HomeMy WebLinkAbout870536.tiff RESOLUTION
RE: APPROVE FAMILY PLANNING PROGRAM CONTRACT BETWEEN THE COLORADO
DEPARTMENT OF HEALTH AND THE WELD COUNTY HEALTH DEPARTMENT
AND AUTHORIZE CHAIRMAN 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, a Family Planning Program Contract between the
Colorado Department of Health and the Weld County Health
Department has been presented to the Board , and
WHEREAS , the term of said Contract is from July I , 1987 ,
through June 30 , 1988 , with the further terms and conditions being
as stated in the Contract , a copy of which is attached hereto and
incorporated herein by reference , and
WHEREAS, after review, the Board deems it advisable to
approve said Contract.
NOW, THEREFORE, BE IT RESOLVED by the Board of County
Commissioners of Weld County , Colorado, that the Family Planning
Program Contract between the Colorado Department of Health and the
Weld County Health Department be , and hereby is , approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be , and
hereby is, authorized to sign said Contract.
The above and foregoing Resolution was , on motion duly made
and seconded , adopted by the following vote on the 29th day of
June , A.D. , 19B7 .
nn �7 --//--- BOARD OF COUNTY COMMISSIONERS
ATTEST: (�waA tUi 1w�I WELD COST -COLORADO
Weld County C erk and Recorder
and Clerk to the Board Go d . y rman
J ! 1 4
BY4:421.2 , _ C. Cirby, Pr -Tem
uty County _lerk
EXCUSED
APPROVED AS TO FORM: Gene R. Brantner
-_
7 6acs-caterguee . con
Co my Atto ney EXCUSED
Frank Yamaguchi
// 1.� i ; 870536
Form 6-AC-02A IR 5/85) tWJ'AR I MEN F(IR AGENCY NUMBER
260000
CONTRACT ROUTy:-ys'L�8,,8.,, /'1
1lUUCC , ((��Cf�_(( <�/ (C I
CONTRACT
THIS CONTRACT. made this 1St day of July 198 7 . by and between the
State of Colorado for the use and benefit of the Department of 11 Health
4210 E. 11th Avenue, Denver, Colorado 80220
hereinafter referred to as the State, and '2 Wel d County Health Department,
_151.E_HaspitaLlioad. Greeley, Colorado 80631
hereinafter referred to as the contractor,
WHEREAS, authority exists in the Law and Funds have been budgeted, appropriated and otherwise made
available and a sufficient unencumbered balance thereof remains available for payment in Fund Number 1001
G/L Account Number33467 . Contract Encumbrance Number376023 ; and
WHEREAS, required approval, clearance and coordination has been accomplished from and with appropriate
agencies: and
WHEREAS, '' the State has formulated a comprehensive State Plan relative to the
Family Planning Program; and
WHEREAS, said comprehensive State Plan allocates funds to be utilized to
implement the Family Planning Program in order to provide these health care services
to the people of Colorado; and
WHEREAS, the Contractor is considered by the State to be an appropriate agency
to fulfill the requirements of the program as herein set forth.
NOW THEREFORE n is hrreb aereea to I for and in consideration of their mutual promises
to each other, hereinafter stated, the parties hereto agree as follows:
I The Contractor will conduct a family planning program in
Weld County which will comply with all applicable
regulations and subsequent amendments as described in Title X (42 CFR,
Subpart. A, Part 59) as authorized under Section 1001 of the Public Health
Service. Act, published in the Federal Register on June 30, 1980, a copy of
which has been made available to the Contractor.
2. The Contractor will make this comprehensive family planning program availablf
to men and women in their reproductive years and will offer the following
components:
a) Outreach services and/or other program effort for patient recruitment.
b) Nursing and medical services which shall include a comprehensive health
and social history and physical examination, in accordance with Title X
(42 CFR, Subpart A, Part 59) as authorized under Section 1001 of the Public
Health Service Act, published in the Federal Register on June 30, 1980,
and the Nursing-Medical Policies and Procedures established by the Colorado
Department of Health Family Planning Program, copies of which have been
made available to the Contractor.
