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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 cc,: lit(ST, -f2,) 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 Contract_Template_Task_Order_0707 14 Pagel of f ao/ a73cP This page left intentionally blank. • 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. To be attached to CDPHE Page I of 4 Revised:07/17/12 Version 1.0(3/12)contract template 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. To be attached to CDPHE Page 2 of 4 Revised:07/17/12 Version 1.0(3/12)contract template 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. To be attached to CDPHE Page 3 of 4 Revised:07/17/12 Version 1.0(3/12)contract template 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. 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CI O) a J LL m N cC m c w N > C m c n w `-' w ca) wuj Y O O � a) O „So co a) m N > C — O m O Y UV m m m m n E n m n- w E O - r O c •-• o d E E CCo owoa) a) om nLmmwv � ova) a) "O, w O UCCUCC 200 CIO : noa) 3om3 2m 2 a c o U n c a) a LT- C a) QDaE) O. = E E 2 m w E 2 c= o U U WO U W o o c U , T T > w E T > -o — To 2 Y Y 002 Y O O U) 0 E E o > > I o o i o r to O 0 Z Z N N `o CO C C O O O V d m m d T T O) N _O O) N n O) N n of To c a) E E a) E c a E ° aEi > = o n a) .O n a) o n a) a o C C 4) o n 4) o o_ °i ° n o C ¢ O Oin O 0w O 0 C C CO .O-. O O O = OC1 W C O) E W U Y W e a) m ' O)N — a) E m O CO > w c a) w a) w t O M Q' m OC1 Cua >' '«C-. N O N N ai c _ 3 H 0 CO O CO la O it CO o 2 > U U w a — T` H J. o a) v m = c a) c 0 > = r m r m n o w o m 0,0 E o � a) =a > nv Yw -C m CO 3 `-) dcaui = cTi � o) o U a) c t m m m 0 0 a) E -O T O O n m m o w e- "O T m N ` m n w - a) - w 0. > r O) w .c O U w "O O > w — a) C U T c y0 = -O Jni ? C w N Q' a) E a) 'O O C Y0t O O V) a) c0 .�-oa mmO = moE EtnaTom -0o-ro E oom r0O >' o 2 0 0- 0 - 0 > o o C n w O)U a) ca T O C w w m O-C N YO U U a) m m E m o m co E >,.-• w m i. coca 0 O` T = n a) J w = m n O co Y co > m 2 U W n a) O U) E 0 c a . O p O n C w 0 O o r E L .O m C -O O L a C L CD U U E CO C d 0co0 ) y , � a a, ow O@U ° Emwmr = m ma O > tic — a3 — O Er _c a) oono SUE cr - a) oo rnm c >.Ua) mroc aaio a) a) -om U O > OI 3 n N a) c a) O co -O n (J a) O C N -O a) -O U 'O C C )a — CO -O a) a) r a) P co a) m > > > «. me � a) QEN ` = 3oc = a) oc ga) -O () o � w aNr"' C EcE � E omo 'EE03 w = n� mo � o > con m . co nm = u) �5 COW w ° OU = o a c oiow . 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C7 Y Y Y Y J N 0 0 N 0 5) E « 0 Td RcuLL > CU O - - in m c _ a. ›..C c r M CO oo OOa Oa y t N 'a N N N N cn U U a) 0 > T a) a a a o am v ° o y a E E E co co my 42 go � E min 0i � oi „ m a ai v C E N 0 - 0 a F U O N m N O N p ` N « 0 a0 > a) O a CO OS d O N O) a d .l Co C7c W 0c muzoo N o c co2 � Na) m o � � oaE t 0tnv m C m � E c..) -5 o c c v y °f 7K cc o o N 'w th co 'O o c• O t Q ui 0 -, co >` N O) �> U >-.-ow N -co Y N 0 O. a) — "O c in' c cn co c _c -O a a) > 0 y _ c Q. 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Ec -oc .4 m g -0 C CO O 0 C C N C c (a a) O m co N L m W O . a V a L 0 -m0 N d c m ` C O E ≥ -O _0 c C C C N - C Q N m a) y0 Et a) a) m U N 30 U p N E p N C C N m .� ❑ ¢ � a>i 042 0moaa _jc0 a - - F- a -0 a a a a a Q E E E E co 2 cow N N ca as 0 0 0 0 co W CO Dco .c N C 0 T T T T C > C O C Y Cl) Y Cl) _I❑CC d 2 2 I up i ' O I O a7 co N O O O N Co V N V CD N N N N 0 m N C) N 2 M CO T N t O m c rn O c) O O a ID m m D J co o) o n o) o Q S 5 D_ C U m C U O c C m a) O Oco O 0 c -co co LL LL O C U C >, C 0 a) 3 0 Z-1 = m `owa O- mc ~ rd CU »paa)i c0 cY5a> > > ❑ o E Z-1 E m o -(3 ° a) 5 a o E c cn c m m moo o w 20 n EC o O a) O C E -o i = .