HomeMy WebLinkAboutCONSENT Consolidated contract No 8 CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-25-001-A8
Contract For: Consolidated Contracts,Amendment 8 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: $71,556 additional,for a total of$5,807,609 PROCESS: if Exempt from Bid Process
Revenue: $71,556 _ 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 CERTIFIES COM1 ' . .CE 1 . 3.'7=.080 AND CHAPTER 42.23 RCW.
CERTIFIED: El N/A:n Sept. 17,2025
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT 131' - DEBAR '.I) BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: n N/A: n Sept. 17,2025
Si�2n,ature Date
STEP 3: RISK MANAGEMENT REVIEW (will be added electronically through Laserfiche):
Electronically approved by Risk Management on 9/29/2025.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 9/29/2025.
Amendment No. 8 reallocates statement of work and increase contract
amount.
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
Page 1 of 17
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 8
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:
hltps. slatcuiwa.sirrrcputnt.cunrlsues%jutt-a:stunjil ,oun.cssitepagcs home..rspx!=eI:9a9468Rda d94d3ea80ac71bc32e4d71/4:
® Adds Statements of Work for the following programs:
OSS LMP Implementation -Effective July 1, 2025
® Amends Statements of Work for the following programs:
OSS LMP Implementation -Effective January 1, 2025
WIC Nutrition Program-Effective January 1, 2025
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-8 Allocations, attached and incorporated by this reference,amends and replaces Exhibit B-7 Allocations as
follows:
® Increase of$71,556 for a revised maximum consideration of$5,807,609.
❑ 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 WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
Heidi Eisenhour,Chair Date Date
APPROVED ArTO FORM ONLY APPROVED AS TO FORM ONLY
lAssistant Attorney General
rim for 09/29/2025
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney Page 1 of 1
CC-25-001-AS
EXHIBIT B-8 Page 2 of 17
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: September 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 8 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 ($6,061) $22,177 $28,238
FFY25 USDA BFPC Prog Mgmt 7WA700WA1 Amd 4,8 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 $28,238
FFY24 USDA BFPC Prog Mgmt 7WA700WA1 Amd 8 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 $6,061 $6,061
FFY24 USDA BFPC Prog Mgmt 7WA700WA1 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 7WA700WA1 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 8 10.557 333.10.55 01/01/25 09/30/25 10/01/24 09/30/25 ($3,448) $144,669 $144,669
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
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 Farm Mkt Ntr Prog Mgmt USDA 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) 01J74301 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 07/01/25 06/30/26 07/01/25 06/30/26 $19,527 $19,527 $33,281
FFY24 PHEP BP1-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 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 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 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 1,7 93.323 333.93.32 01/01/25 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 AI-LHJ NE11OE000053 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 YR1 NGA Not Received Amd 7 93.994 333.93.99 10/01/25 09/30/26 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
SFY26 Sch Based Hlth Cent 1225 Proviso Amd 7 N/A 334.04.90 07/01/25 06/30/26 07/01/25 06/30/26 $140,000 $140,000 $140,000
Page 1of3
EXHIBIT B-8 Page 3 of 17
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: September 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
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 07/01/25 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 07/01/25 06/30/26 $47,404 $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) Amd 8 N/A 334.04.93 07/01/26 06/30/27 07/01/25 06/30/27 $6,571 $6,571 $68,200
Small Onsite Management(ALEA) Amd 8 N/A 334.04.93 07/01/25 06/30/26 07/01/25 06/30/27 536,611 $36,611
Small Onsite Management(ALEA) Amd 8 N/A 334.04.93 01/01/25 06/30/25 07/01/23 06/30/25 ($8,763) $25,018
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
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
SFY27 Wastewater Management-GFS Amd 8 N/A 334.04.93 07/01/26 06/30/27 07/01/26 06/30/27 $31,822 $31,822 $49,824
SFY25 Wastewater Management-GFS Amd 8 N/A 334.04.93 01/01/25 06/30/25 07/01/24 06/30/25 $8,763 $18,002
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)
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 07/01/25 06/30/26 $2,203,000 $2,203,000 $4,536,000
SFY25 FPHS-LH.1 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
YR1 Stimulus-Local Asst(10%of 15%)SS Amd 6 N/A 346.26.64 01/01/25 12/31/27 07/01/23 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 01/01/25 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
YR1 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
Page 2 of 3
EXHIBIT B-S Page 4 of 17
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: September 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
YR 28 SRF-Local Asst(15%)TA Amd 6 N/A 346.26.66 01/01/25 12/31/27 07/01/24 06/30/29 ($1,000) $0 $0
YR 28 SRF-Local Asst(15%)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 I N/A 346.26.66 01/01/25 06/30/25 07/01/23 06/30/25 $1,000
TOTAL $5,807,609 $5,807,609
Total consideration: $5,736,053 GRAND TOTAL $5,807,609
$71,556
GRAND TOTAL $5,807,609 Total Fed $643,638
Total State $5,163,971
*Assistance Listing Number fka Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Page 5 of 17
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: OSS LMP Implementation-Effective January 1,2025 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through June 30,2025 El State El FFATA(Transparency Act) ID Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to fund implemation of the on-site sewage system(OSS)local management plan(LMP).This funding is
what remains of the 2023-2025 biennium and of SFY25 funding allocations.
Revision Purpose: Remove$8,763 from ALEA and add it to GFS.
Master Assistance BARS Allocation
LHJ Funding Period Change
Index Listing Revenue CurrentTotal
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None Allocation
SFY25 WASTEWATER MANAGEMENT-GFS 26701150 N/A 334.04.93 01/01/25 06/30/25 9,239 8,763 18,002
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 01/01/25 06/30/25 33,781 -8,763 25,018
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 43,020 0 43,020
GOALS&MEASURABLE OBJECTIVES
This table summarizes starting and target metrics achieved by implementing the tasks below.This data is reported on an ongoing basis in the semiannual progress reports.
Description
. "OSS com liance" Units Starting
e.
p ( g' p ) Targets
(e.g."systems") Amount
OSS compliant with inspections in Marine Recovery Areas(MRAs) Number of OSS 432 550
OSS compliant with inspections countywide Number of OSS 1446 1,900
Number of OSS failures identified/
OSS failures identified/corrected in MRA number of OSS failures with completed 10/3 12/6
repairs
Number of OSS failure identified/
OSS failures identified/corrected countywide number of OSS failures with completed 26/9 32/16
repairs
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH32053-Amendment 8
Page 6 of 17
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Task 1:Grant Administration This task is to fund the required financial and reporting activities necessary to meet state DOH and Auditor requirements including
administration of LHJ local management plan and OSS LMP grant program.
