HomeMy WebLinkAbout20031298.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 Orderfor the Tuberculosis Program
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment, and the Colorado Department of Public Health and Environment, commencing July
1, 2003, and ending June 30, 2004, 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 the Tuberculosis Program between the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf
of the Weld County Department of Public Health and Environment, and the Colorado Department
of Public Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said task order.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 21st day of May, A.D., 2003.
BO OF COUNTY COMMISSIONERS
WEL AUNT , COLOR O
ATTEST: EL__�d
"16"t/ — ":\ vi E. Lo , Chair
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d County Clerk mi
RobertD. n, Pro-Tel'e Boa
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William✓ I 49
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Glenn Vaad
Date of signature:
2003-1298
HL0030
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DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DEPARTMENT OR AGENCY NUMBER
FHA
CONTRACT ROUTING NUMBER
04-00029
TASK ORDER
Tuberculosis Program
THIS TASK ORDER is made this 1st day of July,2003 by and between:the State of Colorado,for the use and
benefit of 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,3ed Floor,Greeley,Colorado 80631
acting by and though the/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
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. All State
contracts with its political subdivisions are exempt from the state of Colorado State's personnel rules under section
24-50-101 et seg.,and the State procurement code under section 24-101-101,et seq.,C.R.S.,as amended.
The State,in order:to carry out its lawful powers,duties, and responsibilities under Section,25-4-501,et seg),
8C.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. Pursuant to 25-4-501,8 C.R.S.,as amended,the General
Assembly has declared that tuberculosis is an infectious and communicable disease,that it endangers the population
of this state,and that the treatment and control of said disease is a state responsibility and further,pursuant to 25-4-
511,8 C.R.S.,assistance under section 25-4-501,shall be given to any applicant who is suffering from tuberculosis
in any form requiring treatment and is without sufficient means to obtain such treatment. The State,though 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 counties.
The State has formulated a comprehensive State plan,with associated budgets,relative to the State's programs and
services which allocates funds to local health agencies in order to provide certain purchased services to the people of
Colorado. This funding is to be allocated through task order contracts with local health agencies.
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 Number(s)J ! Organizational Unit Code(s)4644,4648, 4645,and 3640, Appropriation Code(s)386
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3g7 Program Code(s)9012,and Object Code(s)5420,2710,under Master Contract Routing Number 00 FAA
00�and Encumbrance Number PO FHA EPI04000001 and PO FHA EP10400029.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 1,2003. 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 fmancial 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 30,2004,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. The Contractor shall provide or coordinate the following services for all individuals within its
service area according to the State's Tuberculosis Manual,CRS 25-4-501-513,and Rules and
Regulations Pertaining to Epidemic and Communicable Disease Control(6-CCR-1009-1,
Regulation 4). Services should be prioritized as follows: finding all patients with active TB and
ensuring completion of therapy,finding and evaluating contacts of TB patients and ensuring
completion of appropriate treatment,and targeted testing of high-risk groups and ensuring
completion of treatment for latent TB infection.
A. Provide active TB treatment,including directly observed therapy as required by reference
above,and ensure adherence to the completion of therapy for all reported cases;
B. Ensure contacts to all newly identified infectious TB cases are identified,investigated,
and receive appropriate evaluation;
C. Provide treatment,including directly observed therapy when appropriate,and ensure
completion of therapy for infected contacts;
D. Collect specimens for mycobacteriology testing on all persons suspected of having TB.
Assure that rapid identification and susceptibilities(isoniazid,rifampin,ethambutol,
streptomycin,and pyrazinamide)are conducted on cultures positive for Mycobacterium
tuberculosis complex;
E. Order TB medications through the State contract pharmacy. Drugs other than first line
drugs and pyridoxine require prior approval from the State TB Program.
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F. Provide,or arrange for,chest x-rays and the interpretation;
G. Provide,or arrange for,laboratory testing and other necessary medical evaluation
services;
H. Periodically monitor and evaluate those persons with active and suspected active TB,
latent TB infection,and all other persons as necessary to protect the public health;
I. Provide treatment for latent TB infection,and ensure adherence to and completion of
therapy;
J. Provide culturally appropriate patient education and information pertaining to TB
treatment and/or follow-up plan;
K. In conjunction with the CDPHE TB Program,set agency specific goals based on
National TB Objectives which is incorporated herein by this reference,made a part
hereof,and attached hereto as"Attachment A".
