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Home My WebLink About890495.tiff • RESOLUTION RF: 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 1 , 1989 , through June 30 , 1991 , 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 study and 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 12th day of June , A.D. , 1989 . BOARD OF COUNTY COMMISSIONERS ATTEST: WELD COUNTY, COLORADO Weld County Jerk and Recorder ! / and Clerk to the Board C.W. Kirby, Ch irman 66.(0at,Y u ne o nson, Pro-Tem Deputy County lerk gthastet APP VED AS TO FORM: ene R. Brantner George Ke ned y/ County Attorney ,/.. Gord 890495 FonnI-AC-02A IR 5/85 I OEPART1EN-t OR AGENCY NI)IBER i 260000 CONTRACT ROUTING N R 1 . CONTRACT THIS CONTRACT, made this 1St day of illlly 198 9 . by and between the — ---- - _- - - State-ofColorado for the use-and benefit of the Department of ., HEALTH 4210 E. 11th Avenue, Denver, Colorado 80220 hereinafter referred to as the State, and •2 WELD COUNTY HEALTH DEPARTMENT 1516 Hospital Rpad. 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 Number 58467 • Contract Encumbrance Number C37801 5 ; and WHEREAS, required approval, clearance and coordination has been accomplished from and with appropriate agencies; and • • WHEREAS,3 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, it is hereby agreed that for and, in consideration of their mutual promises to each other, hereinafter stated, the parties hereto agree as follows: 1.4 The Contractor will conduct a comprehensive 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. r. 890495 Page 1 of 8 pages 2. The Contractor will make this family planning program available to men and women in their reproductive years and will offer the following components as applicable: 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. c) Contraceptive information, education, and supplies regarding all family planning methods. d) Education and counseling regarding family planning, family planning methods, child spacing, infertility, sterilization, nutrition, sexually transmitted diseases, HIV/AIDS, 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 by the State Nursing Section and Family Planning Program for each position. (If there is any reason to question whether or not an applicant may meet these minimum qualifications for education or experience, it is necessary to submit the application to the State Family Planning Program for review and approval prior to employment. ) 4. The contractor agrees to render acceptable services as determined by the State Family Planning Program. This includes compliance with applicable Nursing-Medical Policies and Procedures established by the Colorado Department of Health Family Planning Program, 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, copies of which have been made available to the Contractor, and all fiscal and administrative policies of the Colorado Department of Health Family Planning Program. These have been made available to the Contractor. Program medical/nursing performance will be reviewed on biannual site visits and biannual nursing audits pursuant to the medical/nursing standards and judged acceptable or not. The nursing consultant and administrators assigned by the State Family Planning Program shall have the authority for periodic evaluation of the delegate family planning program based on standards and policies established by the Family Planning Program. The Contractor agrees to cooperate in any evaluation and program recommendations directed by the State. Page 2 of 8 89O495 5. The State will continue payment for family planning services so long as the Contractor submits acceptable data as determined by the State using the Family Planning Data System's Clinic Visit Log and Patient Visit Sample which are attached and by this reference made part hereof as Attachment A. Data on all visits will be collected on log sheets; additional information will be sampled periodically. Both will be done in accordance with the instructions in the data manual and in time periods stated therein. (Manuals have been made available to the Contractor. ) Changes in the order of the log items may be negotiated individually between the State and the Contractor. Any agreed-upon changes will be verified in writing by the State, Family Planning Program. 