HomeMy WebLinkAbout20013011 RESOLUTION
RE: APPROVE TASK ORDER FOR TUBERCULOSIS ELIMINATION COOPERATIVE
AGREEMENT 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
Elimination Cooperative Agreement 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 November 1, 2001, and ending October 31, 2002, 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 Elimination Cooperative
Agreement 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 24th day of October, A.D., 2001.
BOARD OF OUNTY COMMISSIONERS
WELD CO TY, COLORADO
ATTEST: LI � a,� 771 0.(/.v
�', M. J. eile, Ch r
Weld County Clerk to� �? 'O.'-
Glenn V /
�I aa ,
��ff o- em
BY: 'ice/. •
Deputy Clerk to the Bo'".•�� 1
Wil H. Jerke
APPROVE ORM: o c
D vid E. on
Coney
Robert D. Masden
Date of signature: MA/
2001-3011
HL0028
Memorandum
IgoTO: M.J. Geile, Chair
OBoard of County Commissioners
• FROM: Mark E. Wallace, MD, MPH, Director
COLORADO Department of Public Health and
Environment /
1 1 (,ht
DATE: October 22, 2001
SUBJECT: Tuberculosis Elimination Cooperative
Agreement Task Order
Enclosed for the Board review and approval is the Tuberculosis Elimination Cooperative
Agreement task order between the Colorado Department of Public Health and Environment and
Weld County. This task order will address increased tuberculosis activity in the County.
Under the provisions of the task order, WCDPHE will hire temporary staff to provide directly
observed therapy to those with active TB disease, perform further contact investigations as
needed, evaluate and treat newly identified contacts, perform further evaluation and treatment of
previously identified contacts, conduct mass screening at the trailer park where the current
increased TB activity is occurring, and distribute incentives and enablers to increase adherence
with testing and treatment for TB disease and latent TB infection.
For these services, WCDPHE will receive an amount not to exceed $84,241.00 for TB control
and outreach activities, chest x-rays, labs, and medical consultation for the time period
November 1, 2001 through October 31, 2002.
I recommend your approval of this task order.
Enclosure
2001-3011
Department or Agency Name
COLORADO DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
Department or Agency Number
APPROVED WAIVER FORM TASK ORDER FHA
Tuberculosis Program
Contract Routing Number
02-00087
TASK ORDER
This TASK ORDER is made this 17th day of October,2001,by and between: the State of Colorado,for the use and
benefit of the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place
of business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as "the State";
and,the Board of County Commissioners of Weld County(a political subdivision of the state of Colorado),
whose address or principal place of business is 915 10th Street,3rd Floor,Greeley,Colorado 80631, acting by and
through 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
Pursuant to section 25-4-501,C.R.S.,as amended,the General Assembly has declared that tuberculosis: (TB)is an
infectious and communicable disease,it endangers the population of this state,and the treatment and control of this
disease is a state responsibility. In accordance with section 25-4-511,C.R.S.,as amended,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 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 seq.,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. The State and the Contractor agree that the most efficient and effective way of providing these
services is at the local level.
Pursuant to the TB Elimination Cooperative Agreement—U52/CCU800512-19,the State has been awarded monies
by the United States Department of Health and Human Services,Centers for Disease Control and Prevention(CDC)
for tuberculosis control to address an outbreak of tuberculosis(TB)in Weld County Colorado.
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 100,Organizational Unit Code 3640,Appropriation Code 387,Program Code 9012,and Object
Code 5420 under Contract Encumbrance Number PO EPI 0200087,and Master Contract Routing Number 00 FAA
00008. All required approvals,clearances, and coordination have been accomplished from and with all appropriate
agencies.
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NOW THEREFORE,in consideration of their mutual promises to each other, stated below,the parties hereto agree
as follows:
A. PERFORMANCE PERIOD. In accordance with section 24-30-202(1),C.R.S., as amended,the effective
date of this Contract is the date the State Controller approves this Contract. The initial term of this Contract
shall commence on the effective date of this Contract and continue through and including October 31.
