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Home My WebLink About992040.tiff RESOLUTION RE: APPROVE CONTRACT FOR TUBERCULOSIS OUTREACH AND CONTROL PROGRAM AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Contract for the Tuberculosis Outreach and Control Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment, commencing July 1, 1999, and ending December 31, 1999, with further terms and conditions being as stated in said contract, and WHEREAS, after review, the Board deems it advisable to approve said contract, 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 Contract for the Tuberculosis Outreach and Control Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said contract. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 16th day of August, A.D., 1999, nunc pro tunc July 1, 1999. BOARD OF COUNTY COMMISSIONERS COU C ADO ATTEST: Li ► �►`: , Dale K. all, Chair Weld County Clerk to t •: ��S lj �Ciztly� %O\ Barbara.J. Kirkmeyer, Pro-Tem _BY: ✓ /. L • Deputy Clerk to the Boa ►�V1 �j'" f George axer 7, AP, VDA TO FORM: 2-7.2 kit/M. J. Geile _ . nt GIVaa y'Attorney enn u[ ��" c 992040 cc: t HL0025 4 COLORADO MEMORANDUM TO: Dale K. Hall, Chairman, Board of County Commissioners FROM: John S. Pickle, Director, Department of ruivlic teallh and Environment ;- 21 SUBJECT: TB Outreach and Control Contract DATE: August 10, 1999 Enclosed for Board review and approval is a contract between Weld County Department of Public Health and Environment (WCDPHE) and the Colorado Department of Public Health and Environment for the TB Outreach and Control Program. Under the provisions of this contract, WCDPHE will provide active TB treatment, TB preventive treatment, provide for and interpret chest x-rays and other medical evaluation services, conduct contact investigations and TB skin test screening programs. WCDPHE will also follow-up with active patients to ensure they receive appropriate information and education and that they adhere to the completion of their TB therapy. For these services, the Health Department will receive an amount not to exceed$20,522 for the period July 1, 1999 through December 31, 1999. I recommend your approval of this contract. Enc. Department or Agency Name COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Department or Agency Number FHA Contract Routing Number 00-00039 inmm CONTRACT This CONTRACT is made this 11'h day of June 1999 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,Weld County Health Department whose address or principal place of business is 1555 North 17'" Avenue,Greeley,Colorado 80631 hereinafter referred to as"the Contractor". WHEREAS,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 of this Contract in Fund Number 100,Appropriation Accounts 386 and 36'7 and Organization Numbers 4644 and 3640 under Encumbrance Number EP10000039. WHEREAS, pursuant.to 25-4-501 et seq. C.R.S.,the State has appropriated funding to provide Tuberculosis(TB) Control Services; WHEREAS,as of the made date of this Contract,the State has a currently valid Group II purchasing delegation agreement with the Division of Purchasing within the Colorado Department of Personnel; WHEREAS,the State has received funding,pursuant to the Catalog for Federal Domestic Assistance(CFDA) #93.116,for the purpose of assisting State and local agencies in carrying out Tuberculosis Outreach activities designed to prevent transmission of infection and disease; WHEREAS, section 29-1-201, 8 C.R.S.,as amended, encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function,service,or facility lawfully authorized to each of the cooperating or contracting entities,and to this end all State contracts with its political subdivisions are exempt from the State's personnel rules and the State procurement code;and, WHEREAS, all required approvals,clearances,and coordination have been accomplished from and with all appropriate agencies. Page 1 of 19 Pages NOW THEREFORE, in consideration of their mutual promises to each,stated below,the parties hereto agree as follows: A. EFFECTIVE DATE AND TERM. The effective date of this Contract is July 1, 1999 or on the date the State Controller approves this Contract,whichever is later. The initial term of this Contract shall commence on July 1, 1999,and continue through and including December 31, 1999 unless sooner terminated by the parties pursuant to the terms and conditions of this Contract. The total tenn of this Contract, including any extensions or renewals hereof, may not exceed five(5)years. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. 1. The Contractor shall provide or coordinate the following services, in order of priority listed below, for all individuals within the service area according to the State TB Manual and Rules and Regulations Pertaining to Epidemic and Communicable Disease Control effective 4/30/97: a) Provide active TB treatment, including directly observed therapy as required by Regulation 4 as referenced above; b) Conduct contact investigations for newly diagnosed TB cases, including screening and follow-up for contacts to TB; c) Order TB Medications directly through the State Contract Pharmacy and administer TB medication. Medications other than Isoniazid, Rifampin,Ethambutol, Pyazidimide. and Pyridoxine require prior approval for reimbursement by the State; d) Collect bacteriological specimens on all suspects and assure that sensitivities are conducted on positive cultures for INH, Rifampin, Ethambutol, Streptomycin,and Pyrazinamide; e) Provide or arrange for chest x-rays and interpretation; f) Provide or arrange for laboratory testing,and other necessary medical evaluation services; g) Periodically monitor and evaluate persons with active and suspected active TB,TB infection and other persons as necessary to protect the public health; h) Provide TB preventive treatment; 2. TB skin testing,chest x-rays and x-ray interpretations for the following are not eligible for reimbursement under the terms of this contract: • volunteers or employees of health care or long term care facilities • volunteers,employees,or inmates of correctional facilities • volunteers or employees of homeless shelters • volunteers or employees of drug treatment centers • volunteers or employees of schools or child care facilities 3. The Contractor shall recommend and offer an HIV antibody test to: • all persons diagnosed with TB disease.,regardless of age or apparent absence of risk factors for HIV infection; • all persons with positive TB skin tests(PPD)with HIV risk factors;and • foreign-born persons from HIV endemic areas. The Contractor shall refer patients to the State HIV Testing Program. Page 2 of 19 Pages The Contractor shall report all known HIV antibody test results to the State pursuant to section 25-4-1401 et seq C.R.S.. Individuals who refuse testing shall be educated regarding the risks associated with HIV/TB co-infection. 4. The Contractor shall supply the State,with complete patient data for all persons with infection and disease for integration into the TB records system. Data will include: a. TB infection cases(reactors)/Known TB Contacts--initial report of patient name,birth date, demographic and other patient information, risk factors as identified on the "Tuberculosis Surveillance and Case Management Report"(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--Attachment B). b. Suspect/Known Active TB cases-- initial report of patient name, birth date, demographic and other patient information,risk factors as identified on the"Report of Verified Case of Tuberculosis"(RVCT form--see 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 will also be used by the Contractor to report when a TB patient completes treatment, moves or transfers out of the county. The State shall provide format and instructions for any additional data transfer required. 5. The State shall immediately notify the Contractor of all newly arrived Class A or B TB immigrants to the county via a CDC 75.17 form (copy attached and made part hereof as Attachment D). The Contractor, in tum,will contact the immigrant and conduct TB screening including a PPD skin test and chest x-ray for all Class A or B immigrants within 30 days of receipt of notification of their arrival. The Contractor will additionally obtain sputum cultures x 3 if a clinical evaluation by a qualified medical provider or chest x-ray interpretation reveals suspicion of active disease. The Contractor shall provide for appropriate follow-up for these immigrants,complete the CDC 75.17 form and return the completed form to the State. The Contractor further agrees to notify the State if the immigrant fails to appear for the required TB screening within 30 days of receipt of notification of their arrival. 