HomeMy WebLinkAbout20010274.tiff RESOLUTION
RE: APPROVE TASK ORDER FOR TUBERCULOSIS TREATMENT AND OUTREACH
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 the Tuberculosis
Treatment and Outreach 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 upon full execution of said task order, and ending June 30,
2001, 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 Treatment and Outreach
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 29th day of January, A.D., 2001.
BOARD OF COUNTY COMMISSIONERS
WELD COU , COLORADO
ATTEST: get// �� ': EIL®`\ AVE/
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County Clerk to the i
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tkf-NCE
Deputy Clerk to the Boa 4% e 1,Th L✓ ' 1-e
WilllIttiv
H. Jerke
APPRO D AS TO FORM: C F
Davi E. ong�
Attorne
Robert D. Masden
2001-0274
HL0028
.Hi. _
• 4
Memorandum
I TO: M.J. Geile, Chair
C Board of County Commishikners
FROM: Mark E. Wallace, MD, MPH, Director,
COLORADO Department of Public Health and
Environment
e$
DATE: January 25, 2001 Vtt
SUBJECT: Task Order for the TB Control and Outreach
Program
Enclosed for Board review and approval is a task order for the TB Control and Outreach
Program. If approved this task order will become part of the master contract between the
Colorado Department of Public Health and Environment and the Weld County Department of
Public Health and Environment (WCDPHE).
Under the provisions of this task order, WCDPHE will provide TB treatment, TB preventive
treatment, provide for and interpret chest x-rays and other medical evaluation services, conduct
contact investigations and TB skin test screening programs. WCDPHE 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 these services, WCDPHE will receive an amount not to exceed $32,561 for TB control and
outreach activities, chest x-rays, and medical consultation plus $12.50 per visit for directly
observed therapy for the time period January 1, 2001 through June 30, 2001.
I recommend your approval of this task order.
Enclosure
2001-0274
STATE OF COLORADO
Bill Owens,Governor
Jane E.Norton,Executive Director Ter
Dedicated to protecting and improving the health and environment of the people of Colorado m��
4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division �./ �••
Denver,Colorado 80246-1530 8100 Lowry Blvd. •1a76
Phone(303)692-2000 Denver CO 80220-6928
Located in Glendale,Colorado (303)692-3090 Colorado Department
of Health
http://www.cdphe.state.co.us d bi„ t
December 29,2000
Weld County Department of Public Health
ATTN: Judy Nero
1555 North 17"Avenue
Greeley,CO 80631
Ms.Nero,
Enclosed please find four copies of your TB Outreach and Control Task Order with the Colorado
Department of Public Health and Environment. All four copies must be signed with two appropriate
signatures,one the designated authority binding the contractor to the contract,and the other attesting to the
authority of the first. If you have a seal,please affix it to the signature page. Please return all four copies
to:
Juli Bettridge
Colorado Department of Public Health and Environment
DCEED-TB-A3
4300 Cherry Creek Drive South
Denver,CO 80246-1530
Upon receiving the signed contracts,I will have them approved by the proper authorities. I will return to
you a verified copy as soon as possible.
Should you have any questions or require further information,please do not hesitate to contact me. Your
assistance in expediting this Task Order is appreciated.
Sincerely,
Juli Bettridge
TB Program Contract Monitor
Disease Control and Environmental Epidemiology Division
Phone:(303)692-2675
Fax:(303)691-7749
e-mail:luli.bettridge(a state.co.us
end: 4 contracts
Ca Printed on Recycled Paper
Department or Agency Name
COLORADO DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
Department or Agency Number
FHA
Contract Routing Number
01-00158
TASK ORDER
THIS TASK ORDER is made this 17th day of November,2000,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,3r°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 17'"
Avenue,Greeley,Colorado,80631,hereinafter referred to as"the Contractor".
FACTUAL RECITALS
Section 29-1-201,9 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,and to this end all State contracts with its political
subdivisions are exempt from the State's personnel rules and the State procurement code. 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. The State,in order:to carry out its lawful powers,duties,and responsibilities under
Section,25-4-501,et sa,8 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.
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. 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.
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) 100,
Organizational Unit Code(s)3640,4644,4645,4646,and 4648 Appropriation Code(s)355,386 and 387,Program Code(s)9012,
and Object Code(s)5420,2710,under Master Contract Routing Number 00 FAA 00008,and Encumbrance Number PO FHA
EPI0100158 and PO FHA EPI01000001. All required approvals,clearances,and coordination have been accomplished from
and with all appropriate agencies.
Page 1 of 8 Pages
NOW THEREFORE,in consideration of their mutual promises to each other,stated below,the parties hereto agree as follows:
A. PERIOD OF PERFORMANCE AND CONTRACT TERMINATION. The effective date of this Task Order is
January 1,2001,or on the date this Task Order is approved by the State Controller,whichever is later. The term of this
Task Order shall commence on January 1,2001,and continue through and including June 30,2001,unless sooner
terminated by the parties pursuant to the terms and conditions of the Master Contract.
B. SCOPE OF WORK.
1. The Contractor shall provide or coordinate the following services,in order of priority listed below,for all
individuals within the service area according to the State TB Manual and Rules and Regulations Pertaining to
Epidemic and Communicable Disease Control(6-CCR-1009-1,Regulation 4):
a. Provide active TB treatment,including directly observed therapy as required by reference above and
ensure adherence to and completion of therapy for;
b. Ensure contacts to all newly identified sputum smear positive TB cases are identified and investigated;
c. Of the identified contacts,provide appropriate evaluation and follow-up to ensure that those who begin
treatment for latent TB infection complete therapy;
d. Order TB Medications directly through the State Contract Pharmacy and administer TB medication.