2002,unless sooner terminated by the parties pursuant to the terms and conditions of the Master Contract
and this Task Order. The Contractor may commence performance under this Task Order as of its effective
date. The State shall have no financial obligation to the Contractor for any work or services or, any costs or
expenses,incurred by the Contractor prior to the effective date of this Task Order. The total term of this
Task Order, 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 necessary to control this current outbreak of tuberculosis:
A. Hire temporary staff or increasing time of current staff(nursing and outreach)to;
I. Provide directly observed therapy to those with active TB disease.
2. Perform further contact investigations as needed.
3. Evaluate and treat(where appropriate)newly identified contacts.
4. Perform further evaluation and treatment(where appropriate)of previously identified
contacts.
5. Conduct mass screening at the trailer park where the current TB outbreak is
occurring.
B. Distribute incentives and enablers to increase adherence with testing and treatment for TB
disease and latent TB infection.
2. TB skin testing,chest x-rays,and chest x-ray interpretations for the following classes of persons
are not eligible for reimbursement under this Task Order:
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;and,
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 their age or the 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.
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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.
4. The Contractor shall provide the State with complete patient data for all persons with infection and
disease for integration into the TB records system. Patient data shall include,but is not limited to:
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 a part hereof,an attached hereto
as "Attachment B".
B. Known Active TB case: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 a 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
sensitivity,changes in patients'status, diagnosis, or any other information as appropriate.
A TB-10 form shall 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 of the Contractor.
5. The Contractor shall provide,or arrange for,quarantine services for patients requiring isolation.
The Contractor shall also submit a written fmancial statement of need completed by a licensed
social worker,to the State for each patient. This fmancial statement shall indicate whether a
patient has other financial means to cover the costs of quarantine.
6. As required by the CDC,the Contractor shall submit a "Contact Investigation Report" to the State
for each contact it makes. A copy of this form is attached and made a part hereof as "Attachment
D." The Contractor and the State agree to collaborate in automating data collection and transfer of
these reports.
DUTIES AND OBLIGATIONS OF THE STATE.
1. In consideration of those services timely and satisfactorily performed by the Contractor under this
Task Order,the State shall cause to be paid to the Contractor an amount not to exceed Eiehty
Four Thousand,Two Hundred Forty-One DOLLARS,1884,241.00)for the initial term of this
Task Order. Of this total financial obligation of the State,$84,241.00,are identified as attributable
to a funding source of the United States government. This Task Order involves the expenditure of
federal funds. This Task Order is subject to,and contingent upon,the continuing availability of
those funds for the purposes hereof.
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2. The liability of the State,at any time,for payments under this Task Order shall be limited to the
unencumbered remaining balance of those funds. If there is a reduction in the total funds
appropriated for the purposes of this Task Order,then the State, in its sole discretion,may
proportionately reduce the funding for this Task Order,or terminate this Task Order in its entirety.
The State shall reimburse the Contractor for its expenditures in accordance with the budget set
forth below.If the Contractor desires to transfer funds from one line item to another,then the
Contractor shall obtain the prior, express,written permission of the State.
TB OUTBREAK BUDGET
Description Amount
Personnel 41,751.00
Fringe 12,526.00
Travel(In-State) 5,000.00
Equipment 1,170.00
Supplies 648.00
Other 13,520.00
Total Direct Costs 74,615.00
Indirect Costs 9,626.00
TOTAL: $84,241.00
3. To receive compensation under this Task Order,the Contractor shall submit a signed monthly
billing statement,an example of which is incorporated herein by reference,made a part hereof,and
attached hereto as "Attachment E"within sixty(60)calendar days of the end of the billing period
for which services were rendered. The billing statement shall:reference the related Master
Contract and this Task Order by their respective contract routing numbers,which numbers appear
on page 1 of each 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.Billing statements shall be sent to:
Marti Wood
DCEED-A3
Colorado Department of Public Health and Environment
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 letter is incorporated herein by this
reference,made a part hereof,and attached hereto as "Attachment F". 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:
A. Identification of the related Master Contract and this Task Order by their respective
contract routing numbers and the affected paragraph number(s)of this Task Order;
B. The type(s)of service(s)increased or decreased and the new level of each service;
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C. The amount of the increase or decrease in the level of funding for each service and the
new total financial obligation;
D. The intended effective date of the funding change;
E. A provision stating that the Task Order Change Order Letter shall not be valid until
approved the State Controller or such assistant as he may designate.
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 this Master
Contract,and the Additional Provisions,if any, of this Task Order,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 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
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 Change Order Letter has
passed. This 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.
