In one or more counties in a state over a period of
approximately six months, compared to the previous equal time span, any increase in the
number of cases that is considered significant by the TB Program or by the Division of
TB Elimination (DTBE)personnel.
4. A genotype cluster considered to exhibit ongoing transmission.
5. Situations for which extensive TB transmission is confirmed or suspected. These
situations may involve workplaces, schools,unconventional social networks, or other
circumstances in which screening for TB disease and infection involves large numbers of
people or in which multiple cases are suspected.
6. Instances in which transmission is suspected or confirmed among patients in multiple
states. In this circumstance, an infectious source patient has exposed persons in multiple
states, or transmission has been discovered among specific members of a group that
resides or travels to multiple states, such as homeless persons who visit shelters in
multiple states.
7. Instances in which false-positive AFB smears or cultures are suspected. False-positive
AFB smears or cultures may be responsible for misdiagnosis of TB, and unnecessary
tests, treatment, and toxicities for patients. Most false-positive AFB smears or cultures
are based on laboratory cross-contamination,but may also be due to clerical errors and
mislabeling.
How to Report to and Request Assistance from CDC
Specific instances of TB transmission specified above should be reported to the TB Cooperative
Agreement Grant Program Consultant at CDC, Division of TB Elimination--DTBE (404) 639-
10
8126. The TB Response Team Leader will work with the TB Program Manager in reporting to
CDC. The CDC Program Consultant can provide procedures for requesting assistance.
ACTIVATION OF DEPARTMENT-WIDE EMERGENCY RESPONSE PLAN
If the TB response requires additional assistance beyond the scope of TB Response Team and
CDC, a request for assistance should be forwarded through the CDPHE Emergency Response
Plan. This request for assistance must be initiated and approved by the DCEED Director through
the CMO. Careful consideration must be given to leadership, authority and coordination of all
TB response activities when assistance at this level is needed.
DE-ACTIVATION OF TB RESPONSE PLAN
TB Response Plan de-activation procedures will be conducted by the TB Response Team when
the situation no longer supports the need for intensified TB response activities. These
procedures include:
1. Debriefing--TB Response Team meeting to review all activities and outcomes related to
the specific TB response
2. Change of Command --If the TB response required modification of authority, leadership,
or responsibilities during the investigation, a change will be made to restore local public
health agency responsibilities, as previously conducted.
3. Exit Interview--TB Response Team will conduct an exit interview with the local public
health agency and others involved in the TB response to review response activities and
outcomes and collect any additional information with regard to the response.
4. Evaluation of Results --TB Response Team and others, as appropriate, will conduct an
evaluation of activities and outcomes related to the TB response. Evaluation will include
identification of areas of improvement as well as areas of success. This information will
be used to direct future TB responses and changes in procedures, if needed.
5. Final Report --TB Response Team Leader will prepare a final written report, as
appropriate, with regard to the TB response (including all documents related to the TB
response such as correspondence,publications, summary reports, final response
evaluations, etc.)with the assistance from the TB Program Nurse Consultant and TB
Program Manager/Surveillance Coordinator. The final report will be approved by the
DCEED Director prior to distribution.
6. Long-term follow-up of contacts--The local public health agency or their designee will
follow contacts identified during the TB response. Information will be reported to the
Contact Investigation Coordinator initially and at the completion of follow-up (may be
several months after initial response). Contact follow-up information will be added to the
final report.
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Appendix A
TUBERCULOSIS RESPONSE REPORT
Initial Report Information
Date of Report:
Report Source:
❑ Epidemiological TB Data Analysis
❑ TB Case Management Review
❑ Local Public Health Agency/Other State or Federal Agency:
Agency Name
Contact
Phone Number
❑ Other: (specify and include phone numbers if applicable)
Nature and Summary of Report (note if any TB cases are drug-resistant,HIV-infected, in
congregate settings, or foreign-born and/or if there is extensive transmission, involves a public
figure or is a high-profile case):
Clinical findings of case(s): (include symptoms and chest x-ray results, if known)
Laboratory Results:
Evidence of ongoing transmission?
If yes, please specify(e.g. secondary cases, increased rate of skin test conversions):
Estimated number of contacts:
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Initial TB Response Activities
Date report given to TB Response Team Leader:
Date of initial TB Response Team evaluation meeting:
TB Response Team members present at initial meeting:
Date TB Response Team Recommendations submitted to DCEED Director:
Declaration of need to activate TB Response Plan?
If yes, date:
Name/phone number of State and local public health agency staff identified as having authority
for overseeing ongoing TB control efforts for this situation:
Date of next TB Response Team meeting:
Internal/External Communications:
Chief Medical Officer Notified?
If yes, date:
By whom?:
Office of communications needed to set up a special hotline or WATS line?
If yes, date request was initiated:
Appropriate local public health agency representative(s)notified?
If yes, date and who was notified:
TB Cooperative Agreement Program Consultant/CDC notified?
