HomeMy WebLinkAboutState of Washington Department of Health Consolidated Contracts Amendment 7 - 090825JEFFERSON COUNTY PUBLIC HEALTH Page 1 044
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 7
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as "DOH", and
JEFFERSON COUNTY PUBLIC HEALTH, a Local Health Jurisdiction, hereinafter referred to as "LHJ", pursuant to the
Modifications/Waivers clause, and to make necessary changes within the scope of this contract and any subsequent amendments
thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work, includes the following statements of work, which are incorporated by this reference and located on
the DOH Finance SharePoint site in the Upload Center at the following URL:
s://s t fw . h + f in e u cs/ it a /h ?mc 1;9a94688da2d94d3caSOac7fbc32c4d7c
® Adds Statements of Work for the following programs:
Foundational Public Health Services - Effective July 1, 2025
Office of Resiliency & Health Security -PREP - Effective July 1, 2025
School -Based Health Centers Program - Effective July 1, 2025
® Amends Statements of Work for the following programs:
DCHS - ELC COVID-19 Response - Effective January 1, 2025
Maternal & Child Health Block Grant — Effective January 1, 2025
Sexual & Reproductive Health Program - Effective January 1, 2025
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-7 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-6 Allocations as follows:
® Increase of $2,446,631 for a revised maximum consideration of $5,736,053.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations arc attached only for informational purposes.
3. Exhibit C Federal Grant Awards Index, incorporated by this reference, and located in the ConCon, Funding & BARS library at
the URL provided above.
Unless designated otherwise herein, the effective date of this amendment is the date of execution.
.ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force and effect.
IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY WASHINGTON
OARD OF COUNTY COMMISSIONERS
o'
Heidi Eisenhour, Chair Daft
APPROXEL3 FORM ONLY
/ for 08/22/2025
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
Ca25.001-A7 Page I of I
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
APPROVED AS TO FORM ONLY
Assistant Attorney General
09/09/2025
Date
EXHIBIT B-7
Page 2 of 44
Jefferson County Public Health
ALLOCATIONS
Contract
Number:
CLH32053
Contract Term: 2025-2027
Date:
August 1, 2025
Indirect Rate January 1, 2025 through December 31, 2025: 27.38% Public Health
DOH Use
Only
BARS
Statement of Work
Chart of
Accounts
Funding
Chart of
Federal Award
Assist
Revenue
LHJ Funding
Period
Funding Period
Period
Accounts
Chart of Accounts Program Title
Identification #
Amend #
List #*
Code**
Start Date End Date Start Date End Date
Amount
SubTotal
Total
FFY25 USDA BFPC Prog Mgmt
7WA700WA1
Amd 4
10.557
333.10.55
01/01/25
09/30/26
10/01/24
09/30/26
$28,238
$28,238
$28,238
FFY24 USDA BFPC Prog Mgmt
7WA700WAI
Amd 4
10.557
333.10.55
01/01/25
09/30/26
10/01/23
09/30/26
($28,238)
$0
FFY24 USDA BFPC Prog Mgmt
7WA700WAI
Amd 2
10.557
333.10.55
01/01/25
09/30/26
10/01/23
09/30/26
$28,238
FFY25 USDA WIC Client Svs Contracts
7WA700WA7
Amd 4
10.557
333.10.55
01/01/25
09/30/25
10/01/24
09/30/25
$3,975
$148,117
$148,117
FFY25 USDA WIC Client Svs Contracts
7WA700WA7
Amd 2
10.557
333.10.55
01/01/25
09/30/25
10/01/24
09/30/25
$144,142
FFY25 USDA FMNP Mgmt
7WA810WA7
Amd 4
10.572
333.10.57
01/01/25
09/30/25
10/01/24
09/30/25
$637
$637
$637
FFY25 SWIMMING BEACH ACT IAR (ECY)
OIJ74301
Amd 2
66.472
333.66.47
03/01/25
10/31/25
01/01/25
11/30/25
$13,500
$13,500
$13,500
FFY25 PHEP BP2-CDC-LHJ Partners
NU90TU000055
Amd 7
93.069
333.93.06
07/O1/25
06/30/26
°
$19,527
$19,527
$33,281
FFY24 PHEP BPI-CDC-LHJ Partners
NU90TU000055
Amd 1
93.069
333.93.06
01/01/25
06/30/25
07/01/24
06/30/25
$13,754
$13,754
FFY24 OD2A OID CDC Prevent
NU17CE010218
Amd 6
93.136
333.93.13
07/01/25
08/31/25
09/01/24
08/31/25
$16,333
$16,333
$97,889
FFY24 0132A OID CDC Prevent
NU17CE010218
Amd 2
93.136
333.93.13
01/01/25
06/30/25
09/01/24
08/31/25
$32,556
$81,556
FFY24 0132A OID CDC Prevent
NU17CE010218
Amd 1
93.136
333.93.13
01/01/25
06/30/25
09/01/24
08/31/25
$49,000
FFY25 FPHPA Title X Family Plan
FPHPA006560
Amd 5
93.217
333.93.21
04/01/25
03/31/26
04/01/25
03/31/26
$17,023
$17,023
$33,989
FFY24 FPHPA Title X Family Plan
FPHPA006560
Amd 3
93.217
333.93.21
01/01/25
03/31/25
04/01/24
03/31/25
$8,345
$16,966
FFY24 FPHPA Title X Family Plan
FPHPA006560
Amd 21
93.217
333.93.21
01/01/25
03/31/25
04/01/24
03/31/25
$8,621
FFY24 CDC PPHF Ops
NH231P922619
Amd 1
93.268
333.93.26
01/01/25
06/30/25
07/01/23
06/30/25
$10,000
$10,000
$10,000
FFY20 ELC EDE LHJs CDC
NU50CK000515
Amd 1, 7
93.323
333.93.32
01/O1/25
12/31/25
01/15/21
07/31/26
$15,580
$15,580
$15,580
FFY21 CDC COVID-19 PHWFD-LHJ
NU90TP922181
Amd 3
93.354
333.93.35
01/01/25
06/30/25
07/01/23
06/30/25
$51,330
$51,330
$51,330
FFY22 PH Infrastructure Comp Al-LHJ
NEI IOE000053
Amd 3
93.967
333.93.96
01/01/25
11/30/27
12/01/22
11/30/27
$150,300
$150,300
$150,300
FFY25 HRSA MCHBG LHJ Contracts
B04MC54583
Amd 1
93.994
333.93.99
01/01/25
09/30/25
10/01/24
09/30/25
$27,525
$27,525
$27,525
FFY26 MCHBG LHJ Contracts HRSA YRl
NGA Not Received
Amd 7
93.994
333.93.99
10/01/25
09/30/26
$36,700
$36,700
$36,700
SFY25 SBHC Proviso
Amd 1
N/A
334.04.90
01/01/25
06/30/25
07/01/24
06/30/25
$59,000
$59,000
$59,000
SFV26 Sch Based Hlth Cent 1225 Proviso
Amd 7
N/A
334.04.90
07/O1/25
06/30/26
07/O1/25
06/30/26
$140,000
$140,000
$140,000
SFY25 DUH Naloxone DDO HCA IAR
Amd 4
N/A
334.0491
03!01,25
06/30/25
12/ln/24
06/30/25
$15,000
$15,000
$15,000
Page 1 of 3
EXHIBIT B-7
Jefferson County Public Health ALLOCATIONS
Contract Term: 2025-2027
Indirect Rate January 1, 2025 through December 31, 2025: 27.38% Public Health
Page 3 of 44
Contract Number: CLH32053
Date: August 1, 2025
Chart of Accounts Program Title
Federal Award
Identification # Amend #
Assist
List #*
DOH Use Only
BARS Statement of Work Chart of Accounts
Revenue LHJ Funding Period Funding Period
Code** Start Date End Date Start Date End Date
Amount
Funding
Period
SubTotal
Chart of
Accounts
Total
SFY26 Drug User Health Program
Amd 6
N/A
334.04.91
07/01/25
06/30/26
07/01/25
06/30/26
$80,500
$80,500
$120,750
SFY25 Drug User Health Program
Amd 1
N/A
334.04.91
01/01/25
06/30/25
07/01/24
06/30/25
$40,250
$40,250
SFY26 Sexual & Rep Hlth Cost Share
Amd 7
N/A
334.04.91
07/01/25
12/31/25
07101125
06/30/26
S47,404
$47,404
$95,397
SFY25 Sexual & Rep Hlth Cost Share
Amd 1
N/A
334.04.91
01/01/25
06/30/25
07/01/24
06/30/25
$47,993
$47,993
SFY25 SSPS Opiod Harm Red Proviso
Amd 2
N/A
334.04.91
01/01/25
06/30/25
07/01/24
06/30/25
$8,000
$8,000
$8,000
SFY25 LHJ Opioid Campaign Proviso
Amd 3
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
$24,500
$56,000
$56,000
SFY25 LHJ Opioid Campaign Proviso
Amd 1
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
$31,500
Rec Shellfish/Biotoxin
Amd 6
N/A
334.04.93
07/01/25
06/30/26
07/01/25
06/30/26
$7,500
$7,500
$11,200
Rec Shellfish/Biotoxin
Amd I
N/A
334.04.93
01/01/25
06/30/25
07/01/23
06/30/25
$3,700
$3,700
Small Onsite Management (ALEA)
Amd4
N/A
334.04.93
01/01/25
06/30/25
07/01/23
06/30/25
$1,363
$33,781
$33,781
Small Onsite Management (ALEA)
Amd 3
N/A
334.04.93
01/01/25
06/30/25
07/01/23
06/30/25
$32,418
SFY25 Wastewater Management-GFS
Amd 4
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
($1,363)
$9,239
$9,239
SFY25 Wastewater Management-GFS
Amd 3
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
$10,602
SFY26 FPHS-LHJ Funds-GFS
Amd 7
N/A
336.04.25
07/01/25
06/30/26
07�'01 'S
06/30/26
$2,203,000
$2,203,000
$4,536,000
SFY25 FPHS-LHJ Funds-GFS
Amd 1
N/A
336.04.25
01/01/25
06/30/25
07/01/24
06/30/25
$2,333,000
$2,333,000
YRl Stimulus - Local Asst (10% of 15%) SS
YR 28 SRF - Local Asst (15%) SS
YR 28 SRF - Local Asst (15%) SS
YR 27 SRF - Local Asst (15%) SS
YR 27 SRF - Local Asst (15%) SS
Sanitary Survey Fees SS -State
Sanitary Survey Fees SS -State
YRI Stimulus - Local Asst (10% of 15%) TA
YR 28 SRF - Local Asst (15%) TA
YR 28 SRF - Local Asst (15%) TA
YR 27 SRF - Local Asst (15%) TA
YR 27 SRF - Local Asst (15%) TA
Amd 6
N/A
346.26.64
01/01/25
12/31/27
07/01/23
06/30/28
Amd 6
N/A
346.26.64
01/01/25
12/31/27
07/01/24
06/30/29
Amd 4
N/A
346.26.64
01/01/25
12/31/27
07/01/24
06/30/29
Amd 4
N/A
346.26.64
01/01/25
06/30/25
07/01/23
06/30/25
Amd 1
N/A
346.26.64
01/01/25
06/30/25
07/01/23
06/30/25
Amd 6
N/A
346.26.65
01/01/25
12/31/27
07/01/23
12/31/27
Amd 1, 6
N/A
346.26.65
01/01/25
12/31/27
07/01/23
12/31/27
Amd 6
N/A
346.26.66
01/01/25
12/31/27
07/01/23
06/30/28
Amd 6
N/A
346.26.66
01/01/25
12/31/27
07/01/24
06/30/29
Amd4
N/A
346.26.66
01/01/25
12/31/27
07/01/24
06/30/29
Amd 4
N/A
346.26.66
01/01/25
06/30/25
07/01/23
06/30/25
Amd 1
N/A
346.26.66
01/01/25
06/30/25
07/01/23
06/30/25
$1,800 $1,800
($2,200) $0
$2,200
($2,200) $0
$2,200
($400) $1,800
$2,200
$1,000
($1,000)
$1,000
($1,000)
$1,000
$1,000
$0
$0
$1,800
$0
$1,800
$1,000
$0
Page 2 of 3
EXHIBIT B-7
Jefferson County Public Health ALLOCATIONS
Contract Term: 2025-2027
Indirect Rate January 1, 2025 through December 31, 2025: 27.38% Public Health
Page 4 of 44
Contract Number: CLH32053
Date: August 1, 2025
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification # Amend # List #* Code** Start Date End Date Start Date End Date Amount SubTotal Total
TOTAL
Total consideration: $3,289,422
$2,446,631
GRAND TOTAL $5,736,053
*Assistance Listing Number fka Catalog of Federal Domestic Assistance
**Federal revenue codes begin with "333". State revenue codes begin with "334".
$5,736,053 $5,736,053
GRAND TOTAL $5,736,053
Total Fed $647,086
Total State $5,088,967
Page 3 of 3
DOH Program Name or Title: DCHS - ELC COVID-19 Response -
Effective January 1, 2025
SOW Type: Revision Revision # (for this SOW) 1
Period of Performance: January 1, 2025 through December 31, 2025
Exhibit A
Statement of Work
Contract Term: 2025-2027
Page 5 of 44
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
❑ State ® FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide supplemental funding for the LHJ to ensure adequate culturally and linguistically
responsive testing, investigation and contract tracing resources to limit the spread of COVID-19.
Revision Purpose: Extend Period of Performance and LHJ Funding End Date from June 30, 2025 to December 31, 2025.
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Chan e
g
None
Total
Allocation
FFY20 ELC EDE LHJS CDC
1897140E
93.323
333.93.32
01/01/25
12/31/25
15,580
0
15,580
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
15,580
0
15,580
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Participate in public health emergency preparedness and response activities for COVID-19. This may include surveillance, epidemiology, laboratory capacity, infection control,
mitigation, communications and/or other preparedness and response activities for COVID-19.
Examples of key activities include:
• Incident management for the response
• Testing
• Case Investigation/Contact Tracing
• Sustainable isolation and quarantine
• Care coordination
• Surge management
• Data reporting
Exhibit A, Statement of Work Page 1 of 6 Contract Number CLH32053-Amendment 7
Paoe 6 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
NOTE: The purpose of this agreement is to supplement existing funds for local health jurisdictions to carry out surveillance, epidemiology, case investigations and contact
tracing, laboratory capacity, infection control, mitigation, communications, community engagement, and other public health preparedness and response activities for COVID-19.
DCHS COVID-19 Response
1
Establish a budget plan and narrative to be submitted to the
Submit the budget plan and narrative
Within 30 days of receiving
Reimbursement of actual
Department of Health (DOH) Contract Manager. DOH will send
using the template provided.
any new award for DCHS
costs incurred, not to
the "Budget narrative Template", "Budget Guidance" and any
COVID-19 Response tasks.
exceed:
other applicable documents that may be identified.
$15,580 FFY20 ELC
2
1) LHJ Active monitoring activities. In partnership with WA
Data collected and reported into DOH
Enter performance metrics
EDE LHJ
DOH and neighboring Tribes, the LHJ must ensure adequate
systems daily.
daily into DOH identified
ALLOCATION Funding
culturally and linguistically responsive testing, investigation
systems
(MI 1897140E) Funding
and contact tracing resources to limit the spread disease. LHJs
end date 12131125
must conduct the following activities in accordance with the
Quarterly performance
6nn„��
guidance to be provided by DOH.
reporting updates
a. Allocate enough funding to sustain modest local level
capacity for prioritized case investigation and contact
tracing for COVID-19. This includes efforts to conduct
follow-up on outbreak/cluster investigations in prioritized
high risk settings.
i. Contact tracing
1. Strive to maintain the capacity to conduct
Enter all contact tracing data in CREST
targeted investigations as appropriate.
following guidance from -DOH.
2. Have staff that reflect the demographic makeup
of the jurisdiction and who can provide
culturally and linguistically competent and
responsive services. In addition, or alternatively,
enter into an agreement(s) with Tribal,
community -based and/or culturally -specific
organizations to provide such services. DOH
centralized investigations will count towards this
minimum.
3. Ensure all contact tracing staff are trained in
accordance with DOH investigative guidelines
and data entry protocols.
4. Coordinate with Tribal partners in conducting
contact tracing for Tribal members.
5. Ensure contact tracing and case investigations
activities meet DOH case and Contact Tracing
Metrics. (Metrics to be determined
collaboratively by DOH, LHJs and Tribes.
Exhibit A, Statement of Work Page 2 of 6 Contract Number CLH32053-Amendment 7
Paae 7 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Work with DOH to develop a corrective action
plan if unable to meet metrics.
ii. Case investigation
1. Strive to maintain the capacity to conduct
targeted investigations as appropriate.
2. Enter all case investigation and outbreak data in
Enter all case investigation data in WDRS
WDRS following DOH guidance.
following guidance from -DOH.
a) Strive to enter all case investigation and
outbreak data into CREST as directed by
DOH.
b) Ensure all staff designated to utilize WDRS
have access and are trained in the system.
c) Include if new positive cases are tied to a
known existing positive case or indicate
community spread.
d) Conduct targeted case investigation and
monitor outbreaks.
e) Coordinate with Tribal partners in
conducting case investigations for tribal
members.
3. Ensure contact tracing and case investigation
activities meet DOH Case and Contact Tracing
Metrics. (Metrics to be determined
collaboratively by DOH, LHJs, and Tribes.)
Work with DOH to develop a corrective action
plan if unable to meet metrics.
b. Testing
i. Work with partners and Tribes to ensure testing is
available to every person within the jurisdiction
meeting current DOH criteria for testing and other
local testing needs.
ii. Work with partners and Tribes to ensure testing is
provided in a culturally and linguistically responsive
manner with an emphasis on making testing
available to disproportionately impacted
communities and as a part of the jurisdiction's
contact tracing strategy.
iii. Maintain a current list of entities providing COVID-
Maintain a current list of entities
19 testing and at what volume. Provide reports to
providing COVID-19 testing and at what
DOH on testing locations and volume as requested.
volume. Provide reports to DOH Contract
manager on testing locations and volume
as requested.
Exhibit A, Statement of Work Page 3 of 6 Contract Number CLH32053-Amendment 7
Paqe 8 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
c. Surveillance FTE support at a minimum of .5 FTE
Epidemiologist to support daily reporting needs below.
Ensure all COVID positive test results are
i. Ensure all COVID positive lab test results from LHJ
entered into WDRS within 2 days of
are entered in to WDRS by 1) entering data directly in
receipt
to WDRS, 2) sending test results to DOH to enter, or
3) working with DOH and entities conducting tests to
implement an electronic method for test result
submission.
ii. Collaborate with Tribes to ensure Tribal entities with
appropriate public health authority have read/write
access to WDRS and CREST to ensure that all
COVID lab results from their jurisdictions are entered
in WDRS or shared with the LIU or DOH for entry.
d. Tribal Support. Ensure alignment of contact tracing and
Quarterly performance updates related to
support for patients and family by coordinating with local
culturally and linguistic competency and
tribes if a patient identified as American Indian/Alaska
responsiveness, tribal support, infection
Native and/or a member of a WA tribe.
prevention and control for high -risk
populations, community education and
e. Support Infection Prevention and control for high -risk
regional active monitoring activities.
populations
Performance update should include status
i. Migrant and seasonal farmworker support. Partner
of all projects listed.
with farmers, agriculture sector and farmworker
service organizations to develop and execute plans
for testing, quarantine and isolation, and social
service needs for migrant and seasonal farmworkers.
ii. Congregate care facilities: In collaboration with the
state licensing agency (DSHS), support infection
prevention assessments, testing. Infection control
and isolation and quarantine protocols in congregate
care facilities.
iii. High risk businesses or community -based
operations. In collaboration with state licensing
agencies and Labor and Industries, partner with
food processing and manufacturing businesses to
ensure adequate practices to prevent COVID-19
exposure, conduct testing and respond to outbreaks.
iv. Healthcare: Support infection prevention and
control assessments, testing, cohorting, and isolation
procedures. Provide educational resources to a
variety of healthcare setting types (e.g., nursing
homes, hospitals, dental, dialysis).
Exhibit A, Statement of Work Page 4 of 6 Contract Number CLH32053-Amendment 7
Paae 9 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
v. Non -healthcare settings that house vulnerable
populations: In collaboration with state corrections
agency (DOC) and other state partners, support
testing, infection control, isolation and quarantine
and social services and wraparound supports for
individuals living or temporarily residing in
congregate living settings, including detention
centers, prisons, jails, transition housing, homeless
shelters, and other vulnerable populations.
vi. Schools: In collaboration with OSPI and local health
jurisdictions, support infection prevention and
control and outbreak response in K-12 and
university school settings.
f. Ensure adequate resources are directed towards H2A
housing facilities within communities, fishing industries
and long-term care facilities to prevent and control
disease transmission. Funds can be used to hire support
staff, provide incentives or facility -based funding for
onsite infection prevention efforts, etc.
g. Community education. Work with Tribes and partners to
provide culturally and linguistically responsive
community outreach and education related to COVED-19.
h. Establish sustainable isolation and quarantine (I&Q)
Quarterly performance updates to include
measures in accordance with WAC 246-100-045
name, address and capacity of identified
(Conditions and principles for isolation or quarantine).
location that can support isolation and
i. Have at least one (1) location for conducting I&Q
quarantine, and confirmation of
operations identified and confirmed. This location
appropriate planning and coordination as
should be sufficient for supporting I&Q services that
required.
are adequate for the population for your jurisdiction
and have an ability to expand if needed. This can be
through contract/formal agreement; alternatively, the
jurisdiction may establish with an adjacent
jurisdiction a formal agreement to provide the
isolation and quarantine capacity adequate to the
population for your jurisdiction with the ability to
expand.
ii. Maintain ongoing census data for isolation and
Report census numbers to include historic
quarantine for your population.
total by month and monthly total for
current quarter to date
Exhibit A, Statement of Work Page 5 of 6 Contract Number CLH32053-Amendment 7
Pape 10 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
iii. Planning must incorporate transfer or receipt of
people requiring I&Q support to and from adjacent
jurisdictions or state facilities in the event of
localized increased need.
iv. Planning must incorporate indicators for activating
and surging to meet demand and describe the
process for coordinating requests for state I&Q
support, either through mobile teams or the state
facility.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance(&doh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Unique Entity Identifier (UEI) generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.go by DOH as required by P.L. 109-282.
Program Specific Requirements
All work will be performed in accordance with the revised and approved project plans to be submitted to DOH.