° la 0 O E N .C N m '5 0 m m (a O 0 • C Y O .>_ c T O) t � O - m a) ^ 1- L U a) y "O J r ma) N N • .C ≤ C N C m p a C O '�,U_ v CO N J N D -c .c is m a) c O N. C 50 a m O (a ._ COrO U p p m 0 r .0 F2 O m a en O N O -a E O m a) - C m L 4 •L L N p E Q3 O N O m g N U m r d a m m a) m E a-o NCN Cm UN � U � O)UC > Y0 > m E ' ccn N Ta) . a) 0 > U m 'O c c 3 p E O m y0 �O O .0 Q . OU a O C L m @ U E QI E N (n O was c u., a) O 45 m d C 'Es U a) N O Y �, m a — O E LL -O .C N 'w ' (0 _0 .N r 0 a E O (n a) i m c m L.. m V a el �, O C C N ,L T O m 3 o N E a) '. . w a J tm/) m N D p c p — _ ?� 3 m n p c a �' c O U fn .C ❑ O N _ w � >'.c ≥ No a; m - cai off O1mEc mf° cdc2 Ec 20 na CO � o — � .a n� mm O moo C T ❑ o a) � w a) 5- � a) m _ dy cyp`pc sa Uo ≥ a) > mo am a) m a) N O)L.. r0 L.. 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E c _ a C � aU' ¢ c a To U) O o0 CO CO c N N CO O WO � N in O N N U) p I wOO f w U .O .N O w00 m CO C 00 C wU .2 cc w o aa)i Q' D a a a) It w o w W a o N CL W WO O U 2 O d cc w Y co C a . K 1 O5 U t )O a ("10 r oo i co I co co ` Oco N � O v O — i+ O Co co- N , N N — CO N O 0 N 3 - a O — N a) N a) W >. w - O N ) S) O).O_0 0) .•-• w w N T 0 CO c a) E 5 a) E E •c .0 c = o a co O O .O a) o o w W 0 a) 7 COr cu 15 0) O 0) O 0) o 0 O E co a C U d C U m a C � U 0 N 11 O O C 0 Ow w O c -o ° cc O —w u) >, a) E U_ W C 0 C C C w o at Cl) _O 0 O W co F O O c W C C = C o N 0 Uj ao c it �L w - 0 O N a c0 W W o ') W C E 0 .... T 0 W O (0 �? E F O L U D W ≥ O co > 0) co- m0 v00_ � u) 3 0m E N t) -0 o it N N N @ m a) 'WO N C N ` W a) C c E -c E `u —9 o )o I- 3 2 w co .9 m a N aTi• rn m a 'o a) w 0 U N -°c � 'o R w w 'a o C a ac W C 1° w E c 3 a a t p W — W o m ' o o, 0 m m c W E a) -c c o '0 '> c W O C -0 o U J O C C W Y � E E W c >. 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C CC O- Y (n < Y (/) < Y (O < YW < Y co < c to CO LO (° )O CO LO (° LO (° o r .C O el 0 O el el OM o r a el a) co a) (`7 m M a) co a) m a1 m W E Tn T- T� TLl T-O a a a a a N N d N 0 ® 0 N N N N 0) 0 N V ((D V (0n "O 401 -0 W -0 r F C < Q < Q < Q < Q < Q r N 01 >, al as 0) 0 c Co V c 0 O N w m 41 .N_. 0) O w V a U C _U X CO C M w CO 3 m O N V 0 C 0 m (O C C 2T 0 O N O N V 2 -0 0 0 0 'U O N O a o 0 C V r0 '5 a m N 0 E N U m w p y N C 0) ti "Q N O' O 0 co C m 0 a) m m o N a) O N _c V N C 0 0 L "0 N z V m U O. N F U TN Ts N o E5 p N 0' c .a d O ti O m o N N O d c0i 0 a) N O .C) (0 o pOoO���..,,�� W _, 45 a) `a E Y L N m O E m L L 0 > ; c N _se� O > L c 0_ in YO 4 C m °_ N m N Y 03 CV p coC 0 N O N L > .E (0 N N 0 E E m N U O O L a') y gym °' o w d.cm—..... —• 0 d �rc 03 o - N \ Q L m a U a O N L Q m w°' 0. O a L m 4j U N 0 .OO T .- m , m N ® N .3 3 t a) Tr) N o N .3 n a) o E E O E x O p m N U ? Uo O 0 O N C1 m 0 0 Y N 0 0 '�O w w d c m 0 .Z` L.. N 0 0 p1 cnNE a c d L U _ N C � m d a U Q j -C U) m ca d N (� = m V N m -0 _ 0 0 O u l �� � muc' VO CC) VOW ° a) E rip " ca)N c a a; -o o N (0 U a ,_ o -oO dm '— cu° o r E C (0ra) O oac) `m °_ O > 2 of 5 m En E 03 c m CO m C .E N m c m co m - P .E a° O 0 a) v 0 0 CO C -0 O V @ 0 c c a) c (O C L 0 T O. 0 — m m O)p E m m = 0 0 m T To 2 > a�U u > 0 E 0 p w in o ._ E a 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 Hello