6. The State will, in consideration of said services by the Contractor, cause to be paid to the Contractor a sum not to exceed EIGHTY THREE THOUSAND TWO HUNDRED FIFTY ONE ($83,251) Dollars (for fiscal year 1990) ; and for fiscal year 1991 as set forth in a letter to be signed by the State••and the Contractor and approved by the State Controller; to serve approximately 1,450 (for fiscal year 1990) family planning patients (unduplicated count) , subject to change based on differences between estimated and actual funding 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 and 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 2) The 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 one 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 Page 3 of 8 890495 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. 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; must state the source of funding; and the July - Sept. quarterly report must include results of a time study giving percentages of staff time allotted to Bureau of Common Reporting Requirements (BCRR) cost centers and information on square footage. 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) Bi-annual nursing-medical chart audits will be submitted to the family planning nursing consultant upon request. f) 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 a schedule of discounts which is attached and by this reference made part hereof as Attachment B. g) The Contractor must use the cytology laboratory chosen by the State, or a laboratory approved by the State as outlined in the Nursing- Medical Policies and Procedures and the administrative policies and procedures. Follow-up information on all abnormal pap smears will be submitted according to policies and procedures outlined in the Nursing-Medical Policy Manual, copies of which have been made available to the Contractor. Page 4 of 8 890495 h) Equipment and supplies may be purchased with the family planning funds awarded in this contract. No line item billing 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. 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 NINE HUNDRED AND FIFTY SEVEN THOUSAND SEVEN HUNDRED AND EIGHTY NINE DOLLARS ($1,957,789) for the purchase of family planning services. It is further understood and agreed that the maximum amount of State funds available for Fiscal Year 1989-1990 for the purchase of family planning services is in the amount of ONE MILLION NINE HUNDRED AND FIFTY SEVEN THOUSAND SEVEN HUNDRED AND EIGHTY NINE DOLLARS ($1,957,789) 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 which 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 in utilization shall be made through the Letter of Approval. 9. Because the appropriation of funds is a legislative function, funding availability after State fiscal year 1990 is contingent upon an annual appropriation of funds by the legislature, and in the event no appropriation is made, this contract may be cancelled and terminated with no penalty to the State. 