39553O'x10'14 Page I of pages
*tSec oisirtictir.ns on .. P„c.,t Iva p'pr.) 870536
c ) Contraceptive information, education, and supplies regarding all
family' planning methods.
d) Education and counseling regarding family planning, family
planning methods, child spacing, limiting, infertility,
sterilization, nutrition, and related health issues.
e) Follow-up and/or referrals, as appropriate.
3. The Contractor will , on or after the date of this contract, employ only
individuals under this contract who meet the minimum qualifications as set up
v '.ne State Nursing Section and Family Planning Program for each position.
! : here is any reason to question whether or not an applicant may meet these
H. fl qualifications for education or experience, it is necessary to submit
lication to the State Family Planning Program for review and approval
employment. )
• . (lie contractor agrees to render acceptable services as determined by the
Stare Family Planning Program. This includes compliance with applicable
tc;r; ing-Medical Policies and Procedures established by the Colorado Department
• alth Family Planning Program, Title X (42 CFR, Subpart A, Part 59) as
-ized under Section 1001 of the Public Health Service Act, published in
neral Register on June 30, 1980, copies of which have been made
*le to the Contractor, and all fiscal and administrative policies of the
.io Department of Health Family Planning Program. These have been made
bie to the Contractor. Program medical/nursing performance will be
• rw� d on biannual site visits and annual nursing audits pursuant to the
al/nursing standards and judged acceptable or not. The nursing
!cant and administrators assigned by the State Family Planning Program
have the authority for periodic evaluation of the delegate family
9 program based on standards and policies established by the Family
Inc Program. The Contractor agrees to cooperate in any evaluation and
y recommendations directed by the State.
State will continue payment for family planning services so long as
Contractor submits acceptable data as determined by the State using the
Tamiiy Planning Data System' s Clinic Visit Log and Patient Visit Sample which
are ::cached and by this reference made part hereof as Attachment A. Data on
• ^sits will be collected on log sheets ; additional information will be
c ; id periodically. Both will be done in accordance with the instructions
data manual and in time periods stated therein. (Manuals have been
• available to the Contractor. ) Changes in the order of the log items may
• . . -lodated individually between the State and the Contractor. Any
;.;;r . -upon changes will be verified in writing by the State, Family Planning
5 . The State will , in consideration of said services by the Contractor, cause
▪ paid to the Contractor a sum not to exceed SEVENTY FIVE THOUSAND
SIi HUNDRED NINETY-ONE (575.691 ) Dolliars
to serve approximately 1351 family planning patients (unduplicated
court) , subject to change based on differences between estimated and actual
tunjing appropriations and legislative approval, and conditioned upon
affirmation by this State Family Planning Program that services were rendered
in accordance with this contract, as follows:
a) 1 ) The Contractor is entitled to bill for 1/12 of the contract
amount at the end of each of the first two months of each
quarter, based on the State fiscal year. The submission of a
signed reimbursement statement (copy attached ant by reference
made part hereof as Attachment B) is necessary for monthly
payment. A quarterly adjustment will be made at the end of the
last month of each quarter. The adjustment will be based on the
difference between quarterly expenditures and payments already
received. The Contractor must submit a quarterly expenditure
report (copy attached and by reference made part hereof as
Attachment C) and a signed reimbursement statement (Attachment
B) at the end of each quarter; OR
Page 2 of 7 pages 870536
2) Tne Contractor is entitled to bill 1/12 of the contract
amount for each of the first two months of the contract term
(July and August) . An advance for the next month may be
requested throughout the year upon receipt of a statement of
actual expenditures for on the months still outstanding (i .e.
July and August are advanced. To receive a September advance,
actual expenditures must be submitted for July. The September
advance will be adjusted to accurately reflect July' s actual
expenditures. To receive an October advance the actual
expenditures must be submitted for August. The October advance
will be adjusted to accurately reflect actual August
expenditures. ) This process may be repeated until an advance is
made for the month of May. June reimbursement will be made only
upon receipt of a statement of actual expenditures for the month
and shall be contingent upon receipt of statements of actual
expenditures for all months previously advanced. Total
reimbursements shall not exceed the total contract allocation.
