HomeMy WebLinkAbout20142738.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR MATERNAL AND CHILD HEALTH (MCH)
PROGRAM AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Task Order Contract for the Maternal
and Child Health (MCH) Program 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 October 1, 2014, and ending September 30, 2015, 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 the Maternal and Child Health (MCH) Program
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the 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 8th day of September, A.D., 2014.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, C LORADO
ATTEST: t 'e1 ch Lin_
_
Dough ademach r, Chair
1
Weld County Clerk to the BoardBY:
• rbara Kirkmeyer, ro-Tem
4 y Clerk to a Bo ( '�"
De g fir.., , ��.; _ i
"tan P. Conway 3
•
Mike Fre
Coun y Attorney
William F. Garcia
Date of signature: 9/80
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1 °11 2014-2738
H L0d44
1861 Memorandum
TO: Douglas Rademacher, Chair
-LINTY -! Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH, Executive Director
Department of Public Health &Environment
DATE: September 4, 2014
SUBJECT: FY14-15 Continuation Task Order Contract
for the Maternal and Child Health (MCH)
Program
Enclosed for Board review and approval is a contract between the Colorado Department of
Public Health and Environment and the Board of County Commissioners of Weld County on
behalf of the Weld County Department of Public Health and Environment.
The term of the contract is from October 1, 2014, through September 30, 2015. Total funding
for this renewal period will not exceed $326,470. The MCH program encompasses four
separate and distinct programs as described below.
Early Childhood Obesity Prevention
The 2010 Colorado Child Health Survey data demonstrates that 22.9% of Colorado children ages
2 to 14 are overweight or obese. It is known that being overweight or obese leads to a variety
of health problems, especially later in life. The Weld County Five-Year Community Health
Improvement Plan identified obesity prevention as a top priority area to be addressed over the
course of the next five years. In partnership with initiatives already underway at WCDPHE, the
goal for the strategies addressed in the Early Childhood Obesity Prevention Action Plan is to
focus closely upon the maternal and child population and be a voice for maternal and early
childhood health in existing partnerships and efforts.
Health Care Program for Children with Special Needs (HCP): Care Coordination
The HCP program provides services to Weld County children and youth with special health care
needs from birth to age 21, who have, or are at risk for, physical, developmental, behavioral or
emotional conditions. There are no financial or diagnostic criteria; services are free to the
family. The HCP program provides information and resources, individual care
coordination/case management, access to primary and specialty care, and referral to
community resources. This program also facilitates the development and enhancement of
community-based systems of care for children and youth with special health care needs.
Services provided will include interagency collaboration, consultation, and community
involvement.
Health Care Program for Children with Special Needs (HCP): Medical Home
HCP identified the need for a high level stakeholder committee to address barriers to a Medical
Home approach for addressing medical needs of the "resource-challenged" children and
2014-2738
families of Weld County. HCP initiated the Weld Child Resource Consortium (WCRC) in
February 2013. Our three-year plan for this consortium composed of representatives from 17
Greeley/Weld agencies who will continue in 2014-2015 to explore opportunities to eliminate
barriers to the Medical Home approach and to expand exploration of resources that will
support the healthcare needs of all children and youth within the medical home neighborhood
of Weld County.
Adolescent Health & Injury Prevention
This program's focus is directed to the Teen Motor Vehicle Safety program and the successful
program of DRIVE SMART Weld County to help meet their goal of decreasing deaths and
injuries from motor vehicle crashes among adolescents aged 14-19. The program will support
and expand the DRIVE SMART Weld County community traffic safety coalition, increase
knowledge of graduated drivers license laws and willingness to issue citations among law
enforcement personnel, provide safe teen driving programs to students at Weld County high
schools, continue providing P.A.R.T.Y. (Prevent Alcohol and Risk-related Trauma in Youth)
programs to students at Weld County high schools, and provide classes for parents and teens
about graduated driver's licensing laws (GDL).
This FY14-15 Continuation Task Order Contract for the Maternal and Child Health (MCH)
Program was approved for placement on the agenda by the Board via pass-around dated
August 22, 2014.
I recommend approval of this FY14-15 Continuation Task Order Contract for the Maternal and
Child Health (MCH) Program.
DEPARTMENT OF PUBLIC I IEALTH AND ENVIRONMENT
CMS ROUTING NO.15 FHLA 72161
APPROVED TASK ORDER CONTRACT-WAIVER#154
This Task Order Contract is issued pursuant to Master Contract made on 01/17/2012,with routing number 13 FAA 00051
STATE: CONTRACTOR:
State of Colorado for the use& benefit of the Board of County Commissioners of Weld
Department of Public Health and County
Environment 915 10th Street
PSD/MCH Greeley,Colorado 80632-0758
4300 Cherry Creek Drive South for the use and benefit of the Weld County
Denver,Colorado 80246 Department of Public Health and
Environment
1555 North 170i Avenue
Greeley, Colorado 80631
TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE:
7/15/2014 Colorado Political Subdivision
CORE ENCUMBRANCE NUMBER:
CT O201sbo0C Ool59v
TERM: BILLING STATEMENTS RECEIVED:
This Task Order shall be effective upon Monthly
approval by the State Controller,or designee,
or on 10/01/2014,whichever is later. The STATUTORY AUTHORITY:
Task Order shall end on 09/30/2016. C.R.S. 25-1.5-101, 25-4-709
PRICE STRUCTURE: CONTRACT PRICE NOT TO EXCEED:
Cost Reimbursement $326,470.00
PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS: $176,511.04
Exempt STATE FUNDING DOLLARS: $149,958.96
BID/REP/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR:
Not Applicable FY 15: $326,470.00
LAW SPECIFIED VENDOR STATUTE:
Not Applicable
STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE:
Heather Baumgartner Tanya Geiser
Department of Public Health and Environment Administrative Services Director
PSD/MCH Weld County Department of Public Health and
4300 Cherry Creek Drive South Environment
Denver,Colorado 80246 1555 North 17'1 Avenue
Greeley,Colorado 80631
SCOPE OF WORK:
Develop,implement and evaluate evidence-based MCH Action Plans,HCP Care Coordination services,and
HCP Specialty Clinics.
Contract_Template_Task_Order_070714 Page 1 of 6
EXHIBITS,
The following exhibits are hereby incorporated:
Exhibit A- Additional Provisions (and its attachments if any—e.g.,A-1,A-2, etc.)
Exhibit B- Statement of Work(and its attachments if any—e.g.,B-1,B-2, etc.)
Exhibit C - Budget(and its attachments if any—e.g., C-1, C-2, etc.)
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.
1. 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(1),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
Contract_Template_Task_Order_070714 Page 2 of 6
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
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 change 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 §24-105-102 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
Contract_Template_Task_Order_070714 Page 3 of 6
prohibit Contractor from bidding on future contracts.Contractor may contest the final evaluation and result
by: CO 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, 107,201 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.
Contract Template_Task_Order_070714 Page 4 of 6
THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE OF COLORADO:
Board of County Commissioners of Weld County John W. Hiekenlooper, GOVERNOR
for the use and benefit of the Weld County
Department of Public Health and Environment
(a political subdivision of the State of Colorado)
Legal Name of Contracting Entity By
SEP 08 2014 yC/a�
For Exe five Director
Date Q
(� .�,w�Qne-` Department of Public Health and Environment
Signature of Authorized Officer
Douglas Rademacher
Print Name of Authorized Officer
Department Program i� Approval:
Chair By (/(Ptd / ✓/j
Print Title of Authorized Officer 11
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS§2430-202 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 kU adada),
Date G 17-1
d /o
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Contract_Template_Task_Order_070714 Page 6 of 6
EXHIBIT A
ADDITIONAL PROVISIONS
To Contract Dated 07/15/2014-Contract Routing Number 15 FHLA 72161
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified
above.
This Contract contains state and federal funds(see Catalog of Federal Domestic Assistance(CFDA)
number 93.994)The Federal Award Notification Number(FAIN) is B04MC26654.
2. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 27,Annual
Audit, for the purpose of this Task Order,the Contractor is a Subrecipient as defined by Office of
Management and Budget(OMB)Circular A-133 (Audits of States, Local Governments,and Non-Profit
Organizations).