Tuberculin skin testing,chest x-rays,and chest x-ray interpretations are not eligible for
reimbursement under this Task Order for the following:
Correctional facility inmates;
Persons undergoing immigration medical examinations;
Paid or volunteer employees of health care facilities,long-term care facilities,drug treatment
centers,correctional facilities, shelters,schools,or child care facilities.
2. The Contractor shall recommend and offer an HIV antibody test to:
All persons diagnosed with TB disease,regardless of their age or the apparent absence of risk
factors for HIV infection;
All persons with positive tuberculin skin tests with HIV risk factors;
Foreign-born persons from HIV endemic areas.
In accordance with section 25-4-1401,et seq.,C.R.S.,as amended,the Contractor shall report all
known HIV antibody test results to the State. Individuals who refuse testing shall be informed
regarding the risks associated with HIV/TB co-infection.
3. The Contractor shall supply the State,with complete patient data for all persons with infection and
disease for integration into the TB records system. Data will include:
A. Known TB Contacts/Latent TB infection--initial report of patient name,birth date,
demographic and other patient information,risk factors as identified on the
Tuberculosis Surveillance and Case Management Report(TB17)(attached hereto as
"Attachment B"),treatment start date,drug regimen,and dosages. Follow-up report
including length of treatment,treatment completion date,and other case
management/follow-up information via a Patient Follow-up Information and Transfer
form(TB10)(attached hereto as"Attachment C").
B. Suspect/Known Active TB cases--initial report of patient name,birth date,
demographic and other patient information,risk factors as identified on the
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Tuberculosis Surveillance and Case Management Report,treatment start date,drug
regimen,dosages,how treatment was administered(e.g.direct observed therapy),
number of doses given,bacteriological results including drug susceptibility results,
changes in patients'status,diagnosis,or any other information as appropriate. A
Patient Follow-up Information and Transfer form will also be used by the Contractor
to report when a TB patient completes treatment,moves,or transfers out of the county.
The State shall provide format and instructions for any additional data transfer
required.
C. The Contractor shall provide other statistical information regarding number and status
of patients served to the State upon request.
4. The State 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 State of the arrival of a Class A or B
immigrant,the Contractor shall contact that immigrant and conduct a TB screening including a
PPD skin test and chest x-ray. The Contractor shall also obtain sputum cultures x 3 if a clinical
evaluation by a qualified medical provider or chest x-ray interpretation indicates an active disease
in an immigrant. 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 State.
5. The Contractor shall,through the services of a nurse or outreach worker,conduct an outreach
program to ensure that patients receive appropriate information and education and assist with
follow-up needed to fulfill requirements as listed above. Services provided by these workers shall
include,but are not limited to,ensure adherence to and the completion of therapy for TB patients
and implement outreach and contact follow-up activities for all newly reported cases and
suspected cases of TB.
6. The Contractor agrees to provide the State a narrative report for the calendar year by March 1 of
the following calendar year which includes:
A. Progress in implementing outreach activities,results of the evaluation of those activities,and whether the
county TB Program objectives were met.
B. A statement of any difficulties or special problems encountered in meeting the agreement objectives.
C. A statement of action plans designed to overcome or address difficulties and problems.
D. A statement of population served and the special needs of those populations that have been met through
the agreement.
E. A statement of time spent by the outreach workers in TB prevention and follow-up activities.
7. The Contractor shall submit preliminary Contact Investigation Reports(copies attached and made
a part hereof as"Attachment E")to the State after initiation of contact investigation. A final
report should be submitted when the contact investigation is complete. The Contractor and the
State agree to collaborate in automating data collection and transfer of these reports.
8. The Contractor shall provide,or arrange for,quarantine services for patients requiring isolation.
9. The Contractor shall provide consultation to other providers in the service area regarding TB
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reporting,screening,treatment,and follow-up as needed
10. The Contractor will be responsible for monitoring all sub-contracts and for payment of services
rendered. Copies of approved agreements with sub-contractors will be forwarded to the State TB
Program.
11. The Contractor acknowledges that the payment for those TB control services provided pursuant to
section 25-4-513,C.R.S.,as amended,are paid at 80%from state funding sources and 20%from
the county funding sources in which the recipient resides. The Contractor shall be responsible for
the remaining 20%,which may be contributed in the form of an in-kind agency match.
C. COMPENSATION.
1. The Contractor shall be compensated in accordance with the rates set forth in the Scope of Work
hereto. 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-SIX THOUSAND TWO HUNDRED EIGHTY-NINE DOLLARS,($56,289.00)for
the initial term of this Task Order. Of the total financial obligation of the State referenced above,
$4,358.00 are identified as attributable to a funding source of the United States government and,
$51,931.00 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 THOUSAND DOLLARS
($20,000.00)Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2004.