1.1 Bi-monthly Invoicing and Progress Reports Bimonthly/Monthly invoices Bimonthly/monthly for Reimbursement up to
DOH Consolidated Contracts(ConCon)requires billing duration of contract period. $2,151 based on actual
within 60 days of completing work.Local or County Health costs.
subrecipients will submit invoices through the ConCon
process and will send progress reports and deliverables to the
LMP Contract Manager.Invoices must be submitted at least
bi-monthly(per ConCon requirements)but no more
frequently than monthly.Invoices will be reviewed for
consistency with progress.The LMP Contract Manager may
require monthly invoices. _ _
1.2 Semi-Annual Progress Reports Data about the following: Due July 15 for the
Reporting periods are semiannually from January 1— • Qualitative: duration of the contract
June 30 and July 1—December 31. Progress reports include o Summary of work. period.
data described in the outcome column. o Barriers to LMP Implementation.
• Quantitative:
o OSS inventory metrics.
o Enforcement actions.
o Outreach and Education efforts.
Task 2:Local Management Plan Implementation This task includes all work done to implement the county's LMP excluding grant management tasks and inspection
rebates/incentives.
2.1 Database Maintenance and Quality Assurance/Quality a.Provide narrative of data clean-up tasks a-d.Report in semi-annual Reimbursement up to
Control completed and in-progress. progress report in Subtask $28,812 based on actual
Database maintenance and QA/QC is ongoing to ensure 1.2. costs.
accurate tracking methods for all OSS in the county. Specific b.Provide narrative of progress on
tasks include: configuring Energov database for SOM
• Continue to`clean-up'the existing data post data workflows,reports,automation tasks.
conversion in Energov permitting database
• Configure Energov database for SOM workflows, c.Provide narrative of API development
reports,automation tasks. tasks completed and in-progress.
• Develop Application Program Interface(API)between
database and Online-RME. d. Provide narrative of Homeowner Inspector
• Develop replacement Homeowner Inspector Authorization website tasks completed and
Authorization website in-progress.
2.2 Operations and Maintenance Program Administration Data on the following: Report in semi-annual
• Mail inspection reminders to homeowners as needed. • Number of OSS with current progress report in Subtask
• Inspection Compliance tracking/mapping. inspections 1.2.
• Failure and repair tracking/mapping. • Number of OSS failures and
• Compliance enforcement. calculated risk using DOH-provided
• Complaint response. risk assessment.
Exhibit A,Statement of Work Page 2 of 3 Contract Number CLH32053-Amendment 8
Page 7 of 17
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
• O&M data reports about inventory and deficiencies. • Number of repairs.
2.3 Education and Outreach a.Track number of social media posts and a-c.Report in semi-annual
Education and outreach is conducted for OSS owners, mailings progress report in Subtask
realtors,etc.Specific tasks include: 1.2.
• Communicate via social media,website,and mailings b.Track attendance of in-person homeowner
• Provide in-person homeowner septic inspector classes septic inspector classes
for property owners
• Provide online homeowner inspector training and c.Track number of homeowner inspectors
authorization for property owners trained and authorized online
2.4 Professional Development and Coordination a.Attendance and contribution at four(4) a-b.Report attendance
• The LHJ will participate in LMP and West Side meetings per year. semi-annually,as
Coordinators Meetings and will network between scheduled in Task 1.2.
counties. b.Conference and Training participation as
• The LHJ will support professional development available.
through
o Attending DOH OSS Program trainings
o Environmental Heath Conferences
• AEC Conference-Two(2)Staff members
• WOSSA Conference-Two(2)Staff members
Task 3:Homeowner Inspection Rebates/Incentives Program Provide low-income rebates to homeowners.Provide inspection compliance incentives to homeowners in
priority areas.
3.1 Low-Income Homeowner Inspection Rebates Report number of rebates provided for By grant closeout. Reimbursement up to
The LHJ will provide rebates to homeowners for pumping, pumping,monitoring inspections and access $12,057 based on actual
inspection and minor repairs.Rebates issued will be up to risers. costs.
$350.
3.2 Homeowner Inspection Incentives Report number of rebates for pumping, By grant closeout.
Promote pumping,inspection and minor repairs with rebates monitoring inspections and access risers to
to homeowners in priority areas.Rebates issued will be up to grade provided to priority-area homeowners.
$350.
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 financeAdoh.wa.gov.
Exhibit A,Statement of Work Page 3 of 3 Contract Number CLH32053-Amendment 8
•
Page 8 of 17
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: OSS LMP Implementation-Effective July 1,2025 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) 0 Funding Source Federal Compliance Type of Payment
❑Federal<Select One> (check if applicable) ®Reimbursement
Period of Performance: July 1,2025 through June 30,2027 ® State ❑FFATA(Transparency Act) El Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work is to fund implemation of the on-site sewage system(OSS)local management plan(LMP).This funding is
for the 2025-2027 biennium.
Revision Purpose: N/A
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 07/01/25 06/30/26 0 36,611 36,611
SFY27 WASTEWATER MANAGEMENT-GFS 26701170 N/A 334.04.93 07/01/26 06/30/27 0 31,822 31,822
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 07/01/26 06/30/27 0 6,571 6,571
0 0 0
0 0 0
0 0 0
TOTALS 0 75,004 75,004
GOALS&MEASURABLE OBJECTIVES
This table summarizes starting and target metrics achieved by implementing the tasks below. This data is reported on an ongoing basis in the semiannual progress reports.
Description(e.g.,"OSS compliance") Units Starting Targets
(e.g. systems ) Amount
OSS compliant with inspections in Marine Recovery Areas(MRAs) Number of OSS
OSS compliant with inspections countywide Number of OSS
Number of OSS failures identified/
OSS failures identified/corrected in MRA number of OSS failures with completed
repairs
Number of OSS failure identified/
OSS failures identified/corrected countywide number of OSS failures with completed
repairs
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH32053-Amendment 8
Page 9 of 17
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Task 1:Grant Administration This task is to fund the required financial and reporting activities necessary to meet state DOH and Auditor requirements including
administration of LHJ local management plan and OSS LMP grant program.
1.1 Bi-monthly Invoicing and Progress Reports Bimonthly/Monthly invoices Bimonthly/monthly for Reimbursement up to$X
DOH Consolidated Contracts(ConCon)requires billing duration of contract period. based on actual costs.
within 60 days of completing work.Local or County Health
subrecipients will submit invoices through the ConCon
process and will send progress reports and deliverables to the
LMP Contract Manager. Invoices must be submitted at least
bi-monthly(per ConCon requirements)but no more
frequently than monthly.Invoices will be reviewed for
consistency with progress.The LMP Contract Manager may
require monthly invoices.
