HomeMy WebLinkAbout20173877.tiffMEMORANDUM
DATE: September 18, 2020
FROM: Clerk to the Board's Office
SUBJECT: Tyler Document #2017-3877
TO: Department of Public Health and Environment7,et„e,e,/f/%� 1/%5*
Final signatures were not obtained by the parties required to fully execute Tyler
Document #2017-3877, approved by the Weld County Board of Commissioners on November 15,
2017. Due to the prolonged delay in obtaining final signatures, the Clerk to the Board's Office has
deemed it prudent to close this item out. This memorandum will be added to the Commissioners'
files to demonstrate this document was not fully executed.
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t-4LOO9
RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR WOMEN'S WELLNESS CONNECTION
CLINICAL SERVICES AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Task Order Contract for Women's
Wellness Connection Clinical Services between the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld County, on behalf of the Department of
Public Health and Environment, and the Colorado Department of Public Health and Environment,
commencing January 1, 2018 and ending June 29, 2019, with further terms and conditions being
as stated in said task order contract, and
WHEREAS, after review, the Board deems it advisable to approve said task order
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 Task Order Contract for Women's Wellness Connection Clinical
Services between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Public Health and Environment,
and the Colorado Department of Public Health and Environment be and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said task order contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 15th day of November, A.D., 2017.
BOARD OF COUNTY COMMISSIONERS
WELD COJdNTY, COLOJ ADO
ATTEST: ditto) jelto; ok
Weld County Clerk to the Board
BY: O G
uty Clerk to the Board
APPROVED
y Attorney
Date of signature: t` / 17
Julie A. Cozad, Chair
Steve Moreno, Pro-Tem
arbara Kirkmeyer
P c7
cc: HL(re)
09 /2x/20
2017-3877
HL0049
Memorandum
TO: Julie A. Cozad, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH
Executive Director
Department of Public Health & Environment
DATE: November 13, 2017
SUBJECT: Women's' Wellness Connection Clinical
Services Task Order Contract
For the Board's approval is a Task Order Contract between Colorado Department of Public Health
and Environment and the Board of County Commissioners for the County of Weld, State of
Colorado, on behalf of the Weld County Department of Public Health and Environment
("WCDPHE") for the Women's Wellness Connection (WWC) program,
The WWC program provides low-income, uninsured and underserved women capable of
demonstrating lawful presence in Colorado access to timely, high quality screening and
diagnostic services to detect breast and/or cervical cancer at the earliest stages. Detecting breast
and cervical cancer early, while it is still treatable, is much more cost effective than treating
cancer,
This contract will provide funding in the amount of $80,164.00 and shall be effective January 1,
2018, through June 29, 2019. Of this amount, $73,514.00 is attributable to funding from the state
and $ 6,650.00 is attributable to federal funding,
This contract was approved for placement on the Board's agenda via pass -around dated
November 9, 2017. I recommend approval of this task order contract with CDPHE for the WWC
program.
DEPARTMENT OF PUBLIC HEALTH AND
ENVIRONMENT
CMS R( )UTING NO. 18 FHI--1 104208
APPROVED TASK ORDER CONTRACT - WAIVER #154
This task order contract is issued pursuant to master contract made on 11/23/2016, with routing number 18 FAA 00051.
STATE:
State of Colorado for the use & benefit of the
Department of Public Health and Environment
Prevention Services Division
Women's Wellness Connection
4300 Cherry Creek Drive South A4
Denver, Colorado 80246
CONTRACT MADE DATE: 9/27/2017
CORE ENCIJMBRANCE NUMBER.
CT FAAAFHLA201800001758
TERM:
This contract shall be effective upon approval by
the State Controller, or designee, or on 01/01/2018,
whichever is later. The contract shall end on 06/29/2019.
PROCUREMENT METHOD:
RFA 6342
BID/RFP/LIST PRICE AGREEMENT NUMBER:
Not Applicable
LAW SPECIFIED VENDOR STATUTE:
Not Applicable
STATE REPRESENTATIVE:
Contracts Monitor
Cancer Prevention and Early Detection Program
Prevention Services Division
4300 Cherry Creek Drive South
Denver, Colorado 80246
CONTRACTOR:
Board of County Commissioners of Weld County
1150 O Street, Greeley, Colorado 8063 1
for the use and benefit of the
Weld County Department of Public Health and Environment
1555 North 17th Avenue, Greeley, Colorado 80631
CONTRACTOR DUNS: 075757955
CONTRACTOR ENTITY TYPE
Political Subdivision
BILLING STATEMENTS RECEIVED
Monthly
Colorado
STATUTORY ALTHORITY: Colorado Revised Statutes §24-22-
117 (2013); §25-4-1501-1505 (2016); §24-76.5-101-103
(2016)
CLASSIFICATION Subrecipient
CONTRACT PRICE NOT TO EXCEED. $80,164.00
FEDERAL FUNDING DOLLARS: $6,650.00
STATE FUNDING DOLLARS. $73,514.00
OTHER FUNDING DOLLARS. $0.00
Specify "Other' Not Applicable
MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR
FY 18: $80,164.00
PRICE STRUCTURE Cost Reimbursement
CONTRACTOR REPRESENTATIVE
Mark Wallace
Executive Director
1555 North I7th Avenue
Greeley, Colorado 80631
PROJECT DESCRIPTION.
This project serves to implement strategies to address cancer prevention and early detection at one or more levels of the socio-ecological
framework, depending on the needs of the underserved population served by and living within the service area
I 8FHLA 104208_TO ver 30.9.17
Page I of 6
o2 / 7- 31776)
EXHIBITS
The following exhibits are hereby incorporated:
Exhibit A -
Exhibit B -
Exhibit C -
Exhibit D -
Exhibit E -
Additional Provisions (and any of its Attachments; e.g., A -I, A-2, etc.)
Statement of Work (and any of its Attachments; e.g., B -1, B-2, etc.)
Budget (and any of its Attachments; e.g., C-1, C-2, etc.)
Grant Funding Change Letter
Option Letter
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses, the more specific provision shall control.
I . This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including any
renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall be
performed according to the standards, terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(l ), C.R.S., as amended, this Task Order Contract is not valid until it has
been approved by the State Controller, or an authorized delegee thereof. The Contractor is not authorized to,
and shall not; commence performance under this Task Order Contract until this Task Order Contract has been
approved by the State Controller or delegee. The State shall have no financial obligation to the Contractor
whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effective
date of this Task Order Contract. If the State Controller approves this Task Order Contract on or before its
proposed effective date, then the Contractor shall commence performance under this Task Order Contract on
the proposed effective date. If the State Controller approves this Task Order Contract after its proposed
effective date, then the Contractor shall only commence performance under this Task Order Contract on that
later date. The initial term of this Task Order Contract shall continue through and including the date specified
on page one of this Task Order Contract, unless sooner terminated by the parties pursuant to the terms and
conditions of this Task Order Contract and/or the Master Contract. Contractor's commencement of
performance under this Task Order Contract shall be deemed acceptance of the terms and conditions of this
Task Order Contract.
3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made a
part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task Order
Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated, the terms of
this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event of conflicts or
inconsistencies between the Master Contract and this Task Order Contract (including its exhibits and/or
attachments), or between this Task Order Contract and its exhibits and/or attachments, such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the
Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its
exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 4) the
Page 2 of 6
I 8FHLA104208_TO ver 30.9. 17
Additional Provisions - Exhibit A, and its attachments if included, to this Task Order Contract; 5) the
Scope/Statement of Work - Exhibit B, and its attachments if included, to this Task Order Contract; 6) other
exhibits/attachments to this Task Order Contract in their order of appearance.
4. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order
Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the
Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and
attached hereto as "Exhibit B" and "Exhibit C".
5. The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend the
term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or
decrease the amount payable under this Task Order Contract, or add to, delete from, and/or modify this Task
Order Contract's Statement of Work through a contract amendment. To be effective, the amendment must be
signed by the State and the Contractor, and be approved by the State Controller or an authorized delegate
thereof. This contract is subject to such modifications as may be required by changes in Federal or State law,
or their implementing regulations. Any such required modification shall automatically be incorporated into and
be part of this Task Order Contract on the effective date of such cchange as if fully set forth herein.
6. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum
standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's
Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope/Statement of Work - Exhibit
B, establishes or creates standards of performance greater than those set forth in the RFP, then the Contractor
shall also meet those standards of performance under this Task Order Contract.
7. STATEWIDE CONTRACT MANAGEMENT SYSTEM [This section shall apply when the Effective Date
is on or after July 1, 2009 and the maximum amount payable to Contractor hereunder is $100,000 or higher]
By entering into this Task Order Contract, Contractor agrees to be governed, and to abide, by the provisions of
CRS §24-102-205, §24-102-206, §24-103-601, §24-103.5-101 and §24-I05-102 concerning the monitoring of
vendor performance on state contracts and inclusion of contract performance information in a statewide
contract management system.
Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order
Contract, State law, including CRS §24-103.5-101, and State Fiscal Rules, Policies and Guidance. Evaluation
of Contractor's performance shall be part of the normal contract administration process and Contractor's
performance will be systematically recorded in the statewide Contract Management System. Areas of review
shall include, but shall not be limited to quality, cost and timeliness. Collection of information relevant to the
performance of Contractor's obligations under this Task Order Contract shall be determined by the specific
requirements of such obligations and shall include factors tailored to match the requirements of the Statement
of Project of this Task Order Contract. Such performance information shall be entered into the statewide
Contract Management System at intervals established in the Statement of Project and a final review and rating
shall be rendered within 30 days of the end of the Task Order Contract term. Contractor shall be notified
following each performance and shall address or correct any identified problem in a timely manner and
maintain work progress.
Should the final performance evaluation determine that Contractor demonstrated a gross failure to meet the
performance measures established under the Statement of Project, the Executive Director of the Colorado
Department of Personnel and Administration (Executive Director), upon request by the Colorado Department
of Public Health and Environment and showing of good cause, may debar Contractor and
18FHLA I0420S_TO ver 30.9.1'7
Page 3 of 6
prohibit Contractor from bidding on future contracts. Contractor may contest the final evaluation and result by:
(i) filing rebuttal statements, which may result in either removal or correction of the evaluation (CRS §24-105-
102(6)), or (ii) under CRS §24-105-102(6), exercising the debarment protest and appeal rights provided in
CRS §§24-109-106, 107, 20l or 202, which may result in the reversal of the debarment and reinstatement of
Contractor, by the Executive Director, upon showing of good cause.
8. If this Contract involves federal funds or compliance is otherwise federally mandated, the Contractor and its
agent(s) shall at all times during the term of this contract strictly adhere to all applicable federal laws, state
laws, Executive Orders and implementing regulations as they currently exist and may hereafter be amended.
Without limitation, these federal laws and regulations include the Federal Funding Accountability and
Transparency Act of 2006 (Public Law 109-282), as amended by §6062 of Public Law 110-252, including
without limitation all data reporting requirements required there under. This Act is also referred to as FFATA.