Restrictions on Funds (what funds can be used for which activities, not direct payments, etc)
CDC Funding Regulations and Policies
https://www. cdc.gov/grants/documents/General-Terms-and-Conditions-Non-Research-Awards.pdf
Monitoring Visits (frequency, type)
The DOH program contact may conduct monitoring visits during the life of this project. The type, duration, and riming of visit will be determined and scheduled in cooperation
with the subawardee. The DOH Fiscal Monitoring Unit may conduct fiscal monitoring site visits during the life of this project
Special Billing Requirements:
Payment: Upon approval of deliverables and receipt of an invoice voucher, DOH will reimburse for actual allowable costs incurred. Billings for services on a monthly fraction of
the budget will not be accepted or approved.
Submission of Invoice Vouchers: The LHJ shall submit correct monthly A19-1 A invoice vouchers for amounts billable under this statement of work to DOH by the 25th of the
following month or on a frequency no less often than quarterly.
Exhibit A, Statement of Work Page 6 of 6 Contract Number CLH32053-Amendment 7
DOH Program Name or Title: Foundational Public Health Services -
Effective July 1, 2025
SOW Type: Oral Revision # (for this SOW)
Period of Performance: July 1, 2025 through June 30, 2026
Exhibit A
Statement of Work
Contract Term: 2025-2027
Page 11 of 44
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
❑ Federal <Select One> (check if applicable) ❑ Reimbursement
® State ❑ FFATA (Transparency Act) ® Periodic Distribution
❑ Other ❑ Research & Development
Statement of Work Purpose: Per RCW 43.70.512, Foundational Public Health Services (FPHS) funds are for the governmental public health system: local health jurisdictions,
Department of Health, state Board of Health, sovereign tribal nations and Indian health programs. These funds are to build the system's capacity and increase the availability of
FPHS services statewide.
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
Increase (+)
Total
Allocation
SFY26 FPHS - LHJ FUNDS - GFS
99210860
N/A
336.04.25
07/01/25
06/30/26
0
2,203,000
2,203,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
0
2,203,000
2,203,000
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
FPHS funds to each LHJ — See below in Program Specific Requirements
See below in Program Specific
See below in Pro ram
1
— Activity Special Instructions for details
Requirements -Deliverables
Specific Requirements -
S520,000
Deliverables
Assessment Reinforcing Capacity — See below in ProgSpecific
See below in Program Specific
See below in Program
2
Requirements — Activity Special Instructions for details
Requirements - Deliverables
Specific Requirements -
$60,000
Deliverables
Assessment — CHA/CHIP — See below in Program Specific Requirements
See below in Program Specific
See below in Program
3
— Activity Special Instructions for details
Requirements - Deliverables
Specific Requirements -
$30,000
Deliverables
Lifecourse - NEW SFY 24 Full Lifecourse Workforce Capacity — See
See below in Program Specific
See below in Pro
4
below in Program Specific Requirements — Activity Special Instructions for
Requirements - Deliverables
Specific Requirements -
$353,000
details
Deliverables
Exhibit A, Statement of Work Page 1 of 7 Contract Number CLH32053-Amendment 7
Pane 19 of dd
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
CD - NEW SFY 24 Immunization Outreach, Education & Response —
See below in Program Specific
See below in Program
5
See below in Program Specific Requirements — Activity Special
Requirements -Deliverables
Specific Requirements -
$75,000
Instructions for details
Deliverables
EPH - NEW SFY 24 Fully fund Environmental Public Health Policy &
See below in Program Specific
See below in Program
6
Leadership Capacity — See below in Program Specific Requirements —
Requirements -Deliverables
Specific Requirements -
$150,000
ActivitySpecial Instructions for details
Deliverables
7
FC - NEW SFY 24 Strengthening Local Finance Capacity
gt g p ty —See below
See below in Program Specific
See below in Program
in Program Specific Requirements — Activity Special Instructions for details
Requirements - Deliverables
Specific Requirements -
$62,000
Deliverables
8
FC - NEW SFY 24 Public Health Communications — See below in
See below in Program Specific
See below in Program
Program Specific Requirements — Activity Special Instructions for details
Requirements - Deliverables
Specific Requirements -
S200,000
Deliverables
Lifecourse - NEW SFY 24 Illicit Substance Use and Overdose Response
See below in Program Specific
See below in Program
9
— See below in Program Specific Requirements — Activity Special
Requirements - Deliverables
Specific Requirements -
$150,000
Instructions for details
Deliverables
EPR - NEW SFY 24 Emergency Preparedness & Response — Capacity
See below in Program Specific
See below in Program
10
and Capability — See below in Program Specific Requirements — Activity
Requirements -Deliverables
Specific Requirements -
$178,000
Special Instructions for details
Deliverables
Assessment — Shared Regional Epidemiology — General
See below in Program Specific
See below in Program
11
(Assessment/Surveillance, CHA/CHIP) — See below in Program Specific
Requirements -Deliverables
Specific Requirements -
S 150,000
Requirements — ActivitySpecial Instructions for details
Deliverables
12
EPH - NEW SFY 24 Social Work Support — See below in Proom
See below in Program Specific
See below in Program
Specific Requirements — Activity Special Instructions for details
Requirements - Deliverables
Specific Requirements -
S85,000
Deliverables
13
EPH Core Team — Safe and Healthy Communities — See below in
See below in Program Specific
See below in Program
Program Specific Requirements — Activity Special Instructions for details
Requirements - Deliverables
Specific Requirements -
$47,000
Deliverables
14
EPH Core Team — Climate Change Response — See below in Promo * _m
See below in Program Specific
See below in Program
Specific Requirements — Activity Special Instructions for details
Requirements - Deliverables
Specific Requirements -
S80,000
Deliverables
1details
EPH Core Team — System -Wide Data Management Improvement — See
See below in Program Specific
See below in Program
1 5
below in Program Specific Requirements — Activity Special Instructions for
Requirements - Deliverables
Specific Requirements -
$63,000
Deliverables
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to financena,doh.wa.gov.
FPHS staff from DOH and the Washington State Association of Local Public Health Officials (WSALPHO) will coordinate and communicate together to build and assure common
systemwide approaches per FPHS Steering Committee direction and the FPHS framework intent.
• For LIU questions about the use of funds:
o Chris Goodwin, FPHS Policy Advisor, WSALPHO — cgoodwin(a,wsac.org, 564-200-3166
Exhibit A, Statement of Work Page 2 of 7 Contract Number CLH32053-Amendment 7
Page 13 of 44
Brianna Steere, FPHS Policy Advisor, WSALPHO — bsteere ,wsac.org, 564-200-3171
The intent of FPHS funding is outlined in RCW 43.70.512.
Foundational Public Health Services Definitions and related information can be found here: www.doli.wa.gov/fphs.
Stable funding and an iterative decision -making process — The FPHS Steering Committee's roles and responsibilities are outlined in the FPHS Committee & Workgroup
Charter The Steering Committee is the decision making body for FPHS and operates under a consensus -based decision making model, outlined here. The Steering Committee use
an iterative approach to decision making meaning additional tasks and/or funds may be added to a local health jurisdiction's (LHJ) FPHS Statement of Work (SOW) as funding
decisions are made.
Spending of FPHS funds — FPHS funds do not require pre -approval or pre -authorization to spend. FPHS funds are to assure FPHS services are available in each jurisdiction based
on the FPHS Definitions (link) and as reflected in the SOW. Assurance includes providing FPHS as part of your jurisdiction's program operations, contracting with another
governmental public health system partner to provide the service, or receiving the service through a new service delivery model such as cross jurisdictional sharing or regional
staff. FPHS funds are eligible starting at the beginning of each state fiscal year (July 1) regardless of when funds are received by the LHJ, even if the expenditure
occurred before the LHJ's contract was signed.
These funds are not intended for fee -based services such as select environmental public health services. As state funding for FPHS increases, other funds sources (local revenue,
grants, federal block grants) should be directed to the implementation of additional important services and local/state priorities as determined by each agency/jurisdiction.
Annual Allocations — The legislature appropriates FPHS funding on an annual basis and the FPHS Steering Committee allocates funds annually through the FPHS Concurrence
Process for the State Fiscal Year (SFY): July - June.
The Legislature appropriates FPHS funding amounts for each fiscal year of the biennium. This means that funds must be spent within that fiscal year and cannot be carried
forward. Any funds not spent by June 3CO each year must be returned to the State Treasury. Funding allocations reset and begin again at the start of the next fiscal year (July 1).
This Statement of Work is for the period of July 1, 2025-June 30,2026 and may be included in multiple Consolidated Contracts (ConCons) which are based on the calendar year
and renewed every three years.
Disbursement of FPHS funds to LHJs — Unlike other ConCon grants, FPHS bill -back to DOH is NOT required. Half of the annual FPHS funds allocated by the Steering
Committee to each LHJ are disbursed each July and January. The July payments to LHJs and access to FPHS allocation for all other parts of the governmental public health
system occur upon completion of the FPHS Annual Assessment.
Deliverables — FPHS funds are to be used to assure FPHS services statewide. The FPHS accountability process measures how funds are spent, along with changes in system
capacity through the FPHS Annual Assessment, system performance indicators, and other data. DOH, SBOH and local health jurisdictions have agreed to complete:
1. Reporting of spending and spending projections. Process timelines and reporting template are provided by the FPHS Steering Committee via FPHS Support Staff.
2. FPHS Annual Assessment is due each July to report on the previous state fiscal year. Process and reporting template are provided by the FPHS Steering Committee via
FPHS Support Staff. System results are published in the annual FPHS Investment Report available at www.doh.wa.gov/fphs.
BARS Revenue Code: 336.04.25
BARS Expenditure Coding — provided for your reference
Exhibit A, Statement of Work Page 3 of 7 Contract Number CLH32053-Amendment 7
562.xx
BARS Expenditure Codes for FPHS activities: see below
10
FPHS Epidemiology & Surveillance
11
FPHS Community Health Assessment
12
FPHS Emergency Preparedness & Response
13
FPHS Communication
14
FPHS Policy Development
15
FPHS Community Partnership Development
16
FPHS Business Competencies
17
FPHS Technology
20
FPHS CD Data & Planning
21
FPHS Promote Immunizations
23
FPHS Disease Investigation — Tuberculosis B
24
FPHS Disease Investigation — Hepatitis C
25
FPHS Disease Investigation — Syphilis, Gonorrhea & HIV
26
FPHS Disease Investigation — STD other
27
FPHS Disease Investigation — VPD
28
FPHS Disease Investigation — Enteric
29
FPHS Disease Investigation — General CD
40
FPHS EPH Data& Planning
41
FPHS Food
42
FPHS Recreational Water
43
FPHS Drinking Water Quality
44
FPHS On -site Wastewater
45
FPHS Solid & Hazardous Waste
46
FPHS Schools
47
FPHS Temporary Worker Housing
48
FPHS Transient Accommodations
49
FPHS Smoking in Public Places
50
FPHS Other EPH Outbreak Investigations
51
FPHS Zoonotics includes vectors
52
FPHS Radiation
53
FPHS Land Use Planning
60
FPHS MCH Data & Planning
70
FPHS Chronic Disease, Injury & Violence Prevention Data & Planning
80
FPHS Access/Linkage with Medical, Oral and Behavioral Health Care Services Data & Planning
90
FPHS Vital Records
91
FPHS Laboratory — Centralized HSKC Only)
92
FPHS Laboratory
Special References (i.e., RCWs, WACs, etc.):
FPHS Intent - RCW 43.70.512
FPHS Funding — RCW 43.70.515
FPHS Committee & Workgroup Charter
FPHS Steering Committee Consensus Decision Making Model
Page 14 of 44
Exhibit A, Statement of Work Page 4 of 7 Contract Number CLH32053-Amendment 7
Page 15 of 44
Activity Special Instructions:
Investments to Each LHJ:
1. FPHS Funds to Each LHJ
These funds are allocated to be used to provide any programs and services within all of the FPHS Definitions. Each LHJ is empowered to prioritize where and how to use
these funds to maximize equitable, effective and efficient delivery of FPHS to every community in Washington.
Use BARS expenditure codes from the list above that most closely align with expenditure made.
Targeted Investments to Each LHJ:
2. Assessment Reinforcing Capacity (FPHS definition G.2)
Support LHJ assessment capacity with flexible funds to meet locally identified needs. BARS expenditure codes: 562.10 or 11
3. Assessment — CHA/CHIP (FPHS definitions G.3)
Support any CHA/CHIP activity or service (e.g., data analysis, focus groups, report writing, process facilitation) and may be used to contract with other agencies for staff
time or services. Use BARS expenditure codes: 562.11
4. Lifecourse - NEW SFY 24 Full Lifecourse Workforce Capacity (FPHS definitions D, E, F)
Infrastructure and workforce investments to each LHJ to meet fundamental needs in three areas: Maternal/Child/Family Health; Access/Linkage with Medical, Oral and
Behavioral Health Services; and Chronic Disease, Injury and Violence Prevention. Use BARS expenditure codes: 562.60, 562.70, and/or 562.80
5. CD - NEW SFY 24 Immunization Outreach, Education & Response (FPHS definition C.3)
Promote immunization education and use of the statewide immunization registry through evidence -based strategies. Funding can also be used to support vaccine -
preventable disease response. BARS expenditure codes: 562.21 and/or 562.27
6. EPH - NEW SFY 24 Fully fund Environmental Public Health Policy & Leadership Capacity (FPHS definitions B.2, A.C, J.1-3, K.1-2, L.1)
These funds are to be used for staffing costs for environmental health responsibilities and functions (that are not directly fee -based) within leadership, policy development,
foundational public health services implementation, evaluation, or administration, including (but not limited to) Environmental Health Directors. Examples of funded
roles include work relating to general policy, statewide and/or system -wide, and/or cross jurisdictional work, legislation, and rulemaking, SBOH engagement, leadership
support and/or development, workforce development, leadership within health equity, climate, and environmental justice. Use BARS expenditure codes: 562.14, 562.40 —
562.53
7. FC - NEW SFY 24 Strengthening Local Finance Capacity (FPHS definitions L.24, L.6, L.8)
Capacity and infrastructure to assure fiscal management and contract and procurement policies and procedures are effectively implemented to support programs and
services. Use BARS expenditure codes: 562.16
8. FC - NEW SFY 24 Public Health Communications (FPHS definitions I.1-2)
Capacity to enhance the frequency, accuracy, and accessibility of public health communications to diverse populations via various media to support programs and
services. Use BARS expenditure codes: 562.13
9. Lifecourse -NEW SFY 24 Illicit Substance Use and Overdose Response (FPHS definitions D.1-2, DA, F.1-3, G.1-3, I.1-2, J.14.3, K.1-2)
Capacity and infrastructure related to addressing overdose crisis. This includes but is not limited to: Overdose response trainings, convening stakeholders or coordination
groups, data analysis, and community education. Use BARS expenditure codes: 562.13, 562.14, 562.15, 562.60, 562.70, 562.80
Exhibit A, Statement of Work Page 5 of 7 Contract Number CLH32053-Amendment 7
Page 16 of 44
10. EPR - NEW SFY 24 Emergency Preparedness & Response — Capacity and Capability (FPHS definitions H. 14)
Capacity and infrastructure to support and enhance the local delivery of FPHS Emergency Preparedness and Response services and activities across critical subject matter
areas. Use BARS expenditure codes: 562.12
Targeted Investments to Select LHJs — Assurinp FPHS Available for/in Multiple Jurisdictions:
11. Assessment — Shared Regional Epidemiology — General (Assessment/Surveillance, CHA/CHIP) (FPHS definitions G.1,2)
Increase assessment and epidemiology capacity via regional/shared epidemiologist model to meet locally identified needs. Use BARS expenditure codes: 562.10 or 11
Targeted Investments to Select LHJs — Assurine FPHS Available in Own Jurisdiction
12. EPH - NEW SFY 24 Social Work Support (FPHS definitions B.1-3, B.6-7, DA, D.2, DA. E.2, EA, F.2-3, J.1-2, K.1-2, L.3, L.5)
This investment is intended to support non-traditional responses to environmental health complaints and challenges in the context of social work support and care
coordination with social service providers. Activities include: assessment of complaints and challenges; identifying cases and circumstances for engaging in social work
support and care coordination; and engagement with social service providers. Funds may be used to support these activities, as well as related staffing and training
expenses. Use BARS expenditure codes: 562.14, 562.15, 562.40, 562.47, 562.48
EPH -- Core Teams (Applies to all EPH Core Team FPHS Investments) (FPHS definition B.1-7)
Each EPH Core Team investment is for LHJ staff to participate in a cross jurisdictional topic -specific Core Team. The Core Teams are each tasked with developing one or
more model program(s), intended to offer guidance for scalable environmental public health responses relating to their specific sub -topic area(s). Where it makes sense to
do so, the Core Teams may also work on implementation of these model programs. The content and output of these model programs will vary depending on the needs and
approaches specific to each sub -topic area.
Recipients of these Core Team FPHS funds are required to participate in the associated Core Team for each investment. Recipients may spend these funds towards
staffing time necessary to participate and on FPHS-qualifying activities for the specific sub -topic area(s) attached to its associated investment. Each Core Team FPHS
investment is distinctive from all other Core Team FPHS investments.
Core Teams exist outside the FPHS structure, in partnership between LHJs and WA DOH, with one co -lead from each. Model programs developed through Core Team
work will be made available to all Washington public health agencies.
There are currently six EPH Core Teams. They are listed below, with their sub -topic area(s), as applicable.
• System -Wide Data Management Improvement
• Climate -Change Response
• Lead Exposure
• Water System Capacity
• Homelessness Response
• Safe & Healthy Communities
Jefferson is receiving funds to participate in these EPH Core Teams:
EPH -- Core Teams (Applies to all EPH Core Team FPHS Investments) (FPHS definition B.1-7)
Each EPH Core Team investment is for LHJ staff to participate in a cross jurisdictional topic -specific Core Team. The Core Teams are each tasked with developing one or
more model program(s), intended to offer guidance for scalable environmental public health responses relating to their specific sub -topic area(s). Where it makes sense to
Exhibit A, Statement of Work Page 6 of 7 Contract Number CLH32053-Amendment 7
Page 17 of 44
do so, the Core Teams may also work on implementation of these model programs. The content and output of these model programs will vary depending on the needs and
approaches specific to each sub -topic area.
Recipients of these Core Team FPHS funds are required to participate in the associated Core Team for each investment. Recipients may spend these funds towards
staffing time necessary to participate and on FPHS-qualifying activities for the specific sub -topic area(s) attached to its associated investment. Each Core Team FPHS
investment is distinctive from all other Core Team FPHS investments.
Core Teams exist outside the FPHS structure, in partnership between LfUs and WA DOH, with one co -lead from each. Model programs developed through Core Team
work will be made available to all Washington public health agencies.
There are currently six EPH Core Teams. They are listed below, with their sub -topic area(s), as applicable.
• System -Wide Data Management Improvement
• Climate -Change Response
• Lead Exposure
• Water System Capacity
• Homelessness Response
• Safe & Healthy Communities
Jefferson is receiving funds to participate in these EPH Core Teams:
13. EPH Core Team — Safe & Healthy Communities
This Core Team develops system capacity to advance EPH perspectives into planning processes such as State Environmental Policy Act (SEPA) work, Health Impact
Assessments, Comprehensive Plans, and related environmental review opportunities. The Core Team will develop one or more model program(s) to provide scalable
approaches to healthy community planning, which may include wastewater planning and treatment, seawater intrusion in drinking water, ventilation in public buildings,
PFAS contamination, climate change challenges, and other emerging topics identified by the Core Team.
• Use BARS expenditure code: 562.40
14. EPH Core Team — Climate -Change Response
This Core Team will address environmental health concerns related to climate and the effects of climate change.
• Model program development will start with Wildfire Smoke and Harmful Algal Blooms, and may include other priorities and topics.
15. EPH Core Team — System -Wide Data Management Improvement
This Core Team will identify and employ a strategy for data sharing, storage and consistency across the state.
• Use BARS expenditure code: 562.40.
Exhibit A, Statement of Work Page 7 of 7 Contract Number CLH32053-Amendment 7
DOH Program Name or Title: Maternal & Child Health Block Grant —
Effective January 1, 2025
SOW Type: Revision Revision # (for this SOW) 1
Period of Performance: January 1, 2025 through September 30, 2026
Exhibit A
Statement of Work
Contract Term: 2025-2027
Page 18 of 44
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
❑ State ® FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to support local interventions that impact the target population of the Maternal and Child Health
Block Grant.
Revision Purpose: The purpose of this revision is to provide additional funding, add activities and deliverable due dates, and extend the period of performance and funding
period from September 30, 2025 to September 30, 2026, for continuation of MCHBG related activities, and update Program Specific Requirements.
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
Increase (+)
Total
Allocation
FFY25 HRSA MCHBG LHJ CONTRACTS
78101251
93.994
333.93.99
01/01/25
09/30/25
27,525
0
27,525
FFY26 MCHBG LHJ CONTRACTS HRSA YR1
78101261
93.994
333.93.99
10/01/25
09/30/26
0
36,700
36,700
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
27,525
36,700
64,225
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Maternal and Child Health Block Grant (MCHBG) Administration
la
Report actual expenditures for the six-month period
Submit actual expenditures using the MCHBG
May 16, 2025
Reimbursement for actual
from October 1, 2024 through March 31, 2025.
Budget Workbook to DOH Community
costs, not to exceed total
Consultant.
funding consideration.
Monthly Reports must only
lb
Develop 2025-2026 MCHBG Budget Workbook for
Submit MCHBG Budget Workbook to DOH
September 5, 2025
reflect activities paid for
October 1, 2025 through September 30, 2026 using
Community Consultant.
with funds provided in this
DOH -provided template.
I
statement of work for the
lc
Participate in DOH -sponsored annual MCHBG meeting.
LHJ Contract Lead or designee will attend
September 30, 2025
specified funding period.
meeting.
Exhibit A, Statement of Work Page 1 of 5 Contract Number CLH32053-Amendment 7
Paae 19 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Id
Report actual expenditures for October 1, 2024 through
Submit actual expenditures using the MCHBG
December 5, 2025
See Program Specific
September 30, 2025.
Budget Workbook to DOH Community
Requirements and Special
Consultant.
Billing Requirements.
le
Report actual expenditures for the six-month period
Submit actual expenditures using the MCHBG
May 15, 2026
from October 1, 2025 through March 31, 2026.
Budget Workbook to DOH Community
Consultant.
if
Report annual FTE billed to MCHBG.