Increases or decreases in the level of 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:
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;
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 Renewal Letter". A sample letter is
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•
incorporated herein by this reference,made a part hereof,and attached hereto as "Attachment
G". 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:
A. Identification of this related Master Contract and this Task Order by their respective
contract routing numbers and the affected paragraph number(s)of the Task Order;
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. The intended effective date of the renewal;and,
E. 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 Task Order. Except for the General and Special Provisions of the Master Contract,and the
Additional Provisions,if any, of this Task Order,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 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 Letter has passed. This 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.
D. 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.
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IN WITNESS WHEREOF,the parties hereto have executed this Task Order on the day first above written.
CONTRACTOR: STATE:
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 Department of Public Health and Environment
By: By: \ ` t4
Name: M. . Gei1e For the Execu v Director
Title: Chair (10/24/2001) DEPARTME T 'F PUBLIC
FEIN: 84-6000-813 HEALTH S 'I RONMENT
ATTEST r� fix ',; ) , v ``'ROGRAM APPROVAL:
1861
By:
Deputy Clerk�.�
APPROVALS:
COLORADO DEPARTMENT OF LAW COLORADO DEPARTMENT OF PERSONNEL
OFFICE OF THE ATTORNEY GENERAL OFFICE OF THE STATE CONTROLLER
Ken Salazar,Attorney General Arthur L.Barnhart,State Controller
By: NOT REQUIRED By: A e— _—
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND YIRO EN?
Mark E. Wallace, MD, MPH•Director
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- - - - Attachment 4
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT
Colorado Department of Public Health and Environment DCEED-TB-A3
Tuberctiosis Control 4300 Cherry Creek Drive South
Denver,Colorado 80246.1530
(303)692-2679 Phone (303)691-7743 Fax
PATIENT INFORMATION
Name Date of Birth Country of Birth - ....• - Month Year
Address: —f—I ❑USA Arrived in USA
City Zip: II
❑Canada,Japan,Westem Europe,
Home Phone: Australia,New Zealand Refugee:
County of
Work Phone: Residence 0 Mexico,Central or South America ❑Yes
Sex: Race _/— 0 Africa,Middle East' 0 No
❑Male 0 White ❑China,India,Central or ❑ Unknown
Ethnic Orign Southeast Asia, Indonesia,
Female 0 Black - ❑Hispanic 0 Eastern Europe,Russia, Ukraine Alien Number#
0 American IndiaN
Alaskan Native D Non-Hispanic 0 Unknown
Marital Status ❑Asian/Pacific Island 0 Unknown Lenght Colo of residence
in Colorado
•
❑ Unknown
AGENCY SUBMITTING THIS REPORT
Agency's Name: - Agencytounty
Agency's Address: !
City: ZIP: Phone:
Name of Patient's Primary Care Physician:
Address:
Zip: Phone:
MOST RECENT SKIN TEST
Type: Results: Induration Previous It positive,is this a skin test
❑Mantoux-Tubersol 0 Postive _mrn Positive PPD conversion negative to positive
❑Mantoux-Aplisol 0 Negative ❑Yes within 2 years:
❑Tare ❑ Not Done Dat/PPD Given 0 No ❑Yes •
❑Other(specify) 0 Unknown --- Date of last 0 No
0 Other(specify) Date PPD Read negative test 0 Unknown
X-RAY FINDINGS
Date of X-ray: Previous Status X-ray taken by:(Agency's Name):
/_/ Abnormal X-ray: 0 Stacie
❑Worsening Return X-ray to: -"—
X-ray results: Abnormality 0 Improving
❑Normal ❑Ca`^tary ❑Unknown
❑Abnormal ❑ Noncavitary Consistent w/TB
❑Not Done 0 Noncavitary Not Consistent w/TB
❑Unknown 0 Other(Specify) Note:COPHE will separately attach x-ny
findings and recommendations
CLINICAL
Symptoms: Date of Onset of Special Conditions:
❑None 0 Fever Symptoms: 0 Pregnant EDC:_I_I
❑Productive Cough 0 light Sweats —/—I ❑ Postpartum Breast Feed'ng
❑Hemoptysis ❑Other(Specify) 0 Other(Specify):
❑Weight Loss
Name of Person completing: Date:
Comments:
TB-17 0299
. - - Attachment
PATIENT FOLLOW-UP INFORMATION AND TRANSFER FORM (TB-10)
( ) Fa you kdornrstion ( ) Rapi squ"Md
TO: FROM:
Patients Name: SEX Marital Status
Address: M F SMWDSep
W D Sep
City,State,Zip Birthdate I / Race
Phone Number. County:
ACTIVE CASE; YES_ NO_
Confirmed by Lob or PCP diagnosis?.YES_NO_ H yes,date of d ;_i_(_
Date of TBC skin test / I Result In MM:
Fort: Pulmonary Eta Pulmonary(spedfy site) Suspect
LATEST BACTERIOLOGICAL STATUS: Not Done��
a Rant estOr Osis MS Fad QAnRaaeieare OS SS NSA LambsWas spoSsa15
ism
niar
Girt
Other(30*Slot
DRUGS: if patient on drug therapy Mediations and dosage
Date started: I I
Date stopped:_I(_
Number of weeks on DOT:
if patient NOT on drug therapy,give reason:
•
Moat recent x-ray rosulWdate(s)
Previous Hospitalization for TB:When Vahan:
Printery Care Provider. Phone tk
READ YES_ NO_ Medications and dosage
Date of S*test__La_
Date sautea:__L
Date stopped medications:_(,_L_
Reason stopped:
Medication given by whom
HHN«. M.«
RFr OCA nON/NFORMAT7ON: Date of Scanlon: I I
If patient has moved or relocated,gleam orovide new address and phone number.