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.
2. The State shall reimburse the Contractor for expenditures in accordance with the budget below.
The Contractor's transfer of funds from one line item to another must have prior,written approval
of the State:
Budget
TB Control and Outreach
July 1,2003—June 30,2004
Description of Reimbursement Amount Funding Source
Tuberculosis Control and Outreach $46,928.00 State
Tuberculosis Control and Outreach $ 4,358.00 Federal
Chest X-Ray $ 4,431.00 State
Medical Consultation $ 572.00 State
Direct Observed Therapy @$12.50 per visit As Administered State
Total: $56,289.00
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3. To receive compensation under this Task Order,the Contractor shall submit a signed monthly
billing statement,(copies attached and made a part hereof as"Attachment F"),within sixty(60)
calendar days of the end of the billing period for which services were rendered.The billing
statement shall:
A. Reference this Task Order by its Contract Encumbrance number,which number is located on
page one of this document;
B. State the applicable performance dates,the names of payees,and a brief description of the
services performed,total expenditures incurred,and the total reimbursement requested;and
C. Reflect the total program cost as the sum of the"Local Agency Match"and"Amount
Requested for Reimbursement"on the monthly billing statement(Attachment F). The"Local
Agency Match"shall document the Contractor's 20%contribution of program costs.
D. Reimbursement during the initial,or any renewal,teen 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:
Colorado Department of Public Health and Environment,
Marti Wood,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". A sample Task Order Change Order Letter is
incorporated by this reference,made a part hereof,and attached hereto as Attachment G. 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,the Task Order Change Order Letter shall become an
amendment to this Task Order. Except for the General and Special Provisions of the Master
Contract,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 renewal process
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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 the proposed change,then the Contractor shall execute and
return the Task Order Change Order Letter to the State by the date indicated in the Task Order
Change Order Letter. If the Contractor does not agree to and accept the proposed change,or fails
to timely return the partially executed Task Order Change Order Letter by the date indicated in the
Task Order Change Order Letter,then the State may,upon written notice to the Contractor,
terminate this Task Order twenty(20)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 this Task Order. If this Task Order is terminated under this clause,then the parties
shall not be relieved of their respective duties and obligations under this Task Order until the
effective date of termination has passed.
Increases or decreases in the level of contractual funding made through this task order change
order letter process during the initial,or renewal,term of this Task Order may only be made under
the following circumstances:
F. If necessary to fully utilize appropriations of the state of Colorado and/or non-
appropriated federal grant awards;
G. Adjustments to reflect current year expenditures;
H. 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
this Task Order;
I. Closure of programs and/or termination of related contracts or task orders;
J. Delay or difficulty in implementing new programs or services;and,
K. Other special circumstances as deemed appropriate by the State.
5. The State may renew this Task Order through a"Task Order Option to Renew Letter". A sample
Task Order Option to Renew Letter is incorporated herein by this reference,made a part hereof,
and attached hereto as"Attachment H". 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 this 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.
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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,a Task Order Option to Renew 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
renewal process may be used only to:renew this 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 this Task Order,other than those
authorized by the task order change order process described above,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 the proposed renewal term,then the Contractor shall
execute and return a 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 the 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 this Task Order. If the Task Order is terminated
under this clause,then the parties shall not be relieved of their respective duties and obligations
under this Task Order until the effective date of termination has passed.
D. PAYMENT MECHANISM. Payments under this Task Order shall be made either through the State's
Electronic Fund Transfer system or,upon the Contractor's monthly submission of duplicate Task Order
Reimbursement Statements requesting reimbursement for those services provided in the previous billing
period.
E. ADDITIONAL PROVISIONS.
1) The Contractor certifies,to the best of its knowledge and belief,that no federally appropriated funds have
been paid or shall be paid by or on behalf of the Contractor,to any person for influencing or attempting to
influence.
2) The Contractor shall protect the confidentiality of all applicant or recipient records.
F. ATTACHMENTS. All attachments are incorporated herein by this reference and made a part hereof as if
fully set forth herein. In the event of any conflict or inconsistency between the terms of this Task Order
and those of any attachment hereto,the terms and conditions of this Task Order shall control.
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IN WITNESS WHEREOF,the parties hereto have executed this Task Order as of the day first above written.