Submit FTE information on DOH -provided
July 1, 2026
template.
Ig
Develop 2026-2027 MCHBG Budget Workbook for
Submit MCHBG Budget Workbook to DOH
September 4, 2026
October 1, 2026 through September 30, 2027 using
Community Consultant.
DOH- rovided template.
1 h
Participate in DOH -sponsored MCHBG fall regional
LHJ Contract Lead or designee will attend
September 30, 2026
,neeting.
regional meeting.
Implementation
2a
Report 2024-25 MCHBG-funded activities and
Submit monthly reports to DOH Community
January 15, 2025
Reimbursement for actual
outcomes using DOH -provided reporting template. As a
Consultant. Describe in your updates within
February 15, 2025
costs, not to exceed total
foundation of your MCHBG work determine how
each activity of the monthly report how you
March 15, 2025
funding consideration.
processes and programs can close gaps in health
are intentionally focused on closing gaps in
April 15, 2025
Monthly Reports must only
outcomes.
health outcomes.
May 15, 2025
reflect activities paid for
June 15, 2025
with funds provided in this
July 15, 2025
statement of work for the
August 15, 2025
specified funding period.
September 15 2025
2b
Develop 2025-26 MCHBG reporting document for
Submit MCHBG reporting document to DOH
Draft -August 15, 2025
See Program Specific
October 1, 2025 through September 30, 2026 using
Community Consultant.
Final - September 12, 2025
Requirements and Special
DOH -provided template.
Billing Requirements.
2c
Report 2025-26 MCHBG-funded activities and
Submit monthly reports to DOH Community
September report due
outcomes using DOH provided reporting template. As a
Consultant. Describe in your updates within
October 15, 2025
foundation of your MCHBG work determine how
each activity of the monthly report how you
November 15, 2025
processes and programs can close gaps in health
are intentionally focused on closing gaps in
December 15, 2025
outcomes.
health outcomes.
January 15, 2026
February 15, 2026
March 15, 2026
April 15, 2026
May 15, 2026
June 15, 2026
July 15, 2026
August 15, 2026
September 15, 2026
Exhibit A, Statement of Work Page 2 of 5 Contract Number CLH32053-Amendment 7
Paae 20 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Develop 2026-27 MCHBG Monthly Reporting Template
Submit MCHBG reporting document to DOH
Draft —August 14, 2026
for October 1, 2026 through September 30, 2027 using
Community Consultant.
Final — September 11, 2026
DOH -provided template.
Children and Youth with Special Health Care Needs (CYSHCN)
3a
Complete intake and renewal, per reporting guidance
Submit data to DOH per CYSHCN Program
January 15, 2025
Reimbursement for actual
supplied by DOH, on all infants and children served by
guidance.
April 15, 2025
costs, not to exceed total
the CYSHCN Program as referenced in CYSHCN
July 15, 2025
funding consideration.
Program guidance. If no CYSHCN care coordination
Monthly Reports must only
(enabling service) is provided in a given quarter, email
reflect activities paid for
the CHIF administrator at DOH-CHIFAdoh.wa.gov and
with funds provided in this
indicate that zero clients were served during the quarter.
statement of work for the
No spreadsheet is necessary when zero clients are
specified funding period.
served.
3b
Identify unmet needs for CYSHCN on Medicaid and
Submit completed Health Services
30 days after forms are
See Program Specific
refer to DOH CYSHCN Program for approval to access
Authorization forms and Central Treatment
completed
Requirements and Special
Diagnostic and Treatment funds as needed.
Fund requests directly to the CYSHCN
Through September 30,
Billing Requirements.
Program as needed.
2025
3c
Review your program's entry on ParentHelpl23.org
Document in the Administrative box on your
September 30, 2025
annually for accuracy.
MCHBG report that you have updated
information on your local CYSHCN program
with WithinReach/Help Me Grow.
3d
Support improvements to the local system of care
Submit updates as part of monthly reporting
January 15, 2025
(public health services and systems/policy, systems, and
document.
February 15, 2025
environment) for CYSHCN. Refer to the Focus of Work
March 15, 2025
document for example activities and priority areas.
April 15, 2025
May 15, 2025
June 15, 2025
July 15, 2025
August 15, 2025
September 15 2025
3e
Complete intake and renewal, per reporting guidance
Submit data to DOH per CYSHCNProgram
October 15, 2025
supplied by DOH, on all infants and children served by
guidance.
January 15, 2026
the CYSHCN Program as referenced in CYSHCN
April 15, 2026
Program guidance. If no CYSHCN care coordination
July 15, 2026
(enabling service) is provided in a given quarter, email
the CHIF administrator at DOH-CHIF(0doh.wa.gov
and indicate that zero clients were served during the
quarter. No spreadsheet is necessary when zero clients
are served.
3f
Review yourprogram's entry on ParentHelp123.org
Document in the Administrative box on your
September 30, 2026
annually for accuracy.
MCHBG report that you have updated
Exhibit A, Statement of Work Page 3 of 5 Contract Number CLH32053-Amendment 7
Page 21 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
information on your local CYSHCN program
with WithinReach/Help Me Grow.
3g
Support improvements to the local system of care
Submit updates as part of monthly reporting
September report due
(public health services and systems/policy, systems, and
document.
October 15, 2025
environment) for CYSHCN. Refer to the Focus of Work
November 15, 2025
document for example activities and priority areas.
December 15, 2025
January 15, 2026
February 15, 2026
March 15, 2026
April 15, 2026
May 15, 2026
June 15, 2026
July 15, 2026
August 15, 2026
September 15, 2026
MCHBG Assessment and Evaluation
4a
As part of the ongoing 5-year MCHBG Needs
Submit documentation as requested by DOH.
September 30, 2025
Reimbursement for actual
Assessment, participate in activities developed and
costs, not to exceed total
coordinated by DOH using DOH -provided reporting
funding consideration.
template.
Monthly Reports must only
reflect activities paid for
4b
Provide summary of outcomes of MCHBG funded work
Submit documentation as requested by DOH.
November 21, 2025
completed from October 1, 2024 through September 30,
with funds provided in this
2025 using DOH -provided reporting template.
statement of work for the
4c
As part of the ongoing 5-year MCHBG Needs
Submit documentation as requested by DOH.
September 30, 2026
specified funding period.
Assessment, participate in activities developed and
coordinated by DOH using DOH -provided reporting
See Program Specific
template.
Requirements and Special
Billing Requirements.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance ,doh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Unique Entity Identifier (UEI) generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpendinggov by DOH as required by P.L. 109-282.
Exhibit A, Statement of Work Page 4 of 5 Contract Number CLH32053-Amendment 7
Page 22 of 44
Program Specific Requirements
Special Requirements:
All training costs and all travel expenses for such training (for example: per diem, hotel, registration fees) must be pre -approved, unless identified in pre -approved Budget
Workbook. Submit a paragraph to your Community Consultant explaining why the training is necessary to implement a strategy in the approved work plan. Details should also
include total cost of the training and a link to or brochure of the training. Retain a copy of the Community Consultant's approval in your records.
Program Manual, Handbook, Policy References:
CYSHCN Information and Resources:
Children and Youth with Special Health Care Needs Website(wa.gov)
Restrictions on Funds (i.e., disallowed expenses or activities, indirect costs, etc.):
1. At least 30% of federal Title V funds must be used for preventive and primary care services for children and at least 30% must be used for services for children with
special health care needs. [Social Security Law, Sec. 505(a)(3)].
2. Funds may not be used for:
a. Inpatient services, other than inpatient services for children with special health care needs or high -risk pregnant women and infants, and other patient services approved by
Health Resources and Services Administration (HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land, the purchase, construction, or permanent improvement of any building or other facility, or the purchase of major medical
equipment.
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. Payment for any services furnished by a provider or entity who has been excluded under Title XVIII (Medicare), Title XIX (Medicaid), or Title XX (social services block
grant). [Social Security Law, Sec 504(b)].
3. If any charges are imposed for the provision of health services using Title V (MCH Block Grant) funds, such charges will be pursuant to a public schedule of charges; will not
be imposed with respect to services provided to low-income mothers or children; and will be adjusted to reflect the income, resources, and family size of the individual
provided the services. [Social Security Law, Sec. 505 (1) (D)].
Monitoring Visits (i.e., frequency, type, etc.):
Check -ins with DOH Community Consultant as needed.
Billing Requirements:
Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable Al 9-IA invoice voucher. Payment to completely expend the "Total Consideration" for
a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly by the 30th of each month following
the month in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a monthly fraction of the "Total Consideration"
will not be accepted or approved.
Special Instructions:
Contact DOH Community Consultant for approval of expenses not reflected in pre -approved Bbudget Wworkbook.
Exhibit A, Statement of Work Page 5 of 5 Contract Number CLH3 2053 -Amendment 7
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Resiliency & Health Security-PHEP -
Effective July 1, 2025
SOW Type: Original Revision # (for this SOW)
Period of Performance: July 1, 2025 through June 30, 2026
Page 23 of 44
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance T�Pe of Payment
® Federal Subrecipient (check if applicable) 0 Reimbursement
❑ State ® FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work is to establish funding and tasks for LHJs to strengthen their capacity and capability around the Public
Health Response Readiness Framework (CDC) to prepare for, respond to, and recover from public health threats and emergencies through a continuous cycle of planning,
organizing, training, equipping, exercising, evaluating, and implementing corrective actions as described in the Public Health Emergency Preparedness (PREP) Cooperative
Agreement. Many LHJs support a position responsible for public health emergency preparedness and response. LHJs use different titles for these positions. DOH wants to be
respectful of this diversity and refers to the people who fill these important roles as Public Health Emergency Response Coordinators.
This statement of work includes a partial allocation of PHEP funds because DOH has received a partial allocation from the CDC. DOH will add the remaining funds to the
statement of work when they are received. If they are not received, DOH will review the statement of work and adjust actvities as needed.
Guidance Documents - LHJs are strongly encouraged to use the Guidance Documents listed in the Program Specific Requirements in the bottom section of this Statement of Work.
Revision Purpose: NA
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
Increase (+)
Total
Allocation
FFY25 PHEP BP2 - CDC- LHJ PARTNERS
31602254
93.069
333.93.06
07/01/25
06/30/26
0
19,527
19,527
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
0
19,527
19,527
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment
Information and/or
Amount
1
Maintain accurate and up-to-date contact information. This includes
Submit information by September 1,
September 1, 2025
Reimbursement for
names, position titles, email addresses, and phone numbers of key LHJ
2025, and any changes within 30 days of
Within 30 days of the
actual costs not to
staff responsible for this statement of work, including management,
the change.
change.
exceed total funding
Emergency Response Coordinator(s), and accounting and/or financial
allocation amount.
staff.
Mid -and end -of -year reports on template
December 31, 2025
provided by DOH. Note any changes or
June 30, 2026
no changes.
Exhibit A, Statement of Work Page 1 of 10 Contract Number CLH32053-Amendment 7
Paae 24 of 44
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
2
As requested, submit additional information to DOH to comply with
Information requested by DOH.
Upon request from
federal grant requirements and/or DOH requirements.
DOH.
3
Participate with DOH in a site visit (virtual or in person) to develop
Participation in site visit.
As requested by DOH.
stronger relationships, enhance collaboration, and promote a unified
approach to public health preparedness and response efforts.
Preparation and follow-up activities as
requested by DOH.
4
Jurisdictional Risk Assessment
Implementing the preparedness cycle in any organization or jurisdiction is dependent on information about jurisdictional hazards. DOH is
providing every local health jurisdiction with access to the H2azaRDS tool that was developed by the University of Washington. This
Jurisdictional Risk Assessment (JRA) identifies, analyzes, and prioritizes potential public health and medical threats and hazards within the
jurisdiction.
4.1
Participate in the public health disaster risk assessment tool/report
Participation in training.
December 31, 2025
(H2azaRDs tool) training. This training will provide a foundational
understanding of the tool and the rollout of it.
Mid -year reports on template provided by
DOH (note participation in training).
Note: LHJs will be notified at least 30 days in advance of the training
date.
4.2
Complete a jurisdictional risk assessment tool/report during the PHEP
Risk Assessment
December 31, 2025
FFY24 BPI grant period or between July I and December 31, 2025, to
inform the 2026 Integrated Preparedness Planning Workshop (IPPW).
OR
Participate in a jurisdictional risk assessment tool/report during the
PHEP FFY24 BP 1 grant period or between July 1 and December 31,
2025, to inform the 2026 IPPW.
The completed risk assessment report will include:
• Documented risk profiles, capability gaps, and
recommendations to inform planning and resource allocation.
• Preparedness strategies in alignment with local, state, and
federal emergency management frameworks.
• A list of identified risks within the jurisdiction.
• A prioritized ranking of the top five risks.
• A summary of how these risks impact the most affected
populations.
Exhibit A, Statement of Work Page 2 of 10 Contract Number CLH32053-Amendment 7
Paae 25 of 44
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
5
Training
Maintaining baseline training competency is essential for a coordinated and effective public health emergency response. Ensuring staff complete
the appropriate Incident Command System (ICS) training enables them to operate within standardized response structures and communicate
effectively during emergencies. Requiring sub-awardees to verify completion through a DOH -approved training plan promotes accountability
and consistency across jurisdictions.
5.1
Ensure baseline NIMS compliant training competency is maintained as
Mid- and end -of -year reports on
December 31, 2025
determined by the LIU.
templates provided by DOH, including
June 30, 2026
titles, dates, and sponsor of trainings.
PHEP funding may be used to support additional public health
emergency response trainings identified by the LHJ.
6
Exercising
Both state and local health departments follow the Homeland Security Exercise and Evaluation Program (HSEEP) principles. Assessing the
effectiveness of our emergency response plans and the training of those who might respond to the public health impacts of disasters, is a core
component of the preparedness cycle. The act of exercising combined with the learning as demonstrated by an After -Action Report (AAR)
drives future planning and training. It is DOH's responsibility to meet the exercise requirements under our CDC PHEP Cooperative Agreement.
DOH uses the Multi -Year Preparedness Activities Calendar (MYPAC) to demonstrate that sub -recipients of the PHEP funding are participating
in, or leading exercises. Local Jurisdictions and Tribes may use PHEP funding for any exercise that furthers their preparedness.
6.1
If DOH participation is requested, complete the WA DOH Exercise
Exercise Notification Form
As soon as the LHJ is
Notification Form prior to conducting an exercise that was not
aware of the exercise
previously identified in the LHJ's MYPAC or led by DOH.
date and details.
6.2
Conduct, or participate in, at least one emergency response exercise by
Submit a Completed After -Action
For AARs that the LHJ
June 30, 2026.
Report/Improvement Plan (AAR/IP)
are responsible for, 90
days after exercise
LHJs should coordinate preparedness exercises with local partners,
completion. For others,
including Tribes, emergency management, healthcare facilities, and
when the AAR is
first responder agencies. Participation in exercises hosted by other
publicly available.
organizations within the jurisdiction or geographic region is also
strongly encouraged to support regional coordination and strengthen
multi -agency response capabilities.
Note: A real -world response would meet this deliverable.
7
Public Health Emergency Response Planning
A core component of every public health preparedness and response program is maintaining an up-to-date and complete emergency response
plan that describes how the jurisdiction will respond to the public health impacts of the most likely threats faced by the jurisdiction.
7.1
Update or develop LHJ identified sections of the Comprehensive
Describe progress to date in the mid -year
December 31, 2025
Emergency Response Plan addressing gaps/needs identified from an
report on template provided by DOH.
June 30, 2026
After Action Report from an exercise or a real world response
Exhibit A, Statement of Work Page 3 of 10 Contract Number CLH32053-Amendment 7
Paae 26 of 44
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
Emergency Response Plan by June 30,
Align the Plan with National Incident Management System/Incident
2026.
Command System (NIMS/ICS) standards and coordinate with
community -based organizations, healthcare, and local emergency
response agencies.
8
Integrated Preparedness Planning
Washington values the strengths of a decentralized public health system while recognizing that PHEP resources are limited. The Integrated
Preparedness Planning (IPP) process is intended to promote inter jurisdictional efficiency by aligning planning, training, and exercise efforts
across the many public health jurisdictions in the state.
8.1
To inform IPPW, develop a Multi -Year Preparedness Activities
MYPAC
January 5, 2026
Calendar (MYPAC).
Bring (or have available) your MYPAC
January 13-14, 2026
Use the following to inform development of your MYPAC: exercise
to the IPPW (digital or on paper).
plans, emergency response plans, AAR/IPs, IPPs, and response
Highlight activities that are new since
training plans.
January 2025.
8.2
Participate in both days of DOH Integrated Preparedness Planning
Participation in IPPW (DOH will be
January 13-14, 2026
Workshop (IPPW), with at least one representative (virtually or in
looking at sign in documents).
person).
End -of -year report on template provided
June 30, 2026
The IPPW is scheduled for January 13-14, 2026 (location TBD).
by DOH.
8.3
Develop or update a multi -year -integrated preparedness plan with
Multiyear integrated preparedness plan
June 30, 2026
critical response and recovery partners using the whole community
that is aligned with HSEEP principles,
approach.
developed or updated between February 1
and June 30, 2026 (after the IPPW).
Use the information gathered in tasks 8.1. and 8.2 to inform the
development of this plan
9
Emergency Information Sharing
Effective emergency communication and notification are critical for ensuring a timely, coordinated response to public health incidents.
Immediate notification and accurate situation reporting enable rapid decision -making, resource deployment, and situational awareness at the
state, tribal, and local levels. Maintaining reliable communication systems and conducting regular drills help verify readiness, strengthen
coordination, and ensure that response protocols function as intended during real -world emergencies.
9.1
Notification Requirement: Notify the Washington State Department of
Mid- and end -of -year reports on template
December 31, 2025
Health (DOH) Duty Officer at 360-888-0838 or via email at
provided by DOH.
June 30, 2026
hanalertAdoh.wa.gov for any incident that involves the activation of
emergency response plans and/or the implementation of an incident
command structure.
Exhibit A, Statement of Work Page 4 of 10 Contract Number CLH32053-Amendment 7
Paoe 27 of 44
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
9.2
Situation Reporting: Develop situation reports (sitreps) documenting
Mid- and end -of -year reports on template
December 31, 2025
jurisdictional activities during all response incidents that extend
provided by DOH. Note whether
June 30, 2026
beyond two operational periods and require a written Incident Action
Situation Reports were submitted, or
Plan.
there was no need to submit them.
Situation reports may be prepared directly by the LHJ or by another
jurisdiction, provided they include input from the LHJ to ensure
accuracy and completeness.
Submit Situation Reports to DOH Duty Office (hanalert@doh.wa.gov)
during LHJ response as soon as they are available.
9.3
Maintain the Washington Secure Electronic Communications, Urgent
Mid- and end -of -year reports on template
December 31, 2025
Response, and Exchange System (WASECURES) as the primary
provided by DOH.
June 30, 2026
platform for emergency notifications.
Participate in DOH -led notification drills.
Notes:
• Registered users must log in (or respond to an alert) quarterly
at a minimum.
• DOH will provide technical assistance to LHJs on using
WASECURES.
• LHJ may choose to use another notification system in
addition to WASECURES to alert staff during incidents.
9.4
Participate in quarterly WASECURES notification drills coordinated
Mid- and end -of -year reports on template
December 31, 2025
by DOH to support statewide communication readiness.
provided by DOH.
June 30, 2026
9.5
Conduct at least one Local Health Jurisdiction (LHJ)-led drill using the
Submit results of the drill on the mid- OR
December 31, 2025 OR
jurisdiction's preferred staff notification system to ensure operational
end -of -year reports on template provided
June 30, 2026
effectiveness.
by DOH.
10
Medical Materiel and Volunteer Management
Effective medical materiel and volunteer management are essential for ensuring timely access to critical supplies and skilled personnel during
public health emergencies, enabling local health jurisdictions to respond quickly, coordinate resources efficiently, and maintain continuity of
operations under surge conditions. While LHJs are not expected to sustain these capabilities independently, they must have plans in place to
access and coordinate resources through local, mutual aid, and state systems when needed.
10.1
Maintain and update the LHJ's medical materiel management plan
Mid- and end -of -year reports on template
December 31, 2025
components, operational guide, or process document by verifying that
provided by DOH that describe progress
June 30, 2026
the local agency's preferred large parcel delivery sites are accurate and
on this task.
operational and jointly confirmed with DOH, confirming that
Exhibit A, Statement of Work Page 5 of 10 Contract Number CLH32053-Amendment 7
Paoe 28 of 44
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
inventory tracking systems work as intended, and ensuring the LHJ can
Summary of medical materiel
December 31, 2025 OR
procure, store, manage, and distribute palletized and bulk medical
management plan components,
June 30, 2026
supplies during a public health emergency when necessary.
operational guide, or process document.
(You may submit the whole plan, guide,
or document if you prefer.)
10.2
Develop process/procedure to integrate clinical volunteers into your
Mid- and end -of -year reports on
December 31, 2025
emergency response plan(s) including the process for management of
template provided by DOH, including
volunteers during a public health emergency. This could be in
identified volunteer management point
June 30, 2026
partnership with other response partners (EM, Hospitals, Local
of contact.
Volunteer agencies, etc.).
Volunteer management process, procedure,
June 30, 2026
This plan must identify a point of contact to collaborate with state
or plan, including the point of contact.
volunteer registries and support volunteer vetting, credentialing, and
response readiness.
Updated volunteer management point of
As changes occur.
If a Medical Reserve Corps (MRC) is housed within the Local Health
contact, as needed.
Jurisdiction (LHJ), confirm a Point of Contact (POC).
For LHJs without an MRC, identify a POC to liaise with external
volunteer management organizations, including the State Emergency
Medical Reserve Corps.
11
Public Health Information and Warning
Effectively communicating with the public about health risks during emergencies is essential for reducing morbidity and mortality. When
people understand the nature of a threat and what actions they can take to stay safe, they are better equipped to protect themselves and others.
Timely, clear, and culturally appropriate messaging helps minimize confusion, supports informed decision -making, and ultimately saves lives
during public health emergencies.
11.1
Incorporate communication strategies into exercises to strengthen your
Mid- and end -of -year reports on template
December 31, 2025
jurisdiction's capacity to manage and disseminate accurate information
provided by DOH.
June 30, 2026
during emergencies to populations disproportionately affected by top
public health hazards within jurisdiction.
12
Healthcare Coalition Partnerships
Collaboration between local PHEP recipients and healthcare coalitions is essential to align public health and healthcare system preparedness
capabilities, enhance interoperable response plans, and ensure efficient allocation of critical resources during emergencies.