Medications other than isoniazid,rifampin,ethambutol,pyazidimide,and pyridoxine require prior
approval for reimbursement by the State;
e. Collect bacteriological specimens on all suspects and assure that susceptibilities are conducted on
positive cultures for isoniozid,rifampin,ethambutol,streptomycin,and pyrazinamide;
f. Provide or arrange for chest x-rays and interpretation;
g. Provide or arrange for laboratory testing,and other necessary medical evaluation services;
h. Periodically monitor and evaluate persons with active and suspected active TB,TB infection and other
persons as necessary to protect the public health;
i. Provide treatment for latent TB infection;
j. Provide culturally appropriate patient education and information pertaining to TB treatment and/or
follow-up plan.
2. TB skin testing,chest x-rays and x-ray interpretations for the following are not eligible for reimbursement under
the terms of this contract:
• volunteers or employees of health care or long term care facilities
• volunteers,employees,or inmates of correctional facilities
• volunteers or employees of homeless shelters
• volunteers or employees of drug treatment centers
• volunteers or employees of schools or child care facilities
3. The Contractor shall recommend and offer an HIV antibody test to:
• all persons diagnosed with TB disease,regardless of age or apparent absence of risk factors for HIV
infection;
• all persons with positive TB skin tests(PPD)with HIV risk factors;and
• foreign-born persons from HIV endemic areas.
Page 2 of 8 Pages
The Contractor shall report all known HIV antibody test results to the State pursuant to section 25-4-1401 et
C.R.S.. Individuals who refuse testing shall be educated regarding the risks associated with H1 V/TB co-
infection.
4. 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. TB infection cases(reactors)/Known TB Contacts -initial report of patient name,birth date,
demographic and other patient information,risk factors as identified on the "Tuberculosis Surveillance
and Case Management Report"(copy attached and made part hereof as"Attachment A"),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(TB-10 form-copy attached and made part hereof as"Attachment
B").
b. Suspect/Known Active TB cases -initial report of patient name,birth date,demographic and other
patient information,risk factors as identified on the'Report of Verified Case of Tuberculosis"(RVCT
form-copy attached and made part hereof as"Attachment C"),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 TB-10 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.
5. The State shall immediately notify the Contractor of all newly arrived Class A or B TB immigrants to the county
via a Report of Alien with Tuberculosis form(CDC 75.17 copy attached and made part hereof as"Attachment
D"). The Contractor,in turn,will contact the immigrant and conduct TB screening including a PPD skin test
and chest x-ray for all Class A or B immigrants within 30 days of receipt of notification of their arrival. The
Contractor will additionally obtain sputum cultures x 3 if a clinical evaluation by a qualified medical provider or
chest x-ray interpretation reveals suspicion of active disease. The Contractor shall provide for appropriate
follow-up for these immigrants,complete the CDC 75.17 form and return the completed form to the State. The
Contractor further agrees to notify the State if the immigrant fails to appear for the required TB screening within
30 days of receipt of notification of their arrival.
6. The Contractor shall,through the services of Personnel Health Aid III's (1.5 FTE),conduct an outreach
program to ensure that patients receive appropriate information and education and assist with follow-up needed
to fulfill requirements listed above. These workers shall be bilingual. Services provided by these workers shall
include,but are not limited to:
a. 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 suspect cases of TB,paying special attention to
patients with potentially drug resistant cases and their contacts.
b. Ensure completion of therapy through Directly Observed Therapy(DOT),individual accountability,
incentives and enablers. If the national objective for the completion of therapy(90%of reported cases)
is not met or exceeded,the Contractor shall evaluate reasons for nonadherence,devise new strategies,
and discontinue lower-priority activities(e.g.routine skin testing programs where few new infections
are found)and use those resources to ensure completion of therapy for patients with active TB.
Page 3 of 8 Pages
7. The Contractor shall provide the State a narrative report for the initial term of this Task Order,January 1,2001
through and including June 30,2001 by September 1,2001 (this obligation survives the end of this Task Order
term -June 30,2001)which includes:
a. Progress in implementing outreach activities,results of the evaluation of those activities and whether
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 which have been met
through the agreement,non-compliant patients,children,foreign-born,etc.
e. A statement of time spent by the outreach workers in TB prevention and follow-up activities.
The Contractor shall submit report to:
Barb Stone
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South TB-A3
Denver,CO 80246
8. The Contractor shall submit Contact Investigation Reports to the State,as required by Centers for Disease
Control and Prevention(copies attached and made a part hereof as"Attachment E"). The Contractor and the
State agree to collaborate in automating data collection and transfer of these reports.
• Reports of all TB Contact Investigations provided between January 1,2001 and June 30,2001 under
the terms of this Task Order Letter shall be due to the State March 15,2001. This obligation survives
the end of this Task Order term(June 30,2001).
9. Pursuant to 25-4-506 C.R.S.,the Contractor shall provide or arrange for quarantine services for patients
requiring isolation. The Contractor further agrees to provide a written financial statement of need completed by
a licensed social worker,indicating whether the client has other financial means to cover costs of quarantine.
10. The State shall provide statistical analyses upon request by the Contractor regarding the Contractor's TB Control
Program.
11. TB Control services pursuant to 25-4-513,8 C.R.S,are provided at 80%from state funding sources and 20%
from the county 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.
The State shall cause to be paid to the Contractor an amount not to exceed THIRTY TWO THOUSAND
FIVE HUNDRED SIXTY ONE DOLLARS($32,561.00)under this Task Order. Of the total financial
obligation of the State referenced above, TWENTY THREE THOUSAND FOUR HUNDRED NINETY
Page 4 of 8 Pages
FIVE DOLLARS($23,495.001,is derived from The State General Fund. Of the total financial obligation of
the State referenced above,NINE THOUSAND SIXTY SIX DOLLARS($9,066.00) is derived from a source
of the federal government
2. 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 TWO THOUSAND DOLLARS($22,000.00)Statewide
for Tuberculosis Direct Observed Therapy for State Fiscal Year 2001 .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.