Board of County Commissioners of Weld County STATE OF COLORADO
(a political subdivision of the State of Colorado) Bill Owens,Governor
for the use and benefit of the
Weld County Depa t of Public Health and Environment
By: By
Name: D E /21/03 For the Executi rector
Title: 'r DEPARTME O PUBLIC HEALTH
FEIN: 84-6000813 I E I'ONMENT
1/11144
1861 '), ic� ATTEST: PROGRAM APPROVAL:
yo lerk to the Board
1w(F-1:),
ii e By �C.
ity,City and County,Count ,
Special District,or Town Clerk or Equivalent
Deputy Clerk to the Board
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
PUBLIC HEALTH AND ENVIRO E By: aac------------'
I II
B6ALA6 Date:Ma E. MD, MPH•Director
1 i 9 )b3
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Attachment A
National TB Objectives
Completion of therapy
• At least 90 percent of patients with newly diagnosed TB,for whom therapy for one year or less is
indicated*,will complete therapy within 12 months. (*Please refer to the definitions in"Reported
Tuberculosis in the United States 1997 for more information.)
Contact investigation
• Contacts will be identified for at least 90 percent of newly reported sputum AFB-smear positive TB
cases.
• At least 95 percent of contacts to sputum AFB-smear positive TB cases will be evaluated for infection
and disease.
• At least 85 percent of infected contacts that are started on treatment for latent TB infection will
complete therapy.
Reporting
• All new cases of TB disease will be reported using the electronic reporting system developed by
CDC. There will be at least 95 percent completeness for the following variables (question number)in
the expanded Report of Verified Case of Tuberculosis (RVCT): in RVCT, Date of Birth (7), Sex(8),
Race(9)or Ethnic origin (10), Country of Origin (11), Month-Year Arrived in U.S. (12), Status at
Diagnosis of TB(13), Previous Diagnosis of Tuberculosis (14), Major Site of Disease(15), Sputum
Smear(17), Sputum Culture(18), Microscopic Exam of Tissue and Other Body Fluids(19), Culture of
Tissue and Other Body Fluids(20), Chest X-Ray(21), Tuberculin Skin Test at Diagnosis (22),
Resident of Correctional Facility at Time of Diagnosis (25), Resident of Long-Term Care Facility at
Time of Diagnosis(26), Initial Drug Regimen (27), Date Therapy Started (28), Occupation (32); in
Follow Up Report-1, Initial Drug Susceptibility Results (33), Susceptibility Results (34); in Follow Up
Report-2, Sputum Culture Conversion Documented (35), Date Therapy Stopped (36), Reason
Therapy Stopped (37), Directly Observed Therapy(39).
'"Unknown"and"missing"responses are considered not complete. A response of"not done"is
considered complete.
• Drug susceptibility results will be reported for at least 90 percent of all new, culture-positive TB cases.
• HIV status will be reported for at least 75 percent of all newly reported TB cases age 25-44.
Laboratory testing
• For at least 80%of initial diagnostic specimens received by the public health laboratory for TB
diagnosis, the following laboratory turnaround times will be met: reporting of smear-positive or smear-
negative results of acid-fast examination of specimens within 24 hours of specimen receipt; for
culture-positive specimens, reporting of MTB or not MTB within 14-21 days from specimen receipt;
and reporting of drug susceptibility tests for first-line drugs within 15 to 35 days from specimen
receipt.
• For at least 80% of isolates of mycobacteria referred to the public health laboratory for additional
TB diagnostic testing,the following laboratory turn-around times will be met: reporting of isolates
as MTB or not MTB within 7 days of isolate receipt, and reporting of first-line drug susceptibility
tests within 10-14 days from isolate receipt.
Targeted testing and treatment of latent TB infection:
• At least 75%of persons with latent TB infection found through targeted skin testing activities and
started on treatment for TB infection will complete therapy.