I8FHLA 104208_Td ver 30.9.17
Page 4 of 6
SIGNATURE PAGE
Contract Routing \umber: 18 FHL \ 104208
THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT
Fach person signing this Contract represents and warrants that he or she is duly authorized to execute this Contract and to bind the party authorizing his or her
signature.
By:
CONTRACTOR
Board of County Commissioners of Weld County
for the use and benefit of the
Weld County
Department of Public Health and Environment
(a political subdivision of the state of Colorado)
Julie A. Cozad
Print Name of Aothoriorl Tndiyidual
STATE OF COLORADO
John W. Hickenlooper, Governor
Colorado Department of Public Health and
Environment
Larry Wolk, MD, MSPH, Executive Director and
Chief Medical Officer
Chair
By:
Pratt Title qf� u rized En. vidual Lisa McGovern
11 Purchasing and Contracting Section Director. CDPHE
Signature of Aut ed I dividual
NOV 15 2017
Date Date
PROGRAM APPROVAL
Colorado Department of Public Health and Environment
Signature of Authorized CDPHE Program Approver
Date
In accordance with §24-30-202 C.R.S., this Contract is not valid until signed and dated below by the State Controller or an
authorized delegate.
By:
STATE CONTROLLER
Robert Jaros, CPA, MBA, JD
CDPHE Delegate
Effective Date:
I8FH1.A 104208_TU ver 30.9.17
Page 5 of 6
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Page 6 of 6
I 8FHLA I04?08_TO ver 30.9.17
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 09/27/2017 CMS Task Order Routing Number 18 FHLA 104208
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified
above.
1. This Task Order Contract contains federal and state funds (see Catalog of Federal Domestic Assistance
(CFDA) numbers 93.898 and 93.800).
2. The United States Department of Health and Human Services ("USDHHS"), through the Centers for
Disease Control and Prevention ("CDC") has awarded as of 07/20/2017 anticipated federal funds of
$3,476,055.00 under Notice of Cooperative Agreement Award, hereinafter "NCAA", number 1
NU58DP006347-01-00, to perform the following — Colorado Cancer Prevention and Control.
The United States Department of Health and Human Services ("USDHHS"), through the Centers for
Disease Control and Prevention ("CDC") has awarded as of 06/26/2017 anticipated federal funds of
$2,191,193.00 under Notice of Cooperative Agreement Award, hereinafter "NCAA", number 5
NU58DP006082-03-00, to perform the following — Organized Approaches to Increase Colorectal Cancer
Screenings.
If the underlying Award authorizes the State to pay all allowable and allocable expenses of a Contractor as
of the Effective Date of that Award, then the State shall reimburse the Contractor for any allowable and
allocable expenses of the Contractor that have been incurred by the Contractor since the proposed Effective
Date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable
and allocable expenses of a Contractor as of the Effective Date of that Award, then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by
the Contractor on or after the Effective Date of this Task Order Contract, with such effective date being the
later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the
State Controller or delegee.
3. To receive compensation under the Contract, the Contractor shall submit a signed Monthly CDPHE
Reimbursement Invoice Form. This form is accessible from the CDPHE internet website
https://www.colorado.gov/pacificicdphe/standardized-invoice-form-and-links and is incorporated and made
part of this Contract by reference. CDPHE will provide technical assistance in accessing and completing
the form. The CDPHE Reimbursement Invoice Form and Expenditure Details page must be submitted no
later than forty-five (45) calendar days after the end of the billing period for which services were rendered.
Expenditures shall be in accordance with this Statement of Work and Budget.
Scan the completed and signed CDPHE Reimbursement Invoice Form into an electronic document. Email
the scanned invoice and Expenditure Details page to: Cancer Prevention and Early Detection Contracts
Monitor via email at cdphe Cancer@state.co.us
Final billings under the Contract must be received by the State within a reasonable time after the expiration
or termination of the Contract; but in any event no later than forty-five (45) calendar days from the
effective expiration or termination date of the Contract.
Unless otherwise provided for in the Contract, "Local Match", if any, shall be included on all invoices as
required by funding source.
Page 1 of 5
Contract Exhibit-,\_\ddthonalProvisicros_I'askOrder_I7.5.3
EXHIBIT A
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
The Contractor shall not use state funds to satisfy federal cost sharing and matching requirements unless
approved in writing by CDPHE
If applicable, the Contractor shall be reimbursed for the purchase of allowable Patient Navigation and
Clinical Services supplies/operating costs identified in the Women's Wellness Connection (WWC) Patient
Navigation and Clinical Services Allowable Purchases document. This document is located at the
following website www.cdphecancer.org and is incorporated and made part of this Contract by reference.
To receive compensation for Patient Navigation and Clinical Services provided to eligible individual clients
as identified in the Statement of Work under this Contract, the Contractor shall:
a. Navigate eligible low-income women to timely and complete breast and cervical cancer
screening procedures (Patient Navigation); or,
b. Provide CDPHE-funded breast and cervical cancer screening and/or diagnostic
procedures (Clinical Services), to eligible clients.
Colorectal cancer screening and diagnostic services are not eligible for patient navigation or clinical
services reimbursement.
The Contractor shall be paid for Patient Navigation or Clinical Services to individual clients in accordance
with rates as outlined in the Cancer Prevention and Early Detection Bundled Payment System for Patient
Navigation with or without the Clinical Services.
Contractors shall only be paid for cases that meet eligibility, performance, and data requirements. Rates
may be revised or updated during the contract term. Reimbursement policies are defined in the Cancer
Prevention and Early Detection Program Manual. This manual is located at the following website
www.cdphecancer.org and is incorporated and made part of this Contract by reference.
Data entered into the electronic cancer surveillance and tracking (eCaST) data system are the basis for
calculating reimbursement for each client receiving Patient Navigation or Clinical Services. To be
considered for payment, all Cancer Prevention and Early Detection Patient Navigation and Clinical
Services related cancer screening and diagnostic procedures shall be entered into eCaST within thirty (30)
days of service being performed. Patient Navigation or Clinical Services cases that exceed sixty (60)
calendar days in screening length and negatively affect WWC's Performance Indicators may not be
reimbursed at the discretion of the State.
Reimbursement is determined by the clinical outcome of each case; therefore, cases must be clinically
complete or administratively closed before reimbursement occurs.
The Contractor shall receive a contracted eCaST funding amount each fiscal year to provide Patient
Navigation or Clinical Services to individual clients. Once the eCaST funding cap is reached, the Cancer
Prevention and Early Detection Program will not pay for additional expenses incurred by Contractor unless
CDPHE opts to increase funding. Based on performance, the Cancer Prevention and Early Detection
Program may unilaterally change the groups of eligible clients who may be served with eCaST funding.
The Contractor shall not charge the Cancer Prevention and Early Detection program for Clinical Services
not listed on the CPT Code List. This document is incorporated and made part of this Contract by reference
and is available on the following website: www.cdphecancer.org.
Page 2 of 5
Contract Exhibit \_ \ddititmalProvisions_ I'ask(kder 17.5.3
EXHIBIT A
4. Time Limit For Acceptance Of Deliverables.
a. Evaluation Period. The State shall have fifteen (15) calendar days from the date a deliverable is
delivered to the State by the Contractor to evaluate that deliverable, except for those deliverables
that have a different time negotiated by the State and the Contractor.
b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design
specifications for that particular deliverable, or is otherwise deficient, then the State shall notify
the Contractor of the failure or deficiencies, in writing, within fifteen (15) calendar days of: 1) the
date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or
deficiency at the time of delivery; or 2) the date the State becomes aware of the failure or
deficiency. The above time frame shall apply to all deliverables except for those deliverables that
have a different time negotiated by the State and the Contractor in writing pursuant to the State's
fiscal rules.
c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed
deliverable, the Contractor shall have a reasonable period of time, not to exceed fifteen (15)
calendar days, to correct the noted deficiencies. If the Contractor fails to correct such deficiencies
within fifteen (15) calendar days, the Contractor shall be in default of its obligations under this
Task Order Contract and the State, at its option, may elect to terminate this Task Order Contract or
the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract.
5. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination.
The State has determined that this Task Order Contract does not constitute a Business Associate
relationship under HIPAA.
6. This award does not include funds for Research and Development.
7. The State, at its discretion, shall have the option to extend the term under this Task Order beyond the Initial
Term for a period or for successive periods, of I year at the same rates and under the same terms specified
in the Task Order. In order to exercise this option, the State shall provide written notice to Contractor in as
form substantially equivalent to Exhibit D. If exercised, the provisions of the Option Letter shall become
part of and be incorporated in the original Task Order. The total duration of this Task Order shall not
exceed 5 years.
8. The State, at its discretion, shall have the option to increase or decrease the statewide quantity of Goods
and/or Services based upon the rates established in this Task Order and increase the maximum amount
payable accordingly. In order to exercise this option, the State shall provide written notice to Contractor in
as form substantially equivalent to Exhibit D. Delivery of Goods and/or performance of Services shall
continue at the same rates and terms as described in this Task Order.
9. The State, at its discretion, may unilaterally increase or decrease the total funds available under this Grant,
the funds available under the Grant during any State fiscal Year or the funds available for any specific line
items described in this Grant. In order to exercise this right, the State shall provide written notice to
Grantee in a form substantially equivalent to Exhibit E. The exercise of this right shall not be valid until it
has been approved by the contractor.
10. If Contractor indicates full expenditure of funds under this Task Order Contract by March 29 of each grant
year and the full expenditure does not occur, CDPHE has the option to reduce current or upcoming
Contract by said amount or a percent deemed reasonable by CDPHE. CDPHE will notify the Contractor of
the potential need to decrease the current or upcoming budget. If the Contractor indicates at a later date
than March 29 of each grant year an expectation of surplus of funds or inability to fully expend said funds
Page 3 of 5
Ccmtract _f (xhibit-,1_ \ddidonalProvisions_ f'askOrder_ 17.5.3
EXHIBIT A
for unforeseen circumstances that Contractor had not anticipated by March 29, CDPHE will reallocate
unspent funds without any penalties to the Contractor.
Upon receipt of timely written notice of an objection by the State for inability to fully expend funds, the
Contractor shall have a reasonable period of time not to exceed ten (10) calendar days to respond to the
action. If no dispute is received by the State within ten (10) calendar days, the State has the option to
reduce the current budget for the current year and any upcoming budget for future contractual agreements.
1 l . The Contractor shall request prior approval in writing from the Cancer Prevention and Early Detection
Program for any modification to the eCaST budget line item or between budgets for each strategy.
12. Contractor shall request prior approval in writing from the State for all modifications in the Statement of
Work/Work Plan or for any modification to the direct costs in excess of twenty-five percent (25%) of the
total budget for direct costs. Any request for modifications to the Budget in excess of twenty-five percent
(25%) of the total budget for direct costs shall be submitted to the State at least 90 days prior to the end of
the contract period and may require an amendment in accordance with Section 5, Contract Modifications,
of this Task Order Contract.