3. The Contractor's DUNS number is 075757955.
4. To receive compensation under the Contract,the Contractor shall submit a signed Monthly CDPHE
Reimbursement Invoice Form. This form is accessible from the CDPHE interact website
http://www.colorado.gov/cs/Satellite/CDPHE-Main/CBON/1251622941228 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 the 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: MCH Generalist Consultant at
cdrthe.asmchreports@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.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
5. Time Limit For Acceptance Of Deliverables.
a. Evaluation Period. The State shall have thirty(30)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 thirty(30)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.
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EXHIBIT A
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 thirty(30)
calendar days,to correct the noted deficiencies.
6 Health Insurance Portability and Accountability Act(HIPAA)Business Associate Determination.
The State has determined that this Contract does not constitute a Business Associate relationship under
HIPAA.
7. The list of acronyms is attached hereto as Attachment A-I.
8. If Contractor indicates full expenditure of funds under this Contract by May 30 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.The State will notify the Contractor of the potential
need to decrease the current or upcoming budget. If the Contractor indicates at a later date than May 30 of
each grant year an expectation of surplus of funds or inability to fully expend said funds for unforeseen
circumstances that Contractor had not anticipated by May 30, 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.
9. Contractor shall request prior approval in writing from the State for all modifications to 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. Contractor shall submit a Budget Revision Request Form incorporated and
made part of this Task Order Contract by reference and located at www.mchcolorado.org. Any request for
modifications to the Budget in excess of twenty-five percent(25%)of the total budget for direct costs or
$250,000.00,whichever is less, shall be submitted to the MCH Generalist Consultant at least 90 days prior
to the end of the contract period and may require an amendment in accordance with General Provisions,
Section 5,of this Task Order Contract. The Contractor is required to request and receive prior approval in
writing via email by the MCH Generalist Consultant if there are permanent or temporary changes in any
MCH-funded line item supporting staff positions.
10. The Contractor shall adhere to the same guidance as the State when considering food and beverage
purchases. Food or beverages may be purchased for events related to the MCH action plan such as training,
community meetings or events that engage external stakeholders,and/or multi-county regional meetings.
Title V and State General funds may not be used to purchase food or beverages while conducting routine
staff meetings and specialty clinics.Contact the MCH Generalist Consultant if guidance is necessary
I I. Contractor shall retain and use all revenues generated by MCH Program for services in those programs.
The revenue cannot be used for other programs or purposes.
12. Title V, Section 504(b)(6).Title V funds may not be used to pay for any item or service(other than an
emergency item or service) furnished by an individual or entity convicted of a criminal offense under the
Medicare or any State health care program(i.e., Medicaid, Maternal and Child Health,or Social Services
Block Grant Programs).
13. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9, Rights in
Data, Documents and Computer Software or Other Intellectual Property, unless otherwise provided for,all
data collected or produced or derived exclusively from the Contractor's or subcontractor's work under this
Task Order Contract shall remain the sole property of the State, whether in individual, aggregate, identified
or de-identified form or any other form required by the State. To facilitate follow-up,research,surveillance
and evaluation, any such data collected, used or acquired shall be made available in any form required by
the State,to the State and any other entity designated by the State.
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EXHIBIT A
Any such 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. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9, Rights in
Data, Documents and Computer Software or Other Intellectual Property, or Section 23.i,General
Provisions, Media or Public Announcements, the State of Colorado, specifically the Department of Public
Health and Environment, shall be the owner of all printed materials,graphic representations,educational
materials, audio-visual products, or any other media, in whatever form,created under this Task Order
Contract. This requirement applies,but is not limited to,any brochure,flyer,presentation, billboard,radio
spot, website, banner advertisement. The State reserves the right to require logos, or other wording on any
material,representation, product or other media form created under this Task Order Contract.
Any material, representation, product or other media form that will use the State's or logo or information
must be approved by the State prior to production and distribution. A minimum of ten (10)business days is
required for the review and approval process.
15. 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. The law also applies to children's services that are provided in
indoor facilities that are constructed, operated,or maintained with such Federal funds. The law does not
apply to children's services provided in private residences; portions of facilities used for inpatient drug or
alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or
Medicaid; or facilities where Women, Infants and Children(WIC)coupons are redeemed. Failure to
comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty
of up to$1,000 for each violation and/or the imposition of an administrative compliance order on the
responsible entity. By signing this Task Order Contract, Contractor certifies that Contractor shall comply
with the requirements of the Act and shall not allow smoking within any portion of any indoor facility used
for the provision of services for children as defined by the Act. Contractor agrees that it shall require the
language of the Act be included in any subcontracts which contain provisions for children's services and
that all subcontractors shall sign and agree accordingly.
16. Notwithstanding the terms contained in the General Provisions of the Master Contract, Section 10,
Confidential or Proprietary Information,the 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 Task Order 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 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.
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EXHIBIT A
17. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding
Letter substantially equivalent to Attachment A-2. The Grant Funding Change Letter is not valid until it
has been approved by the State Controller or designee.
18. The State may require continued performance for a period of up to 4 years at the same rates and same terms
specified in the Task Order Contract. If the State exercises the option, it will provide written notice to
Contractor at least 30 days prior to the end of the current contract term in a form substantially equivalent to
Attachment A-3. If exercised, the provisions of the Option Letter shall become part of and be
incorporated into the original Task Order Contract.The total duration of this Task Order Contract,
including the exercise of any options under this clause, shall not exceed 5 years.(Note: 5 years is the
maximum allowable.)
19. The Contractor shall not charge for services those individuals of families at or below the official poverty
guidelines,updated periodically in the Federal Register by the U.S. Department of Health and Human
Services under the authority of42 U.S.C.9902(2), in accordance with Title V, Section 501 (I)(B)and
Section 505 (5)(D). The most current version of this document is available on the MCH website:
www.mchcolorado.org and is incorporated and made part of this Task Order Contract by this reference and
the Health Care Program for Children with Special Health Care Needs(RCP) website
www.hcpcolorado.org and is incorporated and made part of this Task Order Contract by this reference. If
the State receives new poverty guidelines from the DHHS during the term of this Task Order Contract,the
State shall immediately update the guidelines on the MCH and HCP websites. The Contractor shall use
these new poverty guidelines, if any, when posted to the websites.
If any charges are imposed for services to clients who are above the one hundred percent(100%)of poverty
level, such charges must be on a sliding scale which takes into account the client's family size, income and
resources. These charges and the sliding fee scale must be made available to the general public and to all
clients and must be based on the agency's usual and customary cost for the service. Clients must
understand they shall not be denied services for inability to pay any of the sliding fee charges.