Attachment B
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT
Colorado Department of Pubic Health and Environment DCEED-TB-A3
Tkberabds Cannot 4300 Cherry Creek Drive South
Denver,Colorado 80246-1530
(303)6922679 Phone (303)691.7740 Fax
•
PATIENT INFORMATION
Name Date of Birth Country of Birth - __• - - Month Year
Address // p USA Arrived in USA
Cdr. Zip: ❑Canada,Japan,Western Europe, //
Home Phone: Australia,New Zealand Refugee:
County ofWork Phone: Residence O Mexico,Central or South th America ❑Yes
/ O Mica,Middle East' ❑No
Sex: Rats
o Male ❑Mb El China,
In ,Central or O tnion:am
Ethnic Orign Southeast Asia,Indonesia,
o Female O Bfaac - p Sc ❑Eastern Europe,Russia,Ukraine Alien Number,
O American kdlen/
Abslnan Native El Non-Hispanic ❑Unknown 1„enylK of residence
Marital Slants ❑AsianPacife lab O Unknown in Colorado -
❑Unknown
AGENCY SUBMITTING THIS REPORT
Agency's Name: Agernytormty
/
Agency's Address:
City: Zq: Phone:
Name of Patient's Primacy Care Physician:
Address
City: Zip: Phone:
MOST RECENT SKIN TEST
Type Results: Induration Previous N positive,is this a sidn test
El MaMmtt-Tubersol O Postive nan Positive PPD conversion negative to positive
o Martmtt-Aprad O Negative ❑Yes within 2 years:
p The ❑Not Done Date PPD`''"e" O No O Yes
❑Other(specify) ❑unknown Date of last O No
O Other(specify) Date PPD Read negative test O Unknown
i 1 r r
X-RAY FINDINGS
Date of X-ray: Previous Status X-ray taken by:(Agency's None):
/ / Abnormal X-ray: p sane
—I—I— O Worserirg Return X-ray to: --
X-ray results: Abnomddy ❑ vhg
❑Normal ❑Cavitary p tthlewam
❑Abnormal O Nonavlary Consent WITS
El Not Done O Noncavtary Not Consistent w/TB
0Ungawn O Otter(Specify) Note:CDPtEwn7 separately attach x-ray
findings and reconlatendafions
CLINICAL
Symptoms: Date of Onset of Special Conditions:
o None O Fear Syrrgtmn: O Pregnant EDC_l l
p Productive Cough OHO Sweats // p Postpartum Bread Feeding
p►iemaplys;s O Otter(Specify) p Other(Specify):
p Weight Loss
Name of Person competing: Date:
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PATIENT FOLLOW-UP INFORMATION AND TRANSFER FORM (TB-10)
( ) For your inrwmstlon ( ) Reply requested
TO: FROM: Attachment C
•
Patients Name: SEX Maw Status
Address: M F SMWDSep
W D Sep
City,State,Yip Birthdate ! ! Race
Phone Number. County:
ACTIVE CAS YES_ NO
Cordirmed by Lab or PCP diagnosis?YES_N0_ . If yes,date of diap os1s I J
Date of TBC.skin test._Li__ Raoul in MM:
Foam Pt*norwy Extra Pulmonary(specify site) Su:p _
LATEST BACTERIOLOGICAL STATUS: Not Done
Mod Rat wed wode almaMdrors
ore trod Pelee • Lsearaywers Spline ad
:view
uiYd
orro
oe.tsp.araw _
DRUGS: ifpatient on drug therapy Medications and dosage
Date started:_/_/__
/
Date stopped:_Li_
Number of weeks on DOT:
If patient NOT on drug therapy,give meson:
Most recent X-ray resu f/date(s)
Previous Hosp zationforTB:Whert Where:
Primary Care Provider Photos
fEACTOR: YES NO • Medications and dosage
Coats of Skin test: _i_/_
Date started: / I
Date stopped medications:_/__/__
Reason:tapped
Mediation given by whom
5ELOCATION INFORMATION; Date of relocation:___/___/___
If patient has moved or relocated,please provide new address and phone number'
•
Colorado Department of Pubic Health and Environment Name of Person completing to form/ Date
4300 Cheny Creek Drive South, DCEED-T&A3 • / !
Denver. Colorado 80222-1530 303-692-2679 1B-1a(tw+r97)COP to
•
Allen(AUeng,Name,AJdress,Phone): IMMIGRANT A REPORT ON ALIEN wt17t TUBERCULOSIS
i OCIL((E/LZX OFFICER:
' - Ibis person recendy entered the United States awl Is reterred Ie you beaus
Um)(gay shows findings consistent with tuberculosis,u Indicated le the
accompanying repon of medial saaminadon performed abroad. 711s pr
may not have received chemotherapy or cbemopropbylu s and Is Wen •
you because you may wish to Initiate preventative treatment, Your Initial
SEX:C3 M ( )P DATE OP BIRTH(Mo.,Day. Yr.) 1/21/64 evaluation would be appreciated. Please check the*poopdste bases below
and ream this fonn to the State Health Officer.*
£3 CLASS B•1•hbenvbsls,clinically active,not Infectious If the alien dote�tepon(by.~.., : please check ben( )and
forward this font toIhe Steteliealth Officer.* Retain for you roeorda
( ) CLASS D•2.1Lbsneulosis,not clinically active,not Infectious the accompanying report of examination performed abroad(ORI37).
lain w sea/ma wthe ew.n*Dims.Crate arvo.sl.