10. The term of this contract is beginning July 1, 1989 and continuing through June 30, 1991. Page 5of8 890495 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 Healsh. Contractor will be solely responsible for its the acts agents, employees, servants and subcontractorsduring the performance of its this contract. adheres to lallmapplicablet federal rmane of this state Maws contract, have the beentror mays strictly ties duringhe perfo 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 enistso given, this agreement shall terminate on the expiration of the thirty days, 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-110, 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 $25,000.00 or more per year in Federal an funds ds in nndthe aggregate from Health, Contractor agrees to have an annual audit, by independent certified public accountant, which meets the requirements of Office of Management and Budget Circular A-128. If Contractor required Contractor's submit auditor willnaudit the proposal indirect cost proposal to Health for review and approval, in accordance with the requirements of OMB Circular A-87. Contractor agrees to furnish one copy of the audit reports to the Health Department Accounting Office within 30 days of their issuance, but not later than nine months after the end of Contractor's fiscal year. 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 or further agrees to its nts to have a cess to its records records and d financial statements as necessary, and istcontrs for a doesod of three contain years Federalafter funds as date ofotheissuance date itfis the signed. report. This contract This requirement is in addition to any other audit requirements contained in other paragraphs within this contract. cost 10. If applicable, Contractor agrees to not use Federal funds to satisfy appropriate l cost sharing and matching requirements unless approved in writing by the app P Agency. Page 6 of 8 Pages 890495 Rev. 06/06/88 • Fords-AC-a26 SPECIAL PROVISIONS CONTROLLER'S APPROVAL I. 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 actor 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 other 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 contractor any order issued thereunder.or attempt,either directly or indirectly. to commit any act defined in this contract to be discriminatory. • 890495 page . 7_ of _8 _ pages Revised 11-85- • Form 6-AC-02C - (7) In the event ,e contractor's non-compliance with the non-discrimina 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(1)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.works within the Statvisions of e are under02,CRS rtaken hereunder r preference nd are f Colorado financed in whole or are applicable par by to this funds.lf public 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 anon-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- iectiionsthalllybeu federal requirements suspended. ndedbut (section only to the extend necessary nece sary to prevent CRS). of the moneys or to eliminate the GENERAL 7. The laws of the State 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 the performance of this Contract, the Contractor shall strictly adhere to all applicable federal and state laws, rules and regulations that have been or may hereafter be established. 9. The signatories hereto aver that they are familiar with 18-8-301.eL 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: WELD COUNTY ADO (Full Legal Name( ROY ROME GOVER STATE OF COLORA R HEALTH DEPARTMENT • for the 'BS E E VE DIRECTOR. Position I Ti efiettal I 8 -6000813 DEPARTMENT .nx......�.m... ,r/./a/.f,.�iu vC ..• .y/,' OF HEALTH (If Attest (Sl !ry f�Zft�t(/1.l,Vt 1 ex t�✓ta(wit) Anest f S all APPROVALS • ATTORNEY GENE DUANE W C ROLLER By By LIFFO� R� . HALL PROGRAM APPROVAL: f" .N�f,(_ Li l-ti �!{ z, j 890495 r E LI S011n3aYtl3H11—�I I _ — - I I I I III ! 'I I I I -I I W —.I 3ONOSS1 a ll I I e wrOlrsoaanYl e l I [ Ili 1 e SWOON001m ! I s A7131'/WY3Y01 2 JI H 1 1 o c wsrsxdn0' III I I I I I I I I llld tl3H101 .`n I a I I I I i I I e r OY/30-01/"1O01 ^„ ! I I I I i I I u [ AO-01(1YtlA01 I I Cc. • - . j OS/I NY'. - 11 I I I 3 u I SSII N0I e [ I I I ' i I 2 1 Cf130 ll/01 NO' + ' ' I ! 