13. All data collected, used or acquired shall be used solely for the purposes of this Task Order Contract. The
Contractor and its subcontractors agree not to release, divulge, publish, transfer, sell, or otherwise make
known any such data to unauthorized persons without the express prior written consent of the State or as
otherwise required by law. This includes a prior written request by the Contractor to the State for
submission of abstracts or reports to conferences, which utilize data collected under this Task Order
Contract.
Notwithstanding the foregoing, the Contractor shall be entitled to retain a set of any such data collected or
work papers necessary to perform its duties under this Task Order Contract and in accordance with
professional standards.
14. Neither the U.S. Department of Health and Human Services (HHS) nor the Centers for Disease Control
(CDC) logo may be displayed on any conference materials if such display would cause confusion as to the
conference source or give false appearance of Government endorsement. Use of the HHS name or logo is
governed by U.S.C. 1320b-10, which prohibits misuse of the HHS name and emblem in written
communication. A non-federal entity is unauthorized to use the HHS name or logo governed by U.S.C.
1320b-10. The appropriate use of the HHS logo is subject to review and approval of the Office of the
Assistant Secretary for Public Affairs (OASPA).
15. The Contractor agrees to provide services to all Program participants and employees in a smoke -free
environment in accordance with Public Law 103-227, also known as "the Pro -Children Act of 1994", (Act).
Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or
leased or contracted for by an entity and used routinely or regularly for the provision of health, day care,
early childhood development services, education or library services to children under the age of 18, if the
services are funded by Federal programs either directly or through State or local governments, by Federal
grant, contract, loan, or loan guarantee.
16. Notwithstanding the terms contained in the General Provisions, Section 10, Confidential or Proprietary
Information, Contractor shall protect the confidentiality of all applicant or recipient records and other
materials that are maintained in accordance with this Task Order Contract. Except for purposes directly
connected with the administration of this Contract, no information about or obtained from any applicant or
recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written
consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with
the exception of information protected by Colorado Statute as it applies to confidentiality for adolescent
services in which case the adolescent minor and not the parent or legal guardian must provide consent or as
otherwise properly ordered by a court of competent jurisdiction. Contractor shall have written policies
Page 4 of 5
Contract_Exhibit-, \, \dditiomalProvisions_ t askOrdcr 17.5.3
EXHIBIT A
governing access, duplication, and dissemination of all such information. Contractor shall advise its
employees, agents, servants, and any subcontractors that they are subject to these confidentiality
requirements.
17. The Contractor affirms that it maintains no affiliations or contractual relationships, direct or indirect, with
tobacco companies, owners, affiliate, subsidiaries, holding companies, or companies involved in any way
in the production, processing, distribution, promotion, sales, or use of tobacco.
18. The State of Colorado, specifically the Colorado Department of Public Health and Environment, shall be
the owner of all equipment as defined by Federal Accounting Standards Advisory Board (FASAB)
Generally Accepted Accounting Principles (GAAP) purchased under this Contract. At the end of the term
of this Task Order Contract, the State shall approve the disposition of all equipment.
19. Contractor shall not use state or federal funds provided under this Contract for the purpose of lobbying as
defined in Colorado Revised Statutes (C.R. S.) 24-6-301(3.5)(a).
Page 5ot5
( ;on tract H.xhibit- \_ \dditimalProvisions=Iask( )rder 17.3.3
EXHIBIT B
STATEMENT OF WORK
To Original Contract Routing Number 18 FHLA 104208
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
I. Entity Name: Weld County Department of Public Health and Environment
H. Project Description:
This project serves to implement strategies to address cancer prevention and early detection at one or more levels
of the socio-ecological framework, depending on the needs of the underserved population served by and living
within the service area.
III. Definitions:
1. Assessment and Planning Process: The Assessment and Planning Process will be used to identify: 1) the
needs of the underserved population served by and living within the organization's service area, 2) ongoing
activities and gaps related to promoting and improving prevention and early detection of cancer, and 3) a
strategic plan for the organization to apply to continue, discontinue or include new Additional Strategies to
improve cancer prevention and early detection based upon the Assessment and Planning Process results.
2. Cancer screening data: Data on the Contractor's breast, cervical and colorectal cancer screenings provided
to their screening -eligible patient population.
3. Direct Assistance: Assistance to individuals who are in need of cancer screening services and have identified
barriers to accessing services at a health system. Assistance may include such things as providing breast,
cervical and colorectal health education, language interpretation and translation services prior to a screening
appointment, scheduling a screening appointment, arranging transportation to the first screening appointment,
assisting to enroll in health insurance, and addressing any other barrier that may arise.
4. eCaST data system: A program management and public health surveillance tool used by CDPHE to meet
program reporting and documentation requirements.
5. Health System: Individual health clinic (includes provider -owned clinic), Federally Qualified Health Center
(FQHC), community health center, hospital, hospital network for the use and benefit of a hospital within their
network (may include hospital foundations), safety net clinic, rural health center, or local public health
agency.
6. Individual or client -level data: Data elements specific to each individual or client participating in the
program.
7. Patient navigation: Individualized assistance offered to clients to help overcome their client's self -identified
psychosocial, cultural and system barriers (e.g., health literacy, financial, transportation, etc.) to healthcare
and facilitate timely access to quality screening and diagnostics as well as initiation of treatment services for
persons diagnosed with cancer.
8. Quality cancer screening: Timely completion of all required procedures needed to determine whether or not
an individual has cancer.
9. Service area: Geographic area served by the organization.
10. Socio-ecological framework: a systems framework with multiple bands of influence (illustrated by a
rainbow -like figure) in which the core of the model is the individual, surrounded by four banks of influence
representing the interpersonal, organizational, community, and policy levels.
II. Subpopulation: Unique populations (example, uninsured or Hispanic) served by the organization for this
project, as approved by CDPHE.
IV. Work Plan:
Goal #1: Reduce breast, cervical and colorectal cancer health disparities, and morbidity and mortality rates, in
Colorado.
Objective #1: No later than the expiration date of the contract, the Contractor shall promote and improve
prevention and early detection of breast, cervical and colorectal cancer among underserved Coloradans served
by and livinit within the service area of the Contractor.
Primary
Activity #1
The Contractor shall complete the annual CDPHE Cancer Prevention and Early Detection
Assessment and Planning Process to identify needs of and existing activities related to
version: Contract Statement or Work - Exhibit B
December 2015
Page I of 5
l 8FHLA 104208_Ex B
EXHIBIT B
promoting and improving prevention and early detection of breast, cervical and colorectal
cancer among underserved women and men served by and living within the service area of
the Contractor.
Sob -Actin hies
#!
I . The Contractor shall conduct an annual assessment for the organization.
2 The Contractor shall prepare a strategic plan based on results of the assessment with
proposed activities.
3. The Contractor shall prepare for implementation of CDPHE-approved strategies
included in the Contractor's • lan.
Primary
Activity #2 ",
1 he Contractor shall provide education in the communities within the service area about
breast, cervical and colorectal cancer prevention and early detection (including during
cancer awareness months), and provide direct assistance to eligible low-income women to
access breast and cervical cancer screening services at a health system.
Sub -Activities
#2
1. The Contractor shall provide education in the community through presentations,
trainings, and distribution of information, at a minimum number of community
organizations and events, as approved by CDPHE.
2. The Contractor shall provide direct assistance to a minimum number of eligible women
from the identified community subpopulation to access cancer screening services, as
approved by CDPHE.
3. The Contractor shall provide aggregate data on education provided in the community
and individual -level data on women receiving direct assistance to access cancer
screenin : .
Primary
activity #3
The Contractor shall navigate eligible low-income women to timely and complete breast and
cervical cancer screening procedures.
Sub -Activities
#3
1. The Contractor shall provide patient navigation to the group(s) of eligible women as
approved by CDPHE.
2. The Contractor shall enter client -level data on qualifying breast and cervical cancer
screenin: • ocedures and 'atient navigation services into the eCaST data s stem.
ary
active its #4
The Contractor shall provide CDPHE-funded breast and cervical cancer screening
procedures to eligible low-income women.
Sub -.actin ities
#4
1. The Contractor shall enter data on qualifying procedures into the eCaST data system.
Standards and
Requirements
I. The content of electronic documents located on CDPHE and non-CDPHE websites and
information contained on CDPHE and non-CDPHE websites may be updated
periodically during the contract term. The Contractor shall monitor documents and
website content for updates and comply with all updates.
2. The Contractor shall comply with any changes, revisions, inclusions, and exclusions to
the CDPHE Cancer Prevention and Early Detection Program. The CDPHE Cancer
Prevention and Early Detection Program is subject at any time to changes, revisions,
inclusions, and exclusions as needed and/or pursuant to directives or changes required
by rule, regulation, statute or guidance.
3. The Contractor shall comply with all requirements stated in the CDPHE Cancer
Prevention and Early Detection Program Manual. This document is incorporated and
made part of this contract by reference and is available on the following website:
www.cdphecancer.org.
4. The Contractor shall use all CDPHE-required forms.
5. The Contractor shall submit all final reports as non -reimbursable deliverables.
6. The Contractor shall utilize the CDPHE Cancer Prevention and Early Detection
Assessment and Planning Tool Template to complete its annual Assessment and
Planning Process. The template is incorporated and made part of this contract by
reference and is located on the following website: www.cdphecancer.org.
7. CDPHE will review and provide feedback of the CDPHE Cancer Prevention and Early
Detection assessment and planning tool within 30 calendar days of the submission
deadline.
version: Contract statement of Work - Exhibit 9
December '_015
Page 2 of 5
I 8FHLA I04208_Ex B
EXHIBIT B
The Contractor shall be guided by the annual CDPHE Cancer Prevention and Early
Detection continuing application that identifies CDPHE-approved planned strategies.
The annual CDPHE Cancer Prevention and Early Detection continuing application shall
be based on the annual CDPHE Cancer Prevention and Early Detection Assessment and
Planning Process. The Cancer Prevention and Early Detection continuing application
template shall be incorporated and made part of this contract by reference and is located
on the following website: www.cdphecancer.org.
9. CDPHE will review and provide feedback of the CDPHE Cancer Prevention and Early
Detection continuing application within 30 calendar days of the receipt.
10. The Contractor shall attend a post -award orientation provided by CDPHE as well as
other required meetings, trainings, webinars and telephone calls for the purpose of
information -sharing, training, technical assistance and contract monitoring.
11. The Contractor shall notify CDPHE within 15 days of a change in key staff responsible
for the performance of work outlined in this statement of work (SOW).
12. The Contractor shall ensure that new staff members receive required training within two
(2) months of hire.
13. The Contractor shall participate in CDPHE evaluation efforts.
14. The Contractor shall compile required evaluation and program monitoring data.
15. The Contractor shall submit, unless otherwise stated, all deliverables to CDPHE via the
method indicated in the CDPHE Cancer Prevention and Early Detection Program
Manual.
16. If purchasing gift cards, the Contractor shall provide to CDPHE upon request written
procedures related to gift card purchasing and handling. At a minimum, the procedures
shall include the following:
a. How the gift card inventory is tracked and maintained
b. Gift card storage and safeguards against theft
c. The primary person responsible for securing and distribution of gift cards
d. A gift card distribution log that records each gift card number, dollar amount,
and the printed name and signature of each gift card recipient.