12.1
Participate in the Northwest Healthcare Response Network (NWHRN)
Mid- and end -of -year reports on template
December 31, 2025
monthly or the Healthcare Alliance (HCA) bi-monthly meetings, at
provided by DOH.
June 30, 2026
least once during each contract reporting period.
Exhibit A, Statement of Work Page 6 of 10 Contract Number CLH32053-Amendment 7
Paae 29 of 44
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
The contract reporting periods are July 1 — December 31, 2025, and
January 1 — June 30, 2026.
12.2
Participate in the following additional activities with the Northwest
Mid- and end -of -year reports on template
December 31, 2025
Healthcare Response Network (NWHRN) or the Healthcare Alliance
provided by DOH.
June 30, 2026
(HCA):
• Communications
• Planning
• Training, and/or exercises.
13
Coordination with Tribes
Tribes bring valuable cultural knowledge, governance structures, and community networks, essential for effective preparedness, response, and
recovery. Partnering with tribes enhances trust, optimizes resource use, and ensures equitable support during crises.
13.1
Seek to engage and coordinate with local tribes on preparedness
Mid- and end -of -year reports on template
December 31, 2025
activities, if you have federally recognized tribes within your LHJ.
provided by DOH.
June 30, 2026
Note: The jurisdictional risk assessment might be an opportunity to
work with tribes (Task #4).
14
Administrative Preparedness Plans/Procedures
Administrative preparedness is essential for LHJs to effectively fulfill their obligation to respond to public health emergencies in their
jurisdiction. Having established administrative procedures that allow your organization to implement appropriate flexibility during declared
emergencies —even in the absence of a formal plan —helps ensure rapid access to resources, contracts, staffing, and operational support during
public health emergencies.
14.1
Based on the unique structure and administrative procedures, review
Mid- and end -of -year reports on template
December 31, 2025
and have an understanding of the following areas:
provided by DOH.
June 30, 2026
• Conditions under which expedited processes can be activated.
• Identification of those authorized to implement emergency
Plan and/or procedures available upon
administrative processes and procedures.
request
• Streamlined processes for securing emergency funding from
federal, state, or both levels of government (recognizing that
state and federal funding is contingent on availability).
• Accelerated procedures for procuring resources, including
additional staff (temporary or permanent).
• Criteria for deactivating emergency processes and
transitioning back to normal operations.
Exhibit A, Statement of Work Page 7 of 10 Contract Number CLH32053-Amendment 7
Paae 30 of 44
Task
Payment
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Information and/or
Amount
15
Build Highly Qualified PHEP Workforce
Maintaining a qualified PREP workforce is essential for ensuring operational readiness and effective emergency response. Ongoing
participation in communities of practice fosters shared learning, supports the dissemination of best practices, and strengthens workforce
competencies needed to execute critical public health preparedness functions.
15.1
Engage in at least one community of practice (CoP) group that
Mid- and end -of -year reports on template
December 31, 2025
identifies problems, solutions, and best practices in public health
provided by DOH.
emergency preparedness. This can be a community of practice led by
June 30, 2026
DOH, CDC, or Northwest Center for Evidence -Based Public Health
Emergency Preparedness and Response.
Note: Attending the MCM CoP (Task 16.2) meets this activity also.
16
Medical Countermeasures — All LHJs, including non -Cities Readiness Initiative (CRI)* LHJs, must be able to meet medical countermeasure
(MCM) capabilities to ensure timely protection of their communities during public health emergencies. Building and maintaining this capability
supports equitable access to life-saving interventions and strengthens the overall statewide response system.
*Non-CRI LHJs are LHJs that do not receive Cities Readiness Initiative (CRI) funding. In Washington State, the LHJs that receive CRI funding
are Clark County Public Health, Public Health — Seattle & King County, Snohomish County Health Department, and Tacoma —Pierce County
Health Department.
16.1
Update MCM plan between July 1, 2025, and June 30, 2026, to reflect
Updated MCM plan (submit once by
December 31, 2025
current capabilities, procedures, and resources, to demonstrate ongoing
June 30, 2026, or sooner).
June 30, 2026
medical countermeasure (MCM) readiness.
If the Plan is not submitted by
If the MCM plan does not include jurisdiction's ability to receive,
December 31, 2025, describe progress to
stage, store, and distribute MCM, provide a comprehensive
date in the mid -year report on template
supplemental report on these capabilities. This report should include:
provided by DOH.
• The process for receiving, staging, storing, and distributing
MCM.
End -of -year report on template provided
by DOH.
16.2
Attend one of the MCM quarterly meetings for the non-CRI LHJs and
Mid- and end -of -year reports on template
December 31, 2025
one MCM community of practice meeting throughout the performance
provided by DOH.
period.
June 30, 2026
Note: Participation in the MCM community of practice also meets the
requirement of Task 15.1.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance(a)doh.wa.gov.
Exhibit A, Statement of Work Page 8 of 10 Contract Number CLH32053-Amendment 7
Page 31 of 44
Federal Fundine Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHI must have a Unique Entity Identifier (UEI) generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Special Requirements:
Guidance Documents - LHJs are strongly encouraged to use the following documents to inform the implementation of activities in this statement of work.
DOH will provide copies of the documents.
New Statement of Work Guidance Document (under development)
Washington State Doctrine for Enhancing Resiliency, Health Security, Response, and Recovery.
Public Health Response Readiness Framework (CDC) — 2024-2028 PHEP Program Priorities — Defines Excellence in Response Operations
Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health
Public Health Emergency Preparedness (PHEP) Cooperative Agreement (2024 — 2029 Guidance Document)
Follow all Federal requirements for use of Federal funds:
Code of Federal Regulations (CFR), Title 2, Subtitle A, Chapter II, Part 200
Uniform Administrative Requirements, Cost Principle, and Audit Requirements for Federal Awards
CFR :: 2 CFR Part 200 -- Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards
Recipients may only use funds for reasonable program purposes, including personnel, travel, supplies, and services." PHEP Notice of Funding Opportunity: Funding Limitations
Supplemental Guidance — February 2024
The following expenses are not allowable with these funds:
• Clothing (except for vests to be worn during exercises or responses).
• Salaries at a rate above Federal Executive Schedule Level II.
• Vehicles (with preapproval, funds may be used to lease vehicles).
• Pay or reimburse backfilling costs for staff.
• Vaccines for seasonal influenza mass vaccination clinics or other routine vaccinations covered by CDC/ACID schedules.
• Influenza vaccines for the public.
• Promotional items and memorabilia.
• Construction or major renovations.
Preapproval from DOH is required to use these funds for:
• Contracting.
• Purchasing food or beverages is generally not allowable (unless employees are in travel status, then reimbursement of food and beverages is allowable).
• Purchasing equipment (see definition of equipment in 2 CFR 200, link above).
Exhibit A, Statement of Work Page 9 of 10 Contract Number CLH32053-Amendment 7
Page 32 of 44
• Disposition of equipment with a current value of (see 2 CFR 200, link above).
• Leasing vehicles.
• Out of state travel.
• Overtime pay for staff directly associated with this statement of work.
• Purchase of caches of vaccine for public health responders and their households to ensure the health and safety of the public health workforce.
• Purchase of caches of vaccine for select critical workforce groups to ensure their health and safety during an exercise testing response plans.
See also DOH A19 Documentation Matrix for additional expenses that may require preapproval.
BILLING
Please refer to the Billing Instructions in the 2025 — 2027 Consolidated Contract.
All expenses on invoices must be related to the Statement of Work Tasks.
Submit invoices monthly on a signed A19-1A invoice voucher form with backup documentation appropriate for risk level. DOH will provide A19 form and risk level.
• Submit invoices monthly within 60 days of the end of the month of service (unless the related ConCon amendment has not been executed, in that case submit invoices as
soon as possible after the amendment is executed).
• Please do not submit invoices until the ConCon amendment including the funds has been executed.
• If invoices include indirect costs, there must be a DOH -approved indirect rate cost agreement.
• If there are no expenses related to this Statement of Work for a month, let the DOH Contact via email.
• If you are submitting a supplemental, revised, corrected, or any additional invoice for a month, please clarify your intentions in the email with the invoice.
• Submit final billing within 60 days of the end of the funding period.
Exhibit A, Statement of Work Page 10 of 10 Contract Number CLH32053-Amendment 7
DOH Program Name or Title: School -Based Health Centers Program -
Effective July 1, 2025
SOW Type: Original Revision # (for this SOW)
Period of Performance: July 1, 2025 through June 30, 2026
Exhibit A
Statement of Work
Contract Term: 2025-2027
Page 33 of 44
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
❑ Federal <Select One> (check if applicable) ® Reimbursement
® State ❑ FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to fulfill the legislative mandate, RCW 43.70.825, and formalize a grant award to Jefferson
County Public Health for a school -based health center (SBHC) operations grant. A school -based health center is defined in the law as "a student -focused health center located in or
adjacent to a school that provides integrated medical, behavioral health, and other health care services such as dental care."
Jefferson County Public Health will complete infrastructure and capacity building tasks and activities outlined in the contract to operate, expand, and/or improve a school -based
health center at Quilcene, Chimacum, and Port Townsend School Districts. Activities include participation in trainings, technical assistance, and contract meetings; expanding,
sustaining, and/or improving SBHC services; and reporting on performance. This contract will be the fourth year of the grant award.
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Chan e
g
Increase (+)
Total
Allocation
SFY26 SCH BASED HLTH CENT 1225 PROVISO
78310860
N/A
334.04.90
07/01/25
06/30/26
0
140,000
140,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
0
140,000
140,000
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
la
Develop or update a grant implementation plan for
SBHC operations grant implementation
September 30, 2025
$15,000
maintaining, expanding, or improving SBHC services.
workplan
Create a workplan that outlines tasks and activities for the
project, including the due date, staff that will work on each
task, and staff s role for each task.
lb
Provide services in accordance with the SBHC Grant
Quarterly report — implementation
Quarterly,
$20,000 ($5,000 per
Requirements before or within three (3) months of the grant
October 15
report)
period.
January 15
April 15
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH3 2053 -Amendment 7
Paae 34 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Provide updates to DOH on progress of SBHC operations
July 15
and workplan completion.
•Include status report of SBHC operations (hours of
operation, staffing model, and services provided) and grant
spending
•Include milestones, successes, challenges, and barriers
2a
Attend bimonthly contract meetings, starting within two (2)
Quarterly report that includes list of dates of
Quarterly,
$10,000 ($2,500 per
months of contract execution, with DOH to discuss progress,
contract meetings attended during the
October 15
report)
support needs, barriers/challenges.
reporting period
January 15
April 15
Provide updates on grant implementation, including grant
July 15
spending, relevant staffing changes, etc.
2b
Participate in at least one key training, support, and/or
Quarterly report that includes:
Quarterly,
$10,000 ($2,500 per
technical assistance activity per quarter, as recommended by
-List of trainings and TA meetings attended
October 15
report)
DOH or WA School -Based Health Alliance (WA SBHA).
during the reporting period
January 15
-List of any additional resources or training
April 15
Identify additional resources or training needed; collaborate
needed
July 15
with DOH to participate in and/or get access to resources, if
needed.
3a
Update the community engagement and/or communications
Community engagement plan
September 30, 2025
$15,000
plan for the 2025-2026 school year. Plan should include
relationship -building activities, youth engagement,
parent/guardian engagement, and advisory group meetings.
3b
Provide updates on implementation of community
Quarterly report — community engagement
Quarterly,
$10,000 ($2,500 per
engagement and communications plans.
October 15
report)
January 15
April 15
July 15
4a
Provide integrated medical and behavioral health services
Quarterly performance measure report
Quarterly,
$20,000 ($5,000 per
that, at minimum, meet the DOH SBHC Grant
October 15
report)
Requirements.
January 15
April 15
Collect and report on required performance measures, using
July 15
provided DOH performance measure spreadsheet, for each
SBHC site.
5a
Identify SBHC operations goals and draft evaluation plan, in
Evaluation plan
September 30, 2025
$15,000
collaboration with DOH SBHC epidemiologist. The plan
will include, at minimum, goals addressing financial
sustainability and health equity.
5b
Provide updates on progress of identified SBHC operations
Quarterly report — evaluation
Quarterly,
$10,000 ($2,500 per
goals and implementation of evaluation plan. Participate in
October 15
report)
DOH SBHC grant program evaluation activities, as
January 15
applicable.
Aril 15
Exhibit A, Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment 7
Paqe 35 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
July 15
5c
Submit report on SBHC evaluation using measures and goals
Evaluation report
June 30, 2026
$15,000
outlined in evaluation plan. Use provided DOH report
template.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance ,doh.wa.gov.
Program Specific Requirements
Special Requirements: Quarterly progress reports will be submitted to the DOH contract manager through an online link provided by DOH.
• Reports should include progress on deliverables to date, budget to actual report, successes, barriers/challenges, and support needs.
• Specific or separate reports should be submitted separately by email and on the specified due date.
Special References (i.e., RCWs, WACs, etc.): In accordance with RCW 43.70.825: Concerning School Based Health Centers (2021), the Washington State Department of Health
(DOH) contemplates awarding a contract to Jefferson County Public Health (LHJ) to operate their school -based health centers.
Definitions: A school -based health center is defined in the law as "a student -focused health center located in or adjacent to a school that provides integrated medical, behavioral
health, and other health care services such as dental care." Upon execution of the contract, the SBHC must meet the minimum requirements, including:
• Be open during regular school hours
• Provide on -site primary care services by a nurse practitioner, physician's assistant, medical doctor, and/or doctor of osteopathy, at least once a week
• Coordinate clinic services
• Provide behavioral health care services by a behavioral health provider that is on -site, through telehealth, and/or through mobile units. If a behavioral health provider is
not licensed, they must be supervised by a licensed behavioral health provider.
Billing Requirements:
• The grantee will invoice no later than 30 days after the month of service, or the submission date of deliverables with an associated cost, as specified in the Statement of
Work (SOW). All invoices for the budget period must be submitted no later than 45 days after the end of the budget period.
• Due dates and deliverables can be negotiated on and changed, as needed, with prior approval from the contract manager.
• Invoices will be submitted on the DOH A-19 form. Invoices must reference this contract number and provide detailed information as requested.
• All invoices must be approved by DOH prior to payment; approval will not be unreasonably withheld. DOH reserves the right to withhold payment until grantee meets
SBHC grant requirements or until an action plan is agreed upon. DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for
allowable costs as outlined in the statement of work and/or budget. DOH will issue payment within 30 days of receiving a correct and complete invoice and approving the
deliverable(s).
• DOH will return all incorrect or incomplete invoices and will not pay for services that occur outside the period of performance.
• The grantee will not invoice for services if they are entitled to payment, have been, or will be paid by any other source for that service.
• The grantee may bill incrementally for progress on objectives, but the entire product will be delivered for the amount specified regardless of time spent on the tasks for each
objective.
• Report due dates and invoice amounts are as follows (invoice amount listed below is an estimate and is flexible based on deliverables completed):
Exhibit A, Statement of Work Page 3 of 4 Contract Number CLH32053-Amendment 7
Page 36 of 44
o Q1 deliverables (July -September) due by October 15, 2025: $65,000
o Q2 deliverables (October -December) due by January 15, 2026: $20,000
o Q3 deliverables (January -March) due by April 15, 2026: $20,000
o Q4 deliverables (April -June) due by July 15, 2026: $35,000
DOH must receive correct and complete invoices within 45 days of the budget period. Late invoices will be paid at the discretion of DOH and are contingent upon the
availability of funds. Failure to submit a properly completed IRS form W-9 may result in delayed payments.
o Submit all final billings within 45 days of the end of the contract
o Submit all required program reports and deliverables within 45 days
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH32053-Amendment 7
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Sexual & Reproductive Health Program -
Effective January 1, 2025
SOW Type: Revision Revision # (for this SOW) 3
Period of Performance: January 1, 2025 through March 31, 2026
Page 37 of 44
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
® State ® FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide sexual and reproductive health services (SRH) to Washington State residents. These
services will comply with all state, federal, and DOH SRHP Manual requirements. It highlights specific requirements, but all must be complied with. Budgets are based on an
approved allocation formula with funds available.
This Statement of Work spans Years 1-4 of the contract, which runs January 1, 2022 — March 31, 2026.
For state funding, due dates after December 31, 2025 are for reporting only. LHJs may not bill under this contract for work done after December 31, 2025.
For federal funding, due dates after March 31, 2026 are for reporting only. LHJs may not bill federal funds under this contract for work done after March 31, 2026.
Revision Purpose: The purpose of this revision is to add $47,404 in Sexual and Reprouctive Health Cost Share funding for the period of 07/01/2025 - 12/31/2025 and to update
billing and payment language.
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Chan e
g
Increase (+)
Total
Allocation
FFY24 FPHPA TITLE X FAMILY PLAN
78430240
93.217
333.93.21
01/01/25
03/31/25
16,966
0
16,966
SFY25 SEXUAL & REP HLTH COST SHARE
78430150
N/A
334.04.91
01/01/25
06/30/25
47,993
0
47,993
FFY25 FPHPA TITLE X FAMILY PLAN
78430250
93.217
333.93.21
04/01/25
03/31/26
17,023
0
17,023
SFY26 SEXUAL & REP HLTH COST SHARE
78431160
N/A
334.04.91
07/01/25
12/31/25
0
47,404
47,404
0
0
0
0
0
0
TOTALS
81,982
47,404
129,386
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1
Sexual and Reproductive Health Program
A19 invoice vouchers submitted in a timely manner
As described in Task 6:
Billing must be based on
(SRHP) & Title X (TX) Services —excluding
accompanied by an R&E workbook showing revenue
Revenue and Expense
a current cost analysis
abortion and other surgical procedures related
and expenses for the month billed and any other
Reports in the Reporting
approved by DOH (see
to SRHP.
required back up documentation per DOH policy.
Requirements section
Reporting Requirements
below.
below).
A. Comply with Washington State SRHP
All reports described in Reporting Requirements
Manual, federal Title X requirements and all
below.
As requested by DOH
Exhibit A, Statement of Work Page 1 of 8 Contract Number CLH32053-Amendment 7
Paae 38 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
state and federal laws. Also see Program
Manual, Handbook, Policy References under
• Other data and documentation in format requested by
to hhek4pay-meat
Reporting Requirements (below).
DOH. (Includes copies of program and financial audits
U
and reviews including summaries conducted by other
• Gemp' n " ,•
B. Complete required Agency Information
entities.)
era pfwvieus SO
Request including Title X Assurance of
Compliance and National Provider Identifier
• o T�desk
%wy aeeepted -#y
aeijita.o reviews --rested
d,,,.umeateAian to P014 in F
(NPI) billing numbers
D
Current data k
available requested is ffla.
C. Provide medical services, community
To F FFstibmitted
DOH/TX
to, an
. edit,.° site visits rifle st
d;_._•....,...ta fi .......adily to
education and outreach, and staff training,
.
ma available prior- and
dwing review.
consistent with state requirements:
• 419-baek V
1. LHJ is responsible for making sure all
DOH Follow
deeunfentatien
required by D
per-fefms site visits. up site visits
peffermed ufAil identified issues are resolved.
staff have the knowledge to carry out
has been stibmi�tt
the requirements of the SOW.
and app�wJ.
• Site review directed by DOH SRHP. Follow-up site
Other dehivrables
2. Medical, laboratory, and other services
visits as needed until identified issues are resolved.
have been met,
related to abortion are not covered by
this task
• Submit documentation to DOH SRHP as requested for
Payment is limited te the
a desk review prior to site visit.
ninium funds
3. Community education services must be
availableferfiUnding
sere.
based on the needs of the community.
0 Appropriate staff and documentation readily available
LHJ must have an Information &
to DOH SRHP prior to and during site visit.
Education (I&E) committee with five
(5) or more members that is broadly
eests deeerding to
representative of the population or
community for which materials are
your approved e 9
intended. The committee must review a
batch of patient -facing materials
annually (at least 15 products or 15% of
Requirernen
the total number of materials, whichever
below).
is smaller); meet at least annually and
er
establish a written record of its
The ,..,.eunt
determination. (42 CFR 59 [59.6])
r-eindiffingi, th,
4. Outreach is to ensure all populations in
SOW divk4ed u?
amber ofinemAs
your community understand the services
fflaining in t
available. Focus your outreach efforts
fiundi euree, plus
on increasing equity.
Exhibit A, Statement of Work Page 2 of 8 Contract Number CLH32053-Amendment 7
Paae 39 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Washington State Sexual and
Rayntent will be
Reproductive Health Network priority
ealeulated by
populations are:
• Teens
Repei4img Requirements
• People who are uninsured or
heleiv).
underinsured, and/or low-
A U flees �' the
income (at or below 250% of
e -Mpwu o�-
the federal poverty line)
end of fie
• Rural communities
• Hispanic
• Black, Indigenous, People of
Color
DOH will authorize
Extra efforts should be made to provide
payment only upon
information and services to people who
satisfactory completion
intersect with multiple priority
and acceptance of
population categories.
deliverables and for
allowable costs as
5. Provide all services in accordance with:
outlined in the statement
• DOH SRHP & Title X Manual
of work and/or budget.
• Other state and federal
*SEE INVOICES and
requirements
PAYMENTS that follows
• Reporting Requirements (see
this table for details.
below)
Payment is limited to the
D. Collect, maintain, and provide data about
CVR data submitted to DOH data contractor (Ahlers &
to
The 15 of the following
maximum funds
each family planning clinic visit as defined
Associates) electronically in a format compatible with
month. Within thirty (30)
available for funding
in the SRH CVR Manual.
1. Maintain a computer system that
Ahlers software.
days of receiving
source. DOH will
includes safety precautions against loss
error/rejection report or
reimburse for actual
of information.
• Data for each month
request from DOH Sexual
allowable costs as
2. Ensure data entry personnel protect
and Reproductive Health
calculated by the R&E
confidentiality of CVR data.
. Corrected CVR data
data manager.
workbook Reporting
k kb (sp g
3. Have ability to retrieve all information
Requirements table)
for auditing and monitoring by DOH or
its designee.
All services must be
billed within 40 days of
E. Notify DOH contract manager of all:
• Key staff and organizational changes.
Email briefly describing change.
As needed to keep
the budget period, 60
days for all other billing.
• Proposed clinic site additions. New
information current.
Specific dates noted in
clinic sites must be approved by DOH
Reporting Requirements,
before offering services supported by
Activity 5, Revenue and
SRHP/Title X funding.
Expense Reports.