20. The State may require forms attached to this Task Order Contract and incorporated herein by reference be
updated during the term of this Task Order Contract. The Contractor will be informed of the new forms as
they are developed. Forms may be sent to contractors or will be available on the MCH web site:
www.mchcolorado.org or the HCP web site: www.hcpcolorado.org and are incorporated and made part of
this Task Order Contract by reference
To be attached to CDPHE Page 4 of 4 Revised:07/17/12
Version 1.0(3/12)contract template
Attachment A-1
Commonly Used Acronyms and Abbreviations That May Be Referenced In the Scope of Work:
ACS American Cancer Society
ACNS Alamosa County Nursing Service
ACF Administration for Children and Families
ADA Americans with Disabilities Act
ADAD Alcohol and Drug Abuse Division
AHA American Heart Association
AIDS Acquired Immune Deficiency Syndrome
ALA American Lung Association
ALA(C) American Lung Association(of Colorado)
AMCHP Association of Maternal Child Health Programs
ANR Americans for Non-Smokers' Rights
ARC Addiction Recovery Centers
ARRA American Recovery and Reinvestment Act
ASC Adams State College
ASSIST American Stop Smoking Intervention Study
ASTHO Association of State and Territorial Health Office
B&G Boys&Girls
BACCHUS BACCHIIS Peer Education Network
BAG Build a Generation
BBLHC Boulder Broomfield Latino Health Coalition
BC Boulder County
BCCP Breast and Cervical Cancer Program
BCHD Bent County Health Dept
BCPH Boulder County Public Health
BCPHA Baca County Public Health Agency
BCDSS Baca County Dept Social Services
BCTEPP Bent County Tobacco Education Prevention Partnership
BGC Boys&Girls Club
BGCMD Boys&Girls of Metro Denver
BHS Broomfield High School
BMTF Baby&Me Tobacco Free
BOCES Board of Cooperative Educational Services
BOI I Board of Health
DRESS Behavioral Risk Factor Surveillance System
BVBAG Buena Vista Build a Generation
BVSD Boulder Valley School District
Bx Biopsy
C Choice
CAD Coronary Artery Disease
CASH Colorado Association of School Board
CB Community-based System
CBE Clinical Breast Exam
CBO Community-based Organization
CC Clear Creek
CC Custer County
CC Community Coordination/Coordinator
CCAP Larimer County Child Care Assistance Program
CCC Colorado Cancer Coalition
CCCHE Colorado Community Coalition for health Equity
CCGC Colorado Clinical Guidelines Collaborative
CCLAA Colorado Clean Indoor Air Act
CCMC Colorado Clinical Managed Care Network
CCMC Commission for Case Manager Certification
CCPD Cancer,Cardiovascular,and Pulmonary Disease
Page 1 of 6
Attachment A-I
CCTCI Colorado Chen Tobacco Collaborative Initiative
CCTEPP Custer County Tobacco Education Prevention Partnership
CDC Centers for Disease Control and Prevention
CDE Colorado Department of Education
CDPI IE Colorado Department of Public I lealth and Environment
CDII Chronic Disease Unit
CEC Career Education Center
CEO Chief Executive Officer
CFDA Catalog of Federal Domestic Assistance
CFFC Colorado Foundation for Families and Children
CFPI Colorado Family Planning Initiative
CHIN Community Health Information Network
CICP Colorado Indigent Care Program
CJ D Colorado Judicial Department
CM Case Management
CMC Colorado Mountain College
CMS Contract Management System
CMS Creative Media Solutions
CNCC Colorado Northwestern Community College
CNS County Nursing Service
CO Colorado
COD Colorado Donated Dental Services Program
COPAN Colorado Physical Activity and Nutrition Program
COV Colorado Van Program
CPCF Colorado Parent and Child Foundation
CPIIA Colorado Public Ilealth Association
CPT Current Procedural Technology
CRC Colorectal Cancer
CRCCP Colorectal Cancer Screening Program
CRLIF Culturally Responsive Urban Education
CSAP Colorado Student Assessment Program
CSI I Coordinated School Ilealth
CSI1 Colorado State University
CSII-P Colorado State University-Pueblo's
C'fC Connect to Care
CTEPA Colorado Tobacco Education and Prevention Alliance
CTFK Campaign for Tobacco-Free Kids
CTRP Colorado Tobacco Research Program
CTP Crossroads Turning Point
CI) University of Colorado. Boulder
CWCCI Colorado Women's Cancer Control Initiative
CY Contract Year
DAISI Denver At-home Intervention Son ice Initiative
DASH Division of Adolescent&School l lealth (CDC)
DC MI I Delta County Memorial Hospital
DI I Denver Health
1)111 IA Denver Health and I hospital Authority
DI IS Department of Human Services
DIMS Unites States Department of Ilealth and Human Services
DOR Department of Revenue
DOS Delta Opportunity School
DSS Department of Social Services
E&l Education and Information
LAP Employee Assistance Program
EBI IV Evidence-Based Home Visiting to Prevent Child Maltreatment Grant Program
ECC Early childhood council
FCC Electrocardiogram
ECCLC Early Childhood Council of l.arimer County
Page 2 of 6
Attachment A-1
ECI.C Early Childhood Leadership Council/Commission
E.D. Executive Director
EHR Electronic Health Record
ENS Early Hcad Start
F.MR Electronic Medical Record
EMT Emergency Medical Technicians
EPA Environmental Protection Agency
EPE Epidemiology Planning and Evaluation
ESL English as a Second Language
EfS Environmental Tobacco Smoke(a.k.a.secondhand smoke)
FIRC Family and Intercultural Resource Center
FICA The Federal Insurance Contribution Act
FDA Food and Drug Administration
FIT/FOBT Fecal Immunochemical Test/Fecal Occult Blood Test
FNA Final Needle Aspiration
FPP Family Planning Program
FPL Federal Poverty Level
FRCC Front Range Community College
FTE Full Time Equivalent
FLIP File Transfer Protocol
FY Fiscal Year
FYI Family Youth Initiatives
GASO Great American Smoke-out
GED General Education Development
GASP CO Group to Alleviate Smoking Pollution of Colorado
Get R!EAL(GR) Resist! Expose Advertising Lies(Youth Empowerment Program)
GI TIT Gay, Lesbian.Bisexual.and Transgender
GYN Gynecological
MCP Health Care Program For Children with Special Needs
HCYS Huerfano County Youth Services
HI IS Health and Human Services
I IIPPA Health Insurance Portability and Accountability Act of 1996
HIPPY Home Instruction for Parents of Preschool Youngster
HIT Health Improvement Team
HIV Human Immunodeficiency Virus
HPV Human Papillomamavirus
HR human Resources
hr hour
IIRSA Health Resources and Services Administration
HSI. High School Leadership
ID Identification
IIK Invest in Kids
ISHT Interagency School Health Team
IT Information Technology
JAC Juvenile Assessment Center
KIS Keeping in STEPP
KMH Keefe Memorial Hospital
KPC Kevin Patrick Caleum
LAIICDHD Las Animas Iluerfano Counties District Health Department
LBW Low Birth Weight
LC Learning Community
LGBT Lesbian,Gay,Bisexual.Transgender
LEM Latins en Movimiento
LHA Local Health Agency
I.HD Local Health Department
LLC Limited Liability Company
LRCC Latino Regional Community Coalition
LRPC Latino a Research and Policy Center
Page 3 of 6
Attachment A-1
LST Life Skills Training
LSTPEN Latino Statewide Tobacco Prevention and Education Netw
LWB Live Well Broomfield
MCI IA Montezuma Housing Authority
MCHD Montezuma County Health Department
MCHS Montezuma-Cortez High School
MCPN Metro Community Provider Network
MCRC Media Campaign Resource Center—CDC
MD Medical Doctor
MHCBBC Mental Health Center Serving Boulder and Broomfield Counties
MIECHV Maternal,Infant and Early Childhood Home Visiting Program
MO Month
MOB Medical Office Building
MOU Memorandum of Understanding
MPA Master of Public Administration in Health and Human Services
MPH Master of Public Health
MRI Magnetic Resonance Imaging Scan
MS Master of Science
MSA Master Settlement Agreement
MUH Multi-user Housing
MYAT Multi-Disciplinary Youth Assessment Team
N/A Not Applicable
NACCHO National Association of County and City Health Officials
NACR Native American Cancer Research
NAQC North American Quitline Consortium
NASBE National Association of State Board of Education
NCCRT National Colorectal Cancer Round Table
NCHD Northeast Colorado Health Department
NCI National Cancer Institute
NE North East
NFP Nurse-Family Partnership
NFPNSO Nurse-Family Partnership National Service Office
NHVP Nurse Home Visitor Program
NIDA National Institute on Drug Abuse
NIH National Institute of Health
NJH National Jewish Medical and Research Center
N-O-T Not-on-Tobacco,(ALA's Youth Smoking Cessation Program)
NP Nurse Practitioner
NPP Nurturing Parenting Program
NRT Nicotine Replacement Therapy
NSBA National School Boards Association
OSH Office on Smoking or Health (CDC)
OTC Over the Counter
PA Physician's Assistant
PAC Prevention Awareness Crew
PACT Partners Assessing Chew Tobacco
PAT Parents as Teachers
PCCHD Pueblo City-County Health Department
PPC Personal Care Providers
PE Presumptive Eligibility
PEN Parent Engagement Network
PVCHC Peak Vista Community Health Center
PI IN Public Health Nurse
PIO Public Information Officer
PM Peer Mentor
PMC Parkview Medical Center
PMR Planning Management Region
PN Patient Navigator
Page 4 of 6
Attachment A-1
PO Purchase Order
PPC Policy Partner Committee
PPFC Pikes Peak Family Connections
PPN Prevention Policy Network