6. The Contractor shall,through the services of Personnel Health Aid III's (1.5 FTE),conduct an outreach program to ensure that patients receive appropriate information and education and assist with follow-up needed to fulfill requirements as listed above. These workers shall be bilingual. Services provided by these workers shall include,but are not limited to: a. Ensure adherence to and the completion of therapy for TB patients and implement outreach and contact follow-up activities for all newly reported cases and suspected cases of TB,paying special attention to patients with potentially drug resistant cases and their contacts. b. Ensure completion of therapy through Directly Observed Therapy(DOT), individual accountability, incentives and enablers. If the national objective for the completion of therapy(90%of reported cases) is not met or exceeded,the Contractor shall evaluate reasons for nonadherence,devise new strategies,and discontinue lower-priority activities(e.g.routine skin testing programs where few new infections are found)and use those resources to ensure completion of therapy for patients with active.TB. Page 3 of 19 Pages 7. The Contractor agrees to provide the State a narrative report for the period of 7/1/99- 12/31/99 by March 1,2000 which includes: a. Progress in implementing outreach activities,results of the evaluation of those activities and whether county TB Program Objectives were met. b. A statement of any difficulties or special problems encountered in meeting the agreement objectives . c. A statement of action plans designed to overcome or address difficulties and problems. d. A statement of population served and the special needs of those populations which have been met through the agreement, non-compliant patients,children, foreign-born, etc. e. A statement of time spent by the outreach workers in TB prevention and follow-up activities. 8. The Contractor shall provide or arrange for quarantine services for patients requiring isolation. The Contractor further agrees to provide a written financial statement of need completed by a licensed social worker, indicating whether client has other financial means to cover costs of quarantine. 9. The State shall provide statistical analyses upon request by the Contractor regarding the Contractor's TB Control Program. 10. The Contractor shall submit Contact Investigation Reports to the State, as required by Centers for Disease Control and Prevention (CDC),(copies attached and made a part hereof as Attachment E),according to the schedule outlined below. The Contractor and the State agree to collaborate in automating data collection and transfer of these reports. • Reports of all TB Contact Investigations provided between July I and December 31, 1999 under the terms of this contract shall be due to the State March 15,2000. This obligation survives the end of this contract term(December 31, 1999). 1. TB Control services pursuant to C.R.S.25-4-501-513„are provided at 80%from state funding sources and 20%from the county in which the recipient resides. The Contractor shall be responsible for the remaining 20%,which may be contributed in the form of an in-kind agency match. C. DUTIES AND OBLIGATIONS OF THE STATE. 1. a) The State shall, in consideration of the Tuberculosis Control services satisfactorily performed by the Contractor under this Contract,cause to be paid to the Contractor a sum not to exceed TWENTY THOUSAND FIVE HUNDRED TWENTY TWO DOLLARS ($20,522.001 for the initial term of this Contract. Of the total financial obligation of the State referenced above, ELEVEN THOUSAND FIVE HUNDRED Page 4 of 19 Pages NINETY SEVEN DOLLARS($11,597.00) is derived from the State General Fund. Of the total financial obligation of the State referenced above, EIGHT THOUSAND NINE HUNDRED TWENTY FIVE DOLLARS($8,925.00) is derived from a source of the federal government. b) Payment pursuant to this Contract shall be made as earned, in whole or in part, from available State funds encumbered in an amount not to exceed THIRTY-EIGHT THOUSAND DOLLARS($38,000,0) Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2000. Of the total financial obligation of the State referenced above,one hundred percent is derived from the State General Fund. The liability of the State,at any time,for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Contract,then the State, in its sole discre- tion, may proportionately reduce the funding for this Contract or terminate this Contract in its entirety. B. The following budget shall govern the expenditure of funds for the initial term of this Contract- July I, 1999 through December 31, 1999. The Contractor's transfer of funds from one line item to another must have the prior, express,written approval of the State: Description Funding Source Amount Tuberculosis Control Services State $ 8,946.00 Federal $ 8,925.00 Chest X-ray State $ 1,931.00 Medical Consultation State $ 720.00 Direct Observed Therapy @$12.50 per visit State As Administered 3. To be compensated under this Contract,the Contractor shall submit a signed billing statement, an example of which is incorporated herein by reference,made a part hereof,and attached hereto as Attachment F,within sixty(60)calendar days of the end of the month for which sery ices were rendered. Reimbursement during the initial,and any extension,term of this Contract shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Contract. The billing statement shall: • Reference this Contract by its contract number,which number is located on page one of this document; • State the applicable performance dates,the names of payees, and a brief description of the services performed,total expenditures incurred,and the total reimbursement requested; • Attach a statement detailing direct observed therapy activity during the invoice period reporting the patient name(s),and the number and date(s)of visits. The State shall keep statements containing patient information confidential and secured;and • Reflect the total program cost as the sum of the"Local Agency Match"and"Amount Requested for Reimbursement"on the monthly billing statement(Attachment F). The "Local Agency Match"shall document the Contractor's 20%contribution of program costs. • Billing statements shall be sent to: Page 5 of 19 Pages Greg Bettridge DCEED-ADM-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 Contract through a"Change Order Letter",a sample of which is incorporated herein by this reference, made a part hereof,and attached hereto as"Attachment G". To be effective,the 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 Change Order Letter shall include the following information: A. Identification of this Contract by its contract number and affected paragraph number(s); B. The type(s)of service(s)or program(s)increased or decreased and the new level of each service or program; C. The amount of the increase or decrease in the level of funding for each service or program and the new total financial obligation; D. The intended effective date of the funding change; and, E. A provision stating that the Change Order Letter shall not be valid until approved by the State Controller or such assistant as he may designate. 5. Upon proper execution and approval,the Change Order Letter shall become an amendment to this Contract. Except for the General and Special Provisions of this Contract,the Change Order Letter shall supersede this Contract in the event of a conflict between the two. It is expressly understood and agreed to by the parties that the 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 Contract, other than those authorized by the contract renewal letter process described below,shall be made by a formal amendment to this Contract executed in accordance with the Fiscal Rules of the State of Colorado. 6. If the Contractor agrees to and accepts the proposed change,then the Contractor shall execute and return the Change Order Letter to the State by the date indicated in the Change Order Letter. If the Contractor does not agree to and accept the proposed change,or fails to timely return the partially executed Change Order Letter by the date indicated in the Change Order Letter,then the State may,upon written notice to the Contractor,terminate this Contract twenty(20) calendar days after the return date indicated in the Change Order Letter has passed. Such written notice shall specify the effective date of termination of this Contract. In the event of termination under this clause,the parties shall not be relieved of their respective duties and obligations under this Contract until the effective date of termination has occurred. 