Assessment & Planning Strategy:
1. The Contractor shall utilize the CDPHE-approved assessment and planning tool.
Targeted Community Outreach Strategy:
I. Contractors that provide direct services to individuals 18 years of age and older shall
ensure they only provide services of benefit to individuals lawfully present in the
United States. The Contractor shall maintain documentation demonstrating the
individual's establishment of lawful presence, which shall include documentation of
an appropriate identification document and an affidavit as required by Colorado
Revised Statutes (C.R.S.), Section 24-76.5-103.
Clinical Services and Patient Navigation Strategies:
I. The Contractor shall enter client -level data on qualifying breast and cervical cancer
screening procedures and patient navigation services, performed on or before June
29, into the eCaST data system no later than July 29, annually and in the final year
by December 31.
2. The Contractor shall comply with required current national clinical guidelines.
Current national clinical guidelines are incorporated and made part of this Contract
by reference and are available on the following website at www.cdphecancer.org
3. Contractors that provide direct services to individuals 18 years of age and older shall
ensure they only provide services of benefit to individuals lawfully present in the
United States. The Contractor shall maintain documentation demonstrating the
individual's establishment of lawful presence, which shall include documentation of
an appropriate identification document and an affidavit as required by Colorado
Revised Statutes (C.R.S.), Section 24-76.5-103.
4. For Clinical Services only, the Contractor shall comply with the requirements for
enrollment of eligible women with an eligible breast or cervical cancer diagnosis
into Health First Colorado's Breast and Cervical Cancer Treatment Program
version: Contract Sm[cmmnt ti'Vvnrk r.xh hir H
Decemher 2015
Page 3of5
18FHLA 104208_Ex B
EXHIBIT B
(BCCP).
5. For Clinical Services only, the Contractor shall offer clients printed resource and
referral materials that direct them to the nearest community Medicaid and Connect
for Health Colorado enrollment location(s), including online enrollment options.
Printed resource materials for Medicaid and Connect for Health Colorado shall be
available for clients with Limited English Proficiency (LEP). Contractors that
routinely offer enrollment services onsite are exempt from this requirement because
the services go beyond this minimum requirement. Information on enrollment
resources, referral locations, LEP and outreach and promotional materials is
incorporated and made part of this contract by reference and is available on the
followin . website www.cd . . ecancer.or ..
Expected
Results of
Activity(s)
1. Increased number of individuals screened for breast, cervical and colorectal cancer.
2. Increased number of quality breast, cervical and colorectal cancer screenings provided
within priority populations
Measurement
of Expected
Results
Analysis of programmatic data submissions, including progress reports, annual assessments,
continuing applications and evaluation information.
Completion Date
Deliverables
1. The Contractor shall submit a draft of the annual completed
CDPHE Cancer Prevention and Early Detection assessment
and planning tool for CDPHE review and approval.
Annually, no later than
October l
2. The Contractor shall submit a final annual CDPHE Cancer
Prevention and Early Detection assessment and planning
tool.
Annually, no later than
December 15
3. The Contractor shall submit a draft CDPHE Cancer
Prevention and Early Detection continuing application for
the next funding year (June 30 through June 29) for CDPHE
review and approval.
Annually, no later than
January 15
4. The Contractor shall submit a final CDPHE Cancer
Prevention and Early Detection continuing application for
the next funding year (June 30 through June 29).
Annually, no later than
February 28
5. The Contractor shall submit progress reports using a
CDPHE-provided template.
Twice per year, no later
than January 15 and
August 15
6. The Contractor shall submit breast, cervical and colorectal
cancer screening data, if applicable.
Annually, no later than
within 90 calendar days of
end of CDPHE-approved
reporting period
V. Monitoring:
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted throughout
the contract period by CDPHE Cancer Prevention and Early Detection Program Contracts Monitor. Methods used
will include a review of documentation determined by CDPHE to be reflective of performance to include progress
reports and other fiscal and programmatic documentation as applicable. The Contractor's performance will be
evaluated at set intervals and communicated to the contractor. A Final Contractor Performance Evaluation will be
conducted at the end of the life of the contract.
VI. Resolution of Non -Compliance:
The Contractor will be notified in writing within 15 calendar days of discovery of a compliance issue. Within 30
calendar days of discovery, the Contractor and the State will collaborate, when appropriate, to determine the
action(s) necessary to rectify the compliance issue and determine when the action(s) must be completed. The
action(s) and time line for completion will be documented in writing and agreed to by both parties. If extenuating
circumstances arise that requires an extension to the time line, the Contractor must email a request to the CDPI-IE
Cancer Prevention and Early Detection Program Contracts Monitor and receive approval for a new due date. The
version' Contract Statement of Work - Exhibit B
December ?O 15
Page 4 of 5
I8FHI.A 104208_Ex B
EXHIBIT B
State will oversee the completion/implementation of the action(s) to ensure time lines are met and the issue(s) is
resolved. If the Contractor demonstrates inaction or disregard for the agreed upon compliance resolution plan, the
State may exercise its rights under the provisions of this contract.
version: Contract Statement of Work - Exhibit B
December 2015
Page 5of5
18FHLA I04208_Ex B
EXHIBIT C
COLORADO
Department of Public
Health 6 Envirostntent
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Assessment & Planning
Contract Routing # 18 FHLA 104208
Contractor Name
Budget Period
Project Name
Position Title
Description of Work
Weld County Department of Public Health
and Environment
1/1/18 - 6/30/18
Assessment and Planning Process
Program Contact Name,
Title, Phone and Email
Cynthia Horn, FNP-C, Clinical Manager
970-400-2433 chorn@co.weld.co.us
Fiscal Contact Name. Title,
Phone and Email
Tanya Geiser, Director, Admin Services
;970) 400-2122, tgeiser@weldgov.com
Expenditure Categories
Personal Services
Sa aried Employees .,
Budget
Item
Supports
SOW
(Yes/No)
Gross or Annual
Salary
Clinical Manager
Lead for grant and Assess/Plan process
Yes
Fringe
0,50%
$121,673.00 $47,367 30
Percent of
Time on
Project
Number of
Months
Total Amount
Requested
from CDPHE
$422.60
Director HCEP
Strategic Plan writing
Yes
$94,099.00
$36,632.74
0.40%
6
$261.46
Data Specialist
Data Collection
Yes
$95,009.00
$36,987.00
0.30%
6
$197.99
$0.00
Personal Services
Hourly Employees
Position
Title/Employee Name
Description of Work
Budget Item Total # of Total Amount
Hourly
Supports SOW Hourly Wage Hours on Requested
Fringe
(Yes/No) Project from CDPHE
TCO Worker
Assessment and Plan Review and Input
Yes
$20.37
$7.93
10
$283
SO
Total Personal Services
(including fringe benefits)
$1,165
Supplies & Operating Expenses
Item
Description of Item (Operating/Supplies)
Budget Item
Supports
SOW
(Yes/No)
Rate
Total Amount
Quantity Requested
from CDPHE
Misc. Operating
Supplies
Office supply and printing allocations to complete assessment and
planning process
Yes
$15.00
2
$30
$0
Total Supplies
& Operating Expenses
$30
Travel
EXHIBIT C
Item
Description of Item (Travel Costs)
Budget Item
SupportSs
OW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Mileage to Post Award
meeting
Mileage to attend mandatory post -award Meeting ($0.515/mile)
Yes
$0.52
231
$119
Meals
Meals while traveling to mandatory post -award meeting (actual receipts)
Yes
$15.00
1
$15
Lodging
Lodging for the mandatory post -award meeting
Yes
$95.00
1
$95
$0
Total Travel
$229
Contractual
Subcontractor Name
Description of Item
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
North Colorado Health
Alliance
EMR Vendor Support for reports
Yes
$100.00
1
$100
SO
Total Contractual
$100
SUB -TOTAL BEFORE INDIRECT
$1,524
Indirect
Item
Description of Item
Total Amount
Requested
from CDPHE
CDPHE-approved
indirect cost rate
agreement
18.08% Total direct costs
$276
Page 2 of 7
EXHIBIT C
AityCOLORADO
Department Public
Ruth 6 Envtro�eunent
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Patient Navigation &
Clinical Services
Contract Routing # 18 FHLA 104208
Contractor Name
Weld County Department of Public Health
and Environment
•
Budget Period
1/1/18 - 6/30/18
Project Name
Cancer RFA -
Patient Navigation & Clinical Services
Program Contact Name,
Title, Phone and Email
Cynthia Horn, FNP-C, Clinical Manager
970-400-2433 thorn@co.weld.co.us
Fiscal Contact Name, Title.
Phone and Email -
Tanya Geiser, Director, Admin Services
(970) 400-2122, tgeiser@weldgov.com
Expenditure Categories
Personal Services
Salaried Employees
Position Title
Description of Work
Budget
Item
Supports
SOW
(Yes/No)
Gross or Annual
Salary
Fringe
Total Amount
Requested
from CDPHE
Percent of
Time on
Project
Number of
Months
Clinical Manager
Provide Clinical Supervision and assure
clinic is prepared to serve clients
Yes
$121,673.00 $47,367.30
0.60%
6
$507.12
30.00
Personal Services
Hourly Employees
Position
Title/Employee Name
Description of Work
Budget Item
Supports SOW
(Yes/No)
Hourly Wage
Hourly
Fringe
r
Total If of Total Amount
Hours on Requested
Project from CDPHE
Office Technician MS
Support Patient Navigator/Clinical Services (make
copies, answer phones, interpret as needed, etc)
Yes
$20.85
$8.12
24
$695
Patient Navigator
Time spent on reports, chart audits, program
evaluation and site visits; (rest of position billed under
bundled payment system per CDPHE)
Yes
$20.37
$7.93
26
$736
$0
Total Personal Services
(including fringe benefits)
$1,938
Supplies & Operating Expenses
Item
Description of Item (Operating/Supplies)
3udget. item
Supports
SOW
(Yes/No)
Rate
Total Amount
Quantity Requested
from CDPHE
Patient Navigation
with Clinical Services
Procedures
Billed in eCaST through 6/30/18 for Eligible Uninusured/Underinsured
Clients Ages 21-39
Yes
$155 00
60
$9,300
Patient Navigation
with Clinical Services
Procedures
Billed in eCaST through 6/30/18 for Eligible Uninusured/Underinsured
Clients Ages 40-64
Yes
$351.00
49
$17,199
Page 3 of 7
EXHIBIT C
Operating/supplies
Allowable purchase of supplies/operating listed on the WWC Patient
Navigation and Clinical Services allowable purchase document on the
WWC website: www.cdphecancer.org
Yes
$4,302.00
1
$4,302
$0
Total Supplies
& Operating Expenses
$30,801
Travel
Item
Description of Item (Travel Costs)
Budget item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Travel
Travel expenses to attend Cancer/Clinical Conference
Yes
$1,000.00
2
$2,000
Mileage
Mileage to attend required Post Award Meeting
Yes
$0.515
231
$119
Meals
Meals while traveling to/from required Post Award Meeting
Yes
$15.00
1
$15
Lodging
Lodging for the required Post Award Meeting
Yes
$95.00
1
$95
$0
Total Travel
$2,229,
Contractual
Subcontractor Name
Description of Item
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
$0
Total Contractual
$l1,
SUB -TOTAL BEFORE INDIRECT
$34,968
Indirect
Item
Description of Item
Total Amount
Requested
from CDPHE
CDPHE-approved
indirect cost rate
agreemer:
18.08% Total direct costs
$1,531
Total Indirect
$1,531
L TOTAL
'36,4999
Page 4 of 7
EXHIBIT C
COLORADO
Department of Public
Health 6 Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Targeted Community Outreach
Contract Routing # 18 FHLA 104208
Contractor Name
Budget Period
Project Name
Weld County Department of Public Health
and Environment
1/1/18 - 6/30/18
Cancer RFA -
Targeted Community Outreach
Program Contact Name,
Title, Phone and Email
Cynthia Horn, FNP-C, Clinical Manager,
970-400-2433 chorn@co.weld.co.us
Fiscal Contact Name, Title,
Phone and Email
Tanya Geiser, Director, Admin Services
(970) 400-2122, tgeiser@weldgov.com
Expenditure Categories
Personal Services
Salaried Employees
Position Title
Description of Work
Budget
Item
Supports
SOW
(Yes/No)
Gross or Annual
Salary
Fringe
Percent of
Time on
Project
Number of
Months
Total Amount
Requested
from CDPHE
Supervisor AO
Provide supervision and oversight to the
TCO Worker and the program.