PRA Policy Resource Alliance
PRAMS Pregnancy Risk Assessment and Monitoring Survey
PRIDE Pure Respect Initiative Direct Education
PSA Public Service Announcement
PSD Prevention Service Division
PTEPP Pueblo Tobacco Education and Prevention Partnership
PVC Prairie View Clinic
Q I Quarter One
Q2 Quarter Two
Q3 Quarter Three
Q4 Quarter Four
QI Quality Improvement
QOL Quality of Life
RDAC Regional Disparities Advisory Council
RFA Request for Applications
RFP Request For Proposals
RIE Reach,Implementation and Effectiveness
RII IEL Regional Institute for Health and Environment
RMC Rocky Mountain Center for Health Promotion& Education
RMRH Rocky Mountain Rural Health
RMYC Rocky Mountain Youth Corps
RN Registered Nurse
Rx Prescription
RY Reconnecting Youth
SafeCare
SAMHSA Substance Abuse Mental Health Services Administration
SB School-based System
SBAG Salida Build A Generation
SBHC School-Based Health Centers
SCYC School Community Youth Coalition
SCRIIC Southern Colorado Regional Health Collaborative
SD Service Delivery
SECH Southeast Colorado hospital
SEMHS Southeast Mental Health Services
SES Socio-Economic Status
SEW School Employee Wellness
SGR Surgeon General's Report
SHAC Smoke-free Housing Action Committee
SHI School Health Index
SHS Secondhand Smoke
SIDS Sudden Infant Death Syndrome
SLV San Luis Valley
SMART Staying Motivated at Reducing Temptations
SMART OUTCOME OBJECTIVE Specific,Measurable,Achievable,Realistic,Time-Bound
SMSU Self Management Service Unit
SOW Scope of Work
SRO School Resource Officer
STD Sexually Transmitted Disease
STEPP State Tobacco Education and Prevention Partnership
STW Straight-to-Work
SVVSD St.Vrain Valley School District
SWOT Strengths,Weaknesses.Opportunities,Threats
SYNAR Synar Regulation
'FA Technical Assistance
Page 5 of 6
Attachment A-1
TABS Tobacco Attitudes and Behavior Survey
TAG Technical Advisory Group(for evaluation&TPEG)
TANF Temporary Aid to Needy Families
TARP Tobacco Advocacy and Resource Partnership
TBI) To Be Determine
TCP Tobacco Control Partners
TDAC Tobacco Disparities Advisory Council
'FUG Tobacco Disparities Grant
TDS Tobacco Disparities Subcommittee
TEACH Teaching Equity to Advance Community Health
TEFAP The Emergency Food Assistance Program
TEPCGP Tobacco Education Prevention and Cessation Grant Program
TEPP Tobacco Education Prevention Partnership
TFCCI Tobacco-Free Colorado Communities Initiative
TFLC Tobacco Free Lorimer County
TES Tobacco-Free Schools
TES Law Tobacco-Free Schools Law
TGYS Tony Grampsas Youth Services
Title V Title V of the Social Security Act
TND Project Toward No Drug Abuse
TPEG Tobacco Program Evaluation Group
TPI Tobacco Prevention Initiative
TRC Tobacco Education and Prevention and Cessation Program Review Committee
TRI Tobacco Rapid Improvement Activity
TRIA Tobacco Rapid Improvement Assessment
T"f l Tony Grampsas Tobacco Initiative
UCD University of Colorado—Denver
UCDHSC Health Sciences Center at UCD(sometimes abr. UCHSC)
IJCDHSC University of Colorado at Denver and Health Sciences Center
URL Uniform Resource Locator
US United States of America
USSTC US Smokeless Tobacco Company
VP Vice President
Well COA Wellness Councils of America
WHU Women's Health Unit
WIC Women.Infants,Children
WWC Women's Wellness Connection
YrC Youth at Crossroads
YE Youth Empowerment
YPH Youth Partnership for Health
Yr Year
YRBS Youth Risk Behavior Survey
YSAP Youth Substance Abuse Prevention Coalition
YTS Youth Tobacco Survey
YVMC Yampa Valley Medical Center
5 A's Ask,Advise,Assess.Assist.Arrange
2A's R Assk,Advise, Refer
Page 6 of 6
GRANT FUNDING CHANGE LETTER
Date: State Fiscal Year: Grant Funding Change Letter# CMS Routing #
TO: >Insert Grantee's name< [including entity type: not-for-profit, political subdivision, etc. The name and entity type
should exactly duplicate the original contract or modification that changed the name.]
In accordance with Section of Exhibit A, Additional Provisions >Choose an item<, 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 word here if previous
amendment(s), renewal(s) have been processed] between the State of Colorado, Department of Public Health
and Environment and <Contractor's Name> beginning <Insert start date of original contract> and ending
on <Insert ending date>, the undersigned commits the following funds to the Grant:
•
The amount of [state/federal/foundation/tax rebate] grant funds available and specified in >Choose an
item< of <insert contract amendment number and routing number> iS >Choose an item< by
$<amount of change for this source>[insert semi-colon and repeat the previous text{starting from"the"}for each
type of funds being modified; ensure that the correct fund type (federal, state, etc.) is inserted each time.] to new total funds
for the period through of$<total new amount for the period> for the following reason:
The change results in a new cumulative grant total of funds available under this agreement of$
[include contract life-time total amount].
The revised budget is incorporated herein by reference and identified as [for example. insert as
"Revised Exhibit C"].
>Choose an item< is hereby modified accordingly.
•
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 , whichever is later.
STATE OF COLORADO
John W. Hickenlooper, GOVERNOR
Department of Public Health and Environment PROGRAM APPROVAL:
By: Lisa McGovern, Purchasing & Contracts Unit By:
Director
Date:
ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Grants.This Grant is not valid until signed and dated below by
the State Controller or delegate.Grantee is not authorized to begin performance until such time. If Grantee begins performing prior
thereto,the State of Colorado is not obligated to pay Grantee for such performance or for any goods and/or services provided
hereunder.
STATE CONTROLLER
Robert Jaros, CPA, MBA,JD
By:
Date:
Attachment A-3
OPTION LETTER
Date: State Fiscal Year: Option Letter No. I CMS Routing #
1) OPTIONS: Choose all applicable options listed in §1 and in §2 and delete the rest.
a.Option to renew only (for an additional term)
b.Change in the amount of goods within current term
c. Change in amount of goods in conjunction with renewal for additional term
d.Level of service change within current term
e. Level of service change in conjunction with renewal for additional term
f. Option to initiate next phase of a contract
2) REQUIRED PROVISIONS. All Option Letters shall contain the appropriate provisions set forth below:
a. For use with Options 1fa-el: In accordance with Section(s) of the Original Contract routing number
between the State of Colorado, Insert Name of Department or Higher Ed Institution , and Contractor's
Name, the State hereby exercises its option for an additional term beginning Insert start date and ending on
Insert ending date at a cost/price specified in Section , AND/OR an increase/decrease in the amount of
goods/services at the same rate(s) as specified in Identify the Section, Schedule, Attachment, Exhibit etc.
b. For use with Option 1(f),please use the following: In accordance with Section(s) of the Original
Contract routing number between the State of Colorado, Insert Name of Department or Higher Ed
Institution , and Contractor's Name, the State hereby exercises its option to initiate Phase indicate which
Phase: 2, 3, 4, etc for the term beginning Insert start date and ending on Insert ending date at the cost/price
specified in Section
c. For use with all Options 1(a-f1: The amount of the current Fiscal Year contract value is
increased/decreased by $ amount of change to a new contract value of Insert New$Amt to as consideration
for services/goods ordered under the contract for the current fiscal year indicate Fiscal Year. The first
sentence in Section is hereby modified accordingly. The total contract value including all previous
amendments, option letters, etc. is Insert New$Amt.
3) Effective Date. The effective date of this Option Letter is upon approval of the State Controller or
whichever is later.
STATE OF COLORADO
John W. Hickenlooper, GOVERNOR PROGRAM APPROVAL:
Department of Public Health and Environment
By:
By: Lisa McGovern, Purchasing & Contracts Unit Director
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:
Page 1 of 1
Effective Date: 1/6/09-Rev 8/25/09
EXHIBIT B
STATEMENT OF WORK
To Task Order Dated 07/15/2014- Contract Routing Number 15 FHLA 72161
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Agreement specified above.
I. Project Description:
The Colorado Maternal and Child Health Program contracts with local public health agencies(LPHAs)to develop,
implement and evaluate evidence-based MCH Action Plans, HCP Care Coordination services,and HCP Specialty
Clinics. Contractors are responsible for contributing to the improvement of 10 state and 18 national MCH
performance measures and outcomes.
II. Definitions:
CDS—the state HCP-developed data system for documentation of Clinic Coordination, Care Coordination and
Information services for Children and Youth with Special Health Care Needs.