1.2 Semi-Annual Progress Reports Data about the following: Due July 15 for the
Reporting periods are semiannually from January 1— • Qualitative: duration of the contract
June 30 and July 1—December 31. Progress reports include o Summary of work. period.
data described in the outcome column. o Barriers to LMP Implementation.
• Quantitative:
o OSS inventory metrics.
o Enforcement actions.
o Outreach and Education efforts.
Task 2:Local Management Plan Implementation This task includes all work done to implement the county's LMP excluding grant management tasks and inspection
rebates/incentives.
2.1 Database Maintenance and Quality Assurance/Quality a.Provide narrative of data clean-up tasks a-d.Report in semi-annual Reimbursement up to$X
Control completed and in-progress. progress report in Subtask based on actual costs.
Database maintenance and QA/QC is ongoing to ensure 1.2.
accurate tracking methods for all OSS in the county. Specific b. Provide narrative of progress on
tasks include: configuring Energov database for SOM
• Continue to`clean-up'the existing data post data workflows,reports,automation tasks.
conversion in Energov permitting database
• Configure Energov database for SOM workflows, c.Provide narrative of API development
reports,automation tasks. tasks completed and in-progress.
• Develop Application Program Interface(API)between
database and Online-RME. d. Provide narrative of Homeowner Inspector
• Develop replacement Homeowner Inspector Authorization website tasks completed and
Authorization website in-progress.
2.2 Operations and Maintenance Program Administration a.Enforcement Protocol a.By first semi-annual
• Mail inspection reminders to homeowners as needed. b.Data on the following: progress report due date
• Inspection Compliance tracking/mapping. • Number of OSS with current
• Failure and repair tracking/mapping. inspections b.Report in semi-annual
• Compliance enforcement. progress report in Subtask
• Complaint response. 1.2.
Exhibit A,Statement of Work Page 2 of 3 Contract Number CLH32053-Amendment 8
Page 10 of 17
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• O&M data reports about inventory and deficiencies. • Number of OSS failures and
calculated risk using DOH-provided
risk assessment.
• Number of repairs.
2.3 Education and Outreach a.Track number of social media posts and a-c.Report in semi-annual
Education and outreach is conducted for OSS owners, mailings progress report in Subtask
realtors,etc.Specific tasks include: 1.2.
• Communicate via social media,website,and mailings b.Track attendance of in-person homeowner
• Provide in-person homeowner septic inspector classes septic inspector classes
for property owners
• Provide online homeowner inspector training and c.Track number of homeowner inspectors
authorization for property owners trained and authorized online
2.4 Professional Development and Coordination a.Attendance and contribution at four(4) a-b.Report attendance
• The LHJ will participate in LMP and West Side meetings per year. semi-annually,as
Coordinators Meetings and will network between scheduled in Task 1.2.
counties. b.Conference and Training participation as
• The LHJ will support professional development available.
through
o Attending DOH OSS Program trainings
o Environmental Heath Conferences
• AEC Conference-Two(2)Staff members
• WOSSA Conference-Two(2)Staff members
Task 3:Homeowner Inspection Rebates/Incentives Program Provide low-income rebates to homeowners.Provide inspection compliance incentives to homeowners in
priority areas.
3.1 Low-Income Homeowner Inspection Rebates a.Provide draft and final process/policy a.Prior to issuing any Reimbursement up to$X
The LHJ will provide rebates to homeowners for pumping, documents to DOH. rebates. based on actual costs.
inspection and minor repairs.Rebates issued will be up to
$X. b.Report number of rebates provided for b.By grant closeout.
pumping,monitoring inspections and access
risers.
3.2 Homeowner Inspection Incentives a.Provide draft and final process/policy a.Prior to issuing any
Promote pumping,inspection and minor repairs with rebates documents to DOH. incentives.
to homeowners in priority areas. Rebates issued will be up to
$X. b.Report number of rebates for pumping, b.By grant closeout.
monitoring inspections and access risers to
grade provided to priority-area homeowners.
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 financeAdoh.wa.gov.
Exhibit A,Statement of Work Page 3 of 3 Contract Number CLH32053-Amendment 8
Page 11 of 17
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: WIC Nutrition Program-Effective January 1,2025 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 3 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: January 1,2025 through December 31,2027 ❑ State ® FFATA(Transparency Act) El Fixed Price
❑ Other ❑Research&Development
Statement of Work Purpose: To provide Women,Infants,and Children(WIC)Nutrition Program services by following WIC federal regulations,WIC state office policies and
procedures,WIC directives,and other rules.Refer to the Program Specific Requirements section of this document.
Revision Purpose: To reduce FFY25 WIC Client Services balance per the negotiated and agreed-upon volunteer recoveries for the remainder of the contract period(-$3,448.36),
exend FFY25 BRSTFDG PEER CN PR MGMT USDA funding period end date from 09/30/26 to 09/30/27 and shift funding($6,061)to FFY24 BRSTFDG PEER CN PR MGMT
USDA,and update the Chart of Accounts(COA)title for FFY25 USDA FMNP MGMT to FFY25 FARM MKT NTR PROG MGMT USDA to match new biennium COA and
revise task language.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Decrease(—) Allocation
FFY25 USDA WIC CLIENT SVS CONTRACTS 76101251 10.557 333.10.55 01/01/25 09/30/25 148,117 -3,448 144,669
FFY24 BRSTFDG PEER CN PR MGMT USDA 7621424A 10.557 333.10.55 01/01/25 09/30/26 0 6,061 6,061
FFY25 BRSTFDG PEER CN PR MGMT USDA 76214250 10.557 333.10.55 01/01/25 09/30/27 28,238 -6,061 22,177
FFY25 FARM MKT NTR PROG MGMT USDA 76540251 10.572 333.10.57 01/01/25 09/30/25 637 0 637
0 0 0
0 0 0
TOTALS 176,992 -3,448 173,544
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
1 WIC Nutrition Program See"Billing
Requirements below.