Yes
$107,545.00
$41,867.27
1.750
$1,307.36
iersonal Services
Hourly Employees
Position
Title/Employee Name
Description of Work
Budget Item
Supports SOW
(Yes/No)
Hourly Wage
Total # of
Hours on
Project
Total Amount
Requested
from CDPHE
Hourly
Fringe
$0.00
Target Community
Outreach Worker 1.0
FTE
Facilitate community events and work with community
organizations to provide outreach and education about
breast, cervical and colon cancer screenings, provide
information about local resources, identify women
eligible to receive direct assistance
Yes
$20.37
$ 7.93
1040
$29,432
Office Technician MS
Administrative program support: answering phone
calls, preparing mailings, clerical support to assist
Targeted Community Outreach Worker
Yes
$20.85
$8.12
26.00
$753
Total Personal Services
(including fringe benefits)
$31,493
Supplies & Operating Expenses
Item
Description of Item (Operating/Supplies)
Budget Item
Supports
SOW
(Yes/No)
Rate
Total Amount
Quantity Requested
from CDPHE
Page 5 of 7
EXHIBIT C
Electronic Medical
Record Fees
The TCO Worker will take a laptop to outreach events and will utilize
Electronic Medical Records to schedule screening appointments for
clients. EMRs will also be used to verify information and screening status.
Yes
$15.00
6
Phone Service
The program will use a cell phone for outreach through phone calls and
text messages as well as for use as a Wifi hot spot when at community
events.
Yes
$70.00
6
Printed Materials
Postcards and flyers for distribution at events as outreach to new clients
in the community; we plan to send 500 postcards in spring (Cervical
Health Awareness) From names gathered from community events and
handing out 500 flyers at outreach events; may also, may also include
printing allocations.
Yes
$0.50
1000
Postage
Postage for postcards sent in spring and other misc postage costs
Yes
$0.40
500
Program Supplies
Coffee and snacks provided during events to open a conversation with
potential clients
Yes
$10.00
30
Marketing Materials
Small incentives at events and larger incentives to women who are
provided direct assistance/get screened at the WCDPHE clinic.
Yes
$0.50
500
Client Transportation
Gift cards or bus tickets to help clients with transportation costs
Yes
$10.00
6
Interpretation
Interpretation as needed for education
Yes
$25.00
1
Misc. Operating/Office
Supplies
Office and other supplies and non -consumable small items of equipment
as needed. May include allocations and/or small items of equipment.
Yes
$25.00
6
Total Supplies
& Operating Expenses
$90
$420
$500
$200
$300
$250
$60
$25
$150
$0
$1,99.5 .
Travel
Item
Description of Item (Travel Costs)
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Mileage to outreach
events
TCO Worker will attend community events and meetings across Weld
County. Estimated 375 miles/ month x 6 months x .515 per mile.
Yes
$0.515
2250
$1,159
Mileage to one day
meetings
TCO Worker will attend a mandatory post -award meeting (.515/mile)
Yes
$0.515
240
$124
Meals
Meals while traveling to/from post -award meeting
Yes
$15.00
$15
Lodging
Lodging for the Past -Award Meeting.
Yes
$95.00
$95
Total Travel
$1,392
Contractual
Subcontractor Name
Description of Item
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
TBD
Work with local media outlets and advertisers to promote breast, cervical
and colorectal awareness; could include bus bench advertising or radio
spots
Yes
$575.00
1
$575
$0
$0
Page 6of7
EXHIBIT C
Total
SUB -TOTAL BEFORE INDIRECT
Indirect
$575
$35,455
Item
Description of Item
Total Amount
Requested
from CDPHE
CDPHE-approved
indirect cost rate
agreement
18.08% Total direct costs
$6,410
Total Indirect
$6,410
TOTAL CONTRACT: $80,164.00
Page 7 of 7
EXHIBIT D
OPTION LETTER
Date:
State Fiscal Year:
Option Letter No.
Original Contract CMS#
Option Letter CMS Routing #
CORE Encumbrance #
DELETE all BLUE text, CUSTOMIZE Red text and CHANGE Red text to Black after customization.
1) OPTIONS: Choose all applicable options listed below
a. Option to extend for a renewal or additional term
b. Option to change amount of goods
c. Option to change amount of services
d. Option to change contract rates
e. Option to initiate next phase of contract
2) REQUIRED PROVISIONS. All Option Letters shall contain the appropriate provisions set forth below:
a. For use with Options a: In accordance with Section(s) enter section the Original Contract referenced above between the
State of Colorado, Colorado Department of Public Health and Environment, and enter Contractor's name the State hereby
exercises its option for an additional term beginning insert start date and ending on insert end date at the rates stated in the
Original Contract, as amended.
b. For use with Option b and c. In accordance with Section(s) enter Section of the Original Contract routing number
referenced above, between the State of Colorado, Colorado Department of Public Health and Environment, and enter
Contractor's name the State hereby exercises its option to Increase/Decrease the quantity of Goods/Services or both at the same
cost/price as specified in enter Exhibit/Attachment nam
c. For use with Option d. In accordance with Section(s ter section of the Original Contract routing number referenced
above, the State hereby exercise its option to modify the ract rates specified in Exhibit'Section Number. The Contract rates
attached to this Option letter in Exhibit/Attachment Name e the rates in the original Contract as of the Option Effective
Date of this Option Letter.
d. For use with Option e: In accordance with Sections) enter section of the Original Contract routing number referenced
above, the State hereby exercise its option to initiate Phase indicate which Phase: 2, 3, 4 etc. which shall begin on insert start
date and ending on insert end date at the cost/price specified in Section enter section the Original Contract referenced above.
e. For use with Options a, b, c that modify the contract value: The amount of the current Fiscal Year contract value is
increased/decreased by $ enter amount of change to a new contract value of insert new $ amount as consideration for
services/goods ordered under the contract for the current fiscal year Indicate Fiscal Year. The first sentence in Section enter
section of the original contract is hereby modified accordingly. The amended total contract financial obligation including all
previous amendments, option letters, etc. is insert new $ amount.
3) Effective Date: The effective date of this Option Letter is upon approval of the State Controller if exact date is required complete
the following: enter date, and include the following: whichever is later.
STATE OF COLORADO
John W. Hickenlooper, GOVERNOR
Department of Public Health and Environment
PROGRAM APPROVAL:
By:
By: Lisa McGovern, Purchasing & Contracts Section Director
Date:
Date:
ALL CONTRACTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below
by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins
performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or
services provided hereunder.
STATE CONTROLLER
Robert Jaros, CPA, MBA, JD
By:
Date:
Contract_Sample OptionLetter_ 17 9 18
Page 1 of 1
EXHIBIT E
GRANT FUNDING CHANGE LETTER
Date:
State Fiscal Year:
Grant Funding Change
CMS Routing #
Letter (GFCL) #
CORE Encumbrance #
TO: <Insert Grantee's name>
In accordance with Section of the Original Contract routing number , [insert the following language here if
previous amendment(s), renewal(s) have been processed] as amended by [include all previous amendment(s), renewal(s) and
their routing numbers], [insert the following words here if previous amendment(s), renewal(s) have been processed] between the State
of Colorado, Department of Public Health and Environment and <insert contractor name> beginning <insert
start date of original contract/ and ending on <insert ending date of current contract amendment>, the undersigned commits
the following funds to the Grant:
The amount of (federal, state, other) grant funds available and specified in Section of <insert previous
contract modification number and routing number> is ❑ increased or ❑ decreased by $ amount of change to new total
funds for the period <date to date> of $ <insert new period cumulative total> for the following reason:
Section is hereby modified accordingly. The revised Budget is incorporated herein by this reference and
identified as Revised Exhibit *. (if budget attached; delete sentence if no budget included.)
Complete the table below; insert/delete rows as needed.
The table below reflects the original budget and all modifications to the total since the effective date of the Original
Contract.
SUMMARY OF CHANGES
Document Type
CMS Routing
#
Funding Source
(federal, state, other)
Period
Dollar Amount
Period
Total
Original Contract
$
$
$
$
$
$
$
$
$
$
Contract Cumulative Grand Total
$
This Grant Funding Change Letter does not constitute an order for services under this Grant.
The effective date of hereof is upon approval of the State Controller or <insert projected effective date>,
whichever is later.
STATE OF COLORADO PROGRAM APPROVAL
John W. Hickenlooper, Governor Colorado Department of Public Health and
Department of Public Health and Environment Environment
By: By:
Lisa McGovern INSERT -Name of Authorized Individual
Purchasing and Contracting Section Director, CDPHE INSERT -Official Title of Authorized Individual
Date Date
In accordance with §24-30-202 C.R.S., this Contract is not valid until signed and dated below by the State Controller or an authorized
delegate.
STATE CONTROLLER
Robert Jaros, CPA, MBA, JD
By:
Name of Agency Delegate -Please delete if contract will be routed to OSC for approval.
Effective Date:
I Contrfnt Grant Fuad►n Change Letter (I I ) ver Oti4 17 Page I of
r
EXHIBIT A
for unforeseen circumstances that Contractor had not anticipated by March 29, CDPHE will reallocate
unspent funds without any penalties to the Contractor.
Upon receipt of timely written notice of an objection by the State for inability to fully expend funds, the
Contractor shall have a reasonable period of time not to exceed ten (10) calendar days to respond to the
action. If no dispute is received by the State within ten (10) calendar days, the State has the option to
reduce the current budget for the current year and any upcoming budget for future contractual agreements.