3. 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:
Description Funding Source Amount
Tuberculosis Control and Outreach State $ 19,250.00
Federal $ 9,066.00
Chest X-rays State $ 3,885.00
Medical Consultation State $ 360.00
Direct Observed Therapy @$12.50 per visit State As Administered
TOTAL: $32,561.00
D. PAYMENT MECHANISM.
1. 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:
• Reference this Task Order by its Contract Encumbrance number,which number is located on page one
of this document;
• 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
• 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.
Billing statements shall be sent to: Jull Bettridge,DCEED-A3,Colorado Department of Public Health
and Environment, 4300 Cherry Creek Drive South, Denver,CO 80246.
Page 5 of 8 Pages
E. ADDITIONAL PROVISIONS.
1. 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 herein by this
reference,made a part hereof,and attached hereto as"Attachment G". To be effective,the 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,the Task Order Change Order Letter shall include the following
information:
B. Identification of the related Master Contract by its contract routing number and this Task Order by its
contract number,and the affected Task Order paragraph number(s);
C. The type(s)of service(s)or program(s)increased or decreased and the new level of each service or
program;
D. The amount of the increase or decrease in the level of funding for each service or program and the new
total financial obligation;
E. The intended effective date of the funding change;and,
F. A provision stating that the Task Order Change Order Letter shall not be valid until approved by the
State Controller or such assistant as he may designate.
Increases or decreases in the level of contractual funding made through this task order change order letter
process during the initial or renewal terms of this Task Order may be made under the following circumstances:
G. If necessary to fully utilize appropriations of the state of Colorado and/or non-appropriated federal
grant awards;
H. Adjustments to reflect current year expenditures;
I. 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;
J. Closure of programs and/or termination of related contracts or task orders;
K. Delay or difficulty in implementing new programs or services;and,
L. Other special circumstances as deemed appropriate by the State.
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 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 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
Page 6 of 8 Pages
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. The written notice shall specify the effective date
of termination of this Task Order. In the event of termination under this clause,the parties shall not be relieved
of their respective duties and obligations under this Task Order until the effective date of termination has
occurred.
2. The State may renew this Task Order through a"Task Order Renewal Letter". A sample Task Order Renewal
Letter is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment H". To
be effective,the Task Order Renewal Letter must be:signed by the State and the Contractor;and,approved by
the State Controller or an authorized designee thereof. Additionally,the Task Order Renewal Letter shall include
the following information:
M. Identification of the related Master Contract by its contract number and this Task Order by its contract
routing number,and the affected Task Order paragraph number(s);
N. 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;
O. 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;
P. The intended effective date of the renewal;and,
Q. A provision stating that the Task Order Renewal Letter shall not be valid until approved by the State
Controller or such assistant as he may designate.
Upon proper execution and approval,the Task Order Renewal Letter shall become an amendment to this
Contract. Except for the General and Special Provisions of this Master Contract,the Task Order Renewal 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 contract renewal letter 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 change order letter 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
the Task Order Renewal Letter to the State by the date indicated in the Task Order Renewal Letter. If the
Contractor does not agree to and accept the proposed renewal term,or fails to timely return the partially executed
Task Order Renewal Letter by the date indicated in the Task Order Renewal 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 Renewal Letter has passed. The written notice shall specify the effective date of
termination of this Task Order. In the event of termination under this clause,the parties shall not be relieved of
their respective duties and obligations under this Task Order until the effective date of termination has occurred.
E. ATTACHMENTS. All attachments to this Task Order 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 and conditions of this Task
Order and those of any attachment hereto,the terms and conditions of this Task Order shall control.
Page 7 of 8 Pages
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 f the State of Colorado)
By: By: X70 d't Ye h
Name: M. J. ile For the Executive Direct
Title: Chair (01/29/2001) Department of Public
FEIN: 84-6000813 Health and Environment
Attestation: S i � r PROGRAM APPROVAL:
86t f s.
X)6Yidd33lle:reEiet ��.� . , Eric eiger
Deputy Clerk to the Board
APPROVALS:
COLORADO DEPARTMENT OF LAW COLORADO DEPARTMENT OF PERSONNEL
OFF ICE OF THE ATTORNEY GENERAL OFFICE OF THE STATE CONTROLLER
Ken Salazar,Attorney General Arthur L. Barnhart,State Controller
By: By: -11C4,75co-ire-Lk
WELD COUNTY DEPARTMENT OF
PUBLIC HEAL H OD ENVIRONMEIff
BY: Page 8 of 8 Pages
Mark E. Wallace, MD, MPH-Director
•
Attachment A
PATIENT FOLLOW-UP INFORMATION AND TRANSFER FORM (TB-10)
( ) Pat your kikmrion ( ) (WV masted
TO: FROM:
•
Patient's Name: SEX Marital Status
Address: M F SMWDSep
W D Sep
City, State, Zip Birthdate I / Race
Phone Number. County:
.«
ACnVECASE; YES_ NO_
Confirmed by Lab or PCP diagnosis?:YES_NO_ Nye*date of diagnos t I /
Date of TBC skin test__Li_ Result In MM:
Form: Pulmonary_ Extra Pulmonary(specify site) Burped
LATEST BACTERIOLOGICAL STATUS: Not Done
i
a I*ss Amur Resaelu we mail QS SKS Drs LS She Sur SeaPaea.�n sae
a
UM
rtle 'Ga
oar Caste su)
DRUGS: Ifpatient on drug therapy Madeatlora and dosage
Date started: / /
Daisppe:_IL_
Number of weeks on DOT:
If pedant NOT on drug therapy,give meson:
Most recent X-ray results/date(s)
•
Previous Hospitalization for TB:When Were:
Primary Cam Provider Phone
REACTOR: YES_ NO Medications and dosage
Date of Skin tat I /
Date stance:_?j___
Date stopped radiations:_LL—
Reason stopped
Mediation given by wham
RE!Or`4TION INFORACATtON: Date of relocation: I l
If patient has moved or relocated.please provide new address and ohone number.