Exhibit A, Statement of Work Page 3 of 8 Contract Number CLH32053-Amendment 7
Paqe 40 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
• Expected clinic site closures. Note:
DOH may, at its sole discretion,
recalculate LHJ's funding allocation if it
closes a clinic site.
• Any other change that might affect
LHJ's ability to provide the sexual and
reproductive services described in this
SOW.
Reporting Requirements
1
Agency Information Request
This information must be reported using the template
April 3011 during each
or format provided by DOH. All signatures and forms
year of this contract.
DOH SRHP requires updated information from
must be completed by April 30'h during each year of
all members of the SRHP Network to ensure
this contract. Requested information will include:
AND
accurate records of LHJ's organization and the
services it provides.
Information about your agency contacts and your
As needed or requested to
organization's staffing
maintain accuracy of
In addition, elements of this report allow DOH to
A. Head of Organization
information.
ensure that SRHP & Title X requirements
B. Head of Finance
including client fees and required services are
C. Medical Director
met. The updated information also assists DOH
D. NPI numbers used to bill Medicaid
to manage this SOW and the Sexual &
E. The following (one person might fill more than one
Reproductive Health Network as a whole.
role)
a. Contract Coordinator
b. Clinical representative
c. Billing contact
d. Outreach and education contact
e. Contact for CVR data
f. Contact for EHR information
Information regarding sexual and reproductive health
related services offered at each clinic site:
A. Cost analysis: How LHJ determines what it costs
to provide services. LHJ uses this to help construct
its fee schedule. A cost analysis must be
performed by LHJ within three years prior to the
start date of this SOW. If contractor cost analysis
was approved by DOH at the beginning of the
contract period, LHJ does not have to resubmit
unless changes are made. LHJ must email DOH
contract manager informing them that no changes
were made.
Exhibit A, Statement of Work Page 4 of 8 Contract Number CLH32053-Amendment 7
Paoe 41 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
B. Sliding fee schedule that includes all services
required in the SRH Manual. Additional SRH-
related services as outlined in Task 1 may also be
included on LHJ's sliding fee schedule.
a. Sliding fee schedule must be based on cost
analysis described above.
b. Fee schedule must be resubmitted for
reapproval anytime there are any significant
changes, which may include changing of
services, fees, etc.
c. LHJ must not implement a revised fee
schedule until it has been approved in writing
by DOH.
d. Income conversion tables must be updated
Submit an updated
annually and approved by DOH
income conversion table
by March 15 of each year
Information related to current Community Outreach Plan:
of the contract.
LHJ's community outreach plan follows a 5-year cycle.
This process must include the following steps:
A. Utilize the state level priority populations, county
level demographic data, and agency profile to
identify unmet need in the community served.
B. Determine objectives and activities to expand
sexual and reproductive health to reach
populations in need of services in the community
served.
C. Measure completion of the objectives and
activities.
2
Program Updates
This information must be reported using the template
During quarterly check
or format provided by DOH. It will include information
ins and as requested by
Summary of ongoing activities related to the
about contractor's work during current and past
DOH
SRH Program. This informs quality improvement
SOWS:
of the Washington State SRH Network.
A. Community education and outreach strategies and
activities and a discussion of their effectiveness.
B. Staff training.
4
Family Planning Annual Report (FPAR)
Organization -level data on clinical services emailed to
Data to be collected
DOH SRH data manager
annually through the end
Information DOH is requesting to develop trend
Number of:
of the grant (2027).
data. All information is for the calendar year
A. Pap tests with an ASC or higher result
(January through December). The subsequent
B. Pap tests with an HSIL or higher result
Exhibit A, Statement of Work Page 5 of 8 Contract Number CLH32053-Amendment 7
Paoe 42 of 44
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
agreements sent to the agency will request that
C. HIV Positive confidential tests
these data be collected and reported on within the
D. HIV Anonymous tests
statement of work period of performance.
E. FTE required to provide sexual and reproductive
health services:
• Physicians
• Physician assistants + nurse practitioners +
certified nurse midwives
• Registered nurses with expanded scope of practice
who are trained and permitted by state specific
regulations to perform all aspects of the physical
assessment.
Financial data emailed to DOH Contract Manager
R&E showing Other Revenue through the end of the grant
as described below.
Subsequent agreements will request that data be collected
and reported on during the appropriate contract period of
performance. (FPAR due 01-31 annually through 2027)
5
Clinic Visit Reports (CVRs)
Clinic visit records must include all elements specified
The 15' of the following
in the Clinic Visit Record (CVR) Manual available at:
month.
httos://www.doh.wa.eov/Portals/l/Documents/Pubs/930-
139-CVRManual.pdf.
Within thirty (30) days of
receiving error or
CVR data must be submitted to DOH data contractor
rejection report or request
(Ahlers & Associates) electronically in a format compatible
from DOH SRH data
with Ahlers software.
manager.
- Each month's CVR data
- Corrected CVR data
6
Revenue and Expense Reports (R&E)
Completed R&E for time period that shows all revenue
Invoices (A19's) and
(including program income) that support Task 1 SRH
R&Es that support
Services and all expenses related to providing those
services through the end
services. R&E workbook will be provided by DOH.
of this contract must be
A. Expenses must match General Ledger.
billed following the
B. Other revenue/program income must reflect revenue
required deadlines:,
actually received in the reporting month.
March Invoices and
All entries on "Other" rows must be accompanied by a
R&Es are due by
description of the revenue source or expense, including any
May loth
calculations uses.
• June Invoices and
R&Es are due by
August loth
• December Invoices
and R&Es are due
by February IOth
Exhibit A, Statement of Work Page 6 of 8 Contract Number CLH32053-Amendment 7
Paae 43 of 44
Task
Payment Information
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
and/or Amount
• All remaining
months must be
billed within 60
days.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance(adoh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Unique Entity Identifier (UEI) generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual, Handbook, Policy References:
LHJ must comply with all state, federal, DOH SRHP, and Title X requirements, policies, and regulations and with their DOH approved Agency Information Dashboard.
Reference documents include:
• DOH SRHP Manual (DOH publication 930-122, available at 930-122-FPRHManualComplete.pdf (wa.gov) Some provisions of this manual are highlighted in this SOW,
but all provisions of the manual must be complied with.
• Clinic Visit Record Manual CMs:Hdoh.wa.gov/sites/default/files/2024-10/930-139-CVRManual.pdf)
• LHJ's approved Agency Information Request.
Billing Requirements:
See Payment column of Tasks and Deliverables table and R&E report description in Reporting Requirements table
Billing must be based on a current cost analysis approved by DOH (see Reporting Requirements table).
D014 resen,es the right to withhold payment upAi4--
Exhibit A, Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment 7
Page 44 of 44
• AePaal allowable eests aeeording to youf approved eest analysis (see Reporting Requirements table). Of
• The amotint remaining in the SOW, divided by the number of menths r-emaining in Fee-,-pltts one, whiehever is less.
Payment will be ealeulated by R&E pFa,.ided by D014 (see Repefting Requirements table).
Final mimbur-sement requests for- eempleted eentraet aetivities must be r-eeeived and approved for- payment by DOH within 4 5 days of the end of the SOW pefied of per-fefffianee.
INVOICES AND PAYMENT: Contractor will submit invoices to the DOH Contract Manager for all amounts to be paid within 30 days of the month of service, or the submission
date of deliverables with an associated cost, as specified in the Statement of Work (SOW). Refer to the SOW, Exhibit A, for invoice due dates on any budgetffunding period(s) that
end during the contract period of performance. DOH must receive correct and complete FINAL invoices no later than 45 days after the contract expiration date. Invoices must
reference the contract number and provide detailed information as required. All invoices must be approved by DOHprior to payment; approval will not be unreasonably withheld.
DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for allowable costs as outlined in the statement of work and/or budget. DOH
will return all incorrect or incomplete invoices and will not pay for services that occur outside the period of performance. The Contractor will not invoice for services if they are
entitled to payment, have been, or will be paid, by any other source for that service.
DOH will issue payment within 30 days of receiving a correct and complete invoice and approving the deliverable(s). Late invoices will be paid at the discretion of DOH and are
contingent upon the availability of finds. Failure to submit a properly completed IRS form W-9 may result in delayed payments.
DOH reserves the right to withhold payment until:
• Compliance issues or a previous SOW are resolved in away accepted by DOH.
Payment is limited to the maximum funds available for funding source.
DOH will reimburse.for:
• Actual allowable costs according to your approved cost analysis (see Reporting Requirements table) and as calculated by the R&E workbook.
Special Instructions:
Accessibility of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to priority populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible, services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal, State, and local governments, including local fire, building, and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis. Acceptance of SRH services must not be a prerequisite to eligibility for, or receipt of, services in any non-SRH
programs of the LHJ.
Availability of Emereency Services
The LHJ must have written plans and procedures for the management of on -site medical emergencies, including emergencies that require transport and after-hours management of
contraceptive emergencies. (See DOH SRH Manual)
If LHJ or DOH discontinues this contract:
See SRHP Manual for close out requirements and resources.
Exhibit A, Statement of Work Page 8 of 8 Contract Number CLH32053-Amendment 7
�e�ehson
Public Health
TO:
FROM:
DATE:
615 Sheridan Street
Port Townsend, WA 98368
www.JeffersonCountyPublicHealth.org
Consent Agenda
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
Board of County Commissioners
Josh Peters, County Administrator
Apple Martine, JCPH Director
Veronica Shaw, JCPH Deputy Director
5e&)4,�,K, 262�
SUBJECT: Agenda Item — Consolidated Contracts Amendment #7 with the Department
of Health; January 1, 2025 — December 31, 2027; $2,446,631 additional
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #7
between JCPH and State of Washington Department of Health (DOH); January 1, 2025 — December 31, 2027;
additional funding of $2,446,631 for a total to date of $5,736,053.
ANALYSIS/STRATEGIC GOALS/PROS and CONS:
The purpose of this agreement is to provide public health services to the people of Washington State. This
Amendment adds and/or amends statements of work (SOW) and funding for the following programs:
• COVID-19 Response: this revision extends the period of performance and Local Health Jurisdiction
(LHJ) Funding until December 31, 2025
• Foundational Public Health Services: these funds are to build governmental public health system's
capacity and increase the availability of FPHS services statewide (funding of $2,203.000)
• Maternal & Child Health Block Grant: this revision provides additional funding, adds activities and
deliverable due dates, extends the period of performance and funding (additional funding of $36,700)
• Office of Resiliency & Health Security-PHEP: this SOW sets funding and tasks for LHJs to prepare for,
respond to, and recover from public health threats and emergencies (funding of $19,527)
• School -Based Health Centers Program: this SOW formalizes a grant to JCPH for infrastructure and
capacity building activities related to county SBHCs (funding of $140,000)
• Sexual & Reproductive Health Program: this revision adds funds for the period 7/1/25 — 12/31/25 and
updates billing language (additional funding of $47,404)
Community Health
Developmental Disabilities
360-385-9400
360-385-9401 (f)
Environmental Public Health
360-385-9444
(f) 360-379-4487
CC-25-001-A7 Always working for a safer and healthier community
FISCAL IMPACT/COST BENEFIT ANALYSIS•
Total consideration for this Contract Amendment is $2,446,631. The Consolidated Contract is funded by DOH,
and comprises both Federal and State funds.
RECOMMENDATION:
JCPH Management recommends BoCC approval of Consolidated Contract Amendment #7 between JCPH and
DOH; January 1, 2025 — December 31, 2027; additional funding of $2,446,631.
REVIEWED BY:
Cb�4 D. Pr-,� I —
Josh Pef6rs, County Administrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 Always working for a safer and healthier community (f) 360-379-4487
360-385-9401 (f)
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-25-001-A7
Contract For: Consolidated Contracts, Amendment 7 Term: 1/1/2025 - 12/31/2027
COUNTY DEPARTMENT: Public Health
Contact Person: Veronica Shaw
Contact Phone: X 409
Contact email: veronica@co.jefferson.wa.us
AMOUNT: $2,446,631 additional, for a total of $5,736,05-3
PROCESS:
10(
Exempt from Bid Process
Revenue: $2,446,631
Cooperative Purchase
Expenditure:
Competitive Sealed Bid
Matching Funds Required:
Small Works Roster
Sources(s) of Matching Funds
Vendor List Bid
Fund # 127
RFP or RFQ
Munis Org/Obj 12756220
Other:
APPROVAL STEPS:
STEP 1: DEPARTMENT CERTIFIESCON " ..SIC
C 3.55.080 AND CHAPTER 4 .23 RCW.
CERTIFIED: ®N/A:
�f .
Signature
ate
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOTEI�N DEBARRED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: 0 N/A:
Signature 6ate
STEP 3: RISK MANAGEMENT REVIEW (will be added electronically through Laserfiche):
Electronically approved by Risk Management on 8/22/2025.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 8/22/2025.
Amendment No. 7 with all prior amendments and original included.
STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY(IF REQUIRED).
STEP 6: CONTRACTOR SIGNS
STEP 7: SUBMIT TO BOCC FOR APPROVAL
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053
Page 1 of 18
AMENDMENT NUMBER: G
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as
"DOH", and JEFFERSON COUNTY PUBLIC HEALTH, a Local Health Jurisdiction, hereinafter referred to as "LHY,
pursuant to the Modifications/Waivers clause, and to make necessary changes within the scope of this contract and any
subsequent amendments thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work, includes the following statements of work, which are incorporated by this reference
and located on the DOH Finance SharePoint site in the Upload Center at the following URL:
https //stateofwa sharcpoint com/sites/doh-ofsfundinfTresources/sitcnaues/home aspx?=ct:9a94688da2d94d3eugOac7thc32c4d7c
® Adds Statements of Work for the following programs:
Infectious Disease Syndemic Prevention Services-SSP - Effective July 1, 2025
Recreational Shellfish Activities - Effective July 1, 2025
® Amends Statements of Work for the following programs:
Office of Drinking Water Group A Program - Effective January 1, 2025
❑ Deletes Statements of Work for the following programs:
2, Exhibit B-6 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-5 Allocations as
follows:
® Increase of $103,533 for a revised maximum consideration of 53,2$9.422.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations are attached only for informational purposes.
3. Exhibit C Federal Grant Awards index, incorporated by this reference, and located in the ConCon, Funding & BARS
library at the URL provided above.
Unless designated otherwise herein, the effective date of this amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force
and effect.
IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY WASH INGTON
BOARD OF COUNTY COMMISSIONERS
dt,is Chair Date
APPROVED AS TO FORM ONLY
July 24, 2025
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
CC-25.001-A6
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
Page t of 1
APPROVED AS TO FORM ONLY
Assistant Attorney General
08/05/2025
s
EXHIBIT B-6
Page 2 of 19
Jefferson County Public Health
ALLOCATIONS
Contract
Number:
CLH32053
Contract Term: 2025-2027
Date:
July 1, 2025
Indirect Rate January 1, 2025 through December 31, 2025: 27.38% Public Health
DOH Use
Only
BARS
Statement
of Work
Chart of
Accounts
Funding
Chart of
Federal Award
Assist
Revenue
LHJ Funding Period
Funding Period
Period
Accounts
Chart of Accounts Program Title
Identification #
Amend #
List #*
Code**
Start Date End Date Start Date End Date
Amount
SubTotal
Total
FFY25 USDA BFPC Prog Mgmt
7WA700WAI
Amd 4
10.557
333.10.55
01/01/25
09/30/26
10/01/24
09/30/26
$28,238
$28,238
$28,238
FFY24 USDA BFPC Prog Mgmt
7WA700WAI
Amd 4
10.557
333.10.55
01/01/25
09/30/26
10/01/23
09/30/26
($28,238)
$0
FFY24 USDA BFPC Prog Mgmt
7WA700WAI
Amd 2
10.557
333.10.55
01/01/25
09/30/26
10/01/23
09/30/26
$28,238
FFY25 USDA WIC Client Svs Contracts
7WA700WA7
Amd 4
10.557
333.10.55
01/01/25
09/30/25
10/01/24
09/30/25
$3,975
$148,117
$148,117
FFY25 USDA WIC Client Svs Contracts
7WA700WA7
Amd 2
10.557
333.10.55
01/01/25
09/30/25
10/01/24
09/30/25
$144,142
FFY25 USDA FMNP Mgmt
7WA810WA7
Amd 4
10.572
333.10.57
01/01/25
09/30/25
10/01/24
09/30/25
$637
$637
$637
FFY25 SWIMMING BEACH ACT IAR (ECY)
OIJ74301
Amd 2
66.472
333.66.47
03/01/25
10/31/25
01/01/25
11/30/25
$13,500
$13,500
$13,500
FFY24 PHEP BPI-CDC-LHJ Partners
NU90TU000055
Amd 1
93.069
333.93.06
01/01/25
06/30/25
07/01/24
06/30/25
$13,754
$13,754
$13,754
FFY24 OD2A OID CDC Prevent
NU17CE010218
Amd 6
93.136
333.93.13
07/01/25
08/31/25
09/01/24
08/31/25
$16,333
$16,333
$97,889
FFY24 OD2A OID CDC Prevent
NU17CE010218
Amd 2
93.136
333.93.13
01/01/25
06/30/25
09/01/24
08/31/25
$32,556
$81,556
FFY24 OD2A OID CDC Prevent
NU17CE010218
Amd 1
93.136
333.93.13
01/01/25
06/30/25
09/01/24
08/31/25
$49,000
FFY25 FPHPA Title X Family Plan
FPHPA006560
Amd 5
93.217
333.93.21
04/01/25
03131/26
04/01/25
03/31/26
$17,023
$17,023
$33,989
FFY24 FPHPA Title X Family Plan
FPHPA006560
Amd 3
93.217
333.93.21
01/01/25
03/31/25
04/01/24
03/31/25
$8,345
$16,966
FFY24 FPHPA Title X Family Plan
FPHPA006560
Amd 21
93.217
333.93.21
01/01/25
03/31/25
04/01/24
03/31/25
$8,621
FFY24 CDC PPHF Ops
NH23IP922619
Amd 1
93.268
333.93.26
01/01/25
06/30/25
07/01/23
06/30/25
$10,000
$10,000
$10,000
FFY20 ELC EDE LHJs CDC
NU50CK000515
Amd 1
93.323
333.93.32
01/01/25
06/30/25
01/15/21
07/31/25
$15,580
$15,580
$15,580
FFY21 CDC COVID-19 PHWFD-LHJ
NU90TP922181
Amd 3
93.354
333.93.35
01/01/25
06/30/25
07/01/23
06/30M
$51,330
$51,330
$51,330
FFY22 PH Infrastructure Comp Al-LHJ
NEI IOE000053
Amd 3
93.967
333.93.96
01/01/25
11/30/27
12/01/22
11/30/27
$150,300
$150,300
$150,300
FFY25 HRSA MCHBG LHJ Contracts
B04MC54583
Amd 1
93.994
333.93.99
01/01/25
09/30/25
10/01/24
09/30/25
$27,525
$27,525
$27,525
SFY25 SBHC Proviso
Amd 1
N/A
334.04.90
01/01/25
06/30/25
07/01/24
06/30/25
$59,000
$59,000
$59,000
SFY25 DUH Naloxone DDO HCA IAR
Amd 4
N/A
334.04.91
03/01/25
06/30/25
12/10/24
06/30/25
$15,000
$15,000
$15,000
SFY26 Drug User Health Program
Amd 6
N/A
334.04.91
07/01/2.5
06/30126
07/01/25
06/30126
$80,500
$80,500
$120,750
SFY25 Drug User Health Program
Amd I
N/A
334.04.91
01/01/25
06/30/25
07/01/24
06/30/25
$40,250
$40,250
SFY25 Sexual & Rep Hlth Cost Share
Amd 1
N/A
334.04.91
01/01/25
06/30/25
07/01/24
06/30/25
$47,993
$47,993
$47,993
SFY25 SSPS Opiod Harm Red Proviso
Amd 2
N/A
334.04.91
01/01/25
06/30/25
07/01/24
06/30/25
$8,000
$8,000
$8,000
Page 1 of 2
EXHIBIT B-6
Jefferson County Public Health ALLOCATIONS
Contract Term: 2025-2027
Indirect Rate January 1, 2025 through December 31, 2025: 27.38% Public Health
Page 3 of 19
Contract Number: CLH32053
Date: July 1, 2025
DOH Use Only
BARS
Statement
of Work
Chart of
Accounts
Funding
Chart of
Federal Award
Assist
Revenue
LHJ Funding Period
Funding Period
Period
Accounts
Chart of Accounts Program Title
Identification #
Amend #
List #*
Code**
Start Date End Date Start Date End Date
Amount
SubTotal
Total
SFY25 LHJ Opioid Campaign Proviso
Amd 3
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
$24,500
$56,000
$56,000
SFY25 LHJ Opioid Campaign Proviso
Amd 1
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
$31,500
Rec Shelltisb/Biotoain
Amd 6
N/A
334.04.93
07/01t25
06/30/26
07/01/25
06/30/26
$7,500
$7,500
$11,200
Rec Shellfish/Biotoxin
Amd I
N/A
334.04.93
01/01/25
06/30/25
07/01/23
06/30/25
$3,700
$3,700
Small Onsite Management (ALEA)
Amd 4
N/A
334.04.93
01/01/25
06/30/25
07/01/23
06/30/25
$1,363
$33,781
$33,781
Small Onsite Management (ALEA)
Amd 3
N/A
334.04.93
01/01/25
06/30/25
07/01/23
06/30/25
$32,418
SFY25 Wastewater Management-GFS
Amd 4
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
($1,363)
$9,239
$9,239
SFY25 Wastewater Management-GFS
Amd 3
N/A
334.04.93
01/01/25
06/30/25
07/01/24
06/30/25
$10,602
SFY25 FPHS-LHJ Funds-GFS
Amd 1
N/A
336.04.25
01/01/25
06/30/25
07/01/24
06/30/25
$2,333,000
$2,333,000
$2,333,000
YRI Stimulus - Local Asst (10% of 15%) SS
Amd 6
N/A
346.26.64
01/01/25
12/31/27
07/01t23
06/30/28
$1,800
$1,800
$1,800
YR 28 SRF - Local Asst (15%) SS
Amd 6
N/A
346.26.64
01/01/25
12/31/27
07/01/24
06/30/29
($2,200)
$0
$0
YR 28 SRF - Local Asst (15%) SS
Amd 4
N/A
346.26.64
01/01/25
12/31/27
07/01/24
06/30/29
$2,200
YR 27 SRF - Local Asst (15%) SS
Amd 4
N/A
346.26.64
01/01/25
06/30/25
07/01/23
06/30/25
($2,200)
$0
YR 27 SRF - Local Asst (15%) SS
Amd 1
N/A
346.26.64
01/01125
06/30/25
07/01/23
06/30/25
$2,200
Sanitary Survey Fees SS -State
Amd 6
N/A
346.26.65
01/01/25
12/31/27
07/01/23
12/31/27
($400)
$1,800
$1,800
Sanitary Survey Fees SS -State
Amd 1, 6
N/A
346.26.65
01/01/25
12/31/27
07/01/23
12/31/27
$2,200
YRI Stimulus - Local Asst (10% of 15%) TA
Amd 6
N/A
346.26.66
01/01/25
12/31/27
07/01/23
06/30/28
$1,000
$1,000
$1,000
YR 28 SRF - Local Asst (15%) TA
Amd 6
N/A
346.26.66
01/01125
12/31/27
07/01/24
06/30/29
($1,000)
$0
$0
YR 28 SRF - Local Asst (1501.) TA
Amd 4
N/A
346.26.66
01/01/25
12/31/27
07/01/24
06/30/29
$1,000
YR 27 SRF - Local Asst (15%) TA
Amd 4
N/A
346.26,66
01/01/25
06/30/25
07/01/23
06/30/25
($1,000)
$0
YR 27 SRF - Local Asst (15%) TA
Amd 1
N/A
346.26.66
01/01/25
06/30/25
07/01/23
06/30/25
$1,000
TOTAL
$3,289,422
$3,289,422
Total consideration:
$3,185,889
GRAND TOTAL
$3,289,422
$103,533
GRAND TOTAL
$3,289,422
Total Fed
$590,859
Total State
$2,698,563
*Assistance Listing Number fka Catalog of Federal Domestic Assistance
"Federal revenue codes begin with "333". State revenue codes begin with "334".