The submission of a signed "Request for Advance" statement (copy
attached and by reference made part hereof as Attachment D) is
necessary for the advance. The Contractor must submit a
quarterly expenditure report (Attachment C) at the end of each
quarter.
b) A quarterly expenditure report must be submitted by the 30th of the
following month and must show total actual costs incurred for family
planning during that quarter and state the source of funding
(contract, patient fees, donations, in-kind or local support) that
was used to cover expenses.
c) Recommendations made by the Family Planning Nursing Consultant to
bring the program into compliance with the Nursing-Medical Policies
and Procedures and the Title X Guidelines (Part 59) following site
visits or data reviews must be met within a three-month period, or
evidence must be shown that progress is being made toward meeting
said recommendations.
d) Recommendations made by the Family Planning administrative staff to
bring the program into compliance with the Title X Guidelines and
State policies and standards following site visits or data reviews
must be met within a three-month period, or evidence must be shown
that progress is being made toward meeting such recommendations.
e) Annual nursing-medical chart audits will be submitted to the
family planning nursing consultant by January 15, 1988 and annually
each year thereafter.
f) An annual audit of adolescent counseling services and the Social
Support to Teens Protocol will be submitted to the Family Planning
Social Work Consultant by December 1 , 1987.
g) Program income generated from patient fee collections and
donations must be used by the program only for family planning
purposes which further the objectives of the legislation under which
this contract is made. In accordance with Title X guidelines (Part
59) no charges shall be made for services provided to patients at or
below 100% of the poverty level . Patients above 100% of poverty
level will be charged based on the sliding fee scale which is
attached and by this reference made part hereof as Attachment E.
h) For all Class III, IV and V or abnormal Pap smears, a semi-annual
report will be submitted by July 15, 1987 and January 15, 1988 and
twice each year thereafter, giving the date the Pap result was
received in the local clinic and the date the patient was seen by a
physician. The annual totals and percentage of abnormals must be
reported by January 1988 and yearly thereafter.
i ) Equipment and supplies may be purchased with the family planning funds
awarded in this contract. No line item budget is required from the
Contractor. The Contractor will return equipment and supplies
purchased through this contract to the State if so requested. An
inventory number will be assigned to this equipment by the State and
the Contractor shall affix the number to the equipment items and
confirm this in writing to the State. Permission must be requested
in writing from the State to purchase a piece of equipment in excess
of $1000.00.
870536
Page 3 of 7 pages
7. Payment pursuant to this contract will be made as earned, in whole or
in part .From available State funds encumbered in an amount not to exceed
ONE MILLION SIX HUNDRED AND FIFTY NINE THOUSAND EIGHT HUNDRED AND EIGHTY
SEVEN DOLLARS ($1 ,659,887) for the purchase of family planning services.
It is fu-ther understood and agreed that the maximum amount of State funds
available for Fiscal Year 1987-1988 for the purchase of family planning
services is in the amount of ONE MILLION SIX HUNDRED AND FIFTY NINE
THOUSAND EIGHT HUNDRED AND EIGHTY SEVEN DOLLARS ($1 ,659,887) or such
lesser amount as may be mandated by executive order or legislative
action. The liability of the State, at any time, shall be limited to the
unencumbered amount remaining in such funds.
8. Changes in reimbursement amounts for the above-named services in
consideration of increased or decreased levels of utilization from the
levels funded in the original contract shall be made with approval of the
Contractor, the State (Family Planning Program) and the State Controller
as evidenced by a mutually signed Letter of Approval whicn shall include
the following:
a) Identification of contract by contract number and
number of the affected paragraph;
b) Type of services increased or decreased;
c) Amount of increase or decrease in funding and
patients to be served;
d) Effective date of the funding change;
e) Authorized signatures of the State, the Contractor
and the State Controller. It is understood that no change
except funding amounts and resulting changes mini utilization
shall be made through the Letter of Approval .