Colorado Department of Public Health and Environment Name of Person completing the tome Date
4300 Cherry Creek Drive South, DCEED-TB-A3 ' / /
Denver, Colorado 80222-1530 303-892-2679 Td3 tDptw4N7)CDPIE
Attachment B
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT
Colorado Department of Public Health and Environment DCEED-TB-A3
Tuberculosis Control 4300 Cherry Creek Drive South
Denver,Colorado 80246-1530
(303)692-2679 Phone (303)691-7749 Fax
PATIENT INFORMATION
Name Date of Birth Country of Birth _ ...• - - Month Year
Address: —/—/ 0 USA Arrived in USA
/ I
City Zip: ❑Canada,Japan,Western Europe, ---
Home Phone: Australia, New Zealand Refugee:
County of
Work Phone: Residence ❑Mexico,Central or South America ❑Yes
—/_ ❑Africa.Middle East' 0 No
Sex: Race
❑Male 0 White ❑China,India,Central or ❑ Unknown
Ethnic Orign Southeast Asia, Indonesia,
❑ Female 0 Black Alien Number#
❑Hispanic D Eastern Europe,Russia,Ukraine
❑American Indian/
Alaskan Native El Non-Hispanic ❑Unknown
Lenght of residence
Marital Status ❑Asian/Pacifc(stand 0 Unknown in Colorado •
❑ Unknown
AGENCY SUBMITTING THIS REPORT
Agency's Name: Agency'County
Agency's Address: —I—
City: Zip: Phone:
Name of Patient's Primary Care Physician:
Address:
City: Zip: Phone:
MOST RECENT SKIN TEST
Type: Results: Induration Previous If positive,is this a skin test
0 Mardoux-Tubersol ❑ Postive _mm Positive PPD conversion negative to positive
❑Mantoux-Aplisol 0 Negative 0 Yes within 2 years:
❑Tine 0 Not Done Date PPD Given 0 No 0 Yes
o Other(specify) 0 Unknown Date of last 0 No
0 Other(specify) Date PPD Read negative test 0 Unknown
I/ -I 1
X-RAY FINDINGS
Date of X-ray: Previous Status X-ray taken by:(Agency's Name):
—l—/ Abnormal X-ray: 0 Statie
II
0 Worsening Return X-ray to: --
X-ray results: Abnormality 0 Improvhg
0 Normal ❑ Cavitary ❑Linlatawn
❑Abnormal 0 Noroavitary Consistent w/TB
❑ Not Done 0 Noncavitary Not Consistent w/TB
❑ Unknown ❑ Otter(Specify) Note:CDPHE will separately attach xray
findings and recommendations
CLINICAL
Symptoms: Date of Onset of Special Conditions:
❑ None 0 Fever Symptoms: 0 Pregnant EDC:_I I
❑Productive Cough ❑ Mght Sweats I ❑ Postpartum Breast Feeding
❑Hemoptysis 0 Otter(Specify) 0 Other(Specify):
❑Weight Loss
Name of Person completing: Date: ,
Cormrcnfs:
TS-17 02/99
.•atients Name: Date of Birth:
- Occupation Yes No Yes No
•
❑Health Care Worker 0 0 Homeless within past year 0 0 Diabetes
❑Correctional Employee 0 0 Resident of Correction Facility L I 0 saicosis
❑Migratory Aricuttural Worker at time of Diagnosis 0 0 Cancer/Malignacies
❑Not Employed within past 24 months If Yes, ❑ 0 Immonsuppressive Therapy
❑Unknown 0 ❑ Federal Prison 0 0 Gastrectomy
C Other Occupation(specify) 0 0 State Prison 0 0 Hepatitis
0 0 Local Jail ❑ ❑ Kidney Failure
How many other persons in household 0 0 Juvenile
besides patient? ❑ ❑ Other Yes No
❑0 ❑ 1-3 ❑4. ❑ 0 Unknown 0 0 Exposed to TB
❑ ❑ Previous Diagnosis of TB
On Medications that may have Yes No - Date:_/ I_
interactions with anti-TB drugs? 0 0 Resident of Long Term Care ❑ ❑ BCG Vaccination
❑Yes ❑ No Specify Facility at time of Diagnosis? Date:_/ I_
It Yes,
❑ 0 Nursing Home Yes No
Yes No ❑ ❑ Hospital 0 ❑ Prior HIV Test
❑ 0 Injecting Drug Use 0 0 Residential Date: / /_
❑ 0 Excessive Alcohol Abuse 0 0 Mental Health If yes,WI's /Site/Provider)
O 0 Non-injecting Illicit Drug Use ❑ 0 Alcohol or Drug Treament -
❑ ❑ Other Pos Neg
❑ ❑ Unknown 0 0 Result
TB FOLLOW-UP
Confirmed diagnosis of TB? 0 Yes ❑ No 0 Suspect Is patient in insolation or in need of isolation/quarantine?