Commands:
•
Colorado Department of Public Health and Environment Name of Person completing the foray Date
4300 Cherry Creek Drive South, DCEED-TB-A3 ' / /
Denver, Colorado 80222-1530 303882-2678 Ta.tpgrevwg7)COPFE
. ,PitledPe.Name: 0. e - _ _ _
IPtrust) IN.1.1 REPORT OF VERIFIED CASE
•.
Street Address: OF TUBERCULOSIS
CDC
1. .er,dual.dry.Slat.) xe Cede) Attachment C
CDC U.S.DEPARTMENT OF HEALTH a HUMAN SERVICES
REPORT OF VERIFIED CASE OF TUBERCULOSIS PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL
a"eaAn AND PREVENTION(CDC)
ATLANTA.GEORGIA 30333
( Li
imam AFPAOVFO OMB NO.Ntoeoxa [y 9a1.lint
SOUNDE% j
1.State Reporting:
2
Specify: State Cue
Number: I I I I I I I I I I
Alpha Slate Coda I Clty/County I I I I I I
Case Number:
3.Date Submitted: By: 4.Address for Case Counting:
Me j`
City !
IIIIIIIIIIIIIII
Within City Limits t❑ Yes 2❑ No
5.Month-Year Reported: 6. Month•year Counted:
County
Mo. Yr. Mo. Yr.
I III Zip Code 1I I I —
7.Date of Birth: 8.Sex: 9. Race:
Mo. Day Yr. 1❑Male
1❑ White 2 Black 3 American Indian or Alaskan Native
2 Female
4 Asian or Pacific Islander:Specify(Optional)
10.Ethnic Origin: 11.Country of Origin: 12.Month-Year Arrived In U.S.: 13.Status at Diagnosis of TB:
1❑ Hispanic If U.S..check here O
Mo. Yr. 1❑Alive
If not U.S.,enter
20 Not Hispanic country code(see list) 2 Dead
14. Previous Diagnosis 15.Major Site of Disease:
of Tuberculosis: So❑ Miliary 'If site is'Other,
enter anatomic
23❑Lymphatic:Other so❑ code(see list)
00 Pulmonary Meningeal
t❑Yes 1 0 Pleural
z9❑ Lymphatic:Unknown 7 0 Peritoneal
2 No 2I O Lymphatic:Cervical 30❑ Bone and/or Joint s o Other'
22❑ Lymphatic; Intrathoracic 4 0 Genitourinary 9 0 Site not Stated
'9 If yes,list year of
previous diagnosis 16.Additional Site of Disease:
'If site is'Other',
oo❑Pulmonary 230 Lymphatic:Other so❑Miliary enter anatomic
code(see anatomic
11 more Than one previous t o❑ Pleural 290 Lymphatic:Unknown 60❑ Meningeal
/ episode,check here 21❑ Lymphatic:Cervical 30❑ Bone and/or Joint 7 0 Peritoneal II more than one
22 Lymphatic: Intrathoracic d0❑ Genitourinary So❑Other' addition..she, O BB
check here
17.Sputum Smear: 18.Sputum Culture: 19.Microscopic Exam of Tissue and Other Body Fluids:
t Positive 30 Not Done t❑Positive 3❑Not Done i❑Positive 3 Not Done
n Comic code(s)enter
2❑Negative 9❑ Unknown 20 Negative 9anatomic
9 ❑ Unknown 20 Negative 9❑ Unknown (see Iist
20.Culture of Tissue and Other Body Fluids: 21.Chest X-Ray:
10 Positive 3❑Not Done If positive, enter I 1❑ Normal 20 Abnormal 30 Not Done e0 Unknown