9. The term of this contract is beginning July 1 , 1987 and continuing
through June 30, 1988.
Page 4 of 7
870536
COLORADO DEPARTMENT OF HEALTH — hereinafter, under the General Provisions
referred to as "Health" .
GENERAL PROVISIONS
(1) The parties of this contract intend that the relationship between them
contemplated by this contract is that of employer-independent contractor. No
agent, employee or servant of Contractor shall be or shall be deemed to be an
employee, agent or servant of Health. Contractor will he solely and entirely
responsible for its acts and the acts of its agents , employees , servants and
subcontractors during the performance of this contract .
(2) At all times during the performance of this contract, the Contractor shall
strictly adhere to all applicable federal and state laws that have been or may
hereafter be established.
(3) Contractor authorizes Health to perform audits and to make inspections for
the purpose of evaluating performance under this contract .
(4) Either party shall have the right to terminate this agreement by giving the
other party thirty days notice by registered mail, return receipt requested. If
notice is so given, this agreement shall terminate on the expiration of the
thirty days, and the liability of the parties hereunder for the further
performance of the terms of this agreement shall thereupon cease, but the parties
shall not be relieved of the duty to perform their obligations up to the date of
termination.
(5) This agreement is intended as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion, or other
amendment hereto shall have any force or effect whatsoever, unless embodied
herein in writing. No subsequent novation, renewal, addition, deletion, or other
amendment hereto shall have any force or effect unless embodied in a written
contract executed and approved pursuant to the State Fiscal Rules.
(6) If this contract involves the expenditure of federal funds , this contract is
contingent upon continued availability of federal funds for payment pursuant to
the terms of this agreement. Contractor also agrees to fulfill the requirements
of Office of Management and Budget Circulars A-87 and A-102 or A-1.1.0, whichever
is applicable.
(7) To be considered for payment , billings for reimbursement pursuant to this
contract must be received within 60 days after the period for which reimbursement
is being requested and final billings on the contract must be received by the
State Health Department within 60 days after the end of the contract term.
(8) If applicable, Local Match is to be submitted on the monthly reimbursement
statements, in the column provided , as required by the funding source.
(9) If Contractor receives X25,000 .00 or more per year in Federal funds in the
aggregate from Health, Contractor agrees to have an annual audit, by an
independent certified public accountant, which meets the requirements of Office
of Management and Budget Circular A-128 or Office of Management and Budget
Circular A-110 : Attachment F, whichever is applicable. Contractor agrees to
furnish one copy of the audit report to the Health Department Accounting Office
within 30 days of its issuance. Contractor agrees to take appropriate corrective
action within six months of the report ' s issuance in instances of noncompliance
with Federal laws and regulations. Contractor agrees to permit health er its
agents to have access to the records and financial statements as necessary, and
further agrees to retain such records and financial statements for a period of
three years after the date of issuance of the audit report . This
contract does contain Federal funds as of the date it is signed . This
requirement is in addition to any other audit requirements contained in other
paragraphs within this contract .
(10) If applicable, Contractor agrees to not use Federal funds to satisfy Federal
cost sharing and matching requirements unless approved in writing by the
appropriate Federal Agency.
Page 5 of 7 Pages
Rev. 01/13/87
W6712D 870536
Form s-Ac-02B SPECIAL PROVISIONS
CONTROLLER'S APPROVAL
1. This contract shall not be deemed valid until it shall have been approved by the Controller of the State of
Colorado or such assistant as he may designate. This provision is applicable to any contract involving the pay-
ment of money by the State. __
FUND AVAILABILITY
2. Financial obligations of the State payable after the current fiscal year are contingent upon funds for that
purpose being appropriated, budgeted and otherwise made available.