7. Increases or decreases in the level of contractual funding made through this change order letter process during the initial or renewal terms of this Contract may be made under the following circumstances: Page 6 of 19 Pages Contract. In the event of termination under this clause,the parties shall not be relieved of their respective duties and obligations under this Contract until the effective date of termination has occurred. D. GENERAL PROVISIONS. I. The parties warrant that each possesses actual, legal authority to enter into this Contract. The parties further warrant that each has taken all actions required by its applicable law, procedures, rules, or by-laws to exercise that authority, and to lawfully authorize its undersigned signatory to execute this Contract and bind that party to its terms. The person or persons signing this Contract,or any attachments or amendments hereto,also warrant(s)that such person(s) possesses actual, legal authority to execute this.Contract,and any attachments or amendments hereto, on behalf of that party. 2. THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE OF THE STATE. NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE CONTRACTOR SHALL BE,OR SHALL BE DEEMED TO BE,AN AGENT OR EMPLOYEE OF THE STATE. THE CONTRACTOR SHALL PAY WHEN DUE ALL REQUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON ANY MONIES PAID PURSUANT TO THIS CONTRACT. THE CONTRACTOR ACKNOWLEDGES THAT THE CONTRACTOR AND ITS EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE CONTRACTOR OR A THIRD PARTY PROVIDES SUCH COVERAGE ANI)THAT THE STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE. THE CONTRACTOR SHALL HAVE NO AUTHORIZATION,EXPRESS OR IMPLIED, TO BIND THE STATE TO ANY AGREEMENTS,LIABILITY,OR UNDERSTANDING EXCEPT AS EXPRESSLY SET FORTH HEREIN. THE CONTRACTOR SHALL PROVIDE AND KEEP IN FORCE WORKERS' COMPENSATION(AND SHOW PROOF OF SUCH INSURANCE)AND UNEMPLOYMENT COMPENSATION INSURANCE IN AMOUNTS REOUIRED BY LAW,AND SHALL BE SOLELY RESPONSIBLE FOR THE ACTS OF THE CONTRACTOR,ITS EMPLOYEES AND AGENTS. 3. If this Contract is in the nature of personal/purchased services,then the State reserves the right to inspect services provided under this Contract at all reasonable times and places during the term of this Contract. "Services",as used in this clause, includes services performed or written work performed in the performance of services. If any of the services do not conform with the terms of this Contract,then the State may require the Contractor to perform the services again in conformity with the terms of this Contract,with no additional compensation to the Contractor for the reperformed services. When defects in the quality or quantity of the services cannot be corrected by reperformance,then the State may: require the Contractor to take all necessary action(s)to ensure that the future performance conforms to the terms of the Contract; and, equitably reduce the payments due to the Contractor under this Contract to reflect the reduced value of the services performed by the Contractor. These remedies in no way limit the other remedies available to the State as set forth in this Contract. Page 8 of 19 Pages 4. If,through any cause attributable to the Contractor's action(s)or inaction(s),the Contractor. fails to fulfill, in a timely and proper manner, its duties and obligations under this Contract;or, violates any of the agreements,covenants,provisions,stipulations,or terms of this Contract, then the State shall thereupon have the right to terminate this Contract for cause by giving written notice thereof to the Contractor. Such written notice shall be given at least ten(10) calendar days before the proposed termination date and shall afford the Contractor the opportunity to cure the default or state why termination is otherwise inappropriate. If this Contract is terminated for default,then all finished or unfinished data,documents, drawings, evaluations, hardware, maps,models, negatives,photographs, reports, software, studies,surveys,or any other material,medium or information, however constituted,which has been or is to be produced or prepared by the Contractor under this Contract shall, at the option of the State,become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to,and accepted by,the State. If applicable,the Contractor shall return any unearned advance payment it received under this Contract to the State. Notwithstanding the above,the Contractor is not relieved of liability to the State for any damages sustained by the State because of the Contractor's breach of this Contract. The State may withhold any payment due to the Contractor under this Contract to mitigate the State's damages until such time as the exact amount of the State's damages from the Contractor's breach of this Contract is determined. If,after terminating this Contract for default, it is determined for any reason that the Contractor was not in default,or that the Contractor's action or inaction was excusable,then such termination shall be treated as a termination for convenience,and the rights and obligations of the parties shall be the same as if this Contract had been terminated for convenience,as described herein. 5. The State may,when the interests of the State so require,terminate this Contract in whole or in part, for the convenience of the State. The State shall give written notice of such termination to the other party specifying the part(s)of the Contract terminated. Such written notice shall be given to the other party at least thirty(30)calendar days before the effective date of termination. If this Contract is terminated for convenience,then all finished or unfinished data,documents, drawings,evaluations,hardware,maps,models,negatives,photographs,reports,software, studies,surveys,or any other material,medium or information,however constituted,which has been.or is to be produced or prepared by the Contractor under this Contract shall,at the option of the State,become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to,and accepted by,the State. If applicable,the Contractor shall return any unearned advance payment it received under this Contract to the State. This paragraph in no way implies that a party has breached this Contract by the exercise of this paragraph. If this Contract is terminated by the State as provided for herein,then the Contractor shall be paid an amount equal to the percentage of services actually performed for,or goods actually delivered to,the State, less any payments already made by the State to the Contractor for those services or goods. However, if less than sixty percent(60%)of the services or goods covered by this Contract have been performed or delivered as of the effective date of termination,then the Contractor shall also be reimbursed(in addition to the above payment)for that portion of those actual"out-of-pocket"expenses(not otherwise reimbursed under this Contract) incurred by the Contractor during the term of this Contract which are directly attributable to the uncompleted portion of the services,or the undelivered portion of the goods,covered by this Contract. In no event shall reimbursement under this clause exceed the total financial obligation of the State to the Contractor under this Contract. If this Contract is terminated for default because of the Contractor's breach of this Contract,then the provisions of paragraph 4 above shall apply. Page 9 of 19 Pages 6. If th is Contract involves federal funds,or compliance is otherwise federally mandated,then the Contractor shall comply with the requirements of the following: A. Office of Management and Budget Circulars A-87,A-2I,or A-122,and A-102 or A-I 10,as applicable; B. the"Hatch Act"(5 U.S.C. 1501-1508)and Public Law 95-454, Section 4728. These federal statutes declare that federal funds cannot be used for partisan political purposes of any kind by any person or organization involved in the administration of federally-assisted programs; C. the"Davis-Bacon Act"(40 Stat. 1494,Mar. 3, 1921,Chap.411,40 U.S.C. 276A-276A-5). This Act requires that all laborers and mechanics employed by contractors or sub-contractors to work on construction projects financed by federal assistance must be paid wages not less than those established for the locality of the project by the Secretary of Labor; D. 42 U.S.C. 6101 et seq,42 U.S.C. 2000d,29 U.S.C. 794. These Acts mandate that no person shall,on the grounds of race,color,national origin,age,or handicap, be excluded from participation in or be subjected to discrimination in any program or activity funded, in whole or in part,by federal funds; E. the"Americans with Disabilities Act" (Public Law 101-336;42 U.S.C. 12101, 12102, 12111 - 12117, 12131 - 12134, 12141 - 12150, 12161 - 12165, 12181 - 12189, 12201 - 12213 and 47 U.S.C. 225 and 47 U.S.C.611); F. if the Contractor is acquiring an interest in real property and displacing households or businesses in the performance of this Contract,then the Contractor is in compliance with the"Uniform Relocation Assistance and Real Property Acquisition Policies Act", as amended(Public Law 91-646, as amended and Public Law 100-17, 101 Stat.246- 256);and, G. when applicable,the Contractor is in compliance with the provisions of the"Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments"(Common Rule). H. Section 2101 of the Federal Acquisition Streamlining Act of 1994, Public Law 103- 355,which prohibits the use of federal money to lobby the legislative body of a political subdivision of the State. 