anatomic code(s)
2 Negative 9 Unknown (see list)
If Abnormal 1❑ Cavitary
Tuberculin(Montour)Skin Test at Diagnosis: (0heck one y 2❑ Noncavitary sisen 3❑ Noncavitary
1❑ Positive 3❑ Not Done ' wCthsTBenl Not Consistent
B
Millimeters(mm)of
Induration
2 Negative a Unknown If Abnormal t Stable 3 Improving
1f Negative,was patient t (check one) 2❑ Worsening 9
anemic? ❑ Yes z❑ No 90 Unknown 9 ❑ Unknown
re=ATm►iaspae1eNa�MI=aurae a 9i mYcean a Wemsal le M7rYd n enrage 3o mhi•e par ieaprae M�iq ar Erne b cs' * g Y W uetlon.aaraip Wang data•ova•.
Olaeer.11 TIN PR 1Nblh t as nRn tam:xood �rweNro w a.dn aeW+19i.'a rry d r.pR a we aaealn a Yawmeaul. wa pee 9•arM1y na maYNWb PgMthe data needed.and
Mepryr�oe Ave.,SW:Wangle,,DC A201.rd to be Office a Mngrwl and Budget Papa rt Mrolon eioMa 0920.4:026);w a.lt Report.
cc 20
503.
swaaoa tenet:an add 1vm Mich egad pre*NsS, an a ddinla Nis Men collected Bert a trararaea NI a*4 M held M Sid orddeeoe..e 0e used only Ice eu.Wrce pupge .and xa rid b•deolo.ed v
wlaaaaE tahat tenet:
a h kieedeY F aoordstn cot Satan]pa(dl a ev PWk It•rd,Santo Ad H2 u.s.G 2.21,1.
- REPORT OF VERIFIED CASE
• - - OF TUBERCULOSIS
•
REPORT OF VERIFIED CASE OF TUBERCULOSIS
23. HIV Status: o❑Negative 3❑ Refused o❑Unknown 24. Homeless Within Past Year:
t❑ Positive e❑Not Offered o❑No
2❑ Indeterminate 5❑Test Done,Results Unknown i❑Yes
9❑ Unknown
If Positive,Based on: i 0 Medical Documentation 2 Patient History 9❑ Unknown
I1 Positive, List: CDC AIDS Patient Number (If AIDS Reported before 1993)
State 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: on No t Yes 9❑Unknown
If Yes,
I❑ Federal Prison 3❑Local Jail s❑Other Correctional Facility
2 State Prison 40 Juvenile
Correctional Facility 9❑Unknown
26. Resident of Long-Term Care Facility at Time of Diagnosis: on No i❑ Yes 9❑ Unknown
If Yes,
❑
1 Nursing Home e❑ Mental Health Residential Facility s❑Other Long-Term Care Facility
2 Hospital-Based Facility 5❑Alcohol or Drug Treatment Facility 9❑ Unknown
3❑ Residential Facility
27.Initial Drug Regimen:
NO YES UNK. NO YES UNK. NO YES UNK.
Isoniazid oL in 90 . Ethionamide on 1❑ 90 Amikacin 0❑ t 9❑
Rifampin on 1❑ 9❑ Kanamycin or: 1❑ 9❑ Rifabutine o❑ in 9
Pyrazinamide 0❑ 1 9❑ Cycloserine 0❑ 1❑ 90 Ciprolloxacin 0❑ i0 9❑
Ethambutol o❑ 1❑ 9❑ Capreomycin o❑ I 9❑ Ofloxacin 0❑ t 9❑
Streptomycin 0❑ 1 9❑ Para•Amino o❑ 1 9 f Other on 1❑ 9❑
Salicylic Acld
26. Date Therapy Started: 29. Infecting Drug Use Within Past Year:
Ma. Yr.