If yes, date and who was notified:
Describe initial TB response activities and control measures:
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Ongoing TB Response Team Activities (repeat this section as needed)
Date:
Type of activity(meeting, conference call, meeting with local public health agency staff,
educational session, etc.):
New findings and recommendations:
Signed:
Date:
De-Activation of TB Response Plan Checklist
❑ Debriefing of TB Response Team and others as appropriate to review all activities and
outcomes related to the situation(include dates)
❑ Change of command restored
❑ Exit Interview
❑ Evaluation of results of all activities and outcomes (specify):
❑ Final TB response report completed, if indicated, and submitted to DCEED Director
(attach all previously written correspondence, publications, summary reports)
❑ Long term follow-up of contacts complete
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INVOICE NUMBER:
CONTRACT REIMBURSEMENT STATEMENT
TO: Colorado Department of Public Health& Environment FROM:
DCEED/A3
4300 Cherry Creek Drive South
Denver,CO 80246
Fax(303)691-7749
Attn: TB Contract Administrator Federal ID Number:
Date of Expenditures From: To: Final Bill
Yes
No
Description of Expenditure Local Agency Match Reimbursement Total
Amount Requested
Grand Total:
This is to certify that the above expenses were incurred per Contract# and we are requesting reimbursement for same.
SIGNATURE (CONTRACTOR): DATE:
I hereby certify that all contract requirements have been met and the amounts are correct. Payment is authorized.
AUTHORIZED DESIGNEE (STATE): DATE: g
4
[Date[ SAMPLE TASK ORDER CHANGE ORDER LETTER Attachment H
Task Order Change Order Letter Number**, Contract Routing Number** ********
State Fiscal Year 20**-20**, ***************Program
This Task Order Change Order Letter is issued pursuant to paragraph*_*.of the Master Contract identified as
contract routing number***** *****and paragraph*.*. of the Task Order identified as contract routing number
***** *****and contract encumbrance number** *** **********. This Task Order Change Order Letter is
between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and JLEGAL
NAME OF CON TRACTOR]. The Task Order has been amended by Task Order Option to Renew Letter**.
contract routing number** *** *****,and/or Task Order Change Order Letter" contract routing number** ***
******,if any. The Task Order,as amended,if applicable,is referred to as the"Original Task Order". This Task
Order Change Order Letter is for the current term of********* ** **** through***********,****. The
maximum amount payable by the State for the work to be performed by the Contractor during this current term is
increased/decreased by**********Dollars,($*.**)for an amended total fmancial obligation of the State of
**********DOLLARS ($*.**). The revised specifications to the original Scope of Work and the revised Budget
are incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment*"and
"Attachment*". The fast sentence in paragraph*_*.of the Original Task Order is modified accordingly. All
other terms and conditions of the Original Task Order are reaffirmed. This change to the Task Order shall be
effective upon approval by the State controller,or designee,or on ********* **,****,whichever is later.
Please sign,date,and return all** originals of this Task Order Change Order Letter by***********,**** to the
attention of: ************ ************,Colorado Department of Public Health and Environment,4300
Cherry Creek Drive South,Mail Code***-***-**,Denver,Colorado 80246. One original of this Task Order
Change Order Letter will be returned to you when fully approved.
[LEGAL NAME OF CONTRACTOR] STATE OF COLORADO
(a political subdivision of the state of Colorado) Bill Owens,Governor
By: By:
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
(Seal) ATTEST: PROGRAM APPROVAL:
By: By:
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:
Arthur L.Barnhart
By:
Date:
Revised:08/30/02
[Date] SAMPLE TASK ORDER OPTION TO RENEW LETTER Attachment I
Task Order Option to Renew Letter Number**, Contract Routing Number** ********
State Fiscal Year 20**-20** ***************Program
This Task Order Option to Renew Letter is issued pursuant to paragraph*_*.of the Master Contract identified by
contract routing number** *** *****and paragraph*. *. of the Task Order identified by contract routing number
** *** *****and contract encumbrance number** *** **********. This Task Order Option to Renew Letter is
between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and"LEGAL
NAME OF CONTRACTOR'. The Task Order has been amended by Task Order Change Order Letter**,contract
routing number**********,and/or Task Order Option to Renew Letter**,contract routing number** ***
******,if any. The Task Order,as amended,if applicable,is referred to as the"Original Task Order". This Task
Order Option to Renew Letter is for the renewal term of********* ** **** through********* **,****. The
maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is
**********Dollars,f*.**1 for an amended total financial obligation of the State of**********DOLLARS, This
is an increase/decrease of($***)of the amount payable from the previous term. The Budget for this renewal term
is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment*". The fust
sentence in paragraph*_*.of the Original Task Order is modified accordingly. All other terms and conditions of
the Original Task Order are reaffirmed. This Task Order Option to Renew Letter is effective upon approval by the
State Controller,or designee,or on***********, ****,whichever is later.
Please sign, date,and return all**originals of this Task Order Option to Renew Letter by********* **,**** to
the attention of: ************ ************,Colorado Department of Public Health and Environment,Mail
Code***-*****,4300 Cherry Creek Drive South,Denver,Colorado 80246. One original of this Task Order
Option to Renew Letter will be returned to you when fully approved.
[LEGAL NAME OF CONTRACTOR] STATE OF COLORADO
(a political subdivision of the state of Colorado) Bill Owens,Governor
By: By:
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
(Seal) ATTEST: PROGRAM APPROVAL:
By: By:
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:
Arthur L.Barnhart
By:
Date:
Revised:08/30/02
Hello