BOND REQUIREMENT
3. If this contract involves the payment of more than fifty thousand dollars for the construction, erection,
repair, maintenance, or improvement of any building, road, bridge, viaduct, tunnel, excavation or other public
works for this State,the contractor shall,before entering the performance of any such work included in this con-
tract, duly execute and deliver to and file with the official whose signature appears below for the State, a good
and sufficient bond or other acceptable surety to be approved by said official in a penal sum not less than one-
half of the total amount payable by the terms of this contract. Such bond shall be duly executed by a qualified
corporate surety,conditioned for the due and faithful performance of the contract,and in addition,shall provide
that if the contractor or his subcontractors fail to duly pay for any labor,materials, team hire, sustenance, pro-
visions,provendor or other supplies used or consumed by such contractor or his subcontractor in performance of
the work contracted to be done,the surety will pay the same in an amount not exceeding the sum specified in the
bond, together with interest at the rate of eight per cent per annum. Unless such bond, when so required, is
executed, delivered and filed, no claim in favor of the contractor arising under this contract shall be audited,
allowed or paid. A certified or cashier's check or a bank money order payable to the Treasurer of the State of
Colorado may be accepted in lieu of a bond. This provision is in compliance with 38-26-106 CRS, as
amended.
INDEMNIFICATION
4. To the extent authorized by law, the contractor shall indemnify, save and hold harmless the State, its
employees and agents,against any and all claims,damages,liability and court awards including costs,expenses,
and attorney fees incurred as a result of any act or omission by the contractor,or its employees, agents, subcon-
tractors, or assignees pursuant to the terms of this contract.
DISCRIMINATION AND AFFIRMATIVE ACTION
5. The contractor agrees to comply with the letter and spirit of the Colorado Antidiscrimination Act of 1957,
as amended, and otter applicable law respecting discrimination and unfair employment practices (24-34-402.
CRS 1982 Replacement Vol.), and as required by Executive Order, Equal Opportunity and Affirmative Action,
dated April 16, 1975. Pursuant thereto, the following provisions shall be contained in all State contracts or
sub-contracts.
During the performance of this contract, the contractor agrees as follows:
(1) The contractor will not discriminate against any employee or applicant for employment because of
race, creed, color, national origin, sex, marital status, religion, ancestry, mental or physical handicap, or
age. The contractor will take affirmative action to insure that applicants are employed,and that employees
are treated during employment, without regard to the above mentioned characteristics. Such action shall
include,but not be limited to the following: employment, upgrading, demotion,or transfer, recruitment or
recruitment advertising; lay-offs or terminations; rates of pay or other forms of compensation; and selec-
tion for training, including apprenticeship. The contractor agrees to post in conspicuous places, available
to employees and applicants for employment, notices to be provided by the contracting officer setting forth
provisions of this non-discrimination clause.
(2) The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the
contractor, state that all qualified applicants will receive consideration for employment without regard to
race, creed, color, national origin, sex, marital status, religion, ancestry, mental or physical
handicap, or age.
(3) The contractor will send to each labor union or representative of workers with which he has collective
bargaining agreement or other contract or understanding, notice to be provided by the contracting officer,
advising the labor union or workers'.representative of the contractor's committment under the Executive
Order, Equal Opportunity and Affirmative Action,dated April 16, 1975,and of the rules, regulations,and
relevant Orders of the Governor.
(4) The contractor and labor unions will furnish all information and reports required by Executive Order,
Equal Opportunity and Affirmative Action of April 16, 1975, and by the rules, regulations and Orders of
the Governor, or pursuant thereto, and will permit access to his books, records, and accounts by the con-
tracting agency and the office of the Governor or his designee for purposes of investigation to ascertain
compliance with such rules, regulations and orders.
(5) A labor organization will not exclude any individual otherwise qualified from full membership rights in
such labor organization, or expel any such individual from membership in such labor organization or dis-
criminate against any of its members in the full enjoyment of work opportunity, because of race, creed,
color, sex, national origin, or ancestry.