Irpey'll O E No 1❑ Yes 9❑ Unknown
30. Non-Infecting Drug Use Within Past Year: 31. Excess Alcohol Use Within Past Year:
on No i❑Yes 9 Unknown o❑ No 1❑Yes 9 Unknown
32. Occupation (Check all that apply within the past 24 months):
1❑Health Care Worker 30 Migratory Agricultural Worker 5❑ Not Employed within Past 24 Months
25 Correctional Employee • Other Occupation 9❑ Unknown
Comments:
COC 72.0A REV.OS/93 1st Copy—Slate REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2 of 2
reliant s nem.. REPORT OF VERIFIED CASE
Lo West, lY I I OF TUBERCULOSIS
,..
Street Aedrus: - - -
_. _.. . _.. 1 -,.Sarni.Clly.sul.1 Zap COOS
CDC U.S.DEPARTMENT OF HEALTH&HUMAN SERVICES
C■L-`_/. �/ PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL
REPORT OF VERIFIED CASE OF TUBERCULOSIS AND PREVENTION ICDCI
exrtesexoduee tl.Mlxa ATLANTA,GEORGIA 30333
.o..avrxlnx
FORM APPROVED ORS NO.0.300036 Esp.Date 11nF
Initial Drug Susceptibility Report (Follow Up Report — 1)
C SOUNDEX State Reporting:Specil Year
Counted: State Case
Number:
ri
Alpha Stale Code City/County
Case Number:
... .]
Submit this report for all culture-positive cases.
/ N
33. Initial Drug Susceptibility Results: ID Drug Susceptibility Testing Done: o❑ No I❑ Yes 9J Unknown
If answer is No or Unknown, do not complete rest of report.
If Yes, Mo. Day Yr.
__
Enter Date First Isolate Collected ICI It(W�
for Which Drug Susceptibility Was Done?
34. Susceptibility Results:
Resistant Susceptible Not QDne Unknown
Isoniazid I,11 2❑ s0 9J
Rifampin I 2❑ 3❑ 9J
Pyrazinamide 1❑ 2❑ 30 9❑
Ethambutol 1❑ z❑ 3❑ 9J
Streptomycin 10 20 3 9_
Ethionamide 1❑ 20 3;_j a -
Kanamycin in • 20 31 I 9_
Cyclone ring 1❑ 2❑ 3❑ 9_I
Capreomycin 10 20 3❑ 0'I
Para-Amino 9❑1❑ 20 3 _
Salicylic Acid1 —
Amikacin 1❑ 20 3❑ 97
Rifabutine I❑ 20 3❑ s❑
Ciprofloxacin 1 20 31-1T,
9_
Ofloxacin 1❑ 20 3❑ 9_'
Other 1❑ 2❑ 30 9L
\ /
Comments:
[ \
MYnaYIebYYY4 an Hs aril eat:pmt CYtlabon a YdNd*Ma been celibate w1F1.9utraun eYa-be held n slid aNdlnta.we be used Only b se edaca WOoes.aid.a not b d acic.MC4
w1r.s0.l9na M aln5d a FY tdbtS H ac tca with Senn JpHm a aY PIpc Nyln S.mc./d H2 U.S.C.2a2m1
CDC 72.90 REV 1292 REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Repon-I
1st Copy—Stets
Pa1lent's Name:
Kalil -- --- - - Ik6il - ---_- - KM i'- - REPORT OF VERIFIED CASE
14tr}et Address: --- OF TUBERCULOSIS
INI. _. sIra.' C.ly.slur' re Coed
CDC
U.S.DEPARTMENT OF HEALTH a HUMAN SERVICES
C. �/ PUBLIC HEALTH SERVICE
■DC REPORT OF VERIFIED CASE OF TUBERCULOSIS CENTERS DISEASE D HEALTH SEN RVICCE
u..aarwaM.M cw'.d ATLANTA.GEORGIA 30333
wwNS0AU
FORM APPROVED OMB NO.0920.0029 Eq.Dale lIIts
Case Completion Report (Follow Up Report - 2)
C SOUNDEX ) [ State Reporting: Year
Counted: State Case
[SecIfy: Number:
Alpha State Code City/County
Case Number
I
35. Sputum Culture II Yes, Dale Specimen Collected II Yes,Dale Specimen Collected on
Conversion Documented: on Initial Positive Sputum Culture: First Consistently Negative Culture:
• Mo. Day Yr. Mo. Day Yr.