1.1 Maintain authorized participating caseload at 100%based on Outcomes based on monthly participation Authorized participating
quarterly average as determined from monthly caseload data from state WIC caseload caseload for March 2025
management reports generated at state WIC office. management reports. through September 2026=
The Department of Health(Department)State WIC Nutrition 280
Program has the option of reducing authorized participating
caseload and corresponding funding when: Authorized participating
1. Unanticipated funding situations occur. caseload for March 2025
Exhibit A,Statement of Work Page 1 of 7 Contract Number CLH32053-Amendment 8
Page 12 of 17
Task Activity Deliverables/Outcomes Due Date/ Time Frame Payment Information
# and/or Amount
2. Reallocations are necessary to redistribute caseload through September 2026=
statewide. 300
3. Caseload declines.
1.2 Submit the annual Nutrition Services Plan for each year of the Nutrition Services Plan First year due 9/30/25 Payment withheld if not
contract. Second year due 9/30/26 received by due date.
Third year due 9/30/27
1.3 Submit the annual Nutrition Services Expenditure Report for Nutrition Services Expenditure Report 11/30/25 Payment withheld if not
each year of the contract. 11/30/26 received by due date.
11/30/27
1.4 Tell participants about other health services in the agency. If Documentation must be available for Biennial WIC Monitor
needed,develop written agreements with other health care review by WIC monitor staff.
agencies and refer participants to these services.
1.5 Provide nutrition education services to participants and Documentation must be available for Biennial WIC Monitor
caregivers in accordance with federal and state requirements. review by WIC monitor staff.
1.6 Issue WIC benefits while assuring adequate WIC card security Documentation must be available for Biennial WIC Monitor
and reconciliation. review by WIC monitor staff
1.7 Collect data,maintain records,and submit reports to effectively Documentation must be available for Biennial WIC Monitor
enforce the non-discrimination laws(Refer to Civil Rights review by WIC monitor staff.
Assurances below).
1.8a Submit entire WIC and Breastfeeding Peer Counseling Budget Budget Workbook First year due 9/30/25
Workbook for each year of the contract Second year due 9/30/26
Third year due 9/30/27
1.8b Submit Rev-Exp Report spreadsheet from the WIC Budget Revenue and Expense Report and A-19 First year due monthly
Workbook monthly with A-19 through September 30,2025
Second year due monthly
through September 30,2026
Third year due monthly
through September 30,2027
2 Breastfeeding Promotion See"Billing
Requirements"below.
2.1 Provide breastfeeding promotion activities in accordance with Status report of chosen activities in First year due 11/30/25
federal and state requirements. Nutrition Services Plan. Second year due 11/30/26
Third year due 11/30/27
Documentation must be available for
review by WIC monitor staff. Biennial WIC Monitor
2.2 Work with community partners to improve practices that affect Status report of chosen activities in First year due 8/30/25
breastfeeding. Choose one or more of the following projects: Nutrition Services Plan. Second year due 8/30/26
■ Provide staff,health care providers and community partners Third year due 8/30/27
virtual breastfeeding training resources.
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH32053-Amendment 8
Page 13 of 17
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
• Work with employers who likely employ low-income Documentation must be available for Biennial WIC Monitor
people to create worksite environments that support review by WIC monitor staff.
breastfeeding.
• Work with birthing hospitals to improve maternity care
practices that affect WIC participant breastfeeding rates.
• Provide participants access to lactation consultants.
Other projects will need pre-approval from the State WIC Office
3 Breastfeeding Peer Counseling Program(BFPC) See"Billing
Requirements"below.
3.1 Provide Breastfeeding Peer Counseling Program activities in Breastfeeding Peer Counseling Annual First year due 12/31/25
accordance with federal and state requirements.The WIC Report and expenditures from the Second year due 12/31/26
Breastfeeding Peer Counseling Program is meant to enhance, previous federal fiscal year. Third year due 12/31/27
not replace,WIC Breastfeeding promotion and support
activities. Documentation must be available for Biennial WIC Monitor
review by WIC monitor staff
3.2 Track Breastfeeding Peer Counseling Program expenditures and Documentation must be available for Biennial WIC Monitor
bill separately from the WIC grant. review by WIC monitor staff.
4 Farmers Market Nutrition Program(FMNP) See"Billing
Requirements"below.
4.1 Issue FMNP benefits to eligible WIC participants by September Document in a Family Alert that FMNP Weeklyune Sep« 2025 and
30 of the current year. benefits were issued. Set the end date to June Sept.2026
Participants have until October 31 of the current year to use October 31 of the current year for the
FMNP benefits at authorized farmers markets and farm stores. alert to dismiss at the end of the season. All se t by Oet , 2025 and
by Oct. 1,2026
and by Oct. 1,2027
Biennial WIC Monitor
procedure
review-by-WIC--ruoniter-sta4
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.
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH32053-Amendment 8
Page 14 of 17
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:
The local agency shall be responsible for providing services according to rules,regulations and other information contained in the following:
• WIC Federal Regulations,USDA,and FNS 7CFR Part 246.
• Washington State WIC Nutrition Program Policy and Procedure Manual
• Office of Management and Budget,Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards,2 CFR 200
• Farmers Market Nutrition Program Federal Regulations,USDA,FNS 7CFR Part 248
• Other directives issued during the term of the contract
Staffing Requirements:
The local agency shall:
• Use Competent Professional Authority staff,as defined by WIC policy,to determine participant eligibility,prescribe an appropriate food package and offer nutrition
education based on the participants'needs.
• Use a Registered Dietitian(RD)or other qualified nutritionist to provide nutrition services to high risk participants,to include development of a high-risk care plan. The
RD is also responsible for quality assurance of WIC nutrition services. See WIC Policy for qualifications for a Registered Dietitian and other qualified nutritionist.
• Assign a qualified person to be the Breastfeeding Coordinator to organize and direct local agency efforts to meet federal and state policies regarding breastfeeding
promotion and support. The Breastfeeding Coordinator must be an International Board Certified Lactation Consultant or attend an intensive lactation management course,
or other state approved training.
Restrictions on Funds(ie.,disallowed expenses or activities,indirect costs,etc.):
The local agency shall follow the instructions found in the Policy and Procedure Manual under WIC Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,
Cost Principles,and Audit Requirements for Federal Awards.
Special References(i.e.,RCWs,WACs,etc.):
What is the WIC program?
1. The WIC program in the state of Washington is administered by the Department of Health.
2. The WIC program is a federally funded program established in 1972 by an amendment to the Child Nutrition Act of 1966.The purpose of the program is to provide nutrition
and health assessment;nutrition education;nutritious food;breastfeeding counseling;and referral services to pregnant,breastfeeding,and postpartum women,infants,and
young children in specific risk categories.
3. Federal regulations governing the WIC program(7 CFR Part 246)require implementation of standards and procedures to guide the state's administration of the WIC program.