Page 2 of 2
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Infectious Disease Svndemic Prevention Services-
SSP - Effective July 1, 2025
SOW Type: Original Revision # (for this SOW)
Period of Performance: July 1, 2025 through June 30, 2026
Page 4 of 19
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
® State ❑ FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide Syndemic Prevention Services for infectious diseases (HIV, STI, and Adult Viral
Hepatitis), supporting the Office of Infectious Disease (OID) within Department of Health (DOH)
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
g
Increase (+)
Total
Allocation
SFY26 DRUG USER HEALTH PROGRAM
12405160
N/A
334.04.91
07/01/25
06/30/26
0
80,500
80,500
FFY24 OD2A OID CDC PREVENT
12405241
93.136
333.93.13
07/01/25
08/31/25
0
16,333
16,333
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
0
96,833
96,833
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1
Syringe Services Programs: Support for Operations:
SSP operations outcomes include delivering
Enter deliverable data into the
Reimbursement of
services and tracking:
DOH/OID issued database for
actual costs incurred,
Provide comprehensive Syringe Services Programs (SSP)
• number of sterile syringes distributed
tracking SSP activities by the
not to exceed $80,500
to people who use drugs (PWUD). This plan of action is
a number of naloxone kits distributed
15th of each month following
for 07/01/25 — 06/30/26
directed to distribute syringes to communities that use
• number of participant encounters
service.
drugs to prevent transmission of infectious disease. SSPs
• number of referrals to health and social
will operate during scheduled hours to provide all
services
required harm reduction supplies, naloxone, and syringes
to prevent transmission of disease and overdose. SSPs
Submit Performance Objectives & Work
will offer referrals to address social determinants of
Plan within the first six months of contract
health.
period that will include:
• Outcomes aligned with program
strategies and activities.
Exhibit A, Statement of Work Page 1 of 10 Contract Number CLH32053-Amendment 6
Paae 5 of 19
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
Priority populations for Syringe Services Programs
• SMART objectives aligned with
include people who use drugs, with a focus on:
performance targets
• People systemically marginalized and
• Activities aligned with program
underserved due to racism — Black/African
outcomes
American, Latino/L.atina/Latine/Latinx,
• Timeline for implementation (including
American Indian/Alaska Native people and
staffmg of the proposed program,
other communities for whom there are
training, etc.)
documented health disparities in your region.
. Anticipated capacity building or
• People who are unhoused or unstably housed.
technical assistance needs.
• People engaged in sex work.
• People involved in the criminal legal system.
NOTE: See Special Requirements, Terms
• Gender expansive/transgender individuals.
and Conditions — Section 7 Performance
• Gay, bi, and other men who have sex with men.
Objectives & Workplans for additional
deliverable information
NOTE: See Special Requirements, Terms and
Conditions — Section 4 Syringe Services Programs:
Support for Operations Program Requirements for
additional task information.
Syringe Services Programs: Clinical Services
SSP Clinical services outcomes may
include, but are not limited to, delivering
Provide direct access to clinical services to improve the
services and tracking:
health and well-being of people who use drugs. At
• Number of wound care sessions
minimum, services must include onsite, low -barrier
• Number of infectious disease tests
access to wound care, infectious disease testing, STI and
conducted (hepatitis C, HIV,
hepatitis C treatment, and medications for opioid use
gonorrhea-chlamydia, syphilis)
disorder. Additional services can include mental health
• % positive of infectious disease tests
services, sexual and reproductive health care, and other
(hepatitis C, HIV, gonorrhea -
primary care and psychosocial support services.
chlamydia, syphilis)
• Number of participants started on
NOTE: See Special Requirements, Terms and
hepatitis C treatment
Conditions — Section 6 Syringe Services Program,
• Number of participants inducted on
Clinical Services Requirements for additional task
medications for opioid use disorder
information.
2
Syringe Services Programs: Haim Reduction Service
Harm reduction care navigation outcomes
Enter deliverable data into the
Reimbursement of
Navigation
include delivering services and tracking:
DOH/OID issued database for
actual costs incurred,
• number of participants enrolled in care
tracking SSP activities by the
not to exceed $16,333
Provide appropriate referrals to SSP participants;
navigation services
15th of each month following
for 07/01/25 — 08/31/25
facilitate access to receive health care and medical
. number of care navigation sessions
service.
services, social services, behavioral health counseling and
. number of referrals to health and social
other services including substance use treatment
services
Exhibit A, Statement of Work Page 2 of 10 Contract Number CLH32053-Amendment 6
Paoe 6 of 19
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
(including medications for opiate use disorder, or
• number of linkages to care for health
MOUD); housing; and advocacy, including but not
and social services
limited to criminal legal involvement, medical providers,
a number of outreach attempts per
benefits navigation, and family reunification.
participant
NOTE: See Special Requirements, Terms and
Conditions — Section 5 Syringe Services Program,
Harm Reduction Care Navigation Requirement for
additional task information
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance a),doh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Unique Entity Identifier (UEI) generated by SAM.gov.
Information about the LIU and this statement of work will be made available on USAS ep nding.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Special Requirements, Terms and Conditions
1. Definitions
a. ANONYMOUS SERVICES- HIV Prevention services including condom distribution, outreach and light touch.
b. CAPACITY BUILDING- The process by which individuals and organizations obtain, improve, and retain the skills, knowledge, tools, equipment, and
other resources needed to do their jobs competently.
c. CONTRACTOR — For the purposes of this Statement of Work Only, the entity receiving funds directly from Washington State Department of Health
(DOH) for client services to prevent or treat conditions named in the statement of work will be referred to as contractor.
d. HARM REDUCTION - Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.
e. INTEGRATED TESTING- For the purpose of this Statement of Work, Integrated Testing includes Human Immunodeficiency Virus (HIV), Gonorrhea
(GC), Chlamydia (CT), Syphilis, Hepatitis C (HCV) and Hepatitis B (HBV).
f. SOCIAL DETERMINANTS OF HEALTH - Social determinants of health (SDOH) are the conditions in the environments where people are born, live,
learn, work, play, worship, and age that affect a wide range of health, fimctioning, and quality -of -life outcomes and risks.
g. YOUTH- For purposes of this agreement, the term "youth" applies to persons under the age of 18.
2. Submission of Invoice Vouchers —
a. On a monthly basis, the CONTRACTOR shall submit complete and correct A19 invoice vouchers with amounts billable to DOH under this statement of work
and the corresponding OID Expense Summary backup form. All A19 invoice vouchers must be submitted by the 25th of the following month. Prior approval is
required for a different frequency of billing.
Exhibit A, Statement of Work Page 3 of 10 Contract Number CLH32053-Amendment 6
Page 7 of 19
i. The CONTRACTOR must provide all backup documentation as required based on the assigned risk level and/or as identified by DOH program staff
to determine allowability of billed expenses. Risk assessments are completed at the beginning of a new contract for all sub -recipient contracts.
Contact your contract manager if you are unaware of your assigned risk level.
ii. DOH may ask for additional backup information to pay invoices based on the needs of the funding sources supporting the work.
b. The CONTRACTOR shall submit all final claims for payment for costs due and payable under this statement of work by July 31, 2026. DOH will pay belated
claims at its discretion, contingent upon the availability of funds.
3. Program Organization — CONTRACTOR must
a. The CONTRACTOR must provide a full updated organizational chart, including Board of Directors with contact information if applicable, and staffing plan
referencing positions described in the budget narrative.
b. The CONTRACTOR must provide job descriptions for any new or changed positions in the updated organizational chart.
i. Any new positions funded through the original contract funds, must have prior DOH approval.
c. The CONTRACTOR must notify their DOH contract manager within 30 days of any staff vacancies related to contracted positions and provide an updated
budget.
i. Any new fiscal staff responsible for invoicing on this contract will need to meet with the assigned OID Contract Manager within 60 days for DOH
invoice overview and training.
4. Syringe Services Program: Support for Operations Program Requirements
a. Operate for a minimum of 8 hours per week and 2 days per week.
b. Provide mobile and/or street outreach (note: programs must have a vehicle for mobile outreach.)
c. Offer safer injection supplies (see list of required safer injection supplies below).
d. Submit monthly SSP data in accordance with DOH standards.
e. Attend required capacity building/training opportunities provided by DOH.
f. Participate in annual site visits with DOH staff.
g. Demonstrate structure for receiving and incorporating participant feedback about services.
h. Partner with relevant local agencies to ensure effective outreach and service provision. (See Scope of Work narrative below for details on MOUs required.)
i. Develop and maintain a Universal Precautions and Sharps Handling policy and procedure, including clear, written policies on handling biohazardous waste,
avoiding unnecessary handling of sharps, and potential needle stick injuries to staff, volunteers, and participants. Programs should follow the universal precaution
guidelines established by the CDC and OSHA. SSPs may need to adapt those precautions to accommodate the circumstances of their work (e.g., mobile and
outreach settings). Programs should also anticipate the potential of needlestick injury and have a "post -exposure -prophylaxis" protocol included in this document.
j. All staff and volunteers working directly with participants/clients must complete CPR certification within the first 3 months after contract start date (if not
already complete).
5. Syringe Services Program, Harm Reduction Care Navigation Requirements
a. Includes all requirements for Syringe Service Program operations (see above)
b. Attend Harm Reduction Care Navigation training provided by DOH.
c. Support participant transportation (e.g., through the provision of bus passes, cab vouchers, or direct transportation).
d. Accompany participants to appointments or provide "warm hand-offs."
e. Full-time care navigators (1.0 FTE) shall not exceed a case load greater than 25 individuals.
f. Submit monthly outcome data in accordance with DOH standards.
6. Syringe Services Program, Clinical Services Requirements
a. Includes all requirements for Syringe Service Program operations (see above)
b. Must have clinical staff licensed to practice in the state of Washington to provide clinical services (e.g., RN, PA, ARNP, LCSW).
c. If providing advanced level clinical services (e.g., PA, ARNP, CNM), programs must have appropriate clinical oversight.
Exhibit A, Statement of Work Page 4 of 10 Contract Number CLH32053-Amendment 6
Page 8 of 19
Note: Clinical services can be provided through sub -contractor arrangement or MOU with a Federally Qualified Health Center or other clinical
partner if there is a justification the relationship will support efforts to reach people who use drugs and provide onsite and/or mobile clinical services.
Clinical services can also be provided using telemedicine services with appropriate description of why in -person services cannot be provided and who
the telemedicine partner(s) will be.
NOTE: Funds from this contract may not be used to purchase basic safer injection supplies (listed below) — Instead, DOH will provide Contractors with supplies.
Below is the list of required supplies for SSP to be provided to Contractors by DOH:
a. Syringes (1 cc 27 gauge 1/2", 28 gauge 1/2", and 29 gauge 1/2"; 1 cc 30 gauge 5/16'; 3 cc 25G 1" and 1.5")
b. Alcohol pads
c. Non -latex tourniquets
d. Sterile water
e. Sterile saline
f. Cookers
g. Cottons and/or cellulose filters
h. Bandages/gauze
i. Sharps containers (1 quart and 2 gallon for distribution, 8 gallon for program use)
j. Naloxone
k. Amber bags
The exceptions to these supplies are vendor or manufacturer supply shortages. If a program expects to run out of one of these items, please contact DOH immediately.
Performance Objectives & Work Plan:
a. Funded Syndemic Prevention Services agencies are required to submit Performance Objectives and Work Plan that provides both a high-level overview of the
period of performance and a detailed description of the first year of the contract period. The work plan should incorporate related program strategies and
activities. Applicants should propose specific, measurable, achievable, realistic, and time -based (SMART) process and/or outcome objectives for each activity
aligned with performance outcomes. The work plan should include training, capacity building, and TA needs to support the implementation of the funded
services. Proposed work plan activities may be adjusted in collaboration with OID staff to better address the overarching goals of the funded services. OID will
provide a template that must be used in developing the work plan.
b. The applicant should address the following outline in their work plan:
i. Contract Year 2 Detailed Work Plan (For each funded service category)
ii. Program strategies and activities
iii. Outcomes aligned with program strategies and activities
iv. SMART objectives aligned with performance targets
V. Activities aligned with program outcomes
vi. Timeline for implementation (including staffing of the proposed program, training, etc.)
vii. Anticipated capacity building or technical assistance needs.
c. Performance Objectives & Work Plans should be submitted by December 31, 2025.
d. OID staff are available to support in developing Performance Objectives & Work Plans in collaboration with funded agencies.
e. Performance Objectives & Work Plans will be reviewed between OID staff and funded agencies at least quarterly. Performance Objectives & Work Plans can be
adjusted throughout the period of performance.
8. Participation in program evaluation activities — The Contractor is expected to participate in program evaluation activities, including evaluation planning, and collecting
and reporting qualitative and quantitative program data, as deemed necessary by OID staff.
Exhibit A, Statement of Work Page 5 of 10 Contract Number CLH32053-Amendment 6
Page 9 of 19
9. Participation in Capacity Building and Technical Assistance Activities designed to increase efficacy of Syndemic Services
a. Opportunities for capacity building and technical assistance for contractor will be offered throughout the contract year by WA DOH and other regional or
national capacity building organizations.
b. Contractors will be expected to meet with WA DOH OID staff on an annual basis to discuss training and will work with DOH to track shared completion of
Capacity Building Needs
c. All contracted staff will be required to complete training in respect to their role. DOH staff and contracted staff will work together to track completion of required
trainings.
10. CLAS Standards — The CONTRACTOR will comply with the National Standards for Culturally and Linguistically Appropriate Services (CLAS) standards (1, 5-9).
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (allianceforclas.org)
11. Participation in Program Monitoring Activities —
a. DOH will conduct semi-annual or annual performance site visits in the following areas:
i. Integrated testing
ii. Syndemic service navigation
iii. PrEP Housing
iv. Syringe Service Programs
V. Mail-order naloxone distribution program
vi. Fiscal Monitoring — To be scheduled by the DOH Fiscal Monitoring Unit
b. Corrective Action Plans — DOH may exercise the following options if the CONTRACTOR does not come into compliance or resolution with programmatic
and/or fiscal monitoring corrective action plan by the due date(s) identified in the CAP. i. § 200.339 Remedies for noncompliance.
If a non -Federal entity fails to comply with the U.S. Constitution, Federal statutes, regulations or the terms and conditions of a Federal award, the Federal
awarding agency or pass -through entity may impose additional conditions, as described in § 200.208. If the Federal awarding agency or pass -through entity
determines that noncompliance cannot be remedied by imposing additional conditions, the Federal awarding agency or pass -through entity may take one or more
of the following actions, as appropriate in the circumstances:
(a) Temporarily withhold cash payments pending correction of the deficiency by the non -Federal entity or more severe enforcement action by the Federal
awarding agency or pass -through entity.
(b) Disallow (that is, deny both use of funds and any applicable matching credit for) all or part of the cost of the activity or action not in compliance.
(c) Wholly or partly suspend or terminate the Federal award.
(d) Initiate suspension or debarment proceedings as authorized under 2 CFR part 180 and Federal awarding agency regulations (or in the case of a pass -through
entity, recommend such a proceeding be initiated by a Federal awarding agency).
(e) Withhold further Federal awards for the project or program.
(f) Take other remedies that may be legally available
12. Contract Management —
a. Fiscal Guidance
i. Indirect- If charging indirect costs, the CONTRACTOR must have a current federally negotiated rate or De Minimis certification of file with DOH.
DOH is not able to reimburse indirect costs without an approved indirect cost rate or De Minimis certification of file.
Exhibit A, Statement of Work Page 6 of 10 Contract Number CLH32053-Amendment 6
Page 10 of 19
ii. Advance Payments Prohibited — DOH funds are "cost reimbursement" funds. DOH will not make payment in advance or in anticipation of services
or supplies provided. This includes payments of "one -twelfth" of the current fiscal year's funding.
iii. Duplication of EIP Services —The CONTRACTOR shall not use contract funds to provide a parallel medication service to EIP. CONTRACTOR's
providing case management services shall make every effort to enroll clients in EIP.
iv. Payment of Cash or Checks to Clients Not Allowed — Where direct provision of service is not possible or effective, vouchers or similar programs,
which may only be exchanged for a specific service (e.g., transportation), shall be used to meet the need for such services. CONTRACTOR shall
administer gift cards voucher programs to assure that recipients cannot readily convert vouchers into cash.
1. Store gift cards that can be redeemed at one merchant or an affiliated group of merchants for specific goods or services are allowable as
incentives for eligible program participants.
2. General -use prepaid cards are considered "cash equivalent" and are therefore unallowable. Such cards generally bear the logo of a payment
network, such as Visa, MasterCard, or American Express, and are accepted by any merchant that accepts those credit or debit cards as payment.
Gift cards that are cobranded with the logo of a payment network and the logo of a merchant or affiliated group of merchants are general -use
prepaid cards, not store gift cards, and therefore are unallowable.
3. The CONTRACTOR must ensure that a policy for managing gift cards with strong internal controls is in place.
V. Funds for Needle Exchange Programs Not Allowed with Federal Funding — CONTRACTOR shall not expend contract federal funds to support
needle exchange programs using funds from HIV Community Services Tasks.
vi. Travel — Out of staff travel requires prior approval from DOH and must follow GSA guidelines and reimbursement rates.
vii. Supervision, under DOH Community Programs contracts, will be understood as the delivery of a set of interrelated functions encompassing
administrative, educational and supportive roles that work collectively to ensure clinical staff (i.e. case managers, navigators, coordinators, assistants,
coaches) are equipped with the skills necessary to deliver competent and ethical services to clients that adhere to best practices within applicable
fields as well as all relevant Statewide Standards. Supervisor; must meet the criteria set forth within the WA State HIV Case Management Standards
and provide the level of interaction and review detailed in that document.
It is the understanding of DOH that Supervision funded under the direct program portion of this contract include at minimum the provision of at least
two of the three functions detailed here: administrative, educational or supportive supervision. Supervision that encompasses only administrative
functions will not be considered billable under Direct Program. To that end, it is the expectation of DOH that those personnel identified as Supervisors
have no more than one degree of separation from direct client care. Exceptions to this rule can be presented and considered to and by DOH Contract
Management. It will fall to the requesting organization to satisfactorily demonstrate that any Supervisory positions falling within the scope of Direct
Program are meeting the expectation of provision of educational or supportive supervision with the aim of directly impacting client experiences,
quality of services, and adherence to best practices and Statewide Standards.
viii. Small and Attractive items — Each Contractor shall perform a risk assessment (both fmancial and operational) on the agency's assets to identify
those assets that are particularly at risk or vulnerable to loss. Operational risks include risks associated with data security on mobile or portable
computing devices that store or have access to state data. Assets so identified that fall below the state's capitalization policy are considered small and
attractive assets. The Contractor shall develop written internal policies for managing small and attractive assets. Internal policies should take into
consideration the WaTech IT Security Standard SEC-04, which includes SEC-04-06-S Mobile Device Security Standard and SEC-04-0I-G Media
Handling and Data Disposal Best Practices - https://watech.wa.goy/policies.
Exhibit A, Statement of Work Page 7 of 10 Contract Number CLH32053-Amendment 6
Page 11 of 19
The Contractor shall implement specific measures to control small and attractive assets in order to minimize identified risks. Periodically, the
Contractor should perform a follow up risk assessment to determine if the additional controls implemented are effective in managing the identified
risks.
Contractor must include, at a minimum, the following assets with unit costs of $300 or more:
1. Laptops and Notebook Computers
2. Tablets and Smart Phones
Agencies must also include the following assets with unit costs of $1,000 or more:
1. Optical Devices, Binoculars, Telescopes, Infiared Viewers, and Rangefinders
2. Cameras and Photographic Projection Equipment
3. Desktop Computers (PCs)
4. Television Sets, DVD Players, Blu-ray Players, and Video Cameras (home type)
ix. Food and Refreshments — Food and refreshments are not allowable direct costs, unless provided in conjunction with allowable meetings, whose
primary purpose is the dissemination of technical information. Pre -approval is required when food and refreshments are purchased for these
meetings. A sign in sheet with the clients' ID number from the DOH approved data system as well as an agenda is required to receive reimbursement
for these charges.
1. The CONTRACTOR shall follow Healthy Nutrition Guidelines for Meetings and Events J Washington State Department of Health
when purchasing food and refreshments for approved meetings.
2. Food for staff meetings/training is unallowable.
PLEASE NOTE: If meals/refreshments are purchased for allowable meetings, food can only be
purchased for clients at the per diem rate. Any expenses over per diem will be denied. U.S. General Services Administration Per Diem
Look Up
X. Reimbursement of disallowed costs — The CONTRACTOR agrees to reimburse DOH for expenditures billed to the DOH for costs that are later
determined through audit or monitoring to be disallowed under the requirements of 2 CFR Part 200 —Uniform Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Audits.
b. Contract Modifications
i. Notice of Change in Services — The CONTRACTOR shall notify DOH program staff, within 45 days, if any situations arise that may impede
implementation of the services contained in the statement of work. DOH and the CONTRACTOR will agree to strategies for resolving any shortfalls.