1 1 . The Contractor shall request prior approval in writing from the Cancer Prevention and Early Detection
Program for any modification to the eCaST budget line item or between budgets for each strategy.
12. Contractor shall request prior approval in writing from the State for all modifications in the Statement of
Work/Work Plan or for any modification to the direct costs in excess of twenty-five percent (25%) of the
total budget for direct costs. Any request for modifications to the Budget in excess of twenty-five percent
(25%) of the total budget for direct costs shall be submitted to the State at least 90 days prior to the end of
the contract period and may require an amendment in accordance with Section 5, Contract Modifications,
of this Task Order Contract.
13. All data collected, used or acquired shall be used solely for the purposes of this Task Order Contract. The
Contractor and its subcontractors agree not to release, divulge, publish, transfer, sell, or otherwise make
known any such data to unauthorized persons without the express prior written consent of the State or as
otherwise required by law. This includes a prior written request by the Contractor to the State for
submission of abstracts or reports to conferences, which utilize data collected under this Task Order
Contract.
Notwithstanding the foregoing, the Contractor shall be entitled to retain a set of any such data collected or
work papers necessary to perform its duties under this Task Order Contract and in accordance with
professional standards.
14. Neither the U.S. Department of Health and Human Services (HHS) nor the Centers for Disease Control
(CDC) logo may be displayed on any conference materials if such display would cause confusion as to the
conference source or give false appearance of Government endorsement. Use of the HHS name or logo is
governed by U.S.C. 1320b -l0, which prohibits misuse of the HHS name and emblem in written
communication. A non-federal entity is unauthorized to use the HHS name or logo governed by U.S.C.
1320b-10. The appropriate use of the I-IHS logo is subject to review and approval of the Office of the
Assistant Secretary for Public Affairs (OASPA).
15. The Contractor agrees to provide services to all Program participants and employees in a smoke -free
environment in accordance with Public Law 103-227, also known as "the Pro -Children Act of 1994", (Act).
Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or
leased or contracted for by an entity and used routinely or regularly for the provision of health, day care,
early childhood development services, education or library services to children under the age of 18, if the
services are funded by Federal programs either directly or through State or local governments, by Federal
grant, contract, loan, or loan guarantee.
16. Notwithstanding the terms contained in the General Provisions, Section 10, Confidential or Proprietary
Information, Contractor shall protect the confidentiality of all applicant or recipient records and other
materials that are maintained in accordance with this Task Order Contract. Except for purposes directly
connected with the administration of this Contract, no information about or obtained from any applicant or
recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written
consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with
the exception of information protected by Colorado Statute as it applies to confidentiality for adolescent
services in which case the adolescent minor and not the parent or legal guardian must provide consent or as
otherwise properly ordered by a court of competent jurisdiction. Contractor shall have written policies
Page 4 of 5
Comtract Exhibit-. \_, \dd it onalProvisions_ I askOrdcr_ 17.3.3
EXHIBIT A
governing access, duplication, and dissemination of all such information. Contractor shall advise its
employees, agents, servants, and any subcontractors that they are subject to these confidentiality
requirements.
17. The Contractor affirms that it maintains no affiliations or contractual relationships, direct or indirect, with
tobacco companies, owners, affiliate, subsidiaries, holding companies, or companies involved in any way
in the production, processing, distribution, promotion, sales, or use of tobacco.
18. The State of Colorado, specifically the Colorado Department of Public Health and Environment, shall be
the owner of all equipment as defined by Federal Accounting Standards Advisory Board (FASAB)
Generally Accepted Accounting Principles (GAAP) purchased under this Contract. At the end of the term
of this Task Order Contract, the State shall approve the disposition of all equipment.
19. Contractor shall not use state or federal funds provided under this Contract for the purpose of lobbying as
defined in Colorado Revised Statutes (C.R. S.) 24-6-301(3.5)(a).
Page 5 of 5
(:on tract _Hchibit-\_,\dditionalProvisum s_I'askOrder 17.5.3
EXHIBIT B
STATEMENT OF WORK
To Original Contract Routing Number 18 FHLA 104208
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
I. Entity Name: Weld County Department of Public Health and Environment
H. Project Description:
This project serves to implement strategies to address cancer prevention and early detection at one or more levels
of the socio-ecological framework, depending on the needs of the underserved population served by and living
within the service area.
III. Definitions:
1. Assessment and Planning Process: The Assessment and Planning Process will be used to identify: 1) the
needs of the underserved population served by and living within the organization's service area, 2) ongoing
activities and gaps related to promoting and improving prevention and early detection of cancer, and 3) a
strategic plan for the organization to apply to continue, discontinue or include new Additional Strategies to
improve cancer prevention and early detection based upon the Assessment and Planning Process results.
2. Cancer screening data: Data on the Contractor's breast, cervical and colorectal cancer screenings provided
to their screening -eligible patient population.
3. Direct Assistance: Assistance to individuals who are in need of cancer screening services and have identified
barriers to accessing services at a health system. Assistance may include such things as providing breast,
cervical and colorectal health education, language interpretation and translation services prior to a screening
appointment, scheduling a screening appointment, arranging transportation to the first screening appointment,
assisting to enroll in health insurance, and addressing any other barrier that may arise.
4. eCaST data system: A program management and public health surveillance tool used by CDPHE to meet
program reporting and documentation requirements.
5. Health System: Individual health clinic (includes provider -owned clinic), Federally Qualified Health Center
(FQHC), community health center, hospital, hospital network for the use and benefit of a hospital within their
network (may include hospital foundations), safety net clinic, rural health center, or local public health
agency.
6. Individual or client -level data: Data elements specific to each individual or client participating in the
program.
7. Patient navigation: Individualized assistance offered to clients to help overcome their client's self -identified
psychosocial, cultural and system barriers (e.g., health literacy, financial, transportation, etc.) to healthcare
and facilitate timely access to quality screening and diagnostics as well as initiation of treatment services for
persons diagnosed with cancer.
8. Quality cancer screening: Timely completion of all required procedures needed to determine whether or not
an individual has cancer.
9. Service area: Geographic area served by the organization.
10. Socio-ecological framework: a systems framework with multiple bands of influence (illustrated by a
rainbow -like figure) in which the core of the model is the individual, surrounded by four banks of influence
representing the interpersonal, organizational, community, and policy levels.
11. Subpopulation: Unique populations (example, uninsured or Hispanic) served by the organization for this
project, as approved by CDPHE.
IV. Work Plan:
Goal #1: Reduce breast, cervical and colorectal cancer health disparities, and morbidity and mortality rates, in
Colorado.
Objective #1: No later than the expiration date of the contract, the Contractor shall promote and improve
prevention and early detection of breast, cervical and colorectal cancer among underserved Coloradans served
by and living within the service area of the Contractor.
Priman
Activity #1
The Contractor shall complete the annual CDPHE Cancer Prevention and Early Detection
Assessment and Planning Process to identify needs of and existing activities related to
version: ContrttcrStatement of Work Exhibit B
December 2015
Page I of 5
I 8FHLA I 04208_Ex B
EXHIBIT B
promoting and improving prevention and early detection of breast, cervical and colorectal
cancer among underserved women and men served by and living within the service area of
the Contractor.
xa
Sub -Activities ,.
1
1. The Contractor shall conduct an annual assessment for the organization.
2. The Contractor shall prepare a strategic plan based on results of the assessment with
proposed activities.
3. The Contractor shall prepare for implementation of CDPHE-approved strategies
included in the Contractor's ► Ian.
Primary
Activity #2 '
The Contractor shall provide education in the communities within the service area about
breast, cervical and colorectal cancer prevention and early detection (including during
cancer awareness months), and provide direct assistance to eligible low-income women to
access breast and cervical cancer screenin: services at a health system.
Sob-:1etivities
#,
1. The Contractor shall provide education in the community through presentations,
trainings, and distribution of information, at a minimum number of community
organizations and events, as approved by CDPHE.
2. The Contractor shall provide direct assistance to a minimum number of eligible women
from the identified community subpopulation to access cancer screening services, as
approved by CDPHE.
3. The Contractor shall provide aggregate data on education provided in the community
and individual -level data on women receiving direct assistance to access cancer
screenin:.
Primary
lctivity #3
The Contractor shall navigate eligible low-income women to timely and complete breast and
cervical cancer screening procedures.
Sub -Activities
#3
1. The Contractor shall provide patient navigation to the group(s) of eligible women as
approved by CDPHE.
2. The Contractor shall enter client -level data on qualifying breast and cervical cancer
screenin: • rocedures and • atient navi o ation services into the eCaST data s stem.
Primary
activity #4
The Contractor shall provide CDPHE-funded breast and cervical cancer screening
procedures to eligible low-income women.
Sub- aetiyities
#4
I . The Contractor shall enter data on qualifying procedures into the eCaST data system.
ml
Standards and
Requirements
. The content of electronic documents located on CDPHE and non-CDPHE websites and
information contained on CDPHE and non-CDPHE websites may be updated
periodically during the contract term. The Contractor shall monitor documents and
website content for updates and comply with all updates.
2. The Contractor shall comply with any changes, revisions, inclusions, and exclusions to
the CDPHE Cancer Prevention and Early Detection Program. The CDPHE Cancer
Prevention and Early Detection Program is subject at any time to changes, revisions,
inclusions, and exclusions as needed and/or pursuant to directives or changes required
by rule, regulation, statute or guidance.
3. The Contractor shall comply with all requirements stated in the CDPHE Cancer
Prevention and Early Detection Program Manual. This document is incorporated and
made part of this contract by reference and is available on the following website:
www.cdphecancer.org.
4. The Contractor shall use all CDPHE-required forms.
5. The Contractor shall submit all final reports as non -reimbursable deliverables.
6. The Contractor shall utilize the CDPHE Cancer Prevention and Early Detection
Assessment and Planning Tool Template to complete its annual Assessment and
Planning Process. The template is incorporated and made part of this contract by
reference and is located on the following website: www.cdphecancer.org.
7. CDPHE will review and provide feedback of the CDPHE Cancer Prevention and Early
Detection assessment and planning tool within 30 calendar days of the submission
deadline.
version' Contract Statement . t Work Ifxhihtt B
December 2015
Page 2of5
18FHC.A I04208_Ex B
EXHIBIT B
The Contractor shall be guided by the annual CDPHE Cancer Prevention and Early
Detection continuing application that identifies CDPHE-approved planned strategies.
The annual CDPHE Cancer Prevention and Early Detection continuing application shall
be based on the annual CDPHE Cancer Prevention and Early Detection Assessment and
Planning Process. The Cancer Prevention and Early Detection continuing application
template shall be incorporated and made part of this contract by reference and is located
on the following website: www.cdphecancer.org.
9. CDPHE will review and provide feedback of the CDPHE Cancer Prevention and Early
Detection continuing application within 30 calendar days of the receipt.
10. The Contractor shall attend a post -award orientation provided by CDPHE as well as
other required meetings, trainings, webinars and telephone calls for the purpose of
information -sharing, training, technical assistance and contract monitoring.
11. The Contractor shall notify CDPHE within 15 days of a change in key staff responsible
for the performance of work outlined in this statement of work (SOW).