These regulations define the rights,responsibilities,and legal procedures of WIC employees,participants,persons acting on behalf of a participant,and retailers.They are
designed to promote:
a. High quality nutrition services;
b. Consistent application of policies and procedures for eligibility determination;
c. Consistent application of policies and procedures for food benefit issuance and delivery;and
d. WIC program compliance.
4. The WIC program implements policies and procedures stated in program manuals,handbooks,contracts,forms,and other program documents approved by the USDA Food
and Nutrition Service.
5. The WIC program may impose sanctions against WIC participants for not following WIC program rules stated on the WIC rights and responsibilities.
6. The WIC program may impose monetary penalties against persons who misuse WIC benefits or WIC food but who are not WIC participants.
Exhibit A,Statement of Work Page 4 of 7 Contract Number CLH32053-Amendment 8
Page 15 of 17
Monitoring Visits(i.e.,frequency,type,etc.):
Program and fiscal monitoring are done on a biennial(every two years)basis and are conducted onsite.
The local agency must maintain on file and have available for review,audit and evaluation:
• All criteria used for certification,including information on income,nutrition risk eligibility and referrals
• Program requirements
• Nutrition education
• All financial records
Assurances/Certifications:
1. Computer Equipment Loaned by the Department of Health WIC Nutrition Program
In order to perform WIC program activities,the Department requires computer equipment,such as computers,signature pads,document scanners,card readers and printers to
be in local WIC clinics or to be transported to mobile clinics. This equipment("Loaned Equipment")is owned by the Department and loaned to the local agency(Contractor).
The Loaned Equipment is supported by the Department. This equipment shall be used for WIC business only or according to WIC Policy and Procedures.
An inventory of Loaned Equipment is kept by the Department. Each time Loaned Equipment is changed,the parties shall complete the Equipment Transfer Form and the
Department updates the inventory. A copy of the Transfer Form will be provided to the contractor. Copies of the updated inventory list may be requested at any time.
The local agency agrees to:
a. Defend,protect and hold harmless the Department or any of its employees from any claims,suits or actions arising from the use of this Loaned Equipment.
b. Assume responsibility for any loss or damage from abnormal wear or use,or from inappropriate storage or transportation. The Department may enforce this by:
1) Requiring reimbursement from the local agency of the value of the Loaned Equipment at the time of the loss or damage.
2) Requiring the local agency to replace the Loaned Equipment with equipment of the same type,manufacturer,and capabilities(as pre-approved by the Department),or
3) Assertion of a lien against the Contractor's property.
c. Notify the Department immediately of any damage to Loaned Equipment.
d. Notify the Department prior to moving or replacing any Loaned Equipment.
The Department recommends Contractors carry insurance against possible loss or theft.
2. Civil Rights Assurance
a. The local agency shall perform all services and duties necessary to comply with federal law in accordance with the following Civil Rights Assurance.
b. "The Program applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964(42 U.S.C.2000d et seq.),Title IX of the Education Amendments
of 1972(20 U.S.C. 1681 et seq.),Section 504 of the Rehabilitation Act of 1973(29 U.S.C.794),Age Discrimination Act of 1975(42 U.S.C.6101 et seq.);all provisions
required by the implementing regulations of the Department of Agriculture;Department of Justice Enforcement Guidelines,28 CFR 50.3 and 42;and FNS directives and
guidelines,to the effect that,no person shall,on the ground of race,color,national origin,sex,age or handicap,be excluded from participation in,be denied benefits of,or
otherwise be subject to discrimination under any program or activity for which the Program applicant receives Federal fmancial assistance from FNS;and hereby gives
assurance that it will immediately take measures necessary to effectuate this agreement.
c. "By accepting this assurance,the Program applicant agrees to compile data,maintain records and submit reports as required,to permit effective enforcement of the
nondiscrimination laws and permit authorized USDA personnel during normal working hours to review such records,books and accounts as needed to ascertain
compliance with the nondiscrimination laws.If there are any violations of this assurance,the Department of Agriculture,Food and Nutrition Service,shall have the right
to seek judicial enforcement of this assurance.This assurance is binding on the Program applicant,its successors,transferees,and assignees,as long as it receives
assistance or retains possession of any assistance from the Department.The person or persons whose signatures appear on the contract are authorized to sign this
assurance on behalf of the Program applicant."
Exhibit A,Statement of Work Page 5 of 7 Contract Number CLH32053-Amendment 8
Page 16 of 17
3. 2CFR 200
The local agency shall comply with all the fiscal and operations requirements prescribed by the state agency as directed by Federal WIC Regulations(7CFR part 246.6),2CFR
part 200,the debarment and suspension requirements of 2CFR part 200.213,if applicable,the lobbying restrictions of 2CFR part 200.245,and FNS guidelines and instructions
and shall provide on a timely basis to the state agency all required information regarding fiscal and program information.
Billing Requirements:
1. Definitions
Contract Period: January 1,2025—December 31,2027
Contract Budget Periods: The time periods for which the funding is budgeted.
• There are four federal budget periods
January 1,2025,through September 30,2025
October 1,2025,through September 30,2026
October 1,2026,through September 30,2027
October 1,2027,through December 30,2027
2. Billing Information:
a. Billings are submitted on an A19-lA invoice. These invoices are provided by the Department in the WIC Budget Workbook and include accounting codes for different
budget categories.
b. Al9s are submitted monthly and must be received by the Department within 60 days following the close of each calendar month. Additional Al9s may be submitted at
any time but must be received within 60 45 days of the close of the federal budget period.
c. Funds are allocated by budget categories and by federal budget periods(refer to the budget spreadsheet).
d. Funds are encumbered or spent only during the budget period;no carry forward from previous time periods or borrowing from future time periods is allowed.
e. Payments are limited to the amounts allocated for the budget period for each budget category.
f. Billings are based on actual costs for completed activities.Advance payments are not allowed. Back up documentation must be retained by the local agency and available
for inspection by the Department or other appropriate authorities.
g. Payments will be made only for WIC approved expenditures.Refer to the Washington State WIC Nutrition Program Policy and Procedure Manual Volume 2,Chapter 4—
Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards.
h. If billing for indirect costs,a Cost Allocation Plan or Federal Indirect Cost Agreement must be submitted prior to payment.
Special Instructions:
The local agency shall:
1. Maintain complete,accurate,and current accounting of all local,state,and federal program funds received and expended.
2. Provide,as necessary,a single audit in accordance with the provisions of 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for
Federal Awards. This circular requires all recipients and sub-recipients of federal funds to have a single audit performed should they spend$750,000 or more of federal grants
or awards from all sources. Contractors spending less than$750,000 in federal grants or awards may also be subject to audit.