e No IL: Yes 9_ Unknown Ir_'—TI-�JI Ir' I�It
36. Date Therapy Stopped: 37. Reason Therapy Stopped:Da Mo. nil
l Yr. ^
I❑ Completed Therapy 3 J Lost s❑ Not TB 2❑Other
2❑ Moved aj_! Uncooperative or Refused 6❑ Died 9❑Unknown
38. Type of Health Care Provider: 39. Directly Observed Therapy: If Yes,Give Site(s)of Directly Observed Therapy:
i J Health Department on No, Totally Self-Administered I❑ In Clinic or Other Facility
2❑ Private/Other I❑ Yes, Totally Directly Observed 2 J In the Field
3❑ Both Health Department 2❑ Yes. Both Directly Observed 3❑ Both in Facility and in the Field
and Private/Other and Self-Administered
9 L Unknown
9 J Unknown Weeks
Number of Weeks of Directly Observed Therapy:
40. Final Drug Susceptibility Results: If Yes.Enter Date Final Isolate
Was Follow-up Drug Susceptibility Testing Done? on No I❑ Yes 9-. Unk. Collected for Which Drug Mo. Day Yr
Susceptibility Was Done: II�II�II
If answer is No or Unknown, do not complete rest of report.
41. Final Susceptibility Resistant Susceolible NDt L12ne Unknown Resistant c'scpntihle Not 1jme Unknown
Results: —
Isoniazid in 2❑ 3D 9— Capreomycin In 2D 3❑ 90
Rif ampin t❑ 2❑ 3❑ y_ Para-Amino 1 z❑ 3❑ SID
Acid
Pyrazinamide 1❑ 2❑ 3❑' 9—
_ Amikacin 1❑ 2❑ 3❑ 99
Ethambulol I❑ z❑ 3;J 9 Rifabutine Ii_ 27 -❑ an
Streptomycin t❑ 2❑ 3❑ 9_, Ciprofloxacin 1 2❑ 3❑ 9L1
Ethionamide i0 2❑ 3D 9❑ Olloxacin i❑ 2❑ 3 9 E
Kanamycin in 2❑ 3 ' 9_ Other iE 2❑ 3❑ 9 E
Cycloserine 1❑ z❑ 3' 9 .
Comments:
[ \
Iniradaen NErwd 0n the Ion.wtct'w0'AO Mina MwN'Aulon a1 any.,diMW htl been COEKMd M'.%amain MM a will be hold In Dna fptdanp,WI be mod any RI MInMIVM re/WEE.Yid well MI be d.1oVM a
Seated w.IW Ds mosoniciimegngaai in xmrdac.ARIA Sedan Saudi a IM PUNIC Hai Bann Ad lu us C.241m1.
CDC 72.90 REV 1292 tat Copy—StateREPORT OF VERIFIED CASE OF TUBERCULOSIS Fallow Up Report-2
COLORADO DEPARTMENT OF PUBLIC HEALTH 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 <15 15-35 >35 Date Date Result No Tx/Date Comments
Name:
BD:
Relation to Source:
Name:
BD:
Relation to Source:
Name:
BD:
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 TO for prolonged and frequent periods of time(e.g.household members,work associate--depending on type of wank/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 TB 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
e
M
6
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: O 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.
n
AUTHORIZED DESIGNEE (STATE): DATE: g
Contractor Notified of Reimbursement Amount Change?
0 Yes 0 No Initial: t�
Attachment f
[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 Leal 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 I",and the revised budget,which is attached
hereto as'Attachment r,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 Bettidee,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:
FEIN:
APPROVALS:
FOR THE STATE CONTROLLER PROGRAM:
Arthur L. Barnhart,State Controller
By: By:
Eric Schleiger,Fiscal Officer
•
Attachment
[Date] Sample Task Order Renewal Letter
State Fiscal Year 19** - **, Task Order Renewal Letter Number", Contract Routing Number**-*****
Pursuant to Part F_5.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 Change Order
Letter***,contract routing number**- ,and/or Task Order Renewal 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 renewal 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 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 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 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.
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:
FEIN:
APPROVALS:
FOR THE STATE CONTROLLER: PROGRAM:
Arthur L.Barnhart,State Controller
By: By:
Eric Schleiger,Fiscal Officer
Hello