Your Initial Evaluations E.Has Patient e ) Received �berapylProplaylnels In the pasty
A.Dleeel Saar(In U.S.) C.X•ny(abroad) D.Presumptive Diagnosis ( )Yu No 14
Positive I i Normal Pulmonary TD•Active •
F.An eat bChemelhenpy/PreplrylaaleJ
Negative Abnormal Pulmonary TB•Not Active ( )Yee intro Not Done Not Donne Pulmonary TD-Activity Undetermined Signature of Physician Date of Evaluation
Unavailable Path nary TD
B.X-ray On U.S.) Non-Th Abnormality
Normal No Abnormality Name of Health Department
Abnomnl
((( III Not Dons 'f
.�... • • 1
This form is not intended to substitute for normal NOTE TO STATE HEALTH OPPICER:Upon receiving Division of Quarantine,Data Mgr(E03)
procedures for reporting tuberculosis to the state this completed copy from the Local health()Mar. Centers for Disease Control end Prevailing(CDC)
Health Department please forwent to: Atlanta,Georgia 30333
CDC 75.17(Rev. 12/94) CLASS B LOCAL HEALTH DEPARTMENT COPY
2*
g
w
O
rutacnment!;
Colorado Department of Public Health and Environment
TB CONTACT INVESTIGATION RECORD
Name of reporting agency Preliminary report Final report
Name of index case Smear
Date case reported Culture
Infectious period Susceptibilities
Contact Type of Country Date
of HIV PPD Results Chet X-ray Diagnosis Start Comments)
Contact* of Birth Exposure initial initial Retest - Date Symptoms
DateResults LTBI Active
Date mm Date mm
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
Name:
DOB/Age:
Relation to source:
lame:
)OB/Age:
Relation to source:
Jame:
)08/Age:
Relation to source:
Type of Contact:
lea Contact-Q: perms who ha•shared air with a known or suspected TB case for prolonged and frequent pedals at time(e.g.ho Behold members,want associates depending on the
type d walWmkannrk)
Wier Contact-S&: persons who do not meet the criteria d e class ceded,but hose limited(Oposure to a kite or suspected TB a Skin tatting for OC's Is Skated only when it Is Wtely
set transmission to this group has take,plan(e.g.signifies*large number d dose collects show positive skin t sb)
Attachment F
INVOICE NUMBER:
CONTRACT REIMBURSEMENT STATEMENT
TO: Colorado Department of Health&Environment FROM:
DCEED/TB 3640 A3
4300 Cherry Creek Drive South
Denver,CO 80246
Attn: Marti Wood TB Contract Administrator
Phone: 303.692.2754 Fax: 303.691.7749 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:
[Date] SAMPLE TASK ORDER CHANGE ORDER LETTER Attachment G
Task Order Change Order Letter Number**. Contract Routing Number*****
State Fiscal Year 20**-20**, Proeram
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 CONTRACTOR!. 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,(S*.**)for an amended total financial obligation of the State of**********DOLLARS (S*.**).
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 first
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,Denver,Colorado 80246,Mail Code: *****-**. 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:
•
[Date] SAMPLE TASK ORDER OPTION TO RENEW LETTER Attachment H
Task Order Renewal Letter Number**. Contract Routing Number*****
State Fiscal Year 20**-20**, Protram
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 Contract 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 Contract,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,
(*.sin 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 first 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,4300 Cherry Creek Drive South,Denver,Colorado 80246,Mail Code: *****-**. 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 2430-202 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 LIC HEALTH A D ENVI 1ENT
By: BY: N6(,( (4 7 Vit (1/
Date: Mark E. Wallace, MD, MPH-Director
rat Memorandum
I CTO: David E. Long, Chair Board of County Commissioners
•
COLORADO FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
Environment 1./1/44DATE: May 19, 2003
SUBJECT: Tuberculosis Program Task Order
Enclosed for Board review and approval is a 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 July 1, 2003 through June 30, 2004,
WCDPHE will receive an amount not to exceed $56,289 plus $12.50 per visit for directly
observed therapy.
I recommend your approval of this task order.
Enclosure
2003-1298
Hello