3. Use Breastfeeding Peer Counseling(BFPC)Program funds only to support the peer counseling program. Once the program is established and peer counselors are trained,the
majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs see Volume 2,Chapter 4—Allowable
Costs. The priority use of BFPC funds is to hire and train peer counselors to provide breastfeeding peer counseling services to WIC participants.
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH32053-Amendment 8
Page 17 of 17
SPECIAL REQUIREMENTS
Contract Budget Period Time Period special requirement Amount Special Requirement Description
funds are available
January 1,2025—September 30, January 2025—September 2025 $2,500 For general training funds.This funding is for all WIC staff to participate in
2025 WIC-related training.Added in the USDA WIC Client Services Contracts
category to cover training registrations,travel expenses,staff time to
participate in training(salary/benefits for part time or contractor),and other
approved training expenses.
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
Exhibit A,Statement of Work Page 7 of 7 Contract Number CLH32053-Amendment 8
Page 1 of 44
JEFFERSON COUNTY PUBLIC HEALTH
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:
hugs:iistateofwa.sharepoint.com/sites/doh-ofsfundingresources/sitepages/home.aspx? eI:9a94688da2d94d3ea80ac7tbc32e4d7c
Z Adds Statements of Work for the following programs:
Foundational Public Health Services-Effective July 1,2025
Office of Resiliency&Health Security-PHEP-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 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 WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
Heidi Eisenhour,Chair Date Date
APPROVED AS TO FORM ONLY APPROVED AS TO FORM ONLY
Assistant Attorney General
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
CC-25-001-A7 Page 1 of 1
Page 1 0144
JEFFERSON COUNTY PUBLIC HEALTH
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"LHP",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:
I. 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:
1ttko://s a w ,sh i 1 . f a / 'r /h X9= -I( dal 4.3 1 4
® Adds Statements of Work for the following programs:
Foundational Public Health Services-Effective July I,2025
Office of Resiliency&Health Security-PHEP-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
E Deletes Statements of Work for the following programs:
2. Exhibit B-7 Allocations,attached and incorporated by this reference,amends and replaces Exhibit 8-6 Allocations as follows:
21 Increase of S2,446,631 for a revised maximum consideration of$5.736,05.3,
❑ 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 end effect.
IN WITNESS WHEREOF,the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
f / /
6 '� �� 409/09/2025
Heidi Eisenhour,Chair Date Date
APPROVED AS'IU FORM ONLY APPROVED AS TO FORM ONLY
// Assistant Attorney General
7 i _ i/ - for 08/22/2025
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
CC-25-001-A7 Page 1 of I
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 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 7WA700WA1 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 7WA700WA1 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) 01J74301 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 PHTFP 8P2-CDC-1.:11.11'artners NU9OTU000055 Arad 7 93.069 333.93.06 07/01/25 06/30126 07/01/25 06130/26 S19.527 $19,527 $33,281
FFY24 PHEP BPI-CDC-LHJ Partners NU9OTU000055 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 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 03/31/26 04/01/25 03/31/26 $17,023 S17,023 $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 03/3I/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 1,7 93.323 333.93.32 01/01/25 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 At-LHJ NE11OE000053 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
FFY26M1CHBG LHJ Contracts URSA YRl N(:A Not Received Amd 7 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 S36.700 $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
SFY26 Sch Based Illth Cent 1225 Proviso Amd 7 N/A 334.04.90 07/01/25 06/30/26 07/01/25 06/30/26 $140,000 5140,000 $140,000
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 S15,000 $15,000 $15,000
Page 1 of 3
EXHIBIT B-7 Page 3 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 LIUJ 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
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 l N/A 334.04.91 01/01/25 06/30/25 07/01/24 06/30/25 S40,250 $40,250
SFYZ6 Sexual&Rep 1llth Cost Share Amd 7 N/A 334.04.91 07/01/25 12/31/25 07/01/25 06/30/26 $47,404 $47,404 S95,347
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
Rcc Shcllfish/Biotoxin Amd 1 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 01/0I/25 06/30/25 07/01/24 06/30/25 (S1,363) $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
SFV'2O FP1IS-Ini Fuotk-C;FS tnncl' N':A 336.04.25 07/01/25 06/30/26 07/01/25 06/30/26 $2,203,000 S2,203,000 $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 S2,333,000 $2,333,000
YR1 Stimulus-Local Asst(10%of 15%)SS Amd 6 N/A 346.26.64 01/01/25 12/31/27 07/01/23 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 S0
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 01/01/25 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
YR1 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 01/01/25 12/31/27 07/01/24 06/30/29 ($1,000) $0 $0
YR 28 SRF-Local Asst(15%)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
Page 2 of 3
EXHIBIT B-7 Page 4 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
DON Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LNJ 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 $5,736,053 $5,736,053
Total consideration: $3,289,422 GRAND TOTAL $5,736,053
$2,446,631
GRAND TOTAL $5,736,053 Total Fed $647,086
Total State $5,088,967
*Assistance Listing Number flea Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Page 5 of 44
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: DCHS-ELC COVID-19 Response- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through December 31, 2025 ❑ 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.
Master Assistance BARS Allocation
LHJ Funding Period Change
Index Listing Revenue CurrentTotal
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None 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 Payment Information
Activity Deliverables/Outcomes Due Date/Time Frame
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
Page 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 12,I,,'d.'
must conduct the following activities in accordance with the Quarterly performance 413072025
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
Page 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 Iist 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
Page 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 LW 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
Page 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 COVID-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 l&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
Page 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.gov 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.govi grants/documents/General-Tenns-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 timing 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 Al 9-lA 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
Page 11 of 44
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Foundational Public Health Services- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑Federal<Select One> (check if applicable) ❑ Reimbursement
Period of Performance: July 1,2025 through June 30,2026 ® State ❑ FFATA(Transparency Act) ®Periodic Distribution
0 Other 0 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
Master Assistance BARS Allocation
LHJ Funding Period Change
Index Listing Revenue CurrentTotal
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) 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 Program
1 —Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $520,000
Deliverables
Assessment ReinforcingCapacity See below in ProgramSee below in Program
2 p ty— Specific See below in Program Specific Specific Requirements- $60,000
Requirements—Activity Special Instructions for details Requirements-Deliverables Deliverables
Assessment—CHA/CHLP—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
See below in Program Specific
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
Page 12 of 44
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
See below in Program Specific
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— Specific Requirements- $150,000
Activity Special Instructions for details Requirements-Deliverables Deliverables
FC-NEW SFY 24 Strengthening Local Finance Capacity—See below See below in Program Specific See below in Program
7 in Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements $62,000
Deliverables
FC-NEW SFY 24 Public Health Communications—See below in See below in Program Specific See below in Program
8 Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements $200,000
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
See below in Program Specific
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
11 (Assessment/Surveillance,CHA/CHIP)—See below in Program Specific See below in Program Specific Specific Requirements- $150,000
Requirements-Deliverables
Requirements—Activity Special Instructions for details Deliverables
EPH-NEW SFY 24 Social Work Support—See below in ProgramSeebelowin Program Specific Sec below in Program
12 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $85,000
Deliverables
EPH Core Team—Safe and Healthy Communities—See below in See below in Program Specific See below in Program
13 Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements $47,000
Deliverables
EPH Core Team—Climate Change Response—See below in Program See below in Program Specific See below in Program
14 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements $80,000
Deliverables
EPH Core Team—System-Wide Data Management Improvement—See See below in Program
15 below in Program Specific Requirements—Activity Special Instructions for See below in Program Specific Specific Requirements- $63,000
details Requirements-Deliverables 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 tivance(adoh.wa.iov.