CRSCN-Colorado Responds to Children with. Special Needs
CYSHCN -Children and Youth with Special Health Care Needs
HCP-Program for Children and Youth with Special Health Care Needs
HCP Care Coordination—The state HCP-developed intervention model for providing care coordination for
families of children and youth with special health care needs.
HCP Consultants—The program staff for HCP who provide technical assistance,consultation and training on
RCP program components.
HCP Specialty Clinics—The state HCP-developed model for coordinating HCP specialty care.
LPHAs- Local Public Health Agencies
MCH-Maternal and Child Health
MCH Action Plans—Action Plans are work plans that Contractors select or develop to describe the goals,
objectives, key activities, persons responsible,and timelines of the MCH effort. Action Plans may be state-
developed and related to the MCH priorities or may be developed by the Contractor.
MCH Generalist Consultants—The primary MCH Program staff who monitor LPHAs' MCH contracts and who
provide technical assistance and consultation to Contractors on program development and implementation.
III. Performance Requirements/Deliverables:
Contractor is required to notify its MCH Generalist Consultant within 15 business days of any significant changes
to their MCH action plan or budget. Changes include, but are not limited to, the following: changes in staffing
including vacancies,changes in plan activities, agency changes or development that directly impact MCH
activities or plans,or community developments that directly impact MCH activities or plans.
Use of the term "partner" within the accompanying work plans connotes a collaboration relationship and not a
legal one unless otherwise specified.
A. Maternal and Child Health Program
I. The Contractor shall perform in accordance with the FY 15 Action Plans: Early Childhood Obesity
Prevention, referenced herein as Attachment B-I; and Teen Motor Vehicle Safety,referenced herein
as Attachment B-2.
2. The Contractor shall perform in accordance with the FY15 MCH Guidelines and shall follow the policies,
procedures,and program expectations set forth in the FY 15 MCH Guidelines. The FY 15 MCH
Guidelines are incorporated and made part hereof by reference, and are located at
www.mchcolorado.org.
Page I of 5
Exhibit B-Statement of Work
FEB2014
EXHIBIT B
3. The MCH Guidelines are periodically updated and the Contractor will be notified by email when
updates/revisions are made. The Contractor is responsible for complying with any updates/revisions.
Revised MCH Guidelines will be posted to the MCH web site referenced in III.A.2.
4. The Contractor shall apply the public health approach throughout the process of developing,
implementing, and evaluating its MCH Action Plans in order to serve the MCH population in the
community. Brownson's evidence-based public health approach is described in the FYI5 MCH
Guidelines and involves the following steps:
o Community assessment
o Quantify the issue
o Develop a concise statement of the issue
o Determine what is known through the scientific literature
o Develop/identify and prioritize program and policy options
o Develop an action plan and implement interventions
o Evaluate the program or policy
5. The Contractor shall contribute to the accomplishment of the MCH state priorities, and state and national
performance measures and outcomes that are outlined in the FYI5 MCH Guidelines located at
www.mchcolorado.org.
6. The Contractor shall focus at least 30%of total MCH/HCP funds on MCH-priority action plans,
including the medical home priority.
7. The Contractor shall focus a majority of their effort and funding for each action plan on population-based
and infrastructure-building strategies from the MCH pyramid,per the review and approval by the state
MCH Program. Enabling services are allowable if they are evidence-based and enhance the population-
based and infrastructure-level work in the action plan. Enabling services should not comprise a majority
of the effort,with the exception of HCP Care Coordination.
For definitions of the different levels of the MCH Pyramid, see the FYI5 MCH Guidelines available
online on the MCH web site located at www.mchcolorado.org.
8. The Contractor shall use evidence-based strategies or programs to address issues in the community. A
strategy or program is considered evidence-based if:
a. It is based on a sound theoretical approach such as health behavior change theory or peer-
reviewed literature;
b. And/or if there is research or program evaluation data that supports the effectiveness of the
approach.
9. During the contract term,the Contractor shall follow the timelines identified in FYI5 action plans to
implement and evaluate work performed under the action plans.
10. The Contractor shall participate in and submit the following processes or reports, incorporated by
reference. These processes and reports, including instructions for completion and submission,are
available in the FYI5 MCH Guidelines located online on the MCH web site located at
www.mchcolorado.org.
a. Progress check-in meetings(3)
MCH Generalist Consultants will conduct three progress check-in meetings with the Contractor
during the contract period in order to monitor the Contractor's progress on the FY 15 action plans
as well as to provide technical assistance and support during plan implementation. During the
progress check-ins,the Contractor and MCH Generalist Consultant use a standardized set of
questions to discuss the Contractor's progress and/or challenges of planning, implementing or
evaluating the MCH Action Plans and to review any relevant work products developed as part of
Page 2 of 5
Exhibit B-Statement of Work
FEB2014
EXHIBIT B
the plan,such as team charters, reports,community road maps, etc. The standardized questions
are available in a document entitled MCH Progress Call Guide on the MCH web site located at
www.mchcolorado.org under Implementation and Invoicing.
The MCH Generalist is responsible for scheduling the check-in with the Contractor. The format
(via phone or in person)of the check-in is at the discretion of the MCH Generalist Consultant
and will be communicated to the Contractor in advance. The MCH Generalist Consultant will
send a follow-up summary of the check-in meeting and will highlight any issues that require
follow-up. Three progress check-in meetings or phone calls will take place during the fiscal year.
The first check-in will occur in October,the second in January,and the last in the spring as part
of planning meetings focused on subsequent year activities.
b. MCH Annual Report on FY15 Action Plans
The FY15 MCH Action Plan Annual Report is due October 31,2015 for the period of October
I,2014 to September 30,2015.The Contractor shall submit the completed report via email to
cdphe.psmchreportsna,state.co.us.
For annual reporting, update the following sections of the MCH priority-related action plans:
• Evaluation of Objective—provide a brief narrative on the progress of the objective,
including successes and challenges. Discuss how the strategy contributed to moving the
objective forward. Include assessment of"as measured by" indicators that correspond
to"criteria for success" in this section.
• Activity Monitoring Plan Completion—comment if the activity was met or unmet.
For annual reporting, update the following sections of the"other" MCH action plans:
• Evaluation of Measure—provide the actual measure of progress for the
measure/indicator previously selected
• Evaluation of Objective—provide a brief narrative on the progress of the objective,
including successes and challenges. Discuss how the strategy contributed to moving the
objective forward.
• Activity Monitoring Plan Completion—comment if the activity was met or unmet.
• Sources of finding and support- provide the amount and source each of each outside
funding stream used to support the work completed. Provide the overall costs for the
program for the period, including CDPHE and outside funding support.
c. HCP Annual Report for FY15
The FY15 HCP Annual Report is due October 31,2015 for the period of October 1,2014 to
September 30,2015. The FY 15 HCP Annual Report Form will be available on the MCH web
site located at www.mchcolorado.org.The Contractor shall submit the completed report via
email to cdphe.psmchreports iestate.co.us.
d. MCH Core Services Final Report for FY15
The Final Report for MCH Core Services should be reported on the MCH Budget form that will
be available on the MCH web site located at www.mchcolorado.or,. The report is due October
31,2015 for the period of October 1, 2014 to September 30,2015. The Contractor shall submit
the completed report via email to cdphe.psmchreportsgstate.co.us.
For each of the Contractor's FY I5 Planning Budgets, review the objectives and activities
included in the corresponding MCH Action Plan(s), report on the percentage of total budget
funds expended on the different levels of the MCH pyramid.
Page 3 of 5
Exhibit B-Statement of Work
FE62014
EXHIBIT B
▪ Direct Services
• Enabling Services
• Population-based Approaches
• Infrastructure Building Approaches
For the Contractor's FY I5 HCP Care Coordination Planning Budget, enter the actual number of
children and youth with special health care needs who received RCP Care Coordination services
with an action plan. Next enter the actual number of children who received information only.
I I. The Contractor shall develop or revise,according to the FY 16 MCH Guidelines,the Contractor's MCH
action plans and budgets for FY I6.
12. The Contractor shall notify the State of programmatic changes that might affect the viability,
effectiveness or productivity of the programs, including but not limited to: changes in personnel; physical
facilities in which services are provided; scope of services that deviates from those proposed by the
Contractor in the MCH action plans; and local interagency or political circumstances that might impact
the MCH Program. Notification shall be in writing within fifteen(15)business days of said change.