1 I i I I 1 I W NS0ID0W _� — — — _ — ( _ _ cc egg I HI H - H O `I - - - N _ Z Za = = _ ^ _ : _ _ _ O taa Li Z s i m — ^ _ _ Z 61.4 Mr z z Q J mitAI N e s - _ _ I S 7 s u - H wz I INlal ls310df 1 co o a S J ONO A3NON I « 1 I O O u. O 01 A1N0-A1dans I I I, 0 "6= 'LI aFN0N I . ≤ 0 N-. ..u '3113'1113111 N 1 I I ,. Z 4 Z i -. 11SIA3tl _I ... $ Yr3),LLISIA III 1N3 1Yd 0l3N R CC 3000 3W03NI I = as I 13S1 e w .tl3N00M'0Y = I. - - - 0 o u CJ _ _ r 5Q _ ~ 9 Q • m N Y 0 .1; j m P m 6 13 e is m — .- — Or = a o m - _ _ N m O Y O w m ¢ G j ^ Z 10 r — — N 2 ti V L Y N =I ac t-V 2uawgDfl V . ATTACHMENT A-2 COLORADO DEPARTMENT OF HEALTH Family Planning Data System PATIENT VISIT SAMPLE month . day veer 1. Date of Visit Milli 2. Service Site Number 11111111 3. Patient Number 11111111111 4. County of Residence Code • 5. Pregnancy History Number of times pregnant iniMi Number of live births NEM 6. Ethnicity/Rees (Check one) Anglo `( Al American Indian I D Black I I a Oriental H Hispanic C Other F Unknown G 7. Seasonal Agricultural Worker (Check one) Seasonal I A Neither Ina Migrant B Unknown S D 8. Purpose of Visit (Check one) Initial Medical WIWI Other New Visit NE© Annual Medical MEM Other Revisit Min 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 Blood Pressure D G.C. Culture N Rubella Immunization P Pap InsertionSmear F Rubella Titer H IUD Removal G Other Medical S 10. Type of Counseling (Check all which apply) Initial or Annual • - Pre-conceptual E Visit Counseling I A Problem Pregnancy F Contraceptive B Sterilization (pre) G Infertility C Adolescent H Nutrition D Other J 11. Contraceptive Method at the End of This Visit (Check all which apply) Oral A Contraceptive Sponge F MD B Natural/Fert. Aware G Diaphragm C Cervical Cap H Condos D None J Foam/Jelly/Cream I B Condom/Spermicide K 12. Provider of Encounter (Check all which apply) Doctor I A Nurse C Nurse Practitioner/ B Other Health D Midlevel Practitioner 13. Referrals Elsewhere (Check all which apply) Infertility A Sterilization I C Prenatal Care B OtherNone I E 0. 890495 "°°`I E 894495 FPDS *2 (5-84) (Revised 1/89) I I I I I I I I I I y 1I I I s uI y 1 1 y a, a c., y. .•-• I 1 • •• . III Y I I Ja O ) L G I I I. q vJ C I I I, 4 GO V n I 1 r 11 y W y I I 7 y < E m 6 7 I I v I 1 \llist I 1 •1111I L. C 1 I1 G a ZI 0. I II C a Ii V 61 I I L FI Z 11 U 0) . Vol a I I y FI a 1 1 p 3 Z I ' CO C� Y. II II as 07 y.i F I I pas oi II p •O = f l I I L L. L .�l I I a+ A NI I I 0. O m O1 E..', I I y V y y ..I U1 1 1 3 . O L y Lr7 C 1 1 y U y O m I s = g n OI 1I II G y ® 0. H U I I 0J 3 y d 0. m a = L L. C O 11 I 0) = y +�' C P a� m N I 1 » U m 7 L.. C.) NI No I I O p L �f e0 y 9 co I I .O OO a+ b =. ro O O 1 I U = m "-I0 :J E. F ' I ..I is V .O O 00 'Y' Li I II e + u E• I I w; L d m C W d 4. O 10-1 1 I O y C O O'tu 5 - >,N O I I ,�•� W a N is 01 S a m Z 0 III 1 0) O v °\�' O ++ F y y a) OEr y 03 ic F .> I II C 01 U = M . O•• �O5 La 0 .O 6 a I 1I Ct.. +O.+ A 07 m 0 Z a.+ l0 Z > O. i 11 C L. t .= ..= OO a)V a. ®a. co I= - I 1 W m p� y N .. Gr O • I it ..5. L C .4 ..I a) c Istr7 a+ 0. co li) II Et a+ a) F L a1 O < m O p 1 I O < d L 'O ..an \ \ \N 1 1 .r Z j y .+ 1:A 7 O U •Q t I II L. N H ® 0 v m U I I y O I I E•, a ATTACHMENT C COLORADO DEPARTMENT OF HEALTH - FAMILY PLANNING PROGRAM VII .01 3 BCRR QUARTERLY EXPENDITURE REPORT OTHER COMMUNITY PATIENT TOTAL MEDICAL LAB PHARMACY HEALTH HEALTH ADM FACILITIES RECORDS EXPENDITURES PERSONNEL COSTS PERSONNEL FRINGE SUBTOTAL (A) OPERATING COSTS TRAVEL SUPPLIES(PURCHASED) CONTRACTUAL OTHER SUBTOTAL (B) TOTAL DIRECT COSTS (TOTAL A + B) VALUE DONATED MSS (In-Kind) DEPRECIATIONS SUBTOTAL (C) (VALUE INKIND - DEP) TOTAL PROGRAM COSTS A * B * C A SQUARE FOOTAGE July-Sept Report Only *DEPRECIATION If you are listing a capital equipment item (items costing $300 or more per unit with a useful life of 2 or more years), complete the following using this formula: Purchased cost divided by life years c depreciation per year, divided by 4 quarters a depreciation amount per quarter. DEPRECIATION I PURCHASE USEFUL * AMOUNT DEPRECIATION ITEM COST LIFE YEARS DIVIDED BY 4 QRTS TOTAL TO DATE AGENCY • COWIETED. BY REPORTING PERIOD 890495 W ✓• te. • M r1 0 = W U) - W 2 W 0 CI 0 vy ' ..U. O .