12. The Contractor shall ensure that new staff members receive required training within two
(2) months of hire.
13. The Contractor shall participate in CDPHE evaluation efforts.
14. The Contractor shall compile required evaluation and program monitoring data.
15. The Contractor shall submit, unless otherwise stated, all deliverables to CDPHE via the
method indicated in the CDPHE Cancer Prevention and Early Detection Program
!Manual.
16. If purchasing gift cards, the Contractor shall provide to CDPHE upon request written
procedures related to gift card purchasing and handling. At a minimum, the procedures
shall include the following:
a. How the gift card inventory is tracked and maintained
b. Gift card storage and safeguards against theft
c. The primary person responsible for securing and distribution of gift cards
d. A gift card distribution log that records each gift card number, dollar amount,
and the printed name and signature of each gift card recipient.
Assessment & Planning Strategy:
1. The Contractor shall utilize the CDPHE-approved assessment and planning tool.
Targeted Community Outreach Strategy:
1. Contractors that provide direct services to individuals 18 years of age and older shall
ensure they only provide services of benefit to individuals lawfully present in the
United States. The Contractor shall maintain documentation demonstrating the
individual's establishment of lawful presence, which shall include documentation of
an appropriate identification document and an affidavit as required by Colorado
Revised Statutes (C.R.S.), Section 24-76.5-103.
Clinical Services and Patient Navigation Strategies:
1. The Contractor shall enter client -level data on qualifying breast and cervical cancer
screening procedures and patient navigation services, performed on or before June
29, into the eCaST data system no later than July 29, annually and in the final year
by December 31.
2 The Contractor shall comply with required current national clinical guidelines.
Current national clinical guidelines are incorporated and made part of this Contract
by reference and are available on the following website at www.cdphecancer.org
3. Contractors that provide direct services to individuals 18 years of age and older shall
ensure they only provide services of benefit to individuals lawfully present in the
United States. The Contractor shall maintain documentation demonstrating the
individual's establishment of lawful presence, which shall include documentation of
an appropriate identification document and an affidavit as required by Colorado
Revised Statutes (C.R.S.), Section 24-76.5-103.
4. For Clinical Services only, the Contractor shall comply with the requirements for
enrollment of eligible women with an eligible breast or cervical cancer diagnosis
into Health First Colorado's Breast and Cervical Cancer Treatment Program
version: Contract Statement of Work - Exhibit B
December 2015
Page 3 of 5
l8FHLA 104208_Ex B
EXHIBIT B
(BCCP).
5. For Clinical Services only, the Contractor shall offer clients printed resource and
referral materials that direct them to the nearest community Medicaid and Connect
for Health Colorado enrollment location(s), including online enrollment options.
Printed resource materials for Medicaid and Connect for Health Colorado shall be
available for clients with Limited English Proficiency (LEP). Contractors that
routinely offer enrollment services onsite are exempt from this requirement because
the services go beyond this minimum requirement. Information on enrollment
resources, referral locations, LEP and outreach and promotional materials is
incorporated and made part of this contract by reference and is available on the
followin_ website www.cd ecancer.or•.
Expected
Results of
Actirity(s)
I . Increased number of individuals screened for breast, cervical and colorectal cancer.
2. Increased number of quality breast, cervical and colorectal cancer screenings provided
within priority populations
Measurement
of Expected
Results
Analysis of programmatic data submissions, including progress reports, annual assessments,
continuing applications and evaluation information.
Completion Date
Deliverables
1. The Contractor shall submit a draft of the annual completed
CDPHE Cancer Prevention and Early Detection assessment
and planning tool for CDPHE review and approval.
Annually, no later than
October l
2. The Contractor shall submit a final annual CDPHE Cancer
Prevention and Early Detection assessment and planning
tool.
Annually, no later than
December 15
3. The Contractor shall submit a draft CDPHE Cancer
Prevention and Early Detection continuing application for
the next funding year (June 30 through June 29) for CDPI-IE
review and approval.
Annually, no later than
January 15
4. The Contractor shall submit a final CDPHE Cancer
Prevention and Early Detection continuing application for
the next funding year (June 30 through June 29).
Annually, no later than
February 28
5. The Contractor shall submit progress reports using a
CDPHE-provided template.
Twice per year, no later
than January 15 and
August 15
6. The Contractor shall submit breast, cervical and colorectal
cancer screening data, if applicable.
Annually, no later than
within 90 calendar days of
end of CDPHE-approved
reporting period
V. Monitoring:
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted throughout
the contract period by CDPHE Cancer Prevention and Early Detection Program Contracts Monitor. Methods used
will include a review of documentation determined by CDPHE to be reflective of performance to include progress
reports and other fiscal and programmatic documentation as applicable. The Contractor's performance will be
evaluated at set intervals and communicated to the contractor. A Final Contractor Performance Evaluation will be
conducted at the end of the life of the contract.
VI. Resolution of Non -Compliance:
The Contractor will be notified in writing within 15 calendar days of discovery of a compliance issue. Within 30
calendar days of discovery, the Contractor and the State will collaborate, when appropriate, to determine the
action(s) necessary to rectify the compliance issue and determine when the action(s) must be completed. The
action(s) and time line for completion will be documented in writing and agreed to by both parties. If extenuating
circumstances arise that requires an extension to the time line, the Contractor must email a request to the CDPHE
Cancer Prevention and Early Detection Program Contracts Monitor and receive approval for a new due date. The
version: Contract Statement of Work - Exhibit 8
December 2015
Page 4 of 5
I 8FHLA104208_Ex B
EXHIBIT B
State will oversee the completion/implementation of the action(s) to ensure time lines are met and the issue(s) is
resolved. If the Contractor demonstrates inaction or disregard for the agreed upon compliance resolution plan, the
State may exercise its rights under the provisions of this contract.
version: Contract Statement of Work - Exhibit B
December 2015
Page 5 of 5
18FHLA I04208_Ex B
EXHIBIT C
COLORADO
Department of Pubic
Health b Envtroieeinent
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Assessment & Planning
Contract Routing # 18 FHLA 104208
Contractor Name
Weld County Department of Public Health
and Environment
Budget Period
1/1/18 - 6/30/18
Project Name
Assessment and Planning Process
Program Contact Name,
Title, Phone and Email
Cynthia Horn, FNP-C, Clinical Manager
970-400-2433 thorn@co.weld.co.us
Fiscal Contact Name, Title,
Phone and Email
Tanya Geiser, Director, Admin Services
(970) 400-2122, tgeiser@weldgov.com
Expenditure Categories
Personal Services
Salaried Employees
Position Title
Description of Work
Budget
Item
Supports
SOW
(Yes/No)
Gross or Annual
Salary
Fringe
Percent of
Time on
Project
Number of
Months
Total Amount
Requested
from CDPHE
Clinical Manager
Lead for grant and Assess/Plan process
Yes
$121,673.00
$47,367.30
0.50%
$422.60
Director HCEP
Strategic Plan writing
Yes
$94,099.00
$36,632.74
0.40%
6
$261.46
Data Specialist
Data Collection
Yes
$95,009.00
$36,987.00
0.30%
$197.99
Personal Services
Hourly Employees
$0.00
Total Amount
Requested
from CDPHE
Position
Title/Employee Name
Description of Work
Budget Item
Supports SOW
(Yes/No)
Hourly Wage
Hourly
Fringe
Total # of
Hours on
Project
TCO Worker
Assessment and Plan Review and Input
Yes
$20.37
$7.93
10
$283
$0
Total Personal Services
(including fringe benefits)
$1,165
Supplies & Operating Expenses
Item
Description of Item (Operating/Supplies)
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Misc. Operating
Supplies
Office supply and printing allocations to complete assessment and
planning process
Yes
$15.00
$30
$0
Total Supplies
& Operating Expenses
$30
Travel
Page 1 of 7
EXHIBIT C
Item
Description of Item (Travel Costs)
Budget Item
S SOW s
OW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Mileage to Post Award
meeting
Mileage to attend mandatory post -award Meeting ($0.515/mile)
Yes
$0.52
231
$119
Meals
Meals while traveling to mandatory post -award meeting (actual receipts)
Yes
$15.00
1
$15
Lodging
Lodging for the mandatory post -award meeting
Yes
$95.00
1
$95
$0
Total Travel
$22 5.4
Contractual
Subcontractor Name
Description of Item
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
North Colorado Health
Alliance
EMR Vendor Support for reports
Yes
$100.00
1
$100
SO
Total Contractual
$l00_
SUB -TOTAL BEFORE INDIRECT
$1,524
Indirect
Item
Description of Item
Total Amount
Requested
from CDPHE
CDPHE-approved
indirect cost rate
agreement
18.08% Total direct costs
$276
Total indirect
$276
Page 2 of 7
EXHIBIT C
COLORADO
Patient Navigation &
H°� t Clinical Services
�
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing # 18 FHLA 104208
Contractor Name
Budget Period
Project Name
Neld County Department of Public Health
and Environment
1/1/18 - 6/30/18
Cancer RFA -
Patient Navigation & Clinical Services
Position Title
Description of Work
Program Contact Name,
Title, Phone and Email
Cynthia Horn, FNP-C, Clinical Manager
970-400-2433 chorn@co.weld.co.us
Fiscal Contact Name, Title,
Phone and Email
Tanya Geiser, Director, Admin Services
(970) 400-2122, tgeiser@weldgov.com
Expenditure Categories
Personal Services
Salaried Employees
Budget
Item
Supports
SOW
(Yes/No)
Gross or Annual
Salary
Fringe
Percent of
Time on
Project
Number of
Months
Total Amount
Requested
from CDPHE
Clinical Manager
Provide Clinical Supervision and assure
clinic is prepared to serve clients
Yes $121,673.00 $47,367.30
Personal Services
Hourly Emp
0.60%
6
$507.12
$0.00
Position
Title/Employee Name
Description of Work
T
Budget Item
Supports SOW Hourly Wage
(Yes/No)
Hourly
Fringe
Total 4 of Total Amount
Hours on Requested
Project from CDPHE
Office Technician MS
Support Patient Navigator/Clinical Services (make
copies, answer phones, interpret as needed, etc)
Yes
$20.85
$8.12
24
$695
Patient Navigator
Time spent on reports, chart audits, program
evaluation and site visits; (rest of position billed under
bundled payment system per CDPHE)
Yes
$20.37
$7.93
26
$736
$0
Total Personal Services
(including fringe benefits)
$ 1,938
Supplies & Operating Expenses
Item
Description of Item (Operating/Supplies)
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Patient Navigation
with Clinical Services
Procedures
Billed in eCaST through 6/30/18 for Eligible Uninusured/Underinsured
Clients Ages 21-39
Yes
$155 00
60
$9,300
Patient Navigation
with Clinical Services
Procedures
Billed in eCaST through 6/30/18 for Eligible Uninusured/Underinsured
Clients Ages 40-64
Yes
$351.00
49
$17,199
Page 3 of 7
EXHIBIT C
Operating/supplies
Allowable purchase of supplies/operating listed on the WWC Patient
Navigation and Clinical Services allowable purchase document on the
WWC website: www.cdphecancer.org
Yes
$4,302.00
1
$4,302
So
&
rota! Supplies
Operating Expenses
$30,801
Travel
Item
Description of Item (Travel Costs)
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Travel
Travel expenses to attend Cancer/Clinical Conference
Yes
$1,000.00
2
$2,000
Mileage
Mileage to attend required Post Award Meeting
Yes
$0.515
231
$119
Meals
Meals while traveling to/from required Post Award Meeting
Yes
$15.00
1
$15
Lodging
Lodging for the required Post Award Meeting
Yes
$95.00
1
$95
$0
Total Travel
$2,224
Contractual
Subcontractor Name
Description of Item
p
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
�0
Total Contractual
$�
SUB -TOTAL BEFORE INDIRECT
$34,968
Indirect
Item
Description of Item
-:✓tai Amourvt
Requested
from CDPHE
CDPHE-approved
indirect cost rate
agreement
18.08% Total direct costs
$1,531
Total Indirect
$1,531
TOTAL
49_
Page 4 of 7
EXHIBIT C
AirCOLORADO
De of
Health 6 Environment
Pubiic
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Targeted Community Outreach
Contract Routing # 18 FHLA 104208
Contractor Name
Budget Period
Project Name
Weld County Department of Public Health
and Environment
1/1/18 - 6/30/18
Cancer RFA -
Targeted Community Outreach
Program Contact Name,
Title, Phone and Email
Cynthia Horn, FNP-C, Clinical Manager,
970-400-2433 thorn@co.weld.co.us
Fiscal Contact Name, Title,
Phone and Email
Tanya Geiser, Director, Admin Services
1970) 400-2122, tgeiser@weldgov.com
Position Title
Description of Work
Expenditure Categories
Personal Services
Salaried Employees
Budget
Item
Supports
SOW
(Yes/No)
Gross or Annual
Salary
Fringe
Percent of
Time on
Project
Number of
Months
Total Amount
Requested
from CDPHE
Supervisor AO
Provide supervision and oversight to the
TCO Worker and the program.