B. Children and Youth with Special Health Care Needs(CYSHCN)
I. The Contractor shall perform in accordance with the FY15 HCP Policy and Guidelines and shall follow
the policies, procedures, and program expectations set forth in the FY15 HCP Policy and Guidelines. The
FY 15 HCP Policy and Guidelines are incorporated and made part hereof by reference,and are located on
the HCP web site located at www.hcpcolorado.or_.
2. The Contractor shall perform in accordance with the FY15 Action Plan: Reducing Barriers to a Medical
Home Approach,referenced herein as Attachment B-3.
3. The HCP Policy and Guidelines are periodically updated and the Contractor will be notified by email
when updates/revisions are made.The Contractor is responsible for complying with any
updates/revisions. Revised HCP Policy and Guidelines will be posted to the HCP web site referenced in
III.B.I.
4. The Contractor shall attend scheduled HCP Policy Advisory Committee(H-PAC)meetings, HCP Annual
Meetings, and quarterly scheduled activities for local HCP staff to promote learning and increase skills,
as organized by CDPHE HCP Program and as referenced in the FY I5 HCP Policy and Guidelines.
5. The local HCP Coordinator shall provide orientation,technical assistance and ongoing training for other
HCP agency staff by referencing the HCP Policy and Guidelines, HCP training modules and other HCP
Resources available online on the HCP web site located at www.hcpcolorado.org.
6. The Contractor shall engage families with CYSHCN and community family leaders to solicit consumer
feedback when serving the CYSHCN population by referencing the Reducing Barriers to a Medical
Home Approach resource document available online on the HCP web site located at
www.hcpcolorado.org.
HCP Care Coordination
I. The Contractor shall provide HCP Care Coordination services using a medical home approach for
CYSHCN residing in the counties the agency is contracted to serve according to the FYI5 HCP Policy
and Guidelines.
2. The Contractor shall provide information and resources to families of CYSHCN in accordance with the
FY 15 HCP Policy and Guidelines.
Page 4 of 5
Exhibit B-Statement of Work
FEB2014
EXHIBIT B
3. The Contractor shall complete required data documentation in the CDS for HCP Care Coordination and
Information services according to the FY15 HCP Policy and Guidelines.
4. The Contractor shall participate in consultation,technical assistance,oversight and training by state HCP
staff on using the CDS for documentation of HCP Care Coordination services.
CRCSN
1. If the contractor elects to receive CRCSN notifications on the FYI5 HCP Care Coordination Planning
Form,the Contractor shall follow the CRCSN guidance set forth in the FYI5 HCP Policy and Guidelines
including the entry of data into CDS.
HCP Specialty Clinics
I. The Contractor agrees to provide clinic coordination for regional HCP Specialty Clinics according to the
FYI5 HCP Specialty Clinic Benchmarks, FYI5 HCP Specialty Clinic Standards and FY15 HCP Policy
and Guidelines.
2. The Contractor shall provide clinic coordination using a medical home approach for all CYSHCN
attending HCP Specialty Clinics according to the FY15 HCP Policy and Guidelines.
3. The Contractor shall participate in consultation,technical assistance,oversight and training by state HCP
staff on HCP Specialty Clinic Coordination and using CDS for documentation of HCP Specialty Clinic
services.
IV. Monitoring:
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted
throughout the contract period by the Program's MCH Generalists and HCP Consultants. Methods used
will include review of documentation reflective of performance to include progress meetings, site visits,
invoices,and data reports. 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.
V. Resolution of Non-Compliance:
The Contractor will be notified in writing within 30 calendar days of discovery of a compliance issue.
Within 45 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 require an extension to the time line,the Contractor
must email a request to the MCH Unit Manager and receive approval of a new due date. The 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 Remedies section of the General Provisions of this
contract.
Page5 of5
Exhibit B-Statement of Work
FEB2014
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EXHIBIT C
°``°) Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
-a,e= Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/7/2014
Weld County Department of Public Health& Amy Antuna,RN,BSN,HCP
Agency Name Environment Program Contact Name,Title, Supervisor
Phone and Email aantuna@co.weld.co.us,970-304-
Budget Period October 1,2014-September 30,2015 6420 ext.2322
Identify the population Tanya Geiser,Director
CYSHCN-Medical Home(MN) Y
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us 970-
Medical Home 304-6410 ext 2122
related to this budget
Expenditure Categories
Personal Services
Salaried Employees
List SOW
deliverable/
primary task
number(s)this Percent of Total Amount
Position Title/Employee budget item Gross or Time on Requested from
Name Description of Work supports Annual Salary Fringe Project CDPHE
HCP Supervisor/Amy Antuna,
WCDPHE FTE 151O Provides ca-facilitation and coordination of Medical $25,260.77 5% $4,507.42
Home Project/WCRC. Actual MH program time is 10%. MH-All objectives $ 64,887.66
Community Health Provides oversight,co-facilitation,coordination of
Manager/Kathy Smith-Stillson, Medical Home Project/WCRC. Actual MH program time MH-All objectives 69181.31 $26,932.28 7.25% $6,968.24
WCDPHE FTE is 1.0 is 10%.
Fringe Fringe is budgeted at 38.93%
Personal Services
Hourly Employees
deliverable/
primary task
number(s)this Total#of Total Amount
Position Title/Employee budget item Hours on Requested from
Name Description of Work supports Hourly Wage Hourly Fringe Project CDPHE
$0.00
$0.00
Total Personal Services
(including fringe benefits) $11,476.00
Supplies&Operating Expenses
Page 1 of 13
EXHIBIT C
° 4 Colorado Department of Public Health and Environment
_..:�, PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
•
•• } Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/7/2014
Weld County Department of Public Health& Amy Antuna,RN,BSN,HCP
Agency Name Environment Program Contact Name,Title, Supervisor
Phone and Email aantuna@co.weld.co.us,970-304-
Budget Period October 1,2014-September 30,2015 6420 ext.2322
Identify the population CVSHCN-Medical Home(MH) Tanya Geiser,Director
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us 970-
Medical Home 304-6410 ext 2122
related to this budget
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Item Description of Item item supports Rate Quantity CDPHE
Supplies/Meeting&Operating Medical Home-WCRC project outreach,marketing,systems building activities, MH-All
printing,office supplies,computer services(network fees,software,and $34.00 2 $68.00
Expenses objectives
printers),and phone services.
Total Supplies
&Operating Expenses $66.00
•
Travel
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Item Description of Item item supports Rate Quantity CDPHE
MCH-MH staff will travel to WCRC meetings at various sites and participate in
Mileage-MH program staff outreach meetings related to MH-WCRC project Annual MH team travel is $0.54 4 $2.00
reimbursed at S.54/mile.
Total Travel $2.00
Contractual
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Subcontractor Name Description of Item item supports Rate Quantity CDPHE
$0.00
$0.00
Total Contractual $0.00
SUB-TOTAL BEFORE INDIRECT $11,546.00
Page 2 of 13
EXHIBIT C
tov•
" �4 Colorado Department of Public Health and Environment
k PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
a c' Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/7/2014
Weld County Department of Public Health& Amy Antuna,RN,BSN,HCP
Agency Name
Environment Program Contact Name,Title, Supervisor
Phone and Email aantuna@co.weld.co.us,970-304-
Budget Period October 1,2014-September 30,2015 6420 ext.2322
Identify the population CYSHCN-Medical Home(MH) Y
Tan a Geiser,Director
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us 970-
Medical Home 304-6410 ext 2122
related to this budget
Indirect
Total Amount
Requested from
Item Description of Item CDPHE
Negotiated Indirect cost
rate(Federal,State,or 2014 CDPHE Negotiated Indirect Rate(Public Health Services Division=12.59%) $1,454
CDPHE)
Total Indirect 51,45400
TOTAL AMOUNT REQUESTED FROM CDPHE $13,000
=�&fz� .s :: ,. .:>' '` ' .., `„ ' �K:OE'@ -. .•. .. ' } '�, .W ar*' `W"°i+ «.tr" ,751r,#.S »°t1
What percentage of funding from the budget total is allocated to work at each level of the MCHI HCP CARE COORDINATION ONLY
Page 3 of 13
EXHIBIT C
t nrcoca
4�6 Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
*,as r Contract Routing# 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/12/2014
Weld County Department of Public Health& Kelly Campbell,Health
Agency Name Environment Program Contact Name,Title, Communication Supervisor
Phone and Email kcampbell@weldgov.com 970
Budget Period October 1,2014-September 30,2015 304-6470
Identify the population for
Child/Adolescent(CA) Tanya Geiser,Director
this budget Fiscal Contact Name,Title, Administrative Services
Phone and Email tgeiser@co.weld.co.us 970
Identify all action plans Teen Motor Vehicle Safety(TMV) 304-6410,ext 2122
related to this budget
Expenditure Categories
Personal Services
Salaried Employees
List SOW
deliverable/
primary task
number(s)this Percent of Total Amount
Position Title/Employee budget item Gross or Annual Time on Requested from
Name Description of Work supports Salary Fringe Project CDPHE
Primary MCH liaison;provides management of
MCH project deliverables,supervises MCH staff,
Health Education
directs work plan activities,monitors grant CASH-All
Supervisor-Kelly Campbell $64,674.57 $ 25,178 15% $13,477.86
expenditures,and is responsible for reporting and Objectives
1.0 FTE
evaluation of MCH program.Actual time spent in
program estimated at.20 FTE.