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 LID questions about the use of funds:
o Chris Goodwin,FPHS Policy Advisor,WSALPHO—cgoodwin(i wsac.org,564-200-3166
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH32053-Amendment 7
Page 13 of 44
o Brianna Steere,FPHS Policy Advisor,WSALPHO—hste:kela,%%sac.ozg,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.doh.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&Workeroup
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 30th 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.cov/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
Page 14 of 44
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(TB)
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(PHSKC Only)
92 FPHS Laboratory
Special References(i.e.,RCWs,WACs,etc.):
FPIIS Intent-RCW 43.70.512
FPHS Funding RCW 43.70.515
FPHS Committee&Workgroup Charter
HITS Steering Committee Consensus'Decision Making Model
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.2-4,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,D.4,F.1-3,G.1-3,I.1-2,J.1-J.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. 1-4)
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—Assuring 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—Assuring FPIIS Available in Own Jurisdiction
12. EPH-NEW SFY 24 Social Work Support(FPHS definitions B.1-3,B.6-7,DA,D.2,D.4.E.2,E.4,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 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:
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
Page 18 of 44
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Maternal&Child Health Block Grant— Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: January 1,2025 through September 30,2026 ID State ®FFATA(Transparency Act) ❑Fixed Price
El Other 0 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.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) 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 YRI 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
1 a 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. 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
Page 19 of 44
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
I d 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 Coninnutity 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.
I f Report annual FTE billed to MCHBG. Submit FTE information on DOH provided July I, 2026
template.
Ig Develop 2026-2027 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 4, 2026
October I. 2026 through September 30, 2027 using Community Consultant.
DOH-provided template.
111 Participate in DOH-sponsored MCHBG fall regional LHJ Contract Lead or designee will attend September 30, 2026
meeting 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:Handed 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 intentional/v 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
Page 20 of 44
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Zd Develop 2026-27 MCHBG Monthly Reporting Template Submit;41CI1BG reporting document to DOH Draft.--August 14, 2026
far October 1,2026 through September 30, 2027 using Community Consultant. Final September II,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 Cliff administrator at DOH-C'I-IlF0 doh.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 ThroHgh September 30, Billing Requirements.
Program as needed. 2025
3c Review your program's entry on ParentHelp123.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 CYSHCN Program 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. Il no CYSHCN care coordination July 15, 2026
(enabling service)is provided in a given quarter, email
the CHIP administrator at DOH-CHIFtkdolt.wa.gov
and indicate that zero clients were served during the
quarter. No spreadsheet is necessary when zero clients
are served.
3f Review your program's entry on.Parentlleip I2$.or,r; Document in the Administrative box on your September 30, 2026
annually/or 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 CISHCN 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 fir example activities and priority areas. December 15, 2025
January 15, 2026
February 15,2026
March 15, 2026
April15, 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
4b Provide summary o/'outcomes of;LfCHBG.funded work Submit documentation as requested by DOH. November 21, 2025 reflect activities paid for
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(i4doh.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 LIIJ 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.s v 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:
hildmi-ante# #h-with--` l--i-le trli-Orf tlk t*sttttw o,.: `..F:.
(lealik-Seuvrees.Ar tit iza n it(fi lain
Children and Youth with Special Health Card i,,ey v lI trsitetit`ta 9i.j
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 9-1A 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 I workbook.
Exhibit A,Statement of Work Page 5 of 5 Contract Number CLH32053-Amendment 7
Page 23 of 44
Exhibit A
Statement of Work
Contract Term:2025-2027
DOH Program Name or Title: Office of Resiliency&Health Security-PHEP- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance T 'e of Payment
®Federal Subrecipient (check if applicable) Reimbursement
Period of Performance: July 1,2025 through June 30,2026 CI 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 PREP 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
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY25 PREP 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 Payment
Activity Deliverables/Outcomes Due Date/Time Frame 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
Page 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 1 and December 31,2025,to
inform the 2026 Integrated Preparedness Planning Workshop(IPPW).
OR
Participate in a jurisdictional risk assessment tool/report during the
PREP FFY24 BP I 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
Page 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 LHJ. templates provided by DOH,including June 30,2026
titles,dates,and sponsor of trainings.
PREP 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 PREP 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 F ercise Exercise Notification Form As soon as the LHJ is
Notification Fom 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
Page 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
hanalert(u doh.wa.Pov 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
Page 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
Page 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
Page 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
Page 30 of 44
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
15 Build Highly Qualified PREP Workforce
Maintaining a qualified PHEP 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 fnancc(adoh.wa.gov.
Exhibit A,Statement of Work Page 8 of 10 Contract Number CLH32053-Amendment 7
Page 31 of 44
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
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/ACIP 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-IA invoice voucher form with backup documentation appropriate for risk level. DOH will provide Al 9 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
Page 33 of 44
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: School-Based Health Centers Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: July 1,2025 through June 30,2026 ® State El FFATA(Transparency Act) ID 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
Master Assistance BARS Allocation
LHJ Funding Period Change
Index Listing Revenue CurrentTotal
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) 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
W 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 staffs 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 CLH32053-Amendment 7
Page 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. April 15
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment 7
Page 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 financerhdoh.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
Page 37 of 44
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Sexual&Reproductive Health Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 3 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through March 31,2026 ® State ® FFATA(Transparency Act) ❑ Fixed Price
❑ Other EI 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.