(6) A labor organization,or the employees or members thereof will not aid, abet, incite,compel or coerce
the doing of any act defined in this contract to be discriminatory or obstruct or prevent any person from
complying with the provisions of this contract or any order issued thereunder;or attempt,either directly or
indirectly, to commit any act defined in this contract to be discriminatory. c
395-53-01-1022 page 6 of 7 pages 870536
Revised 11-85
Form 6-AC-02C
(7) In the event of the contractor's non-compliance with the non-discrimination clauses of this con-
tract or with any of such rules, regulations, or orders, this contract may be cancelled, terminated or sus-
pended in whole or in part and the contractor may be declared ineligible for further State contracts in
accordance with procedures, authorized in Executive Order, Equal Opportunity and Affirmative
Action of April 16, 1975 and the rules, regulations,or orders promulgated in accordance therewith, and
such other sanctions as may be imposed and remedies as may be invoked as provided in Executive
Order, Equal Opportunity and Affirmative Action of April 16, 1975, or by rules, regulations, or orders
promulgated in accordance therewith, or as otherwise provided by law.
(8) The contractor will include the provisions of paragraph(I)through(8) in every sub-contract and
subcontractor purchase order unless exempted by rules, regulations, or orders issued pursuant to
Executive Order, Equal Opportunity and Affirmative Action of April 16, 1975, so that such provisions
will be binding upon each subcontractor or vendor. The contractor will take such action with respect to
any sub-contracting or purchase order as the contracting agency may direct, as a means of enforcing
such provisions, including sanctions for non-compliance; provided, however, that in the event the con-
tractor becomes involved in,or is threatened with, litigation with the subcontractor or vendor as a result
of such direction by the contracting agency, the contractor may request the State of Colorado to enter
into such litigation to protect the interest of the State of Colorado.
COLORADO LABOR PREFERENCE
6 a. Provisions of 8-17-101 & 102,CRS for preference of Colorado labor are applicable to this contract if public
works within the State are undertaken hereunder and are financed in whole or in part by State funds.
b. When a construction contract for a public project is to be awarded to a bidder, a resident bidder shall be
allowed a preference against a non-resident bidder from a state or foreign country equal to the preference given or
required by the state or foreign country in which the non-resident bidder is a resident. If it is determined by the
officer responsible for awarding the bid that compliance with this subsection.06 may cause denial of federal funds
which would otherwise be available or would otherwise be inconsistent with requirements of federal law, this sub-
section shall be suspended, but only to the extend necessary to prevent denial of the moneys or to eliminate the
inconsistency with federal requirements (section 8-19-101 and 102, CRS).
GENERAL
7. The laws of the Stat_ of Colorado and rules and regulations issued pursuant thereto shall be applied in the
interpretation, execution and enforcement of this contract. Any provision of this contract whether or not incor-
porated herein by reference which provides for arbitration by any extra-judicial body or person or which is other-
wise in conflict with said laws, rules and regulations shall be considered null and void. Nothing contained in any
provision incorporated herein by reference which purports to negate this or any other special provision in whole or
in part shall be valid or enforceable or available in any action at law whether by way of complaint, defense or other-
wise. Any provision rendered null and void by the operation of this provision will not invalidate the remainder of
this contract to the extent that the contract is capable of execution.
8. At all times during t-c performance of this Contract. the Contractor shall strictly adhere to all applicable
federal and state laws, ru es and regulations that have been or may hereafter be established.
9. The signatories hereto aver that they are familiar with 18-8-301, et. seq., (Bribery and Corrupt Influences)
and 18-8-401, et. seq., (Abuse of Public Office), CRS 1978 Replacement Vol., and that no violation of such pro-
visions is present.
10. The signatories aver that to their knowledge, no state employee has a personal or beneficial interest what
soever in the service or property described herein:
IN WITNESS WHEREOF, the parties hereto have executed this Contract on the day first above
written.