Clerical support including data entry,copyting and
Office Technician ill- printing,inventory control,supply orders,meeting CASH-All $38,810.06 $ 15,109 25% $13,479.70
Marjorie Hanson 1.0 FTE coordination,graphic design and social Objectives
media/website designing and updating.
Coordinate grant evaluation and data analysis.
Assist with stakeholder interviews,creation of
Health Data Specialist CASH-All
county specific fact sheets and development of $85,014.00 $ 33,096 2% $2,362.20
Cindy Kronauge 1.0 FTE community educational presentations.Actual time Objectives
spent in program estimated at.05 FTE.
Fringe Fringe budgeted at 38.93% $ - $0.00
Personal Services
Hourly Employees
deliverable/
primary task
number(s)this Total#of Total Amount
Position Title/Employee budget item Hours on Requested from
Name Description of Work supports Hourly Wage Hourly Fringe Project CDPHE
$0
Total Personal Services
(including fringe benefits) $29,319.76
Page 4 of 13
EXHIBIT C
°`t,`°4
C if Colorado Department of Public Health and Environment
•
$ PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/12/2014
Weld County Department of Public Health& Kelly Campbell,Health
Agency Name
Environment Program Contact Name,Title, Communication Supervisor
Phone and Email kcampbell@weldgov.com 970
Budget Period October 1,2014-September 30,2015 304-6470
Identify the population for
this budget Child/Adolescent(CA) Tanya Geiser,Director
Fiscal Contact Name,Title, Administrative Services
Phone and Email tgeiser@co.weld.co.us 970-
Identify all action plans
Teen Motor Vehicle Safety(TMV) 304-6410,ext 2122
related to this budget
Supplies&Operating Expenses
List SOW
deliverable/
primary task
number(s)this Total Amount
budget item Requested from
Item Description of Item supports Rate Quantity CDPHE
Supplies&Operating
Misc supplies,meeting and operating expenses $24.50 3 573.50
Expenses
Total Supplies
&Operating Expenses $73.50
Travel
List SOW
deliverable/
primary task
number(s)this Total Amount
budget item Requested from
Item Description of Item supports Rate Quantity CDPHE
Travel Expenses Misc travel expenses including mileage,hotel,meals $1.00 1 $1.00
Total Travel
$1.00
Contractual
List SOW
deliverable/
primary task
number(s)this Total Amount
budget item Requested from
Subcontractor Name Description of Item supports Rate Quantity CDPHE
Public relations professional to promote programs,coordinate media
campaigns,coordinate the implementation of the Teen Safe Driving
programs at participating high schools ans assist with stakeholder and
law enforcement advovacy campaigns. Sub-contractor will serve as CASH-All
Lynn Tausen $25.00 200 $5,000.00
the community liason and media contact for DRIVE SMART Weld Objectives
County. Estimated at 20 hrs/mo for 10 months(August-May)
Total Contractual $5,000.00
SUB-TOTAL BEFORE INDIRECT $34,394.26
Page 5 of 13
EXHIBIT C
4w` Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/12/2014
Weld County Department of Public Health& Kelly Campbell,Health
Agency Name Environment Program Contact Name,Title, Communication Supervisor
Phone and Email kcampbell@weldgov.com 970
Budget Period October 1,2014-September 30,2015 304-6470
Identify the population for
this budget Child/Adolescent(CA) Tanya Geiser,Director
Fiscal Contact Name,Title, Administrative Services
Phone and Email tgeiser@co.weld.co.us 970
Identify all action plans
Teen Motor Vehicle Safety(TMV) 304-6410,ext 2122
related to this budget
Indirect
Total Amount
Requested from
Item Description of Item CDPHE
Negotiated Indirect cost
rate(Federal,State,or 2014 CDPHE Negotiated Indirect Rate(Health Communication,Education&Planning Division=1339%) $4,605
CDPHE)
Total Indirect $4,605.3e
TOTAL AMOUNT REQUESTED FROM CDPHE $39,000
What percentage of funding from the budget total is allocated to work at each level of the MCH HCP CARE COORDINATION ONLY
Page 6 of 13
EXHIBIT C
CA4�b Colorado Department of Public Health and Environment
,. • PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
J Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/6/2014
Weld County Department of Public Health& Kathy Smith-Stillson,PhD,RN.
Agency Name
Environment Program Contact Name,Title, Community Health Manager 970-
Phone and Email 304-6420 ext.2316 ksmith-
Budget Period October 1,2014-September 30,2015 stillson@weldgov.com
Identify the population Women of reproductive age ad infants/children Tanya Geiser,Director
for this budget birth to age 5 Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us 970-
Early Childhood Obesity Prevention 304-6410,EXT 2122
related to this budget
Expenditure Categories
Personal Services
Salaried Employees
List SOW
deliverable/
primary task
number(s)this Percent of Total Amount
Position Title/Employee budget item Gross or Time on Requested from
Name Description of Work supports Annual Salary Fringe Project CDPHE
ECOP Action Plan
CINDY KRONAUGE,Public ECOP Data Specialist Objectives A,B,C, $85,014.00 $ 33,096 2% $2,362.20
Health Data Specialist and G
ECOP Action Plan
MIKE SCHWAN,Health Plans,Coordinates,and Implements Weld ECOP Objectives A,B,C, $55,141.26 $ 21,466 100% $76,607.75
Commun Specialist II Action Plan
and G
KATHY SMITH-STILLSON, ECOP Action Plan
Public Health Nurse Supervision of Weld ECOP Action Plan Objectives A,B,C, $69,181.31 $ 26,932 6% $5,766.82
Supervisor and G
Fringe Fringe is budgeted at 38.93% $ - $0.00
Personal Services
Hourly Employees
deliverable/
primary task
number(s)this Total ft of Total Amount
Position Title/Employee budget item Hours on Requested from
Name Description of Work supports Hourly Wage Hourly Fringe Project CDPHE
$0.00
$0.00
Total Personal Services
(including fringe benefits) $64,736.77
Supplies&Operating Expenses
Page 7 of 13
EXHIBIT C
Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
• s•
Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/6/2014
Weld County Department of Public Health& Kathy Smith-Stillson,PhD,RN.
Agency Name
Environment Program Contact Name,Title, Community Health Manager 970-
Phone and Email 304-6420 ext.2316 ksmith-
Budget Period October 1,2014-September 30,2015
stillson@weldgov.com
Identify the population Women of reproductive age ad infants/children Tanya Geiser,Director
for this budget birth to age 5 Fiscal Contact Name,Title, Administrative Services
Phone and Email tgeiser@co.weld.co.us 970-
Identify all action plans
Early Childhood Obesity Prevention 304-6410,EXT 2122
related to this budget
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Item Description of Item item supports Rate Quantity CDPHE
ECOP Action
Supplies&Operating
Training materials,media,and operating expenses Plan Objectives $41.00 2 $82.00
Expenses
A,B,C,and G
Total Supplies
&Operating Expenses $82.00
Travel
List SOW
deliverable/
primary task
number(s) Total Amount
• this budget Requested from
Item Description of Item item supports Rate Quantity CDPHE
• ECOP Action
Plan Objectives $0.54 4 $2.00
Misc travel expenses including mileage,hotel,meals. Mileage rate is
A,B,C,and G
Travel Expenses .54/mile
Total Travel 5200
Contractual
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Subcontractor Name Description of Item item supports Rate Quantity CDPHE
$0.00
Total Contractual $0.00
SUB-TOTAL BEFORE INDIRECT
$84,820.77
Page 8 of 13
EXHIBIT C
°a�< Colorado Department of Public Health and Environment
PREVENTION SERVICES VICES DIVISION- BUDGET WITH JUSTIFICATION FORM
�• Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: 5/6/2014
Weld County Department of Public Health& Kathy Smith-Stillson,PhD,RN.