Yes
$107,545.00
$41,867.27
1.75%
$1,307.36
Personal Services
Hourly Employees
Total Amount
Requested
from CDPHE
Position
Title/Employee Name
Description of Work
Budget Item
Supports SOW
(Yes/No)
Hourly Wage
Hourly
Fringe
Total # of
Hours on
Project
Target Community
Outreach Worker 1.0
FTE
Facilitate community events and work with community
organizations to provide outreach and education about
breast, cervical and colon cancer screenings, provide
information about local resources, identify women
eligible to receive direct assistance
Yes
$20.37
$7.93
1040
$29,432
Office Technician MS
Administrative program support; answering phone
calls, preparing mailings, clerical support to assist
Targeted Community Outreach Worker
Yes
$ 20.85
$8.12
26.00
$753
Total Personal Services
(including fringe benefits)
$31,493
Supplies & Operating Expenses
Description of Item (Operating/Supplies)
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Page 5 of 7
EXHIBIT C
Electronic Medical
Record Fees
The TCO Worker will take a laptop to outreach events and will utilize
Electronic Medical Records to schedule screening appointments for
clients. EMRs will also be used to verify information and screening status.
Yes
$15.00
6 $90
Phone Service
The program will use a cell phone for outreach through phone calls and
text messages as well as for use as a Wifi hot spot when at community
events.
Yes
$70.00
6 $420
Printed Materials
Postcards and flyers for distribution at events as outreach to new clients
in the community; we plan to send 500 postcards in spring (Cervical
Health Awareness) from names gathered from community events and
handing out 500 flyers at outreach events; may also, may also include
printing allocations.
Yes
$0.50
1000
$500
Postage
Postage for postcards sent in spring and other misc postage costs
Yes
$0.40
500
$200
Program Supplies
Coffee and snacks provided during events to open a conversation with
potential clients
Yes
$10.00
30
$300
Marketing Materials
Small incentives at events and larger incentives to women who are
provided direct assistance/get screened at the WCDPHE clinic.
Yes
$0.50
500
$250
Client Transportation
Gift cards or bus tickets to help clients with transportation costs
Yes
$10.00
6
$60
Interpretation
Interpretation as needed for education
Yes
$25.00
1
$25
Misc. Operating/Office
Supplies
Office and other supplies and non -consumable small items of equipment
as needed. May include allocations and/or small items of equipment.
Yes
$25.00
6
$150
$0
Total Supplies
& Operating Expenses
$1,995„
Travel
Item
Description of Item (Travel Costs)
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
Mileage to outreach
events
TCO Worker will attend community events and meetings across Weld
County. Estimated 375 miles/ month x 6 months x .515 per mile.
Yes
$0.515
2250
$1,159
Mileage to one day
meetings
TCO Worker will attend a mandatory post -award meeting 515 mile
(.515/mile) )
Yes
$0.515
240
$124
Meals
Meals while traveling to/from post -award meeting
Yes
$15.00
1
$15
Lodging
Lodging for the Post -Award Meeting.
Yes
$95.00
1
$95
$0
r
Total Travel
$1,392
Contractual
Subcontractor Name
Description of Item
Budget Item
Supports
SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested
from CDPHE
TBD
Work with local media outlets and advertisers to promote breast, cervical
and colorectal awareness; could include bus bench advertising or radio
spots
Yes
$575.00
1
$575
$0
$0
Page 6 of 7
r
Total Contractual
$57
SUB -TOTAL. BEFORE INDIRECT
$35,455
indirect
Item
Description of Item
Total Amount
Requested
from CDPHE
CDPHE-approved
indirect cost rate
agreement
18.08% Total direct costs
$6,410
Total Indirect
$6,410
TOTAL CONTRACT: $80,164.00
EXHIBIT D
OPTION LETTER
Date:
State Fiscal Year:
Option Letter No.
Original Contract CMS#
Option Letter CMS Routing #
CORE Encumbrance #
DELETE all BLUE text, CUSTOMIZE Red text and CHANGE Red text to Black after customization.
1) OPTIONS: Choose all applicable options listed below
a. Option to extend for a renewal or additional term
b. Option to change amount of goods
c. Option to change amount of services
d. Option to change contract rates
e. Option to initiate next phase of contract
2) REQUIRED PROVISIONS. All Option Letters shall contain the appropriate provisions set forth below:
a. For use with Options a: In accordance with Section(s) enter section the Original Contract referenced above between the
State of Colorado, Colorado Department of Public Health and Environment, and enter Contractor's name the State hereby
exercises its option for an additional term beginning insert start date and ending on insert end date at the rates stated in the
Original Contract, as amended.
b. For use with Option b and c. In accordance with Section(s) enter Section of the Original Contract routing number
referenced above, between the State of Colorado, Colorado Department of Public Health and Environment, and enter
Contractor's name the State hereby exercises its option to Increase/Decrease the quantity of Goods/Services or both at the same
cost/price as specified in enter Exhibit/Attachment name.
c. For use with Option d. In accordance with Section(s) enter section of the Original Contract routing number referenced
above, the State hereby exercise its option to modify the Contract rates specified in Exhibit/Section Number. The Contract rates
attached to this Option letter in Exhibit/Attachment Name replace the rates in the original Contract as of the Option Effective
Date of this Option Letter.
d. For use with Option e: In accordance with Section(s) enter section of the Original Contract routing number referenced
above, the State hereby exercise its option to initiate Phase indicate which Phase: 2, 3, 4 etc. which shall begin on insert start
date and ending on insert end date at the cost/price specified in Section enter section the Original Contract referenced above.
e. For use with Options a, b, c that modify the contract value: The amount of the current Fiscal Year contract value is
increased/decreased by $ enter amount of change to a new contract value of insert new $ amount as consideration for
services/goods ordered under the contract for the current fiscal year Indicate Fiscal Year. The first sentence in Section enter
section of the original contract is hereby modified accordingly. The amended total contract financial obligation including all
previous amendments, option letters, etc. is insert new $ amount.
3) Effective Date: The effective date of this Option Letter is upon approval of the State Controller if exact date is required complete
the following: enter date, and include the following: whichever is later.
STATE OF COLORADO
John W. Hickenlooper, GOVERNOR
Department of Public Health and Environment
PROGRAM APPROVAL:
By:
By: Lisa McGovern, Purchasing & Contracts Section Director
Date:
Date:
%LL CONTRACTS REOLTRE APPROVAL BY THE STATE CONTROLLER
CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below
by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins
performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or
services provided hereunder.
STATE CONTROLLER
Robert Jaros, CPA, MBA, JD
By:
Date:
Contract_Sample OptionLetter_ 17 9 18
Page 1 of 1
EXHIBIT E
GRANT FUNDING CHANGE LETTER
Date:
State Fiscal Year:
Grant Funding Change
CMS Routing #
Letter (GFCL) #
CORE Encumbrance #
TO: <Insert Grantee's name>
In accordance with Section of the Original Contract routing number , [insert the following language here if
previous amendment(s), renewal(s) have been processed] as amended by [include all previous amendment(s), renewal(s) and
their routing numbers], [insert the following words here if previous amendment(s), renewal(s) have been processed] between the State
of Colorado, Department of Public Health and Environment and <insert contractor name> beginning <insert
start date of original contract> and ending on <insert ending date of current contract amendment>, the undersigned commits
the following funds to the Grant:
The amount of (federal, state, other) grant funds available and specified in Section of <insert previous
contract modification number and routing number> is ❑ increased or ❑ decreased by $ amount of change to new total
funds for the period <date to date> of $ <insert new period cumulative total> for the following reason:
Section is hereby modified accordingly. The revised Budget is incorporated herein by this reference and
identified as Revised Exhibit *. (if budget attached; delete sentence if no budget included.)
Complete the table below; insert/delete rows as needed.
The table below reflects the original budget and all modifications to the total since the effective date of the Original
Contract.
SUMMARY OF CHANGES
Document Type
CMS Routing
#
Funding Source
(federal, state, other)
Period
Dollar Amount
Period
Total
Original Contract
$
$
$
$
$
$
$
$
$
$
Contract Cumulative Grand Total
$
This Grant Funding Change Letter does not constitute an order for services under this Grant.
The effective date of hereof is upon approval of the State Controller or <insert projected effective date>,
whichever is later.
STATE OF COLORADO PROGRAM APPROVAL
John W. Hickenlooper, Governor Colorado Department of Public Health and
Department of Public Health and Environment Environment
By: By:
Lisa McGovern INSERT -Name of Authorized Individual
Purchasing and Contracting Section Director. CDPHE INSERT -Official Title of Authorized Individual
Date Date
In accordance with §24-30-202 C.R.S., this Contract is not valid until signed and dated below by the State Controller or an authorized
delegate.
STATE CONTROLLER
Robert Jaros, CPA, MBA, JD
By:
Name of Agency Delegate -Please delete if contract will be routed to 0SC for approval.
Effective Date:
I(Amu act Grant Funding Change 1etter ( 1 I ) ver O.4 17 PageI of III
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