Contractor :
(Full Legal Name) WELD COUNTY HEALTH --_- STATE OF COLORADO
ROY ROMER, GOVERNOR
DEPARTMENT -
6
•5 EXEC IV DIRECTOR
Position (Title)
Director
DEPARTMENT
Social ace,„I, Numb, .r 1ed, al I I) Number OF HEALTH _
BOARD OF COUNTY COMMISSIONERS
(31IX� PCLITI WELD COUNTY CO DO
.L- ••
By: '+ 6/29/87
st (Seal q�t,t (r "%An. , nff^4�{, ni La y, airman
u
—O71"--174-C¢Q9,/ —
XXXI XXXX e,Y Clerk
APPROVALS
ATTORNEY ERA EWOODARD CO TR LLER
By �R �� — By
. JAM STRG
First Assi ant Attica;., Gen,,,
4—Gp,,wral Lewai jet.iva. --
PROGRAM: _17//i-L(i /L(--- L-y-
870536
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COLORADO DEPARTMENT OF HEALTH
Family Planning Data System
n
PATIENT VISIT SAMPLE - -�-I
n
Tenth I 1 h day year -
1. Date of Visit I 3
m
I I I I I I l i Z
2. -Service Site Number =
n
3. Patient Number I 1 1 1 1 1 I I I ] I ro
4. County of Residence Code I I I
5. Pregnancy History
Number of times pregnant 0- i
Number of live births I��
6. Ethnicity/Race (Check one)
Anglo A American Indian D
Black 8 Oriental E
Hispanic I C Other F
Unknown G
7. Seasonal Agricultural Worker (Check one)
Seasonal A Neither C
Migrant Unknown 0
8. Purpose of Visit (Check one)
Initial Medical I IA I Other New Visit C
Annual Medical Ill Other Revisit D
9. Medical Services Provided (Check all which apply)
Complete Initial Pregnancy Testing H
or Annual Medical A Diaphragm Fit J
Hct/Hgb B Contraceptive Revisit K
Other Blood Test C Vaginal Infection N
Blood Pressure D G.C. Culture N
Pap Smear Here E Rubella Immunization P
IUD Insertion F Rubella Titer R
IUD Removal G Other Medical S _
10. Type of Counseling (Check all which apply)
___
Initial or Annual Pre-conceptual E
Visit Counseling Problem (pre)
Pregnancy F
Contraceptive Sterilization (pre) G
Infertility Adolescent N
.._
Nutrition Other J
11. Contraceptive Method at the End of This Visit (Check all which apply)
Oral A Contraceptive Sponge —F
IUD B Natural/Fert. Aware. G
Diaphragm C Other H
Condom D None • J.
Foam/Jelly/Cream E
12. Provider of Encounter (Check all which apply)
Doctor • A Nurse C
Nurse Practitioner/ B Other Health 0
Midlevel Practitioner
13. Referrals Elsewhere (Check all which apply)
Infertility [-A Sterilization C
Prenatal Care B Other D
None E y
•
FPDS #2 (5-84) 870536
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VII.013
COLORADO DEPARTMENT OF HEALTH - FAMILY PLANNING PROGRAM
BCRR QUARTERLY EXPENDITURE REPORT
1 I OTHER 'COMMUNITY' I 1 PATIENT I TOTAL I
1 MEDICAL : LAB :PHARMACY 1 HEALTH : HEALTH 1 ADM :FACILITIES: RECORDS I EXPENDITURES 1 y
1 1 1 : 1 : I 1 _I r+
I "I f+
PERSONNEL COSTS :
PERSONNEL : : I i i : I I 1 I =5-
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SUBTOTAL (A) I I I I I I I I I I rt
OPERATING COSTS
TRAVEL
SUPPLIES (PURCHASED): 1 1 I I I I 1 I
CONTRACTUAL
OTHER
SUBTOTAL (B)
TOTAL DIRECT COSTS 1
(TOTAL OF (A) + (B))1
VALUE DONATED MIS
(In-kind)
1
DEPRECIATION* I 1 I I I 1 I I 1 I
SUBTOTAL (C)
(VALUE MIS+DEPREC.) 1
TOTAL PROGRAM COSTS 1
A I B I C
SQUARE FOOTAGE :
Jly-Sep Report Only 1 I I I I I I I I I
BCRR Quarterly Expenditure Report *DEPRECIATION
If you are listing a capital equipment item (items costing $300 or more per unit
Agency: with a useful life of 2 or more years). Complete the following using the formula:
Purchased cost divided by life years = depreciation per year
Completed by: divide by 4 quarters : depreciation amount per quarter.