If confirmed list primary site: ❑ Yes ❑ No
Secondary she: If yes.describe:
Hospital Admission: Was a contact investigation initiated: ❑ Yes ❑ No
Hospital: If yes,is a Contact Investigation form needed? ❑ Yes ❑ No
Admission Diagnosis: Date sent_I/_ By whom?:
Date: I/
LABORATORY
SMEAR CULTURE LAST POSITIVE Laboratory Submitted to:
Pos Neg Not Done Pos Neg Not Done 0 Colorado Department of Public Health and Envirome
❑Sputum ❑ 0 0 0 0 0 Date:_I / 0 Other Laboratory(specify)
❑Urine 0 ..0 0 0 0 0 Date: / 1_
❑Gastric 0 0 0 0 0 0 Date: I_I_
❑Other , 0 0 0 _ 0 0 0 Date: I/_ Date: / 1
TREATMENT SOURCE INFORAMTION
❑Current Person Who Exposed this Patient
❑Past'-- ['Completed full course Name:
0 Started but did not complete full course Address:
❑ Unknown,if completed full course City. State: Zip - Phone: /_I
If treated in the past was this for. 0 Active Disease Closeness of Source to Case: Source Sputum results:
0 Preventive Therapy 0 Household 0 MTB Culture Positive
DOT By: •
0 Workplace ❑ AFB Smear Positive
Drug Regimen:(Mark all that apply) . -Date Started ❑ Other 0 Smear and Culture Negative
Isoniazid _mg / I ❑ Unknown ❑ Unknown
B-6 _mg - / / Laboratory
Rifampin _mg __/_/_
Pyrazinamide _mg ' _/ I
Ethamubutol _mg - / I
•
Streptomycin _mg / /_
Ethionamide _mg i /_
Other(specify)
radians Name: (Lash Woolf OF VERIFIED CASE
(Fusel) Oa I.)
Street Address: OF TUBERCULOSIS
i. her,sham.City,slate) Zip Code) Attachment C
CDC S
U.B.DEPARTMENT OF HEALTH&HUMAN SERVICES
PUBLIC HEALTH SERVICE
REPORT OF VERIFIED CASE OF TUBERCULOSI CENTERS FOR DISEASE CONTROL
mnoK oRtaalorlela AND PREVENTION(CDC)
eralerrne ATLANTA,GEORGIA 30333
FORK APPROVED ORD NO.N20.pete Pep.Dale tins
C SOUNDEX 1. State Reporting: 2.
j [ Specil State Case
Y: Number:
Alpha State Code Clty/County
Case Number:
3.Dale Submitted: By: A.Address for Case Counting:
I Oa y Yr.
ITI City
Within City Limits I❑ Yes 20 No
5.Month-Year Reported: 6.Month-Year Counted:
County
Mo. Vt Mo. Yr.
Zip Code —
7.Date of Birth: B.Sex: 9. Race:
Mo. Day Yr. I 0 Male
1❑White 2 Black 3❑ American Indian or Alaskan Native
2 Female
s❑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:
t❑ Hispanic If U.S.,check here ❑ Mo. Yr.
❑ Alive
If not U.S., enter
2❑ Not Hispanic country code(see list) 2 Dead
14. Previous Diagnosis 15.Major Site of Disease:
of Tuberculosis: so❑ Miliary 'It site is'Other',
enter anatomic
00❑ Pulmonary 23❑ Lymphatic: Other 60❑ Meningeal code(see list)
i 0 Yes i 0 Pleural 29 Lymphatic:
❑ Unknown 700 Peritoneal
20 No 2I❑ Lymphatic: Cervical 30❑ Bone and/or Joint sof I Other'
22 Lymphatic: Intrathoracic 40❑Genitourinary 90❑ Site not Stated
19 If yes, list year of
previous diagnosis 16.Additional Site of Disease: 'If site is'Other',
oo❑ Pulmonar enter anatomic
Y 23❑ Lymphatic:Other Son Miliary code(see list)
i on Pleural 29❑ Lymphatic:Unknown 60❑ Meningeal
I❑ If more than one previous
episode,check here 2I❑ Lymphatic:Cervical 30❑ Bone and/or Joint 700 Peritoneal
If more than one
22 Lymphatic: Intrathoracic ao❑ Genitourinary son Other' aadolonal mre, O ee
check here
17.Sputum Smear: 15.Sputum Culture: 19. Microscopic Exam of Tissue and Other Body Fluids:
i❑ Positive 3❑ Not Done i❑ Positive 3❑ Not Done i❑ Positive 3❑ Not Done If positive,enter
anatomic oode(s
2 Negative 9❑ Unknown 2 Negative 9 Unknown 2 Negative 9❑ Unknown (see list)
20.Culture of Tissue and Other Body Fluids: 21.Chest X-Ray:
1❑ Positive 3 Not Done If positive, enter i❑ Normal 2❑Abnormal 3 Not Done 9 Unknown
anatomic code(s)
2 Negative 9 Unknown (see list)
If Abnormal i❑ Cavilary 2❑ Noncavitary 30 Noncavitary
22.Tuberculin(Mantoux)Skin Test at Diagnosis: (check one) Consistent Not Consistent
Positive 3 . with TB with TB
1
❑ Not Done Millimeters(mm)of
Induration
2 Negative 9❑ Unknown If Abnormal I❑ Stable 3 Improving
(check one)
if Negative,was patient anemic? i❑ Yes 20 No 9 Unknown 2❑Worsening 9❑ Unknown
CruskNay bsden dot:aeaeceon S Manleaon M enMKW ld average 30 nereres pr�eappK Owlets ane b
Orr.ATM PR Hobert
Hmralm ar Bldg..
R . s.m mll.nNM.ra to Ave.,aW I SW;Was aKYnI.m Kerelryr/cYv eyes ar a ifes of lM and
irclslpe data sources.ytm.nlq ilrapo porn 2 501 data AS v Humphrey Bldg.,Nn.7218:203 kldepensnce A wawsiglan,00 20401,aria b to deoe S MeragelaN age Budget P 9P •edudrq Moen mind=
aPNwdt e6Reecum PmNa IO920aot6):watletVat DC 205at
bentntdn mdetad on Malone:meat wd perms U__a,of edhedrl he bean wand nN a O ersn.ee sal t me be held In end oaederv.M to heed orw b Keeellence Wrpaeea.end all not be deabaed or
'meeeed Male tie mtee•a hdNeal h emaderlba ee,Sects 30e(a):tones
Pwc Hrm Sent.Aa(a2 u.5 c.2ean1.