7. If this Contract involves federal funds,or compliance is otherwise federally mandated,then by signing and submitting this Contract,the Contractor affirmatively avers that: A. the Contractor is in compliance with the requirements of the"Drug-Free Workplace Act"(Public Law 100-690 Title V,Subtitle D,41 U.S.C. 701 et seq.);and, B. the Contractor hereby certifies that it is not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily excluded from covered transactions by Page 10 of 19 Pages any federal department or agency. The Contractor agrees to comply with all applicable regulations pursuant to Executive Order 12549, including, Debarment and Suspension and Participants'Responsibilities,29 C.F.R.98.510(1990). C. the Contractor agrees to comply with all applicable regulations pursuant to Section 319 of Public Law 101-121,Guidance for New Restrictions on Lobbying, including, Certification and Disclosure,29 C.F.R.93.110(1990). 8. If this Contract involves the expenditure of federal or state funds,then this Contract is subject to,and contingent upon,the continued availability of those funds for payment pursuant to the terms of this Contract. If those funds,or any part thereof,become unavailable as determined by the State,then the State may immediately terminate this Contract. 9. To be considered for payment, billings for payments pursuant to this Contract must be received within a reasonable time after the period for which payment is requested;but in no event no later than ninety(90)calendar days after the relevant performance period has passed. Final billings under this Contract must be received by the State within a reasonable time after the expiration or termination of this Contract;but in no event no later than ninety(90)calendar days from the effective expiration or termination date of this Contract. 10. Unless otherwise provided for in this Contract, "Local Match"shall be included on all billing statements, in the column provided therefor,as required by the funding source. 11. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. 12. In accordance with Office of Management and Budget(OMB)Circular A-I33 (Audits of States, Local Governments,and Non-Profit Organizations),if the Contractor receives federal funds from any source, including State pass through money, in an aggregate amount in excess of $300,000.00(June 24, 1997),in a State fiscal year(July 1 through June 30),then the Contractor shall have an annual audit performed by an independent certified public accountant which meets the requirements of OMB Circular A-133. If the Contractor is required to submit an annual indirect cost proposal to the State for review and approval,then the Contractor's auditor shall audit the proposal in accordance with the requirements of OMB Circulars A-21 (Cost Principles for Educational Institutions),A-87(Cost Principles for State, Local and Tribal Governments), or A-I2.2(Cost Principles for Non-Profit Organizations),whichever is applicable. The Contractor shall furnish one(1)copy of the audit report(s)to the State's Accounting Office within thirty (30)calendar days of issuance; but in no event later than nine(9)months after the end of the Contractor's fiscal year. If(an) instance(s)of noncompliance with federal laws and regulations occurs,then the Contractor shall take all appropriate corrective action(s)within six(6)months of the issuance of(a)report(s). 13. The Contractor shall grant to the State,or its authorized agents, access to the Contractor's relevant records and financial statements. The Contractor shall retain all such records and Page II of 19 Pages financial statements for a period of six(6)years after the date of issuance of a final audit report. This requirement is in addition to any other audit requirements contained in other paragraphs of this Contract. 14. Unless otherwise provided for in this Contract,for all contracts with terms longer than three(3) months,the Contractor shall submit a written progress report, if required by this Contract, specifying the progress made for each activity identified in this Contract. These progress reports shall be in accordance with the procedures developed and prescribed by the State. The preparation of progress reports in a timely manner is the responsibility of the Contractor. If the Contractor fails to comply with this provision,then such failure: may result in a delay of payment of funds;or, termination of this Contract. Progress reports shall be submitted to the State no later than the end of each calendar quarter, or at such other time as may otherwise be specified. 15. The'Contractor shall maintain a complete file of all records,documents,communications,and other materials which pertain to this Contract. Such materials shall be sufficient to properly reflect all direct and indirect costs of labor,materials,equipment,supplies,and services,and other costs of whatever nature for which a contract payment was made. These records shall be maintained according to generally accepted accounting principles and shall be easily separable from other records of the Contractor. Copies of all such records,documents,communications, and other materials shall be the property of the State and shall be maintained by the Contractor, in a central location as custodian for the State,on behalf of the State,for a period of six(6)years from the date of final payment under this Contract,or for such further period as may be necessary to resolve any pending matters,including,but not limited to,audits performed by the federal government. 16. The'Contractor authorizes the State,or its authorized agents or designees,to perform audits or make inspections of its records for the purpose of evaluating its performance under this Contract at any reasonable time during the term of this Contract and for a period of three(3)years following the termination of this Contract. As such,the Contractor shall permit the State,any appropriate federal agency or agencies,or any other duly authorized governmental agent or agency,to monitor all activities conducted by the Contractor pursuant to the terms of this Contract. Such monitoring may include,but is not limited to: internal evaluation procedures, examination of program data,special analyses, on-site checks,formal audit examinations,or any other reasonable procedures. All monitoring shall be performed by the State in such a manner that'it shall not unduly interfere with the work of the Contractor. 17. If the Contractor obtains access to any records, files,or information of the State in connection with.,or during the performance of,this Contract,then the Contractor shall keep all such records, files, or information confidential and shall comply with all laws and regulations concerning the confidentiality of all such records, files,or information to the same extent as such laws and regulations apply to the State. Any breach of confidentiality by the Contractor or third party agents of the Contractor shall constitute good cause for the State to cancel this Contract,without liability to the State. Any State waiver of an alleged breach of confidentiality by the Contractor, or third party agents of the Contractor,does not constitute a waiver of any subsequent breach by the Contractor,or third party agents of the Contractor. 18. Unless otherwise agreed to in this Contract,or in a written amendment executed and approved Page 12 of 19 Pages pursuant to Fiscal Rules of the State of Colorado,the parties agree that all material, information, data. computer software,documentation, studies,and evaluations produced in the performance of this Contract for which the State has made a payment under this Contract are the sole property of the State. 19. If any copyrightable material is produced under this Contract,then the State,and any applicable federal funding entity,shall have a paid in full, irrevocable,royalty free,and non-exclusive license to reproduce, publish,or otherwise use,and authorize others to use,the copyrightable material for any purpose authorized by the Copyright Law of the United States as now or hereinafter enacted. Upon the written request of the Contractor shall provide the State with three(3)copies of all such copyrightable material. 20. If required by the terms and conditions of a federal or state grant,the Contractor shall obtain the prior approval of the State and all necessary third parties prior to publishing any materials produced under this Contract. If required by the terms and conditions of a federal or state grant, the Contractor shall also credit the State and all necessary third parties with assisting in the publication of any materials produced under this Contract. 