� a4� ... 7 L .+ 7 ia ��d G0 m p O 1 s on 7. G i. 0 H . O y — . 0. 0 C .3 w p a) a ... O W C. 0 7 U 0 6 .. .n .0. 0 L co ••••• v O F O. Co. O F GZ W. F W m tr7 Z 05 .. 3 E z 01 Ct F 0 F C Z C z m m E y co a Z 00 F N0 <I C = ++ >I.=• T <'E 0 0C O 4) O SS 411 0fl C 0) L C r1 .7 a U < W < VI y U 02 9 ..W. F O < C L '+ ptrp�70 p 0 4) 0 p 0g Z 0 a F O J i a .. to 1+L. 1. a oa N .w 0 4ia -, = • C C CO O ply MI o y W U N O 8 WO v. 0 ++ 4 L F.1 O 0. 00 0 U O C 0co U F i. 0 .0 0) . < .a W O La my y OO W < 0) o O = = p w co. •O r L 0 F F O W •w 0 .w d '� oc z ; w < mom+ aa 05 . z 0 7 6) • — aU CC^ v .0 [.. 0 Cid d OL U .0 W O N to dW �+ ++ F co 0ZUZ� y Oa• >, o Z 1 ,� 0. � v 0 U h0 z co, O z C '� cc in W ..Ci O y CC >�00 U t fl a. y cra o h7 ..• W. °fl �-+ h0 �.co .+ N C Fr S ce L 0) 0. b y a. ---- 0N F .t.4 ri � .�i < y W t < m U e i• e..i Cz.7 = d 7 y 7 G p O - - 0 W v 6i 0 F U • VII.009 ATTACHMENT E COLORADO DEPARTMENT OF HEALTH FAMILY PLANNING PROGRAM ADJUSTED TOTAL GROSS INCOME AND FAMILY SIZE CODES - 1989 FAMILY SIZE ANNUAL INCOME MONTHLY INCOME WEEKLY INCOME CODE Less than 5980 Less than 498 Less than 115 1 1 5981-8970 499-747 116-173 2 8971-11960 748-996 174-230 3 More than 11961 More than 997 More than 231 4 Less than 8020 Less than 668 Less than 154 1 2 8021-12030 669-1002 155-231 2 12031-16040 1003-1336 232-308 3 More than 16041 More than 1337 More than 309 4 ' Less than 10060 Less than 838 Less than 193 1 3 10061-15090 839-1257 194-290 2 15091-20120 1258-1676 291-386 3 More than 20121 More than 1677 More than 387 4 Less than 12100 Less than 1008 Less than 233 1 4 12101-18150 1009-1512 234-350 2 18151-24200 1513-2016 351-466 3 More than 24201 More than 2017 More than 467 4 r-•' Less than 14140 Less than 1179 Less than 272 1 5 14141-21210 1180-1769 273-408 2 21211-28280 1770-2358 409-544 3 More than 28281 More than 2359 More than 545 4 Less than 16180 Less than 1348 Less than 311 1 6 16181-24270 1349-2022 312-467 2 24271-32360 2023-2696 468-622 3 More than 32361 More than 2697 More than 623 4 Less than 18220 Less than 1518 Less than 350 1 7 18221-27330 1519-2277 351-525 2 27331-36440 2278-3036 526-700 3 More than 36441 More than 3037 More than 701 4 Less than 20260 Less than 1688 Less than 390 1 8 20261-30390 1689-2532 391-585 2 30391-40520 2533-3376 586-780 3 More than 40521 More than 3377 More than 781 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 1989 guidelines. Code 2: Between 101% and 150% poverty as defined by 1989 guidelines. Code 3: Between 151% and 200% poverty as defined by 1989 guidelines. Code 4: Above 200% poverty as defined by 1989 guidelines. NOTE: For family units with more than 8 members, add $2040 for each additional member. April 1989 330495 • WELD COUNTY HEALTH DEPARTMENT CONTRACT SUMMARY (Contract Name) Family Planning Program Granting Agency: Colorado Department of Health • Term of contract: July 1, 1989 through June 30, 1991 Amount: $83,251.00 Difference from previous contract: decrease of $1706.00; This decrease is related to a -decrease in numbers of patients served. 1989 contract is to serve about 1,550 patients and 1990 is for 1450 patients. County Citizens Affected: Men and women in their reproductive years. Program Summary: Outreach and Patient Recruitment Health and Social History Medical Exam and Lab Testing Contraceptive Information and Supplies Follow up and Referrals Benefit to Health Department: Provides the funding for services above and allows Weld County Health Department to offer this on a sliding fee scale. Responsibility of Health Department: To conduct a comprehensive Family Planning Program in compliance with Title X and Colorado Department of Health Regulations. County Fiscal Impact: decrease of $1706 (9%) Hello