REPORT OF VERIFIED CASE
'e
OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
23. HIV Status: o❑ Negative 3 Refused 99 Unknown 24. Homeless Within Past Year:
1❑ Positive 4❑ Not Offered o❑ No
2 Indeterminate 5 Test Done,Results Unknown 1❑Yes
99 Unknown
If Positive,Based on: 1❑ Medical Documentation 29 Patient History 9❑ Unknown
If Positive, List: CDC AIDS Patient Number (II AIDS Reported before 1993)
Slate HIV/AIDS Patient Number (If AIDS Reported 1993 or Later)
City/County HIV/AIDS Patient Number (II AIDS Reported 1993 or Later)
25. Resident of Correctional Facility at Time of Diagnosis: 09 No 1❑ Yes 9❑ Unknown
If Yes,
1❑ Federal Prison 3❑ Local Jail 59 Other Correctional Facility
2❑ State Prison 4 Juven rreile nal Facility 9 Unknown
Coctio
26. Resident of Long-Term Care Facility at Time of Diagnosis: 0❑ No I 9 Yes 9❑ Unknown
If Yes, I Nursing Home a Mental Health Residential Facility❑ ❑ 60 Other Long-Term Care Facility
2 Hospital-Based Facility 5❑Alcohol or Drug Treatment Facility 99 Unknown
3❑ Residential Facility
27.Initial Drug Regimen:
NO YES UNK. NO YES UNK. NO YES UNK.
Isoniazid 0❑ 1❑ 9❑ . Ethionamide o❑ 1 9 Amikacin on I❑ 9❑
Rifampin on I❑ 9 Kanamycin on 1❑ 9 Rifabutine on in 9❑
Pyrazinamide o9 19 9❑ Cycloserine on 1❑ 9 Ciproiloxacin 0❑ 1 9
Ethambutol 0❑ i0 9 Capreomycin o9 19 9❑ Olloxacin on 1 9❑
Streptomycin 0❑ 1 9 Para-Amino on 1❑ 9❑ Other 0❑ 1❑ 9❑
Salicylic Acid
28. Date Therapy Started: 29. Injecting Drug Use Within Past Year:
Ma. Day Yr.
II_IIi 0❑ No 1❑ Yes 99 Unknown
30. Non-Injecting Drug Use Within Past Year: 31. Excess Alcohol Use Within Past Year:
o❑ No I❑ Yes 9❑ Unknown o❑ No 1❑Yes 9 Unknown
32. Occupation (Check all that apply within the past 20 months):
1❑ Health Care Worker z❑ Correctional Employee 3❑ Migratory Agricultural Worker 5❑ Not Employed within Past 24 Months
4❑ Other Occupation a Unknown
Comments:
( I
CDC r2.9A REV.05323 1st Copy—State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2o12
_ Patient's Name: REPORT OF VERIFIED CASE
IL..II (FOCI IM I I OF TUBERCULOSIS
•
• Street!Address:
(MUN--,.Sir..i.Car.Male Zip Cede?
U.S.DEPARTMENT OF HEALTH a HUMAN SERVICES
CDC PUBLIC C HEALTH OL
CENTERS FOR DISEASE CONTROL
REPORT OF VERIFIED CASE OF TUBERCULOSIS AND PREVENTION(CDC)
i[�l(p rpw Cv5[M[CP:li9L
ATLANTA.GEORGIA 30333
Mo vE Ol FORM APPROVED OMB NO.0920002E Exp.Owe tuts
Initial Drug Susceptibility Report (Follow Up Report - 1)
( SOUNDEX State Reporting: Year Slate Case
Number:
Counted:
Specify:
Alpha Stale Code City/County
Case Number:
Submit this report for all culture-positive cases.
33. Initial Drug Susceptibility Results:
Was Drug Susceptibility Testing Done: on No t Yes 9❑ Unknown
If answer is No or Unknown, do not complete rest of report.
H Yes. Mo. Day rr.
Enter Date First Isolate Collected ImI WT
for Which Drug Susceptibility Was Done?
34. Susceptibility Results:
Resistant len n w Suscentible Not Done Unknown
Isoniazid i 21 ! 3❑ 9!_',
R ifampin 1❑ 2 3❑ 9'J!
Pyrazinamide i0 2 3❑ 9J
Ethambutol 1❑ 2 3D 9! !
Streptomycin 1❑ z❑ 3 L 9_
Ethionamide 1 E z❑ 3J 9_,
Kanamycir 1❑ 2u 37 9—
Cyciose tine 1❑ 2❑ 3❑ 9'J
Capreomycin in 2❑ 3 9'—
Para-Amino 1❑ z— 3❑ s_.
Salicylic Acid
Amikacin 1 2❑ 3❑ 9'J
Rifabutine 1❑ 2❑ 31D sJ
Ciprofloxacin IL z❑ 3❑ 9—!