21. Neither the Contractor nor the State shall be liable to the other for any delay in,or failure of performance of,any covenant or promise contained in this Contract;nor shall any delay or failure constitute default or give rise to any liability for damages if, and only to the extent that, such delay or failure is caused by a supervening cause. As used in this Contract,"supervening cause"is defined to mean: an act of God, fire,explosion,action of the elements,strike, interruption of transportation,rationing,court action, illegality,unusually severe weather,war, or arty other cause which is beyond the control of the affected party and which, by the exercise of reasonable diligence,could not have been prevented by the affected party. 22. It is expressly understood and agreed to between the parties that the enforcement of the terms and conditions of this Contract,and all rights of action related to such enforcement, shall be strictly reserved to the State and the named Contractor. Nothing contained in this Contract shall give or allow any claim or right of action whatsoever to or by any third person. Nothing contained in this Contract shall be construed as a waiver of any provision of the Colorado Governmental Immunity Act,section 24-10-101 et seq.,C.R.S.,as amended. It is the express inters of the State and the named Contractor that any person or entity,other than the State or the named Contractor,receiving services or benefits under this Contract shall be deemed an incidental beneficiary only. 23. To the extent that this Contract may be executed and performance of the obligations of the parties may be accomplished within the intent of this Contract,the terms of this Contract are severable. If any term or provision of this Contract is declared invalid by a court of competent jurisdiction, or becomes inoperative for any other reason,then such invalidity or failure shall not affect the validity of any other term or provision of this Contract. 24. The waiver of a breach of a term or provision of this Contract shall not be construed as a waiver Page 13 of 19 Pages of a breach of any other term or provision of this Contract or,as a waiver of a breach of the same term or provision upon subsequent breach. 25. If this Contract is in the nature of personal/purchased services,then,except for accounts receivable,the rights,duties,and obligations of the Contractor cannot be assigned, delegated,or otherwise transferred,except with the prior,express,written consent of the State. 26. Except as otherwise provided for herein,this Contract shall inure to the benefit of,and be binding upon,the parties hereto and their respective successors and assigns. 27. Unless otherwise provided for in this Contract,the Contractor shall notify the State, within five (5)working days after being served with a summons,complaint,or other pleading in a case which involves any services provided under this Contract and which has been filed in any federal or state court or administrative agency. The Contractor shall immediately deliver copies of any such documents to the State. 28. This Contract is subject to such modifications as may be required by changes in applicable federal or state law, or federal or state implementing rules, regulations,or procedures of that federal or state law. Any such required modification shall be automatically incorporated into, and be made a part of,this Contract as of the effective date of such change as if that change was fully set forth herein. Except as provided above,no modification of this Contract shall be effective unless such modification is agreed to in writing by both parties in an amendment to this Contract that has been previously executed and approved in accordance with applicable law. 29. Notwithstanding anything herein to the contrary,the parties understand and agree that all terms and conditions of this Contract,and the exhibits and attachments hereto,which may require continued performance or compliance beyond the termination date of this Contract shall survive such termination date and shall be enforceable as provided herein in the event of a failure to perform or comply by a party to this Contract. 30. Notwithstanding any other provision of this Contract to the contrary,no term or condition of this Contract shall be construed or interpreted as a waiver,express or implied,of any of the immunities,rights,benefits,protections,or other provisions of the Colorado Governmental Immunity Act(CGIA),section 24-10-101,et see,C.R.S.,as now or hereafter amended. The parties understand and agree that liability for claims for injuries to persons or property arising out c f the alleged negligence of the State of Colorado, its departments, institutions,agencies, boards,officials,and employees is controlled and limited by the provisions of section 24-10-101 et seiz„C.R.S.,as now or hereafter amended. 31. The captions and headings used in this Contract are for identification only,and shall be disregarded in any construction of the terms,provisions,and conditions of this Contract. Page I4 of 19 Pages 32. The parties hereto agree that venue for any action related to this Contract shall be in the City and County of Denver,Colorado. 33. All attachments to this Contract are incorporated herein by this reference and made a part hereof as if fully set forth herein. In the event of any conflict or inconsistency between the terms of this Contract and those of any attachment to this Contract,the terms and conditions of this Contract shall control. 34. This Contract is 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 Fiscal Rules of the State of Colorado. E. 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 payment of money by the State. FUND AVAILABILITY 2. Financial obligations of the State of Colorado 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 work for this State,the contractor shall,before entering upon the performance of any such work included in this contract,duly execute and deliver to the State official who will sign the contract,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 upon the 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,provisions,provendor or other supplies used or consumed by such contractor or his subcontractor in performance of the work contracted to be done or fails to pay any person who supplies rental machinery,tools,or equipment in the prosecution of the work 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 is executed,delivered and filed,no claim in favor of the contractor arising under such 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 CRS 38-26-106. Page 15 of 19 Pages 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,subcontractors,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 (CRS 24-34-402),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: (a) 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 advertisements; lay-offs or terminations;rates of pay or other forms of compensation;and selection 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. (b) 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. (c) The contractor will send to each labor union or representative of workers with which he has a 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 commitment under the Executive Order, Equal Opportunity and Affirmative Action,dated April 16, 1975, and of the rules,regulations,and relevant Orders of the Governor. (d) 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 contracting agency and the office of the Governor or his designee for purposes of investigation to ascertain compliance with such rules,regulations and orders. (e) 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 discriminate against any of its members in the full enjoyment of work opportunity because of race,creed, color, sex,national origin,or ancestry. Page 16 of 19 Pages (fl 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. (g) In the event of the contractor's non-compliance with the non-discrimination clauses of this contract or with any of such rules,regulations,or orders,this contract may be canceled,terminated or suspended 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. (h) The contractor will include the provisions of paragraphs(a)through(h)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 contractor 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 6a. Provisions of CRS 8-17-101 & 102 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 the subsection .06 may cause denial of federal funds which would otherwise be available or would otherwise be inconsistent with requirements of Federal law,this subsection shall be suspended,but only to the extent necessary to prevent denial,of the moneys or to eliminate the inconsistency with Federal requirements(CRS 8-19-101 and 102). 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 incorporated herein by reference which provides for arbitration by any extra-judicial body or person or which is otherwise in conflict with said laws,rules,and regulations shall be considered null Page 17 of 19 Pages 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 otherwise. 