DOH retains the right to withhold funds in the event of substantial noncompliance.
ii. Contract Amendments — Effective Date — The CONTRACTOR shall not begin providing services authorized by a contract amendment until the
CONTRACTOR has received a signed and fully executed copy of the contract amendment from DOH.
1. Local Health Jurisdiction (LHJ) Contractors — Request for contract amendments must be received no less than 60 days prior to the Draft Due
Date identified by the CON CON SOW Schedule on the CON CON Dashboard.
2. Non- LHJ Contractors — Request for contract amendments must be received no later than 60 days prior to the end of the Federal Fiscal Year
(FFY) and 90 days prior to end of the State Fiscal Year (SFY).
a. Amendments must be signed prior to the end of the FFY or SFY end date.
EX. FFY end date is 12/31, contract amendment request due to contract manager by 11/1
Exhibit A, Statement of Work Page 8 of 10 Contract Number CLH32053-Amendment 6
Page 12 of 19
13. Content Review and Website Disclaimer Notice
In accordance with all federal guidance, contractors receiving funds through DOH will submit all proposed written materials requiring review for HIV -related scientific or
medical accuracy including written materials, audio visual materials, and pictorials, including social marketing and advertising materials, educational materials, social
media communications (e.g., Facebook, twitter) and other electronic communications, such as internet/webpages to the OID Content Review Committee. CONTRACTOR
shall submit all materials to be reviewed for scientific or medical accuracy to:
Michael Barnes, Washington State Department of Health
PO Box 47841
Olympia, WA 98504-7841
Phone: 360-810-1880
Email: Michael.Bames@doh.wa.gov
For social marketing campaigns and media strategies, please adhere to the program guidance on the review of HIV -related educational and informational materials for
CDC assistance programs hLtps://www.cdc.gov/hiy/pdf/fimdingLannouncements/psl2-1201/cdc-hiv-psl2-1201-content-review-guidance.pdf
14. Youth and Peer Outreach Workers
All programs, including CONTRACTORS, using youth (either paid or volunteer) in program activities will use caution and judgment in the venues / situations where
youth workers are placed. Agencies will give careful consideration to the age appropriateness of the activity or venue. Agencies will also ensure that organizational staff
and youth comply with all relevant laws and regulations regarding entrance into adult establishments and environments. Agencies will also maintain and implement
appropriate safety protocols that include clear explanation of the appropriate laws and curfews and clearly delineate safe and appropriate participation of youth in program
outreach activities.
15. Whistleblower
a. Whistleblower statue, 41 U.S.C. & 4712, applies to all employees working for CONTRACTOR, subcontractors, and subgrantees on federal grants and contracts.
The statue (41 U.S.C. & 4712) states that an "employee of a CONTRACTOR, subcontractor, grantee, or subgrantee, may not be discharged, demoted, or
otherwise discriminated against as a reprisal for "whistleblowing." In addition, whistleblower protections cannot be waived by an agreement, policy, form, or
condition of employment.
b. The National Defense Authorization Act (NDAA) for Fiscal Year 2013 (Pub. L. 112-239, enacted January 2, 2013) mandates a pilot program entitled "Pilot
Program for Enhancement of Contractor Employee Whistleblower Protections." This program requires all grantees, their subgrantees, and subcontractors to:
i. Inform their employees working on any federal award they are subject to the whistleblower rights and remedies of the pilot program
ii. Inform their employees in writing of employee whistleblower protections under 41 U.S.C. & 4712 in the predominant native language of the
workforce; and,
iii. CONTRACTOR and grantees will include such requirements in any agreement made with a subcontractor or subgrantee.
16. Allowable Costs
All expenditures incurred and reimbursements made for performance under this statement of work shall be based on actual allowable costs. Costs can include direct labor,
direct material, and other direct costs specific to the performance of activities or achievement of deliverables under this statement of work.
For information in determining allowable costs, please reference OMB Circulars:
2 CFR200 (State, Local and Indian Tribal governments) at: https://www.federalre tg ster•gov/documents/2013/12/26/2013-30465/uniform-administrative-
requirements-cost-principles-and-audit-requirements-for-federal-awards.
Exhibit A, Statement of Work Page 9 of 10 Contract Number CLH32053-Amendment 6
Page 13 of 19
"Disclosure of information is governed by the Washington Administrative Code (WAC) 246-101-120, 520 and 635, and the Revised Code of Washington (RCW)
70.24.080, 70.24.084, and 70.24.105 regarding the exchange of medical information among health care providers related to HIV/AIDS or STI diagnosis and treatment.
Please note that CONTRACTORS fit under the definition of "health care providers ' and "individuals with knowledge of a person with a reportable disease or condition"
in the WAC and RCW.
DOH statutory authority to have access to the confidential information or limited Dataset(s) identified in this agreement to the Information Recipient: RCW 43.70.050
Information Recipient's statutory authority to receive the confidential information or limited Dataset(s) identified in this Agreement: RCW 70.02.220 (7)
Exhibit A, Statement of Work Page 10 of 10 Contract Number CLH32053-Amendment 6
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Drinking Water Group A Program -
Effective January 1, 2025
SOW Type: Revision Revision # (for this SOW) 2
Period of Performance: January 1, 2025 through December 31, 2027
Page 14 of 19
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
® Federal Contractor (check if applicable) ❑ Reimbursement
® State ® FFATA (Transparency Act) ® Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non -community Group A water systems
Revision Purpose: To change the MI code for Sanitary Survey Fees SS - State from 24232522 to 24112522 and extend the funding period end date from 06/30/25 to 12/31/27,
remove 1 Sanitary Survey for 3 or more connections ($800), and change the Chart of Accounts Master Index Title from YR 28 SRF - LOCAL ASST (15%) to YR1 STIMULUS -
LOCAL ASST (10% OF 15%) for SS and TA.
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
g
Decrease"
Total
Allocation
SANITARY SURVEY FEES SS -STATE
24112522
N/A
346.26.65
01/01/25
12/31/27
2,200
-400
1,800
YR 27 SRF - LOCAL ASST 15% SS
24119227
N/A
346.26.64
01/01/25
12/31/25
0
0
0
YR 27 SRF - LOCAL ASST 15% TA
24119227
N/A
346.26.66
01/01/25
12/31/25
0
0
0
YR 28 SRF - LOCAL ASST 15% SS
24119228
N/A
346.26.64
01/01/25
12/31/27
2,200
-2,200
0
YRl STIMULUS - LOCAL ASST 10% OF 15% SS
24144240
N/A
346.26.64
01/01/25
12/31/27
0
1,800
1,800
YR 28 SRF - LOCAL ASST 15% TA
24119228
N/A
346.26.66
01/01/25
12/31/27
1,000
-1,000
0
YRl STIMULUS - LOCAL ASST 10% OF 15% TA
24144240
N/A
346.26.66
01/01/25
12/31/27
0
1,000
1,000
0
0
0
0
0
0
TOTALS
1 5,400
-8001
4,600
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information and/or Amount
I
Trained LHJ staff will conduct sanitary surveys of
Provide Final* Sanitary Survey Reports
Final Sanitary Survey
Upon ODW acceptance of the Final
small community and non -community Group A
to ODW Regional Office. Complete
Reports must be
Sanitary Survey Report, the LHJ shall be
water systems identified by the DOH Office of
Sanitary Survey Reports shall include:
received by the ODW
paid $400 for each sanitary survey of a non -
Drinking Water (ODW) Regional Office.
1. Cover letter identifying significant
Regional Office within
community system with three or fewer
deficiencies, significant findings,
30 calendar days of
connections.
See Special Instructions for task activity.
observations, recommendations, and
conducting the sanitary
referrals for further ODW follow-
survey.
Upon ODW acceptance of the Final
UP.
I
I Sanitary Survey RepoM the LHJ shall be
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH32053-Amendment 6
Panes 1 ri of 14
Task
#
Activity
ty
Deliverables/Outcomes
Due Date/Time Frame
Payment Information and/or Amount
The purpose of this statement of work is to provide
2. Completed Small Water System
paid $800 for each sanitary survey of a non -
funding to the LHJ for conducting sanitary surveys
checklist.
community system with four or more
and providing technical assistance to small
3. Updated Water Facilities Inventory
connections and each community system.
community and non -community Group A water
(WFI).
systems.
4. Photos of water system with text
Payment is inclusive of all associated costs
identifying features
such as travel, lodging, per diem.
5. Any other supporting documents.
Payment is authorized upon receipt and
*Final Reports reviewed and accepted by
acceptance of the Final Sanitary Survey
the ODW Regional Office.
Report within the 30-day deadline.
Late or incomplete reports may not be
accepted for payment.
2
Trained LIU staff will conduct Special Purpose
Provide completed SPI Report and any
Completed SPI Reports
Upon acceptance of the completed SPI
Investigations (SPI) of small community and non-
supporting documents and photos to
must be received by the
Report, the LHJ shall be paid $800 for each
community Group A water systems identified by
ODW Regional Office.
ODW Regional Office
SPI.
the ODW Regional Office.
within 2 working days
of the service request.
Payment is inclusive of all associated costs
See Special Instructions for task activity.
such as travel, lodging, per diem.
Payment is authorized upon receipt and
acceptance of completed SPI Report within
the 2-working day deadline.
Late or incomplete reports may not be
accepted for payment.
3
Trained LHJ staff will provide direct technical
Provide completed TA Report and any
Completed TA Report
Upon acceptance of the completed TA
assistance (TA) to small community and non-
supporting documents and photos to
must be received by the
Report, the LHJ shall be paid for each
community Group A water systems identified by
ODW Regional Office.
ODW Regional Office
technical assistance activity as follows:
the ODW Regional Office.
within 30 calendar
• Up to 3 hours of work: $250
days of providing
• 3-6 hours of work: $500
See Special Instructions for task activity.
technical assistance.
. More than 6 hours of work: $750
Payment is inclusive of all associated costs
such as consulting fee, travel, lodging, per
diem.
Payment is authorized upon receipt and
acceptance of completed TA Report within
the 30-day deadline.
Late or incomplete reports may not be
accepted for payment.
Exhibit A, Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment 6
Paae 16 of 19
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information and/or Amount
4
LHJ staff performing the activities under tasks 1, 2
For training attended in person, prior to
Annually
For training attended in person, LHJ shall
and 3 attend periodic required survey training as
attending the training, submit an
be paid mileage, per diem, lodging, and
directed by DOH.
"Authorization for Travel (Non-
registration costs as approved on the pre -
Employee)" DOH Form 710-013 to the
authorization form in accordance with the
See Special Instructions for task activity.
ODW Program Contact for approval (to
current rates listed on the OFM Website
ensure enough funds are available).
htt ://www.of-n.Nva. ov/resources/travel.as
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance(a,doh.wa.gov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Unique Entity Identifier (UEI) generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpendingov by DOH as required by P.L. 109-282.
Program Specific Requirements
Data Sharing
The Office of Drinking Water will share water system information and files with the local health jurisdiction to support the work identified in this statement of work. To request
water system data please contact the regional office with the name of the water system, water system ID#, specific information being requested and any timeline requirements. If
allowable, please give administrative staff 3 to 5 business days to provide records.
Program Manual, Handbook, Policy References: Field Guide (DOH Publication 331-486).
Special References:
Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work, ODW contracts with the LHJ to conduct sanitary surveys (and SPIs and
provide technical assistance) for small community and non -community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys (and
SPIs and provide technical assistance) for small community and non -community water systems with surface water sources, large water systems, and systems with complex
treatment.
LHJ staff assigned to perform activities under tasks 1, 2, and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4, below.
Special Billing Requirements
The LHJ shall submit quarterly invoices within 30 days following the end of the quarter in which work was completed, noting on the invoice the quarter and year being billed for.
Payment cannot exceed a maximum accumulative fee of $4, 300-$3,600-for Task 1, and $1,000 for Task 2, Task 3 and Task 4 combined during the contracting period, to be paid
at the rates specified in the Payment Method/Amount section above. When invoicing for sanitary surveys, bill half to BARS Revenue Code 346.26.64 and half to BARS Revenue
Code 346.26.65.
Exhibit A, Statement of Work Page 3 of 4 Contract Number CLH32053-Amendment 6
Page 17 of 19
When invoicing for Task 1, submit the list of WS Name, ID #, Amount Billed, Survey Date and Letter Date for which you are requesting payment.
When invoicing for Task 2-3, submit the list of WS Name, ID #, TA Date and description of TA work performed, and Amount Billed.
When invoicing for Task 4, submit receipts and the signed pre -authorization form for non -employee travel to the ODW Program Contact below and a signed A19-IA Invoice
Voucher to DOH Grants Management, billing to BARS Revenue Code 346.26.66 under Technical Assistance (TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW. Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance (Field Guide). The sanitary survey will include an
evaluation of the following eight elements: source; treatment; distribution system; finished water storage; pumps, pump facilities and controls; monitoring, reporting and data
verification; system management and operation; and certified operator compliance. If a system is more complex than anticipated or other significant issues arise, the LHJ may
request ODW assistance.
• No more than 3 surveys of non -community systems with three or fewer connections be completed between January 1, 2025, and December 31, 2025.
• No more than 4 3 surveys of non -community systems with four or more connections and all community systems to be completed between January 1, 2025 and
December 31, 2025.
The process for assignment of surveys to the LHJ, notification of the water system, and ODW follow-up with unresponsive water systems; and other roles and responsibilities of
the LHJ are described in the Field Guide.
Task 2
Trained LHJ staff will perform Special Purpose Investigations (SPIs) as assigned by ODW. SPIs are inspections to determine the cause of positive coliform samples or the cause of
other emergency conditions. SPIs may also include sanitary surveys of newly discovered Group A water systems. Additional detail about conducting SPIs is described in the Field
Guide. The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staff will conduct Technical Assistance as assigned by ODW. Technical Assistance includes assisting water system personnel in completing work or verifying work
has been addressed as required, requested, or advised by the ODW to meet applicable drinking water regulations. Examples of technical assistance activities are described in the
Field Guide. The ODW Regional Office must authorize in advance any technical assistance provided by the LHJ to a water system.
Task 4
LHJ staff assigned to perform activities under tasks 1, 2, and 3 must be trained and approved by ODW prior to performing work.
If required trainings, workshops or meetings are not available, not scheduled, or if the LHJ staff person is unable to attend these activities prior to conducting assigned tasks, the
LHJ staff person may, with ODW approval, substitute other training activities to be determined by ODW. Such substitute activities may include one-on-one training with ODW
staff, co -surveys with ODW staff, or other activities as arranged and pre -approved by ODW. LHJ staff may not perform the activities under tasks 1, 2, and 3 without completing
the training that has been arranged and approved by ODW.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH32053-Amendment 6
DOH Program Name or Title: Recreational Shellfish Activities -
Effective July 1, 2025
SOW Type: Original Revision # (for this SOW)
Period of Performance: July 1, 2025 through June 30, 2026
Exhibit A
Statement of Work
Contract Term: 2025-2027
Page 18 of 19
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
Funding Source Federal Compliance Type of Payment
❑ Federal <Select One> (check if applicable) ® Reimbursement
® State ❑ FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide funds for shellfish harvesting safety.
Revision Purpose: N/A
DOH Chart of Accounts Master Index Title
Master
Index
Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Chan e
g
Increase (+)
Total
Allocation
REC. SHELLFISH/BIOTOXIN
26402600
N/A
334.04.93
07/01/25
06/30/26
0
7,500
7,500
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS
0
7,500
7,500
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1
Biotoxin Monitoring
Submit annual report on DOH approved
Email Report to DOH by
$7,000
• Collect monitoring samples on schedule according to
format of activities for the year, including the
February 15, 2026
Department of Health (DOH) Biotoxin Monitoring Plan,
number of sites monitored and samples
coordinate deviations from the schedule with DOH, notify
collected, and number and names of beaches
(See Special Instructions
DOH in advance if samples cannot be collected.
posted with signs.
below.)
• Conduct emergency biotoxin sampling when needed.
• Post / remove recreational shellfish warning and / or
classification signs on beaches and restock cages as
needed
• Issue biotoxin news releases during biotoxin closures in
Jefferson County.
• This task may also include recruiting, training, and
coordination of volunteers, and fuel reimbursement funds
for volunteer biotoxin monitoring.
Exhibit A, Statement of Work Page 1 of 2 Contract Number CLH32053-Amendment 6
Pane 1q of 1q
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
2
Outreach
Submit annual report including the number
Email Report to DOH by
$500
• Staff educational booths at local events.
of events staffed and amount of educational
February 15, 2026
• Distribute safe shellfish harvesting information.
materials distributed.
(See Special Instructions
below.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to financena,doh.wa.gov.
Program Specific Requirements
Program Manual, Handbook, Policy References:
Department of Health's Biotoxin Monitoring Plan
Special References (i.e., RCWs, WACs, etc.):
Chapter 246-280 WAC
https://doh. wa. gov/community-and-environment/sheUfish/recreational-shel l fi sh
https://doh.wa.sov/about-us/t)ro2mms-and-services/environmental-public-health/environmental-health-and-safetv/about-shellfish-t)roaram/about-biotoxins-and-illness-t)revention-
rp ogram
Special Instructions:
Report for work performed in 2025 must be submitted via email to Liz Maier (liz.maier(@doh.wa.gov) by February 15, 2026.
The report format will be provided by DOH and may be modified throughout the period of performance via email announcement.
Exhibit A, Statement of Work Page 2 of 2 Contract Number CLH32053-Amendment 6
Page 1 of 11
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053
AMENDMENT NUMBER: 5
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HE.AI...TH hereinafter referred to as
"DOII", and JEFFERSON COUNTY PUBLIC HEALTH, H, a Local health Jurisdiction, hereinafter referred to as "LI-1J",
pursuant to the Modifications/Waivers clause, and to make necessary changes within the scope of this contract and any
subsequent amendments thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work, includes the following statements of work, which are incorporated by this reference
and located on the DOH Finance SharePoint site in the Upload Center at the following URL:
https:`/stateofwa.sharepoint.eonr:'sites;doll-ofsfi tidint,resourcesisitepattes/honie.aspx?°e1:9a94688da2d94d3ea8Oac7tbe32e-ld7c
❑ Adds Statements of Work for the following programs:
® Amends Statements of Work for the following programs:
Sexual & Reproductive Health Program - Effective January 1, 2025
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-5 Allocations, attached and incorporated by this reference, arnends and replaces Exhibit B-4 Allocations as
follows:
® Increase of ,. 1.7 023 for a revised maximum consideration of $3 1
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations are attached only for infonnational purposes.
3. Exhibit C Federal Grant Awards Index, incorporated by this reference, and located in the ConCon, Funding & BARS
library at the URL provided above.
Unless designated otherwise herein, the effective date of this amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force
and effect.
IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY WASHINGTON
BOARD OF COUNTY COMMISSIONERS
Heidi Eisenhour. Chair Date
APPROVED AS TO FORM ONLY
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
APPROVED AS TO FORM ONLY
Assistant Attorney General
Date
Cc-25-001-A5 Page I of i
EXHIBIT B-5
Page 2 of 11
Jefferson County Public Health
ALLOCATIONS
Contract
Number:
Cl..1132053
Contract Term: 2025-2027
Date:
June 1, 2025
Indirect Rate January 1, 2025 through December 31, 2025: 27.38% Public Health
DOH Use
Only
BARS
Statement of Work
Chart of
Accounts
Funding
Chart of
Federal Award
Assist
Revenue
LHJ Funding
Period
Funding Period
Period
Accounts -
Chart of Accounts Program Title
Identification #
Amend #
List #*
Code**
Start Date End Date Start Date End Date
Amount
SubTotal
Total
FFY25USDA BFPC Pro- Mgmt
7%VA700WA1
Amd4
10.557
333.10.55
'01/01/25
09'30/26
10/01/24
(79/10/26
$28,238
$28,238
$28,238
FFY24 USDA BFPC Prog Mgmt
7WA700WAI
Amd 4
10.557
333.10.55
01/01/25
09/30/26
10/1) 1 /2 3
09G0/26
($28,238)
$0
FFY24 USDA BFPC Prog Mgmt
7WA700WAI
Amd 2
10.557
333.10.55
011OU25
09/30/26
10/01/23
0430/26
$28,238
FFY25 USDA WIC Client Svs Contracts
7WA700WA7
Amd 4
10.557
333.10.55
01/01/25
09/30/25
10/01,24
09(3Q/25
$3,975
$148A 17
$148,117
FFY25 USDA WIC Client Sys Contracts
7WA70OWA7
Amd 2
10.557
333.10 iti
01/01/25
09/30/25
10/01 /21
09.`31123
S144,142
FFY25 USDA FMNP Mgmt
7WA810WA7
Amd 4
10.572
333.10 57
01/01/25
09/30/25
10/01 2 ]
041131f25
$637
$637
$637
FFY25 SWIMMING BEACH ACT JAR (ECY)
OIJ74301
Amd 2
66.472
333.66.47
03/01/25
10,31/25
01/01/25
11/30/25
$13,500
$137500
$13,500
FFY24 PREP BPI-CDC-LHJ Partners
NU90TU000055
Amd 1
93.069
333.93.06
01/01/25
06/30/25
07/0 124
06;30/25
$13,754
$13,754
$13-754
FFY24 OD2A OID CDC Prevent
NU 17CEO10218
Amd 2
93.136
333.93.13
01/01/25
06/30/25
09/1) 1 /24
08/311125
$32,556
$81-556
$81,556
FFY24 OD2A OID CDC Prevent
NU I7CEO10218
Amd 1
93.136
33 3.93.13
01/01/25
06/3012i
09/01 /24
08/31/25
$49,000
FFY25 FPHPA Title X Famil) Plan
FPHPA006560
Amd 5
93,217
33193.21
04101/25
03131i26
04/01/25
()3/31/261
517,023
1;17,023
533,989
FFY24 FPHPA Title X Family Plan
FPIIPA006560
Amd 3
93.217
333.93.21
0110U25
03/31'25
04/01/24
03/31/25
$8,345
$16.966
FFY24 FPHPA Title X Family Plan
FPHP.A006560
Amd 21
93.217
333,93.21
01/01/25
03/31 /25
04/0 1/24
03/31/25
$8,621
FFY24 CDC PPHFOps
N1123IP922619
Amd1
93.268
333.932A
O1,01/'_'5
06/30;`25
07/01,123
06/30/25
$10,000
$10,000
$10,000
FFY20ELCEDELHJsCDC
NU50Ck000515
Amd 1
93.323
333.93.32
011101/25
06130/25
01/15!21
07/31/25
$15,580
$15,580
$1i,580
FFY21 CDC COViD-19 PHWFD-LIIJ
NU90TP922181
Amd 3
93.354
333.93.35
01/01/25
06/30/25
07/01/23
06/30/25
$51,330
$51,330
$51,330
FFY22 PH Infrastructure Comp AI-LHJ
NE IOE000053
Arad 3
93.967
333.9396
01/0U25
11/30/27
12/01/22
1 P30/27
$150,300
$150 300
$150.300
FFY25 HRSA MCHBG LHJ Contracts
B04MC54583
Amd 1
93.994
333.93.99
01/01125
09/30i25
10/01/24
09/30/25
$27,525
$27,525
$27,51-5
SFY25 SBHC Proviso
Amd I
N/A
334.04.90
01 /01/2i
06/30/25
07/1i124
(15/30/25
$59,000
$59,000
$59,000
SFY25 DUH Naloxone DDO FICA JAR
Amd 4
N/A
334.04 91
03/01 /25
06/30/2i
12/ 10 /24
06/30/25
S I i,000
S15,000
$15,000
SFY25 Drug User Health Program
Amd I
N/A
334.0491
01/01/25
06,/30/25
07/01/24
06/30/25
$40,250
$40,250
S40,250
SFY25 Sexual & Rep Hlth Cost Share
Amd I
N/A
334.04-91
0 1/01/25
06/30/25
07/0 1,124
06/3,(1/25
$47,993
S47,993
$47,993
SFY25 SSPS Opiod Harm Red Proviso
Amd 2
N/A
334.04.91
01101/2S
06/30/25
07/01/1-4
06/30 25
$8,000
$8,000
$8,000
SFY25 LIiJ Opioid Campaign Proviso
Amd 3
N/A
334.04.93
0 U01/25
06/30i2i
07/01/24
06/30/25
$24,500
$56,000
$56,000
SFY25 LHJ Opioid Campaign Proviso
Amd I
N/A
334.04.93
01A)1/25
(630/2S
07/01 24
06/30/25
$31,500
Page
1 of 2
EXHIBIT B-5
Page 3 of 11
Jefferson County Public Health
ALLOCATIONS
Contract Number:
CLH32053
Contract Term: 2025-2027
Date:
June 1, 2025
Indirect Rate January 1, 2025 through December 31,
2025: 27.38% Public Health
DOH Use
Only
BARS
Statement
of Work
Chart of
accounts
Funding
Chart of
Federal Award
Assist
Revenue
LHJ Funding
Period
Funding Period
Period
Accounts
Chart of Accounts Program Title
Identification #
Amend #
List #*
Code**
Start Date End Date Start Date End Date
Amount
SubTotal
Total
Ree Shelltish/Biotoxin
Amd I
N/A
334.04.93
01/01/25
06/30/25
07/0 12
$3,700
$3,700
$3;700
Small Onsite Management (ALEA)
Amd 4
N/A
334.04.93
01/01/25
06/30/25
07/01/23
06/30/25
$1,363
$33-781
$33,781
Small Onsite Management (ALEA)
Antd3
N/A
334.04.93
0101/25
06/30/25
07:`0VP3
06/30/25
$32,418
SFY25 Wastewater Management-GFS
Amd 4
N/A
334.04.93
01/01/25
06 30/25
07101'24
06`30/25
($1,363)
$9,239
$9 239
SFY25 Wastewater Management-GFS
Amd 3
N/A
334.04,93
01/01/25
06/30/25)
07/01/24
06/30/25
$10,602
SFY25 FPIIS-LHJ Funds-GFS
Amd I
N/A
336.0425
01/01/25
06/30/25
07/01 /24
06/30/25';
$2 333,000
$2,333,000
$2.333 000
YR 28 SRF - Local Asst (15%) SS
Amd 4
N/A
346.26 64
01/01/25
12/31 /27
07/01/24
06/30/29
$2,200
$2.200
$2,200
YR 27 SRF - Local Asst (I5%) SS
Amd 4
N/A
346.26-64
0 1/0 1/25
06/30/25
07/01 23
06/30/25
($2,200)
$0
YR 27 SRF - Local Asst (15%) SS
Amd 1
N/A
34626.64
01/01/25
06€30/25
07/� 11 ?
1jh/30i25
$2,200
Sanitary Survey Fees SS -State
Amd I
N/A
34626 65
01/01/25
06/30f25
07/01/23
12/31/27
$2,200
$2,200
$2,200
YR28SRF - Local Asst (15%)TA
Amd4
N/A
346.26.66
01/01/25
12/31/27
07./01124
06.30/29
$1,000
$1,000
$1,000
YR 27 SRF - Local Asst (15%) TA
Amd 4
N/A
346.26.66
0 1/0 1 /25
06/30/25
07/01 /3 3,
06/30/25
($1,000)
$0
YR 27 SRF - Local Asst (15%) TA
Amd l
N/A
346.26.66
0 110 1/25
06/30/25
07J01 /23
ii6/ 0/25
$1,000
TOTAL
$3,185,889
$3,185,889
Total consideration:
$3,168,866
GRAND TOTAL
S3,185,889
S 17,023
GRAND TOTAL.
$3,185,889
Total Fed
S574,526
Total State
S2,611,363
*Assistance Listing Number fka Catalog of Federal Domestic Assistance
**Federal revenue codes begin with "333 State revenue codes begin with 934
Page 2 of 2
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Sexual & Reproductive Health Program -
Effective January 1. 2025
SOW Type: Revision Revision # (for this SOW) 2
Period of Performance: January 1, 2025 through March 31. 2026
Page 4 of 11
Local Health Jurisdiction Name: Jefferson Countv Public Health
Contract Number: CLH32053
Funding Source - Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
® State ® FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide sexual and reproductive health services (SRH) to Washington State residents. These
services will comply with all state. federal, and DOH SRHP Manual requirements. It highlights specific requirements, but all must be complied with. Budgets are based on an
approved allocation formula .with finds available.
This Statement of Work spans Years 1-4 of the contract, which runs January 1, 2022 — March 31, 2026.
For state funding, due dates after June 30, 2025 are for reporting only. LHJs may not bill under this contract for work done after June 30. 2025.
For federal funding, due dates after March 31. 2026 are for reporting only. LHJs may not bill federal funds under this contract for work done after March 31, 2026.
Revision Purpose: The purpose of this revision is to add $17.023 in Title X federal funding for the period of 04/01/2025 - 03/31/2026, extend the SOW period of perfonnance
from 06/30/2025 to 03/31/2026, and revise language in task table and Program Specific Requirements section.
Master
� Index
DOH Chart of Accounts Master Index Title ' Code
Assistance
Listing
Number
BARS
Revenue
Code
LHJ Funding Period
Start Date End Date
Current
Allocation
Allocation
Change
g
Increase (+)
Total
Allocation
FFY24 FPHPA TITLE X FAMILY PLAN i 78430240
93.217
333.93.21
01/01/25
03/31/25
16,966
0
16.966
SFY25 SEXUAL & REP HLTH COST SHARE 78430150
N/A
3 34.04.91
01/01/25
06/30/25
47,991
0
47.993
FFY25 FPHPA TITLE X FAMILY PLAN 78430250
93.217
333.93.211
04/01/25
0, :1 26
0
17.023
17.023
0
0
0
0
0
0
0
0
0
TOTALS
64,959
17,023
81,982
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
1
Sexual and Reproductive Health Program
. A19 invoice vouchers submitted in atimely manner
Nh 1111-e th`t" HIEH! '.
Billing must be based
(SRHP) & Title X (TX) Services —excluding
accompanied by an R&E workbook showing revenue
:.
on a current cost
abortion and other surgical procedures related to
and expenses for the month billed and any other
qtiai-ieiz}v-
analysis approved by
SRH P.
required back up documentation per DOH policy.
DOH (see Reporting
As described in Task 6
Requirements below).
A. Comply with Washington State SRHP Manual,
. All reports described in Reporting Requirements
Revenue and Expense
federaf Title X requirements and all state and
below.
I Reports inthe
Exhibit A, Statement of Work Page I of 8 Contract Number CLH32053-Amendment 5
Paae 5 of 11
Task
#
I
Activity !
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
federal laws. Also see Program Manual.
Reporting
DOH reserves the right
Handbook, Policy References under Reporting
• Other data and documentation in format requested by
Requirements WL'Iiru;
to withhold payment
Requirements (below).
DOH. (Includes copies of program and financial audits
below.
until:
and reviews including summaries conducted by other
• Compliance issues
B. Complete required Agency Information Request
entities.)
As requested by DOH
or a previous SOW
including Title X Assurance of Compliance and
are resolved in a
National Provider Identifier (NPI) billing
. To facilitate DOH/TX desk reviews —requested
way accepted by
numbers
documentation available to DOH in requested format.
DOH
• Current data is
C. Provide medical services, community education
• To facilitate DOH/TX site -visits —appropriate staff
submitted to, and
and outreach, and staff training, consistent with
and documentation readily available prior to and
accepted by,
state requirements:
during review.
Ahlers.
• A 19 back up
I . LHJ is responsible for making sure all staff
DOH performs site visits. Follow-up site visits are
documentation
have the knowledge to carry out the
performed until identified issues are resolved.
required by DOH
requirements of the SOW.
has been submitted
and approved.
2. Medical, laboratory, and other services
. Other deliverables
related to abortion are not covered by this
have been met.
task.
!
Payment is limited to
3. Community education services must be
the maximum funds
based on the needs of the community. LHJ
available for funding
must have an information & Education
source.
(i&E) committee with five (5) or more
members that is broadly representative of
DOH will reimburse
the population or community for which
for:
materials are intended. The committee
• Actual allowable
must review a batch of patient -facing
costs according to
materials annually (at least 15 products or
your approved cost
15% of the total number of materials,
analysis (see
whichever is smaller): meet at least
Repotting
annually and establish a written record of
Requirements
its determination. (42 CFR 59 [59.6])
below).
or
4. Outreach is to ensure all populations in
• The amount
your community understand the services
remaining in the
available. Focus your outreach efforts on
SOW divided by
increasing equity.
the number of
months remaining
Washington State Sexual and Reproductive
in the funding
Health Network priority populations are:
source, plus one,
Teens
whichever is less.
Exhibit A, Statement of Work Page 2 of 8 Contract Number CLH32053-Amendment 5
Paoe 6 of 11
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
• People who are uninsured or
underinsured, and/or low-income
Payment will be
(at or below 250% of the federal
calculated by R&E
poverty line)
provided by DOH (see
• Rural communities
Reporting Requirements
• Hispanic
below).
• Black. Indigenous, People of
All services through the
Color
Extra efforts should be made to provide
end of this contract
information and services to people who
period must be billed
intersect with multiple priority population
within 60 days.
categories.
5. Provide all services in accordance with:
• DOH SRHP & Title X Manual
• Other state and federal
requirements
• Reporting Requirements (see
below)
D. Collect, maintain, and provide data about each
CVR data submitted to DOH data contractor (Ahlers &
family planning clinic visit as defined in the
Associates) electronically in a format compatible with
"
The I j of the
SRH CVR Manual.
ahlers software.
following month.
1. Maintain a computer system that includes
safety precautions against loss of
. Data for each month
W ithin thirty 30
( ) days
information.
of receiving
ry
2. Ensure data entpersonnel protect
&Corrected CVR data
error/rejection report or
confidentiality of CVR data.
request from DOH
3. Have ability to retrieve all information for
Sexual and
auditing and monitoring by DOH or its
Reproductive Health
designee.
data manager.
E. Notify DOH contract manager of all:
Email briefly describing change.
As needed to keep
• Kev staff and organizational changes.
information current.
Proposed clinic site additions. New clinic
sites must be approved by DOH before
offering services supported by SRHP/Title
X funding.
• Expected clinic site closures. Note: DOH
mav, at its sole discretion, recalculate
LHJYs funding allocation if it closes a clinic
site.
Exhibit A, Statement of Work Page 3 of 8 Contract Number CLH32053-Amendment
Paoe 7 of 11
Task
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
#
• Any other change that might affect LHJ's
ability to provide the sexual and
reproductive services described in this
SOW.
Reporting Requirements
1
Agency Information Request
This information must be reported using the template
April 30" during each
or format provided by DOH. All signatures and forms
year of this contract.
DOH SRHP requires updated information from all
must be completed by April 30t6 during each year of
members of the SRHP Network to ensure accurate
this contract. Requested information will include:
AND
records of LHJ's organization and the services it
provides.
Information about your agency contacts and your
As needed or requested
organization's staffing
to maintain accuracy of
In addition, elements of this report allow DOH to
A. Head of Organization
information.
ensure that SRHP & Title X requirements including
B. Head of Finance
client fees and required services are met. The
C. Medical Director
updated information also assists DOH to manage
D. NPI numbers used to bill Medicaid
this SOW and the Sexual & Reproductive Health
E. The following (one person might fill more than one
Network as a.whole.
role)
a. Contract Coordinator
b. Clinical representative
c. Billing contact
d. Outreach and education contact
e. Contact for CVR data
f. Contact for EHR information
Information regarding sexual and reproductive health
related services offered at each clinic site:
A. Cost analysis: How LHJ determines what it costs
to provide services. LHJ uses this to help construct
its fee schedule. A cost analysis must be
performed by LHJ within three years prior to the
j start date of this SOW. If contractor cost analysis
j was approved by DOH at the beginning of the
contract period. LHJ does not have to resubmit
` unless changes are made. LHJ must email DOH
i
j contract manager informing them that no changes
were made.
B. Sliding fee schedule that includes all services
required in the SRH Manual. Additional SRH-
related services as outlined in Task 1 may also be
included on LHJ's sliding fee schedule.
Exhibit A, Statement of Work Page 4 of 8 Contract Number CLH32053-Amendment 5
Paoe 8 of 11
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
a. Sliding fee schedule must be based on cost
analysis described above.
b. Fee schedule must be resubmitted for
reapproval anytime there are any significant
changes. which may include changing of
services. fees, etc.
c. LHJ must not implement a revised fee
schedule until it has been approved in writing
by DOH.
d. Income conversion tables must be updated
Submit an updated
annually and approved by DOH
income conversion
table by March 15 of
Information related to current Community Outreach Plan:
each year of the
contract.
LHJ's community outreach plan follows a 5-year cycle.
This process must include the following steps:
A. Utilize the state level priority populations, county
level demographic data, and agency profile to
identify unmet need in the community served.
B. Determine objectives and activities to expand
sexual and reproductive health to reach
populations in need of services in the community
served:
C. Measure completion of the objectives and
activities.
2
Program Updates
This information must be reported using the template
During quarterly check
or format provided by DOH. It will include information
ins and as requested by
Summary of ongoing activities related to the SRH
about contractor's work during current and past
DOH
Program. This informs quality improvement of the
sows:
Washington State SRH Network.
A. Community education and outreach strategies and
activities and a discussion of their effectiveness.
B. Staff training.
4
Family Planning Annual Report (FPAR)
Organization -level data on clinical services emailed to
Data to be collected
DOH SRH data manager
annually through the
Information DOH is requesting to develop trend
Number of:
end of the grant (2027).
data. All information is for the calendar year
A. Pap tests with an ASC or higher result
(January through December). The subsequent
B. Pap tests with an HSIL or higher result
agreements sent to the agency will request that these
C. HIV Positive confidential tests
data be collected and reported on within the
D. HIV Anonymous tests
statement of work period of performance.
E. FTE required to provide sexual and reproductive
health services:
• Phvsicians
Exhibit A, Statement of Work Page 5 of 8 Contract Number CLH32053-Amendment 5
Paae 9 of 11
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
• Physician assistants nurse practitioners+
certified nurse midwives
i
• Registered nurses with e\panded scope of practice
who are trained and permitted by state specific
regulations to perform all aspects of the physical
assessment.
Financial data emailed to DOH Contract Manager
R&E showing Other Revenue through the end of the grant
as described below.
Subsequent agreements will request that data be collected
and reported on during the appropriate contract period of
performance. (FPAR due 01-31 annually through 2027)
5
Clinic Visit Reports (CVRs)
Clinic visit records must include all elements specified
in the Clinic Visit Record (CVR) Manual available at:
The 15" of the
following month.
bttl)s://www.doh.wa.p,ov/Portals/1 /Documents/Pubs/930-
139-( \'R)flanual.ndf.
Within thirty (30) days
of receiving error or
CVR data must be submitted to DOH data contractor
rejection report or
(Ahlers & Associates) electronically in a format compatible
request from DOH
with Ahlers software.
SRH data manager.
- Each month's CVR data
- Corrected CVR data
- rill he ..6onaged in 1024(A`R-s
Dfit.
elements
.iTriic�=rc3:
6
Revenue and Expense Reports (R&E)
Completed R&E for time period that shows all revenue
S4i 4+ ed tji4t-: +e4i
(including program income) that support Task 1 SRH
i+=N-e+e
Services and all expenses related to providing those
services. R&E workbook will be provided by DOH.
A. Expenses must match General Ledger.
f:
B. Other revenue/program income must reflect revenue
actually received in the reporting month.
- p „ ,tllifees,1 if
'
fi
Al entries on "Other" rows must be accompanied by a
✓
description of the revenue source or expense, including an
calculations uses.tt
i;44o�!s nitist e
stth+f+itted 1 -1-- he
I
Invoices (419'sj and
_.._..__._.._.......... ..---.--.._.__.---.----.L_.__..._...__._..__..___._._---------_----._....
Rck /a III st, p port
Exhibit A, Statement of Work Page 6 of 8 Contract Number CLH32053-Amendment 5
Page 10 of 11
Task
#
Activity
Deliverables/Outcomes
Due Date/Time Frame
Payment Information
and/or Amount
TI is c ' throu-1i 0 L,
clld of this COntrcll'I
mllav he pilled
tol/nu'it,k� the requires!
,lecldhnc's:
• I hll'Ch 112VOlces
and RK, Es are clue
h v 1/av Kith
• June Invoices pnd
R& Es are due hr
.-111gust 10117
• December
1;7L'olces and
Rh Es are due bi
Vebruary 101h
• ,-I//renwbil'ila
Imonths
must he
hilted irithin 60
da vs.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other
finance -related inquiry, may be sent to finance'd;doh.wa.eov.
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
This statement of .work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see hokN the federal funds are spent.
To comply with this act and be eligible to perfonn the activities in this statement of work, the LHJ must have a Unique Entity identifier (UEi) generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on L!SASpendine.sov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual, Handbook, Policy References:
LHJ must comply with all state, federal, DOH SRHP, and Title X requirements. policies. and regulations and with their DOH approved Agency information Dashboard.
Reference documents include:
• DOH SRHP Manual (DOH publication 930-122, available at 930-122-FPRI-IManualComplete.pdf (wa.gow) Some provisions of this manual are highlighted in this SOW,
but all provisions of the manual must be complied with.
• Clinic Visit Record Manual (https://doh wa (,ov/sites%default/files/2024-10 030-1 39-CVRNlanual.pdt)
• LHJ's approved Agency Information Request.
Exhibit A, Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment
Page 11 of 11
Billing Requirements:
See Payment column of Tasks and Deliverables table and RKF report description in kcportinLI Izeciuirernents table
Billiw nutst he hosed on a curlew cmi anah-"iY u;! '0011 (sec Rcportiul, r
DOfI rescue+ the ri�uht 10 lrit17hold parm.cr7r Will.I
• on"plianc'e i5sne+ or 0171 M are re s'Ull'ed in a it'G_l' acc'epicil 6l'
• Current data i5 >tlhlnitiecl to. CWi! rlccCptetl hv, Ih/C1-s.
• a 19 buck up documcolation required br D0I1 hits heel' slrhrnittrd anal cn,�/, 1:, :.11
• Other deliverables hale been mct.
13illit7g r'eimblo-Selnc nl shrill i7C1!7pc r7 110 17701'e 117C711 n70illllll' 41.5 c()i13 hest molltt0l' s'th'101171 p a;l".
13il1bVs in oicc..s shall include topic; rt backup docume77tcl1i0n hrr all expenses accui _ ��r. �`el'_: �„ ckfined hy.419 Backup Documentation 14an i_x_
Backup docnMeM01i017 Can include'. hlrr 1 � not liinited 1c1: receipts, invoices hillirgo and uneruiin,cc rrcurdc ilin7CS17r;
and accoltntin- expense repOrls.
• . I dditional backup dociamcniation ma � be regnesied if needed.
• Parniews will nol he made. aild iu oices 11 ill be returiled k7 toll it SI'WfCicw backup docioncilialiun is uor prurided irrilhill 'O llclrs of our receipt w
reimbl'—scincitl.
Pavinew is limited to the' I7 avii lion available for llindillg soiree.
DOH frill reimburse Ior.
• lc'ttraJ allrnt�ahle costs uc�cntdinp to)ycnlr approved cost unalt.sis� (,)cc Reporlim Rcquireincaic rahler. Or
• Y'lte amrnmi renrerinin,- ir7 ihr ,SOI1 diricled nr the n7rnihc'r al'rnurtllt.e remtrfnirtll In the ,tirr7ci'mg sn7'rce. pl(ts one. l:laiehever is less'.
Payment frill be Calculated Lr l'?&1': proriae_i hi' DOH tsce Reporting Requirements, 10hlrr.
l inal rc'Ilithlt!'.tie177ent regv is f;p- COM'/)hled c'ontr'acl ac'livilies 171ust he rec'eilCvd and appr ovcLl bl' Dull It ithi17 4 i dal`b 01 the end of the .VM thriOcl 0l PCIJorl7Jr7:"C.
Special Instructions:
Accessibilitv of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to priority populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible, services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal, State, and local governments, including local fire, building, and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis. Acceptance of SRH services must not be a prerequisite to eligibility for, or receipt -of, services in any non-SRH
programs of the LHJ.
Availability of Emergency Services
The LHJ must have written plans and procedures for the management of on -site medical emergencies, including emergencies that require transport and after-hours management of
contraceptive emergencies. (See DON SRH Manual)
If LHJ or DOH discontinues this contract:
See SRHP Manual for close out requirements and resources.
Exhibit A, Statement of Work Page 8 of 8 Contract Number CLH32053-Amendment 5
Signature:
Signature:
Email• ggilbert@co.jefferson.wa.us Email: Brend a.Henri kson@DOH.WA.GOV