Ofloxacin 1❑ z❑ 31J 91_
Other 1❑ 2❑ 3❑ 9 L
t I
Comments:
[ "'s
samara sanity r MS 1om1*411th wined permit at a My VMsidial M been Mrled wl a guawde.t1 x wa be held in sleet conhdefee.wa be used ONy kg sur.wnce purposes,and wa net be disclosed of
..wre.FMaA sanity
Or t.tMel M amdree wl Sedan 3OB(dl dl M Pubic Heal S.rwce Act H2 u.s.c.242"1
CDC 72.913 REV 12-92 REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow OP Repon.I
let Copy—State
Patient's Name:
uasn 1"1" --- - - - M I _. REPORT OF VERIFIED CASE
'Street Address: -_ _ I • OF TUBERCULOSIS
INum,,. Si,aa Coy.Sim., _ Zip Coder
CDC U.S.DEPARTMENT OF HEALTH&HUMAN S SERVICES
FOR SE SERVICE
REPORT OF VERIFIED CASE OF TUBERCULOSIS CENTERS FOR DISEASE SERVICE
AND PREVENTION I CDC,
esn worw nxrry aeon ATLANTA_GEORGIA 30333
FORM APPROVED OMB NO.09te-0pas Eq.Dale I Ibis
Case Completion Report (Follow Up Report — 2)
C SOUNDER 1 State Reporting:
J Year State Case
Number:
Counted:
Specify:
Alpha State Code City/County
Case Number:
35. Sputum Culture If Yes. Date Specimen Collected If Yes. Dale Specimen Collected on
Conversion Documented: on Initial Positive Sputum Culture. First Consistently Negative Culture:
ran
• Mo aV Yr Mo. Day Yr.
0 No I` Yes 9 Unknown
36. Date Therapy Stopped: 37. Reason Therapy Stopped:
Mo. Day Yr.
II—Ill t❑ Completed Therapy 3H Lost 5 Not TB
4.
2❑ Moved Uncooperative or Refused 6n Died 9 Unknown
38. Type of Health Care Provider: 39. Directly Observed Therapy: If Yes. Give Site(s)of Directly Observed Therapy:
1 I Health Department 0❑ No,Totally Self-Administered 1_I In Clinic or Other Facility
2❑ Private/Other I❑ Yes, Totally Directly Observed 2 i In the Field
alE Both Health Department 2❑ Yes, Both Directly Observed 3 Both in Facility and in the Field
and Private/Other and Self-Administered
Unknown Weeks
9
9❑ Unknown —
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? on No t❑ Yes 9' ' Unk. Collected for Which Drug Mo. Da y Yr.
Susceptibility Was Done: Il—II�ll
If answer is No or Unknown, do not complete rest of report.
41. Final Susceptibility Resistant Susgentible Not QQoe Unknown Resistant Suscentible No]Done Unknown
Results: _
Isoniazid I❑ 2❑ 3❑ 9 Capfeomycin IJ' 2'J 3❑ 9❑
Rifampin to 2 3❑' 9— Para-Amino IhI 2❑ 3J 9]
— Salicylic Acid
Pyrazinamide I❑ 2D 3❑ 9 Amikacin t❑ 2❑ 3 9❑
Ethambutol 1❑ z❑ 3` 9 Rifabutine li^'" 2❑ -❑ 9❑
Streptomycin in 2❑ 3❑ 9_, Clp roftoxacin I❑ 2r13❑ 9❑
Ethionamide I z❑ 31_ s ! Ofloxacin I❑ 2❑ 3E19❑
Kanamycin 1 2❑ air 9_ Other 1❑ 2❑ 3❑ 9L1CycloserIne 1❑ 2E 3' 9_
Comments:
inonoikan axioms cares loan,Morn would same denUManon ol any individual has been coictad win a guaranies mai,1 sot M MM in*via ca tMrce.M be used oar i v swvSManse Pincus.and eat MI be dNdosed w
released w,E,uA the canna 01 rho wavival n accordance min SeOan seem d IM Pubic Sea Seonce Acl 142 u S C.2e2m1.
CDC 22.9C REV 12-92 REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Repoli-2
1st Copy—State
Allen(AUeng,Name,Address,Phone): IMMIGRANT A• REPORT ON ALIEN WITh TUBERCULOSIS
itOCAL HEALTH OFFICER:
- "this person recently entered the United States and is referred to you because
the X-ray shows findings consistent with tuberculosis,as indicated in the
accompanying report of medical examination performed abroad. This pawn
• • may not have received chemotherapy or chemoprophyiaxis and is referred to
you because you may with to initiate preventative treatment. Your Initial
SEX:I;)M I JP DATE OP BIRTH(Mo.,Day,Yr.) 1/21/64 evaluation would be appreciated. Please check the appropriate boxes below
and return this form to the State Health Officer.*
[J CLASS O-I -7Lberculosis,clinically active,not infectious If the ellen doeslo report%) - • please check here[ )and
forward this form tolhe Stateilealth Officer.• Retain for you records
I I CLASS D-2-Tuberculosis,not clinically active,not infectious the accompanying report of examination perforated abroad(OP-I.57).
•ultaay MS nMSYwt re•1e Centerslr Dlsere C.,wd asthenia.'
Your Initial Evaluations E.Has Patient Received Chemotherapy/Prophylaxis In the past?
A.Direct Smear(In U.S.) C.X-ray(abroad) D.Presumptive Diagnosis [ I Yes ( )No I I Unknown
Positive Normal Pulmonary TB-Active F.Are you prescribing Chemotherapy/Prophylaxis?
Negative Abnormal Pulmonary TB-Not Active • [ I Yes
[ Not Done Not Done Pulmonary TB-Activity Undetermined Signature of Physician Date of Evaluation
I
Unavailable L+atrappulmonary TB
B.X-ray(In U.S.) Nnn TB Abnormality
Iff
Normal No Abnormality Name of Health Department
Abnormal
Not Done •�
•
This form Is not Imenled 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 Officer, Centers for Disease Control and Prevention(CDC)
- health Department please forward to: Atlanta, Georgia 30333
•
• CDC 75.17(Rev. 12/94) CLASS B LOCAL HEALTH DEPARTMENT COPY
•
•
tr
i3
•
COLORADO DEPARTMENT OF PUBLIC IIEALTI-I AND ENVIRONMENT
TB CONTACT INVESTIGATION RECORD .