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. Pursuant to CRS 24-30-202.4(as amended), the state controller may withhold debts owed to state agencies under the vendor offset intercept system for: (a)unpaid child support debt of child support arrearages;(b)unpaid balance of tax,accrued interest,or other charges specified in Article 21,Title 39, CRS;(c)unpaid loans due to the student loan division of the department of higher education',(d)owed amounts required to be paid to the unemployment compensation fund ;and(e) other unpaid debts owing to the state or any agency thereof,the amount of which is found to be owing as a result of final agency determination or reduced to judgment as certified by the controller. 10. The signatories aver that they are familiar with CRS 18-8-301,et seq.,(Bribery and Corrupt Influences)arid CRS 18-8-401, et seq.,(Abuse of Public Office), and that no violation of such provisions is present. 11. The signatories aver that to their knowledge,no state employee has any personal or beneficial interest whatsoever in the service or property described herein. Page 18 of 19 Pages IN WITNESS WHEREOF,the parties hereto have executed this Contract on the day first above written. Contractor:Weld County Board of Commissioners State of Colorado Weld C Health�Depjartment Bill Owens,Governor By: 0. dale K. tCh r:/ 6/99) Position(Title) Chair By: 846000813 _ Department of Federal I.D.Number Public Health and Environment G� ROGRAM APPROVAL: Attest(Affix Seal) / ,, s A. Koleski,l By: tii WELD COUN PART . sitioliixffile the Boardr ox De puty Clerk to B • JO S. PICKLE. M.S.E.H. DIRECTOR APPROVALS: `t ATTORNEY GENERAL c ac,> 5, STATE G:,. ROLLER ART 1 L eI\RNHART v By: _ B 0 K Salazar L. Barnhart Page 19 of 19 Pages Attachment A TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT Cstorado Department of Public Health and Environment 4300Plenty 3� Drive South TrOanarbala ControlDenver,Colorado 80246-1530 • (303)692-2679 Phone (303)782-0338 Fax PATIENT INFORMATION Nun= Date of Birth Country of Birth Month Year A Address I—I Arrived❑ USA ff City: Zig: 0 Canada,Japan,Western Europe. Australia,New Zealand Refugee: Home Phone: County of 0 Mexico.Central or South America ❑Yes Work Phone: Residence f 0 Afriq,Middle East ❑ No Sex: Race 0 China,India,Central or 0 Unknown ❑Male ❑White Ethnic Orign Southeast Asia,Indonesia. Female 0 Black ❑ Eastern Europe,Russia,Ukraine Alien Nurnberg ❑ ❑ Hispanic ❑American Indian/ ❑ Non-Hispanic 0 Unknown Lenght of residence Alaskan Native Marital Status ❑Asian/Pacific Island 0 Unknown in Colorado ❑Unknown AGENCY SUBMITTING THIS REPORT Agency County Agency*Name: I_ Agency's Address: Zip: Phone: _ Name of Patient's Primary Care Physician: Addrest : Phone:Cttr MOST RECENT SKIN TEST Type: Results: Induration Previous If positive,is this a skin test mm Positive PM) conversion negative to positive ❑Mantow Tubarsd ❑ Negative 0 Yes within 2 years: ❑The etatt,Aptsol ❑ t Done Date PPD Read 0 No ❑Yes ❑ 0 Not f f 0 No ❑Other(spry) 0 UNaowm Date of last 0 Unknown ❑Other(apeecify) negative test X-RAY FINDINGS Date of X-ray Previous Status X-ray taken by:(Agenneys Name): Indngs: AbnonnalX-ray 0 stable _II _II 0 Worsening Rehm X-ray to: X-ray results: Abnormality 0 Improving . ❑No 0 Cavtary 0 Unknown ❑Abnormal 0 Noncavitary Consistent wiTB ❑Not Done 0 Noncavtary Not Consistent wITS Note:CDPffE will separately attain x-ray ❑Unknown ❑Other(Sprxdy) findings and recommendations CLINICAL Date of Onset of special Conditions: symptoms: Symptoms: O Pregnant EDC: ❑None 0 Fever I I 0 Postpartum Breast Feeding ❑Pmduclive Cough 0 Night Sweats 0 PostpOther rtum Breast ❑Memoplysis ❑Other(Spe'dfy) p weight toss Date: _ Plante of Person completing:__, Comment= TB-17 02195 ratan Name: irate or roam: Att CtIjlelht A Occuradon Yes No Yes No 0 Heath Core Worker 0 0 Homeless within past year 0 0 Diabetes ❑Correctional Employee ❑ 0 Resident of Correction Facility ❑ 0 Ukases ❑tignaary Ariantual Worker at time of Diagnosis 0 0 CanoerlMaipraaes ❑Hot Employed within past 24 months H Yes, 0 0 Imnonsuppressive Therapy ❑Unknown 0 0 Federal Prison ❑ ❑ Gasbedomy ❑Other Occupation(specify) 0 0 State Prison 0 0 Hepatitis O 0 Local Jail 0 0 Kidney Failure O 0 Juvenile How many other persons in household 0 0 Other Yes No besides patient? ❑U 01-3 ❑4+ 0 0 unknown ❑ 0 Exposed to TB 0 0 Previous Diagnosis of TB Yes No Date: / / On Me6ntions that may have interactions with anti-TB drugs? ❑ ❑ Resident of Long Term Care ❑ ❑ BCG vaccination ❑Yes 0 No Specify Facility at time of Diagnosis? Date: //_ If Yes, ❑ ❑ Nursing Home Yes No Yes No ❑ 0 Hospital ❑ 0 Prior NW Test 0 0 Residential - Date: / /_ ❑ 0 Injectingcsi a Al Use 0 0 Mental Health If yes,Where(Site/Provider ❑ 0 Excessive ng Inaohol Abuse 0 0 Alcohol or Drug Treament ❑ 0 Non-injecting tficit Drug Use ❑ 0 Other Pos Neg ❑ ❑ Unknown ❑ ❑ Result - TB FOLLOW-UP Cotrlinned diagnosis of TB? 0 Yes 0 No 0 Suspect Is patient in Insolation or in need of Isoationlquarantine? Kconfrmed list primary site: 0 Yes 0 No Secondary site: if yes.describe: Was a contact investigation initiated: 0 Yes o No Hospital Admission: If yes,is a Contact Investigation form needed? 0 Yes 0 No Hospital: Date sent / /_ By whom?: Admission Diagnosis: Date // LABORATORY SMEAR CULTURE LAST POSITIVE Laboratory Submitted to Pos Neg Not Done Pos Neg Not Done 0 Colorado Department of Pubic Health and Envkome ❑Sprrhrn 0 0 0 0 0 0 Date:—/f ❑Other Laboratory(specify) ❑Urine ❑ ❑ - ❑ ❑ ❑ ❑ Date_/I ❑Gestic ❑ ❑ ❑ ❑ ❑ ❑ Oats // ❑Other 0 0 0 0 ❑ ❑ Data_I I Date:I/. . TREAT ENT SOURCE INFORAMTION ❑Current Person Who Exposed this Patient ❑Past 0 Completed full course Name: ❑Started but rid not complete full course Address: ❑Unknown If completed OA course may:. State: tip Phone:_!I Iftreated in the past was this for. 0 Active Disease Closeness of Source to Case: Source Sputum results: 0 Preventive Therapy 0 Household 0 MTB Culture Positive ce 0 AFB Smear Positive DOT By: 0 Other ❑ Smear and Culture Negative Drug Regimen:(Mark at that apply) Date Started 0 0 Unknown 0 unknown Isoth S _mg I /—/— Laboatory 5-6 __mg Riampin mg / / Pyrazinamide mg // Elham butol __mg _,J__/..._ »h _rip I / a hlonamide _mg // Other(specify) Attachment B PATIENT FOLLOW-UP INFORMATION AND TRANSFER FORM (TB-10) ( ) Fa your kdotttvdof ( ) Reply tegtMsud TO: FROM: • Patients Name: SEX Marital Status Address: M F SMWDSep W D Sep City,State,Zip Birthdate / / Race Phone Number. County: .** ACTIVE CASE; YES_ NO_ Confined by Lab or PCP dtagnosisr YES_NO_ If yes,date of diagnosis: / / Date of TBC skin test_1 .1_ Rosati?'MM: Form: Pulmonary Extra Pulmonary(specify site)— Suspect_ LATEST BACTERIOLOt31CAL STATUS: Not Done Nat Ronan mes m adVals Mod Arm Cuba RoduLIMM Cos Lest Podia taearay t.ss sperma :min tiro. Cat oaa(sv.wstu> DRUGS: if patient on drug therapy Medications and dosage Date started:_�1— Date stopped:._I 1_ Number of weeks on DOT: If patent NOT on drug therapy,give reason: Most recent X-ray resuttsflate(s) Previous Hospltsllzatlon ix TB:When. —Whi ` Primary Caro Provider._ _Phone t• R a YES__ NO Medications end dosage Date of Skin teak / I— Date started; / I Date stopped medications:.�_I Reason stopped: Medication given by whom RELOCATION INFORWAIIOt Date of relocation: If patient has moved or relocated.W's"provide new address and phone number. Colorado Department of Public Health and Environment Name of Person completing the tonal Date 4300 Cherry Creek IDrive South / l, DCEED-TB-A3 Te tt>titw4 ►tE Denver,Cotoratlo 80222-1530 303-692-2679 Attachment C ratNM'a Name: r..11 I a 1 I REPORT OF VERIFIED CASE 0.4.00 OF TUBERCULOSIS Steal Address: ...zi.c...l (Id Nr.illrrl.Car.alal1 _.. U.S.DEPARTMENT OF HEALTH a HUMAN SERVICES ajC PUBLIC HEALTH SERVICE CENTERS FOR PREVENTION CONTROL �yEPORT OF VERIFIED CASE OF TUBERCULOSIS � UBLICHEALT SERVICE ATLANTA,GEORGIA 30133 FORM APPEOVtO OM NO.Mean a Eq.Isola III.3 wwaw,rls Initial Drug Susceptibility Report (Follow Up Report — 1)�SOUNDEX te Reporting: Year State Case C ❑❑ ❑ Counted: Number: JI Specify: 1� City/County i I I Alpha State Code Case Number: I J , \.