(See Sched) DEPRECIATION
Reporting Period: PURCHASE USEFUL f ANT PER YEAR DEPRECIATION
ITEM COST LIFE YEARS DIVIDED BY 4 QTRS TOTAL TO DATE
870536
VII .014
REVENUES
AMOUNT
ANOUNI EXPENDED YTD
RECEIVED THIS OTR UNEXPENDED
SOURCE OF FUNDING _.
COLO. DEPT. OF HEALTH
PATIENT FEES
PATIENT DONATIONS
LOCAL SUPPORT
TOTAL
NOTE: The following information is for the July-Sept report only.
The first column should show the 1 of FTE (based on 2080 hrs per year); then
list the Z of tine that person spends on various activities. (We suggest using
a time study oncelyearj
BCRR FTE CATEGORIES
Z OF MEDICAL LAB PHARM. O.H. C.H. ADM FACILITY P.A. QUARTERLY
FTE SALARY
PHYSICIAN
MID LEVEL PRACTITIONER
PHARMACY
NURSES
MEDICAL SUPPORT
LABORATORY
OTHER HEALTH
COMMUNITY SERVICE
ADMINISTRATION
PATIENT RECORDS
FACILITY
TOTAL
870536
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COLORADO DEP/ TMENT OF HEALTH FAMILY PL. NING PROGRAM !
ADJUSTED TOTAL GROSS INCOME AND FAMILY SIZE CODES - 1987
FAMILY ATTACHMENT E
SIZE ANNUAL INCOME MONTHLY INCOME WEEKLY INCOME CODE
Less than 5500 Less than 458 Less than 106 1
1 5500 - 8250 458 - 687 106 - 159 2
8251 - 11,000 688 - 916 160 - 212 3
More than 11,000 More than 916 More than 212 4
Less than 7400 Less than 617 Less than 142 1
7401 - 11,100 618 - 925 143 - 213
2 11,101 - 14,800 926 - 1234 214 - 284 3
More than 14,800 More than 1234 More than 284 4
Less than 9300 Less than 775 Less than 179 1
3 9301 - 13,950 776 - 1162 180 - 268 2
13,951 -. 18,600 1163 - 1550 269 - 358 3
More than 18,600 More than 1550 More than 358 4
Less than 11,200 Less than 933 Less than 215 1 el
11,201 -• 16,800 934 - 1399 216 - 322'. 2
4 16,801 -• 22,400 1400 - 1866 323 - 430 3
More than 22,400 More than 1866 More than 430 4
Less than 13,100 Less than 1092 Less than 252 1
5 13,101 -- 19,650 1093 - 1638 253 - 378 2
19,651 -- 26,200 1639 - 2184 379 - 504 3
More than 26,200 More than 2184 More than 504 4
Less than 15,000 Less than 1250 Less than 288 1
6 15,001 -- 22,500 1251 - 1875 289 - 432 2
22,501 -- 30,000 1876 - 2500 433 - 576 3
More than 30,000 More than 2500 More than 576 4
—t
Less than 16,900 Less than 1408 Less 1
16,901 -- 25,350 1409 - 2112 326 - 487 2
7 25,351 -- 33,800 2113 - 2816 488 - 650 3
More than 33,800 More than 2816 More than 650 4
Less than 18,800 Less than 1567 Less than 361 1
18,801 - 28,200 1568 - 2350 362 - 541 2
8 28,201 - 37,600 2351 - 3134 542 - 722 3
More than 37,600 More than 3134 More than 722 4
Use Codes 1 to 4 with Sliding Fee Scale prices to determine amount patients pay for services and
supplies.
Code 1: Below 100% poverty as defined by 1987 guidelines.
Code 2: Between 101% and 150% poverty as defined by 1987 guidelines.
Code 3: Between 151% and 200% poverty as defined by 1987 guidelines.
Code 4: Above 200% poverty as defined by 1987 guidelines.
NOTE: For family units with more than 8 members, add $1900 for each additional member.
March 1987
870536
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