Name of Reporting Agency: Date:
Name of Source Case: Site of TB:
Date Case Reported:
Type of Preventive
Contact PPD Results(mm) Therapy TB Disease
Age (see codes X-ray
below)* Baseline Retest Date& Yes Date
Contact <I5 15-35 >35 Date Date Result No Tx/Date Comments
Name:
BD: •
Relation to Source:
Name:
BD: •
Relation to Source:
Name:
RD:
Relation to Source:
Name:
BD:
Relation to Source:
Name:
BD:
Relation to Source:
•Close Contact(C): persons who have shared air with a known or suspected case of TB for prolonged and frequent periods of time(e.g.household members,work associate--depending on type of work/environment)
Other Contact(OC): persons who do not meet the criteria of a close contact,but have had limited exposure to a known or suspected Tit case. Skin testing for OCs is indicated only when it is likely that transmission to this
group has taken place(e.g.significantly large number of close contacts show positive skin tests)
•
•
TB-3 08/22/97 C-
B
mr
t+1
INVOICE NUMBER
CONTRACT REIMBURSEMENT STATEMENT
TO: FROM:
Colorado Dept of Public Health & Environment
4300 Cherry Creek Dr. S, Denver 80246
FAX: ( 303 )782-0904 DATE OF EXPENDITURE:
TYPE OF FROM: Final
PROGRAM: Bill?
FEDERAL ID TO: ❑ Yes
NUMBER: ❑ 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.
m
n
AUTHORIZED DESIGNEE (STATE): DATE:
w
Contractor Notified of Reimbursement Amount Change?
❑Yes 0 No Initial:
Attachment G
[Date] Sample Task Order Change Order Letter
State Fiscal Year 2000-2001,Task Order Change Order Letter Number**,Contract Routing Number**-*****
Pursuant to Part F_3.of the Master Contract with contract routing number**-*****and paragraph **of the Task
Order with contract routing number**-*****and contract encumbrance number***********,(as amended by
Task Order Renewal Letter**,contract routing number**-*****,and/or Task Order Change Order Letter**
contract routing number **-*****, if any),hereinafter referred to as the"Original Task Order"(a copy of which is
attached hereto and by this reference incorporated herein and made a part hereof)between the State of Colorado,
Department of Public Health and Environment and Contractor's Legal Name,for the term from ********* **
****,through ********* ** ****,the parties agree that the maximum amount payable by the State for the eligible
services referenced in paragraph **of the Original Task Order is increased/decreased by dollar amount
DOLLARS,($*.**)for a new total financial obligation of the State of dollar amount DOLLARS,($*.**). The
revised Scope of Work,which is attached hereto as"Attachment 1",and the revised budget,which is attached
hereto as'Attachment 2",are incorporated herein by this reference and made a part hereof. The first sentence in
paragraph'*of the Original Task Order is hereby modified accordingly. All other terms and conditions of the
Original Task Order are hereby reaffirmed. This amendment to the Original Task Order is intended to be effective
as of***********,****. However,in no event shall this amendment be deemed valid until it shall have been
approved by the State Controller or such assistant as he may designate.
Please sign,date,and return all **originals of this Task Order Change Order Letter by********* ** ****,to the
attention of:Juli Bettidge,Colorado Department of Public Health and Environment,4300 Cherry Creek Drive
South,Denver,Colorado 80246,Mail Code:DCEED-A3. One original of this Task Order Change Order Letter
will be returned to you when fully approved.
Contractor's Legal Name STATE OF COLORADO
(legal type of entity) Bill Owens,Governor
By: By:
For the Executive Director
Print Name: DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT
Title:
FUN:
APPROVALS:
FOR THE STATE CONTROLLER PROGRAM:
Arthur L. Barnhart,State Controller
By: By:
Eric Schleiger,Fiscal Officer
Attachment H
[Date] Sample Task Order Renewal Letter
State Fiscal Year 19** - **, Task Order Renewal Letter Number**
, Contract Routing Number"-a«"
Pursuant to Part F.S..of the Master Contract with contract routing number**-***** and paragraph**of the Task Order with
contract routing number**-***** and contract encumbrance number*********** amended by Task Order Change Order
Letter**,contract routing number**-***** ,
O contract
routing
number ),
hereinafter referred to as the"Original Task Order"(a copy of which is attached hereto and by this reference incorporated herein
and made a part hereof)between the State of Colorado,Department of Public Health and Environment and Contractor's
Legal Name,for the renewal term from ********* ** **«« ough*** ***** ** ****
imum
amount payable by the State for the eligible services referenced in paragraph** of the Original TaskOrdeies ris increased/dee that the ecreased
by dollar amount DOLLARS,($*.**)for a new total financial obligation of the State of dollar amount DOLLARS,($*.**).
The Scope of Work,which is attached hereto as°Attachment I",and the budget,which is attached hereto as°Attachment 2",are
incorporated herein by this reference and made a part hereof. The first sentence in paragraph**of the Original Task Order is
hereby modified accordingly. All other terms and conditions of the Original Task Order are hereby reaffirmed. This amendment
to the Original Task Order is intended to be effective as of ** ****. However,
in shall this amendment be
deemed valid until it shall have been approved by the State Controller or such assistant as he may designate.
Please sign,date,and return all **originals of this Task Order Renewal 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 Letter will be returned to you when fully
approved.
Contractors Legal Name STATE OF COLORADO
(legal type of entity) Bill Owens,Governor
By:
By:
Print Name: For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
Title: AND ENVIRONMENT
FEIN:
APPROVALS:
FOR THE STATE CONTROLLER: PROGRAM:
Arthur L.Barnhart,State Controller
By:
By:
Eric Schleiger,Fiscal Officer
Hello