___ ] Submit this report for all culture-positive cases. X N. 33. Initial Drug Susceptibility Results: Was Drug Susceptibility Testinci Done: o❑No I❑ Yes 9❑Unknown If answer is No or Unknown, do not complete rest of report. Yr If Yes. I I t l Enter Date First Isolate Collected for Which Drug Susceptibility Was Done? 34. Susceptibility Results: Unknown Resistant Susceptible Net Mine Isoniazid I❑ 2❑ 3 9 Rifampin 1❑ 2 E 3 9 Pyrazinamide i❑ 2 3 9 Ethambutol I❑ 2❑ 3 °❑ Streptomycin 1 2❑ 3 9 Ethionamide 1 2❑ 3❑ °❑ Kanamycin I❑ 20 3❑ e❑ Cycloserine I❑ 2❑ 3❑ °❑ CapreOmycin I❑ 20 3❑ .0 Para-Amino 1❑ 20 a0 e❑ Salicylic:Acid Amikacin ID 2❑ 30 °❑ Rlfabutine I❑ 2❑ 3❑ °❑ Ciprofloxacin I❑ 29 3❑ °❑ Ofloxacin t❑ 2❑ 3 9❑ Other 1❑ 20 3❑ 9❑ Comments \ .. _I_J Itrir.tW. penrn.. kolco 4 or'lFeN+rir wrn Candid selG s2 IM Mid«ant ririolr—Imsd Gan aa asmaan suppnot w as rat llr*WOW< COC nut REV 1242 tat Copy—Slate REPORT OF VERIFIED CASE OF 111BERCULOSIS Follow Up Asp*- Attachment C •stsaro Name: (rang M I REPORT OF VERIFIED CASE (teen OF TUBERCULOSIS Street Address: Zip Coal mee. er.Street.CRT.item .. .. U.S.DEPARTMENT OF HEALTH&HUMAN SERVICES a •MID PREVENTION HEALTH SERVICE .i�a.i �F �� .a �.a r.1f CENTERS FOR DISEASE CONTROL ��ilel:i�ale�'l�i:it/r a • �l`1��1:t$iJtSl�la�� ATLANTA.GEORGIA(CDC) eeemeweeyeNmeea Foam APPROVIEO ome NO-leaNxe ay.Oa tires oeweee,ts Case Completion Report (Follow Up Report - 2) SOUNDEX State Reporting: Year State Case C ❑ ❑ Counted: Number: Specify: r City/County Er f I L , ] Alpha Stale Code I 1 Case Number: N If Yes,Dale Specimen Collected If Yes. Date Specimen Collected on 35. Con Documented:o( on Initial Positive Sputum Culture: First Consistently Negative Culture: Conversion Mo. _o� Yr. Mo. Da Yr. rill o❑No 1❑Yes a❑unknown I 36. Date Therapy Stopped: 37. Reason Therapy Stopped: Yr. ILJ Ili t D Completed Therapy 3D Lost s❑ Not TB �❑ Uncooperative or Refused 7❑Other ITI 2❑ Moved a❑ Died a❑Unknown 38. Type of Health Care Provider: 39. Directly Observed Therapy: It Yes,Give Site(s)of Directly Observed Therapy: t❑Health Department 0 No,Totally Sell-Administered 1❑ In Clinic or Other Facility 2 Private/Other I❑ Yes,Totally Directly Observed 2D 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 Weeks 9❑ Unknown 9 Unknown Number of Weeks of Directly Observed Therapy: 40. Final Drug Susceptibility Results: If Yes,Enter Date Final Isolate Collected for Which Drug Mo. Day Yr. Was Follow-up Drug Susceptibility Testing Done? o❑No I❑Yes 9 Unk' Susceptibility Was Done: II—Ill-�-II If answer Is No or Unknown, do not complete rest of report. 41. Final Susceptibility Beabtant Fettelagible RID= ilgym Builgail Std Mf&ic Wiens Results: Isoniazld I❑ 2❑ a❑ s❑ Capreomycin I❑ 2❑ 3D eD o❑ Para-Amino e❑ a❑ a o❑ Rifampin I❑ 2❑ a❑ Salicylic Acid Pyrazinamide 1❑ 2 3D s❑ Amikacin I❑ z❑ 3 o❑ Ethambutol iD 2 a❑ o❑ Rilabutlne I❑ 2❑ a❑ s Streptomycin I❑ 2❑ 3 s❑ Ciprofloxacin I❑ 2D 3 a❑ Ethionamide I❑ 2 3❑ a❑ Ofloxacin 1❑ 2 3 s❑ Kanatnycin i❑ 2❑ 3D a Other I❑ 2 3D a❑ Cycloserine t❑ 2❑ 3❑ a❑ Comments: N [— hill eey Wetlen ms MMMer/w epuma esm len al ami MweFWeeWerNMeelier2 U.S.C.Me�et beINNS Ott swearce.me be teed seller emMmelaWaeea&CM ml le Seemed r* COCT2SC REV 1242 1st Copy-State REPORT OF VERIFIED CASE Or TAWERC*A.OSIS Feb.a tip Repmt-2 Attachment C _%. OCCUPATIONAL SUPPLEMENT OF VERIFIED CASE OF (el ►atbM'e Names (fMiu (M 1.1 I4n1 Street Address: rw ? IV cm.) rc: inv ..suss Car.Maul U.S.DEPARTMENT OF HEALTH£HUMAN RIVES SUPPLEMENT TO THE REPORT OF CEMEIIs fOuCNEtHSE *E VERIFIED CASE OF TUBERCULOSIS (TB) Ae1O ATLANTA.* *03tgo;a aeaewewaae.rro Mitt APPROVED ONO Na esaablt Eg AM HIos wae,reee .. Site ID: Month-Year Reported: State Reporting: State Cue IIII Me, Yr. Specify: NCItountyumber. I 111Alpha State Code [ [ case Number: I l l l L 1 I.Wes this person employed at the time he/she was diagnosed with TB? 2.What was the reason the person was not employed?(Theck only one.) (Mat('yes'if the person had a job,even if he/she was temporarily not at work due to a reason such as illness or vacation.) i❑ Student 5❑Institutionalized(e.g.,Wing in prison.jail,nursing home.etc.) 2❑Retired 6❑Disabled by a physical,mental,or other health condition f❑Yes Of yes,skip to question 5.) a❑Homemaker 7❑Other(specify) o❑No t❑Unknown (If unknown,skip to question 3.) 40 unemployed 9❑UnMugwn 3.Ilea this person ever been employed, 4.What was the approximate'last date 5.Was this person on at the time of active veou y wi h the aimed stew evenfor days? this person was employed? a (/o. Darr. t❑Yes 0❑No 9❑Unknown I❑Yes 0❑No e❑Unknown m (IF NO OR UNKNOWN,STOP'HERE.) 1 7.ax What tkin: For questions 6 and 7,describe this person's chief job activity i r business. 0 ion s� a. kind of work was this person doing? I If this person was not working at the time of diagnosis,q - _ describehisther the t recent one at w�lrktr he/she workedthe or business.If this ost hoursson had . 7. than one job, (e.g., registered nurse.personnel manager.supervisor of abler department, gasoline engine assembler,cake cm,etc.) 6.Industry: a.What kind of business or Industry did this person work fort b..What were Nis person's most Important activities or duties? (Describe the activity at location where enrpk./4d.) (e.g., patient are,aNec9rg hiring policies.supervising order decks, Of-11,enginelanufatpenPubfialhfg�mall etc) assembling assembling engkies,icing cakes, etc.) silo engine manufacturing,read,Wkery.e1G) 9.In addition to the job described in questions 6 and 7,has this person IL Was the person— (Check ONE) ever wonted(for pay or as a vohmtier)or tved in any of thefotorly 1❑ employee of a PRIVATE FOR PROFIT company or business or fib?(Check all that apply.t not*Needy desabed in of an Yrdvldtd for wages,alderycr commissions questions 6 and 74 YES NO IN/u. SO employee of■PRIVATE-IOT•FOR-PROFIT,taexem (,or t❑ o❑ e❑ chartable organization II Nhasinq home ----'--...---....._..__._..__.,_. t❑ local GOVERNMENT employee(city,county,etc.) b. Hoopla-------___.--......_-._-- __ l o❑ t❑ a❑ sate GOVERNMENT enpkiyee c. Hospice.-.....-..._.__..._..._.............-............ 1❑ o❑ 9❑ f❑ o❑ SO 6❑ federal GOVERNMENT anmlt9Yee t❑ o❑ 9❑ sit SELF-EMPLOYED in own HOT INCORPORATED business, • e. Doctor's office— professional practice,or farm I. Ambulance service-.._- t❑ o❑ e❑ TO SELF-EMPLOYED hi own INCORPORATED business, • g. Volunteer organization providing seMce (❑ o❑ 9p professional practice,or arm primarily to oS patientst❑ 0❑ e❑ 'e❑ wading WITHOUT PAY lo Ian*business or farm h. Center tor alcohol or drug abuse Yeaonent.._. _ _.. _ i. Shelter for homeless persons t❑ 0❑ e❑ front ALL sources In the -t❑ -o❑ _9❑ . 1 .smcg was this person'shetotalyear household IncomeJ. "Fhxherd tonne _..._._._........_-....._..........._._. *slender year peter to the year of diagnosis? t❑ o❑ e❑ ?For inert.t to person It Mend.rah s glvebe5,=about. C .k -Morgue -..--------•--' — ID 1O e❑ e❑ 'i Ma'H tom M�a.tdcmg wages r eflysWeMe? tit*Income• : L prawn or al --. ._..- • aetudly ayww�and gevenanida ueblaunoe.t net Income m. Parole or probation office _._._.._. .____.....— t❑ o❑ e❑ awes' low abovette dote rhwud.) I � UMW ANNUAL • e❑Nona Oa $ ' IN YOWts ♦' ' . -' . .. ,IE Mz1I;.AeaaO aware.away eaat Y e°1-Oee• ?rust=red.saes.• ?lase Aramaic dwafaY eeeeaterrallt leidrh YaaeeeeS atS porn, ?year areeaeeaw______eewR r^abV er" halae a�a�Y�e bFlB Mira TAerr' rare lama cIteesr ag.t It 0..t rreMe94aetw 0C100al.rid WMpae a NereeeiminO k1 lYddst Pied Wallet%0(:10693. oa�a ATMNei'Wall a aetoi s3. ,wrw We 1N1 'at 3.w rs Ha ..sun aid wa miss feaeu aYaarnaraeW wK4reMtlrwwYpraatle't'°ea°eMry�M��4rl YelwrsaeMeaeraa�rrree MridlM M l+Yh altlwlarwwwa its mud, MMarewwarwe Wauea '?Carddrrrw.aweaer M.tlrlarmerwe.r.adwtaaeMa13.e nl6elW3.rsate. a_YSA191bre .-. r__..<•.... OOOI1rAt101VLa1RlIHa3/rlOnEldOmr OF VOWED GVEOF T3. rep to Attachment C OCCUPATIONAL VEi SuPPLIFX EMENT OFF%IO)i.thr!r.- rut NTrF rE P5 SRI LDi IRSNSL.rTTEO TO CDC Is 11.14as anyone in this person's house hold,whether or hehhe Is Sated 12.Has this P not erson ever lived outside the United States? Is this person,ever had active TB?Ys same brother,slater.son. I❑Yas *O No 9❑Unknown dstyhter,or my other person WtIW �D�' M yes, sP9ua courtly telte 10 Yes 0❑No 9❑Unknown re person the most lime.:14.M the described in questions 6 and 7, It How much school has this person COMPLETED?completed r (Check iy does(did)this person work M a health-related for the highest level or grade already axnpieted or degree received.) occupation?(such as a nurse's aide or physician Os❑ Associate degree in college or in a job in a health-care organization or facility 01 O No grades completed Oa a clinical laboratory.) 02 Q Elementary or junior high school 07❑ Bachelors degree n college(e.g.BA or BS) se❑ Masters degree(e.g.,MA,MS,MEEng,MEd, l❑ Yes 0[.3 No 9❑ Unknown 030 Some high school,no diploma MSW,MBA) graduate h5Plamhe a equivalent) (IF NO OR UNKNOWN, STOP HERE.) 040 High school pig❑ Degree above Masters level(e.g..MD,PhD. os❑ Some college,no degree 00s,OW,LLB,JO) Ni. Ymen responding to questions 15 through 23,please refer to the current or most recent job this person has held in a health-care Health-Care Worker Questionnaire organization,lacaty,dMkat ttberat01Y.or in a twalhrelawd occupation.This job 9hald be she same Pb desalted in questions 6 and 7. 16.What type of facility was the place 17•Mproximatel how many i patien t beds l/6.Who was the location W the workptare? where the person worked? were in the ffty where tie person worked? City-.— 1❑Federal 1❑No inpatient beds 5❑300.399 beds County: — State: 2❑City(municipal),county,or state 2❑ 1-99 beds 6❑400-499 beds 30 Private 3❑ 100-199 tens 79 2500 beds Was the job with M city knits? 