Agency Name
Environment Program Contact Name,Title, Community Health Manager 970-
Phone and Email 304-6420 ext.2316 ksmith-
Budget Period October 1,2014-September 30,2015 stillson@weldgov.com
Identify the population Women of reproductive age ad infants/children Tanya Geiser,Director
for this budget birth to age 5 Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us 970-
Early Childhood Obesity Prevention 304-6410,EXT 2122
related to this budget
Indirect
Total Amount
Requested from
Item Description of Item CDPHE
Negotiated Indirect cost
rate(Federal,State,or 2014 CDPHE Negotiated Indirect Rate(Public Health Services Division=12.59%) $10,679
CDPHE)
Total Indirect $10,618.93
TOTAL AMOUNT REQUESTED FROM CDPHE $95,500
�3:yr�d'�ra,t " i�." fr lf.5 . . �i2'! .;;is Cu' s.e. �• 1l. ?'f Yk SRS S4" Aa li.:t Y d•
What percentage of funding from the budget total is allocated to work at each level of the MCH HCP CARE COORDINATION ONLY
Page 9 of 13
EXHIBIT C
e°,a„ Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
C• Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: May 7,2014
Weld County Department of Public Health& Amy Antuna,RN,BSN,HCP
Agency Name
Environment Program Contact Name,Title, Supervisor
Phone and Email aantuna@co.weld.co.us,970-304-
Budget Period October 1,2014-September 30,2015 6420 ext.2322
Identify the population
CYSHCN-HCP Care Coordination(CC) Tanya Geiser,Director
for this budget Fiscal Contact Name,Title, Administrative Services
Phone and Email tgeiser@co.weld.co.us 970-
Identify all action plans
304-6410 ext 2122
related to this budget
Expenditure Categories
Personal Services
Salaried Employees
List SOW
deliverable/
primary task
number(s)this Percent of Total Amount
Position Title/Employee budget item Gross or Time on Requested from
Name Description of Work supports Annual Salary Fringe Project CDPHE
Provides direct oversight and supervision of HCP care
coordination program and staff,directs care coordination
HCP Supervisor/Amy Antuna activities,oversees HCP support group activities,participates in HCP-CC $64,887.66 $ 25,261 60% 554,089.06
HCP program outreach and represents HCP on several
community groups/coalitions,responsible for reporting and
evaluation of HCP program. Actual HCP program time is 90%.
Provides care coordination services to HCP clients,assists with
Public Health Nurse/Cynthia
HCP program outreach and attends HCP community meetings. HCP-CC $56,530.00 $ 22,007 70% 554,975.99
Luark
Actual HCP program time is 100%.
Provides psychosocial care coordination services to HCP
clients,coordinates and facilitates monthly HCP support group,
Public Health Social Worker/
HCP program outreach and represents HCP on several HCP-CC $61,117.71 $ 23,793 8% $6,792.87
Aurora Medina
community groups/coalitions. Actual HCP program time is
80%.
Provides oversight of HCP program and HCP staff,participates
Community Health Manager/Kathy o
Smith-Stinson in reporting and evaluation of HCP program.Actual time HCP-CC $69,181.31 $ 26,932 2% $1,922.27
program FTE is 2%.
Provides care coordination services to HCP clients,assists with
Public Health Nurse/Jan Tarr HCP program outreach and attends HCP community meetings. HCP-CC $53,296.51 $ 20,748 50% $37,022.42
Actual HCP program time is 50%.
Page 10 of 13
EXHIBIT C
to Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
ra,e' Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: May 7,2014
Weld County Department of Public Health& Amy Antuna,RN,BSN,HCP
Agency Name
Environment Program Contact Name,Title, Supervisor
Phone and Email aantuna@co.weld.co.us,970-304-
Budget Period October 1,2014-September 30,2015 6420 ext.2322
Identify the population
CVSHCN-HCP Care Coordination(CC) Tanya Geiser,Director
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans
304-6410 ext 2122
Phone and Email tgeiser@co.weld.co.us 970-
related to this budget
Administrative support to HCP team. Responsibilities include
Office Technician/Rosie Varela- interpretation and translation,CDS data entry,EMR data entry. HCP-CC $28,806.51 $ 11,214 10% $4,002.09
Martinez materials preparation,assists HCP staff with care coordination
activities,etc.Actual HCP program time is 80%
For all above listed employees:fringe includes medicare,
unemployment,workers'compensation,PERA,life/AD&D $ _ $0.00
insurance,health insurance,accrual-vacation,accrual-holiday,
accrual-sick.Estimated at 38.93%
Personal Services
Hourly Employees
List SOW
deliverable/primary
Position Title/Employee Description of Work task numbers)this Hourly Wage Hourly Fringe Total#of Hours Total Amount
Name on Project
budget item Requested from
supports CDPHE
$0.00
$0.00
Total Personal Services
(including fringe benefits) $158,tto5.o0
Supplies&Operating Expenses
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Item Description of Item item supports Rate Quantity CDPHE
MCH-HCP Care
Supplies&Operating Expenses HCP program outreach,marketing,and systems building activities,printing, $50.00 3 $150.00
Cmordinaton
postage,office supplies,computer services(network fees,software,and
printers),phone services,facility fees for official HCP functions.
$0.00
Total Supplies
&Operating Expenses $150.00
Travel
Page 11 of 13
EXHIBIT C
js, �p Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
/616` Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: May 7,2014
Weld County Department of Public Health& Amy Antuna,RN,BSN,HCP
Agency Name
Environment Program Contact Name,Title, Supervisor
Phone and Email aantuna@co.weld.co.us,970-304-
Budget Period October 1,2014-September 30,2015 6420 ext.2322
Identify the population CYSHCN-HCP Care Coordination(CC) Tanya Geiser,Director
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans
304-6410 ext 2122
Phone and Email tgeiser@co.weld.co.us 970-
related to this budget
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Item Description of Item item supports Rate Quantity CDPHE
Mileage HCP-CC $0.54 2 $1.08
MCH-HCP staff will travel to MCH/HCP meetings at various sites,and
participate in various outreach opportunities and client home visits related to
the HCP program. Annual HCP team travel is reimbursed at$.54/mile.
$0.00
Total Travel
BLOB
Contractual
List SOW
deliverable/
primary task
number(s) Total Amount
this budget Requested from
Subcontractor Name Description of Item item supports Rate Quantity CDPHE
Contractor to provide misc education services or
Unknown $1.00 1 $1.00
other contractual services
$0.00
Total Contractual $1.00
SUB-TOTAL BEFORE INDIRECT S158,957.08
Indirect
Total Amount
Requested from
Item Description of Item CDPHE
Page 12 of 13
EXHIBIT C
° �4, Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
.1,76
e sr Contract Routing # 15 FHLA 72161
Colorado Department FY15 Maternal and Child Health Planning Budget
of Public Health
and Environment
Date Completed: May 7,2014
Weld County Department of Public Health& Amy Antuna,RN,BSN,HCP
Agency Name
Environment Program Contact Name,Title, Supervisor
Phone and Email aantuna@co.weld.co.us,970-304-
Budget Period October 1,2014-September 30,2015 6420 ext.2322
Identify the population
CYSHCN-HCP Care Coordination(CC)
for this budget Tanya Geiser,Director
Fiscal ContaR Name,Title, Administrative Services
li Identify all action plans Phone and Email tgeiser@co.weld.co.us 970.
304-6410 ext 2122
related to this budget
Negotiated Indirect cost
rate(Federal,State,or 2014 CDPHE Negotiated Indirect Rate(Public Health Services Division=12.59%) $20,013
CDPHE)
Total Indirect $20,013.00
TOTAL AMOUNT REQUESTED FROM CDPHE $178,970
What percentage of funding from the budget total is allocated to work at each level of the MCH HCP CARE COORDINATION ONLY
Page 13 of 13
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