40 200-299 beds 9❑Unknown 1❑Yes O❑N No 9❑Unknown 90 Unknown ------------- 16-Whet was the approximate Wit the person terminated 20.Where in the facility did this person primary work? (Check only ONE) gran when thedma at the tadtittrt began of diagnosints, prior to the date of diagnosis,what was the o1❑ Admitting orrice tz❑ Operating or recovery room approximate date hehhe 130 Outpatient clinic stopped working at this facility? p2 Q Business offices Moe Yr. Mo. Yr. od❑ Emergency room 14 Pathology/arnopsy I 1 O4 Facility-wide is Pediatric ward 05❑ Intensive-care unit 16❑ Psychiatric ward 90 Unknown i❑Currently work here ix Laboratory 17 Respiratory therapy e Unknown m❑ Laundry 1e❑ Surgical ward -------- 080 Medical ward 19❑ Other(sPedfY) 21.OId this person usually work M a location where patients with to❑ Multiple wards or services Wive 761re0elhred do or semen(eq.,a man,wail.or clinic)? II❑ obstelicsyy teroh00y wain 00 Q Unknown i D Yes o❑No e Q Unknown t \ Ii of lash,dined'a9 activities that the person pedamed as a routine pal al this job.) r�Job Activities: (For the following YES NO UNK. YES NO UNK. h.Processed laboratory specimens Mx _ 1❑ 00 9❑ t❑ 0❑ ID n ei1i1(AFB)anew r culture...............__. a. Ticked fed patients_—•—__._each_. I. PManned or assisted with autopsy with1❑ 0❑ 9❑ b. Conducted one-on-one patient teaching or - ........ t❑ 0❑ 9❑ t 0❑ 9❑ oanselaq-___, _...._.__.....__._. j. Pedonnted«assisted with brorhdh05009Y ----- 1❑ O❑ e❑ k. Performed or assisted with endotradte9i d. Gave klxkons ant skis tests I D 0❑ e❑ htobation or suctioning 1❑ 0❑ 9❑g ......_ tQ o❑ 9❑ I. Per e. or t❑ 00 9❑ e. Entered hpakerx males_.`__._' administered e«osokzed lions I. Assisted inpatients wilt acWlhes of daily Wing 1❑ 0❑ 9❑ (e.g.,bathing,changing dressings) g. Collected « for rttycduacNMal(�!Fe)_..._..._ I❑ 0❑ 9❑censertic. Nes this person ever had BOG vaccine Me vaccination egeMat TB)? Mo. Yr t❑Yes Date of Bea: C—r 0 No 9❑Unknown l Cessnartts: —_ - .---•.-^ ^_ To We ggVWTOF sow+--ew-FTB Pgefa. _...C,.,. OCaAAw«ML BU PLEmrs r s C n is .3 aI '8i „ a I 3 • s a a' s a ! I ' T So g la ; ' e .x ; 11 ai s • w1 g i� V 6 a < .s a a3 � i g1 i a t > Y V t o Q — 2 " r q 3 n .1 ' G 3 - A2 " 0 - E. e o;v '• " _z g q 7 z f z A _ 3 3 Got = p " . i g a s iI� o.. — : . S E . vac, o .. V < u se E a l Le 5• t itc. 3 aoi e. a 0 4 Zee. 3 $ • a c _ ='J=2 a g p '` : 3 t^ . 3 2 -B. F 1:t E $ 3 i8e a 2 12 ' a—c a0 4 G E. >J C ' ob r 4e -O.l aPPPaEi ` >, C/p s• � = < E s '22Rip � t3 ? di -- a 8 :2aawzz U >- " L u u - > 7 z a c • • Ni u " �' T V p e o � L " M - r� e " vwEo•3 g s }a',' o: • e • €S°> oa a oa e o _ • C, z .i Gz<zD 3 �C qq0 o o x " 3 a !; 2 8 e � 3 n s8 < o o E'1 3 a y ig. N NLa L, 0a11 a P _ 3 5 - S so 0 G G tr1E ">o o g $g o z r. r., 7h33a �-° ga p 6 '' " " — i t4ZZ w o.o—o Ce G r e �z<z u a op--.. A-- 3p a V 4 iuowgofl flr ! $) \ 3 d \' § . . %! e in to ) V - § r , - ' $) z , at ] © 21 . � § \ • } \ / I $) zS 2a ks,FA R§ ore § ® �4 g . 4-5 g & ! lu ` E ) 2 ka � -I | _ 0 !__ \ 2 _ - 0a] j \ 0 cl ....- C... \ C_ !0 Oa\ \ \ \ /\\ < § k\} § ]k3 j /\ \\ \\} 0 en A -1g ° % C \\ - < _ _ 0a & .. ? i < © .. V | tR 7 $ \ # ! tE S E 0CO 3 .. - Cl) k 2 c.2fae c VI -a o = .. ! } : $ \ \ W. Bk } S \ I Bk I . Bk ) B }J § zk3 a wa_o a ) \ \ § ) % ii d / t � , la 2 \ wi U 2 § , I r I- \ \ ElU / < § ; . % ° ii k k \ k Fal ® 4 E/ m g 3 HI H z a .2 \ m § \ ; / 0 0 get ] k 0 3 C 0 o k E. \ } z a i Q R ° u. . , ! ( 0 A { c & .. ( CO( © « — ) .0 / as C \ 44 / O \ / j \ F ) /] ) 2 » % O O § k � � 0 H § / -'4 $ 2 j / \ \ k Attachment G STATE OF COLORADO Bill Owens,Governor •' Jane E.Norton,Executive Director =: 1`• Dedicated to protecting and impoving the health and environment of the people of Colorado GI 4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division Denver,Colorado 80246-1530 8100 Lowry Blvd. Phone(303)692-2000 Denver CO 80220-6928 - Located in Glendale,Colorado (303)692-3090 Colorado Department of Public Health http://www.cdphestate.co.us :End Environment Date] Sample Contract Change Order Letter State Fiscal Year 19** - **. Contract Change Order Letter Number**• Contract Routing Number"*-***** Pursuant to paragraph**of the contract with contract routing number**- and contract encumbrance number ,(as amended by Contract Renewal Letter«*,contract routing number**-****• and/or Contract Change Order Letter e• contract routing number*!**••*,if any),hereinafter referred to as the"Original Contract"(a copy of which is attached hereto and by this reference incorporated herein and made a part hereof)between the State of Colorado, Department of Public Health and Environment and Contractor's Legal Name for the term from _ ** **** through **,•**'',the parties agree that the maximum amount payable by the State for the eligible services referenced in paragraph**of the Original Contract is increased/decreased by dollar amount DOLLARS ($*.**)for a new total financial obligation of the State of dollar amount DOLLARS($•.**). The revised work plan,which is attached hereto as"Attachment I",and the revised budget,which is attached hereto as"Attachment 2",are incorporated herein by this reference and made a part hereof. The first sentence in paragraph **of the Original Contract is hereby modified accordingly. All ether terms and conditions of the Original Contract are hereby reaffirmed. This amendment to the Original Contract 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 Contract Renewal Letter by********* ** **** to the attention of: _,Colorado Department of Public Heallth and Environment,4300 Cherry Creek Drive South,Denver,Colorado 80246,Mail Code: ***"--** One original of this Contract Renewal 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: CONTROLLER: PROGRAM: By: By: Arthur L. Barnhart Attachment H STATE OF COLORADO Bill Owens,Governor ' Jane E.Norton,Executive Director , Dedicated to and im the health and environment d the people of Colorado s• protecting proving G1 I . 4300 CherryCreek Dr.S. Laboratory and Radiation Services Division • Denver,Colorado 80246-1530 8100 Lowry Blvd. Phone(303)692-2000 Denver CO 80220-6928 Colorado Department Located in Glendale,Colorado (303)692-3090 of Public Health http:gwww.cdphestate.co.us and Environment [Date! State Fiscal Year 19** - **, Contract Renewal Letter Number "*, Contract Routing Number **-***** Pursuant to paragraph ** of the contract with contract routing number **-*****and contract encumbrance number ,(as amended by Change Order Letter **,contract routing number**-*****,and/or Contract Renewal Letter! ,contract routing number **--***** if any), hereinafter referred to as the"Original Contract"(a copy of which is attached hereto and by this reference 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 Contract is increased/decreased by dollar amount DOLLARS, ($*.**) for a new total financial obligation of the State of dollar amount DOLLARS($*.**). The revised work plan,which is attached hereto as"Attachment 1", and the revised budget,which is attached hereto as"Attachment 2", are incorporated herein by this reference and made a part hereof. The first sentence in paragraph **of the Original Contract is hereby modified accordingly. All other terms and conditions of the Original Contract are hereby reaffirmed. This amendment to the Original Contract is intended to be effecl.ive 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 Contract Renewal Letter by ********* **, ****•to the attention of: ************ Mail Code: ****h ** Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver,Colorado 80246-1530 Attachment H One original of this Contract Renewal 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: PROGRAM: By: APPROVALS: L. A. Koleski,Jr. CONTROLLER By: Arthur Barnhart • b COLORADO MEMORANDUM TO: Dale K. Hall, Chairman, Board of County Commissioners FROM: John S. Pickle, Director, Department of Bu tic Health and Environment . .-/l` ' � iCa SUBJECT: TB Outreach and Control Contract DATE: August 10, 1999 Enclosed for Board review and approval is a contract between Weld County Department of Public Health and Environment (WCDPHE) and the Colorado Department of Public Health and Environment for the TB Outreach and Control Program. Under the provisions of this contract, WCDPHE will provide active TB treatment, TB preventive treatment, provide for and interpret chest x-rays and other medical evaluation services, conduct contact investigations and TB skin test screening programs. WCDPHE will also follow-up with active patients to ensure they receive appropriate information and education and that they adhere to the completion of their TB therapy. For these services, the Health Department will receive an amount not to exceed $20,522 for the period July 1, 1999 through December 31, 1999. I recommend your approval of this contract. Enc. cc ;_G t,. Hello