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) 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
Page 38 of 44
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
state and federal laws.Also see Program (?t 1 -Fes - -fie-rYthi
Manual,Handbook,Policy References under • Other data and documentation in format requested by to-,ri kurld'Ivtpr,rrr
Reporting Requirements(below). DOH. (Includes copies of program and financial audits faratil-
and reviews including summaries conducted by other s.... --£farralrliiarta -ire
B. Complete required Agency Information entities.) ffir-at- ZF '
Request including Title X Assurance of are negolved irrcr
Compliance and National Provider Identifier 4,--..—...1 eye.)014, X— iew _-1,Nt :ted r a i..
(NPI)billing numbers flat ati a ;4¢ ,I:1{ _ir-ft,.4a 4; �.,at., DOH
• Crffrent-datat-is
C. Provide medical services,community •--- :14-44cilitate;l . -s t s......._a wig ff s- rgrmtted.torarad
education and outreach,and staff training, 1€lof;tt{ ►bore-seac#ily- itthir p-40E-tf-.td tiwe rteel-tir,<lfrl s-
consistent with state requirements: dt .fevie ..-........A-1-4-14ere rip
documentation
1. LHJ is responsible for making sure all 1 } }-p g ot; .,,}..ig,,;-..FY,}{t ,. ite....visits..aiv f€rail-1Sr l4
staff have the knowledge to carry out p leffii-�c# .tntil i le?a=iti i ue - - sl-v # has tx•on-.stabinittecl
the requirements of the SOW. emd-a pi vee
• Site review directed by DONSR.lIP. Follow-up site •— Other deliverables
2. Medical, laboratory,and other services visits as needed until identified issues are resolved. ha -beerrrme..
related to abortion are not covered by
this task. • Submit documentation to DOII SRHP as requested for Pa .
a desk review prior to site visit. itha4mtoolimds
3. Community education services must be ca f4vlrlf=k -Iatirr
based on the needs of the community. • Appropriate staff and documentation readily available mice.
LHJ must have an Information& to DOH SRHP prior to and during site visit.
Education(I&E)committee with five I. _t l l-_ .
-wtFi tlrtrr:;e={as::
(5)or more members that is broadly •.
----rlcterfrl callcri+etlrle
representative of the population or
community for which materials are {:fe.r arrrlara zfa
intended.The committee must review a
batch of patient-facing materials
Repf
annually(at least 15 products or 15%of
b
the total number of materials,whichever below),
r eats
is smaller);meet at least annually and
establish a written record of its ........- The amount
determination.(42 CFR 59[59.6])
aarrafftinisrp,-i4-flre
4. Outreach is to ensure all populations in -dtridcl l the
r$aartrha ' s your community understand the services
available.Focus your outreach efforts + teling ro-r r flra
titis
on increasing equity. trrrrc#rrf s terea� .
less.
Exhibit A,Statement of Work Page 2 of 8 Contract Number CLH32053-Amendment 7
Page 39 of 44
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Washington State Sexual and {'r ,trrerrt-u-rll-er-
Reproductive Health Network priority
populations are: ph,m,itieti-A,44-41- ee
• Teens 'ep a+tg-Req ;rerm rtts
• People who are uninsured or 4i :
underinsured,and/or low-
income(at or below 250%of
the federal poverty line) end-rJ-f{rfs- 'etrrt-ttet
• Rural communities
• Hispanic wit'in
• Black,Indigenous,People of DOH will authorize
Color
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 frllons
• Reporting Requirements(see this table far details.
below)
Payment is limited to the
D. Collect,maintain,and provide data about CVR data submitted to DOH data contractor(Ahlers& The 15'of the following maximum Jitnds
each family planning clinic visit as defined
in the SRH CVR Manual. Associates)electronically in a format compatible with month.Within thirty(30) available ford funding
1. Maintain a computer system that Ahlers software. days of receiving source.DOH will
error/rejection report or reimburse for actual
includes safety precautions against loss • Data for each month request from DOH Sexual allowable costs as
of information. and Reproductive Health calculated by the R&E
2. Ensure data entry personnel protect • Corrected CVR data data manager. workbook(see Reporting
confidentiality of CVR data.
3. Have ability to retrieve all information Require ntents 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: the budget period, 60
• Key staff and organizational changes. Email briefly describing change. As needed to keep days for all other billing.
information current. ip erfc dates noted in
• Proposed clinic site additions.New S
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
Page 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 30th 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 30th 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
Page 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 I 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
Page 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 15th of the following
in the Clinic Visit Record(CVR)Manual available at: month.
htips://www.doh.wa.go«t/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:
• March Invoices and
actually received in the reporting month. R&Es are due by
All entries on"Other"rows must be accompanied by a May 10th
description of the revenue source or expense,including any
• June Invoices and
calculations uses.
R&Es are due by
August 10th
• December Invoices
and R&Es are due
by February 10th
Exhibit A,Statement of Work Page 6 of 8 Contract Number CLH32053-Amendment 7
Page43of44
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# 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@dohwa.V.ON.
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 9:30-122-FPRHivlanualComplete.pdf(wa.eov)Some provisions of this manual are highlighted in this SOW,
but all provisions of the manual must be complied with.
• Clinic Visit Record Manual(httpts r doh.Aag visite:/defaults`filet2024-I0/930-139-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).
DOWieser es-the f frAff.t ftlLl l p oem-usuil,
4, ---t'f iitt liaitee4sst a-1 Yitr -SOW-are-rosetvedi wey-iteeepted by DOW.
44— Stu-thita+s subnitt tt'r.taftcl£be,el ted by;Asters;
ttti- ifod-by-C 11 tas-beenstibittitt an4 opproYed:
• Other .
l }l+ngl it t t �str= tt tt • shim-mtnta r i ee at*-ittett artd- 1, tlttt tatra ly'o bzsi-t ithes-speridi Otos:
l3illirtg in s ltttlf in kale-eopieY-of-bat } tits tetttati t#tt#th e att it ttfthe- otoritct -risk-tee= -a,-e#e#it tlby-r 4413atlttrp-L3e ttt tetttttth rt-Matr+?t,
13ae#tttp-door t ntatieit-ea€t-inelodo Ott-is not-firmted-trtc r e invoieesAillittg erds.-worl-tk#er,,positive~time-toyd-atten tee-r rtk-(a-imesheets4ri w voodiefi
and ttt that+ttgr t tt rererbf.
44- Aiblitionofbiwkoff ileettmentioiownlay ho-fetities.teffifoeeilekb
•—lrttyttteat r wiff lot-bet ode,toad iov ei-dill-be tur l to-yeti-if 41 ettt-fool ilo.t o~teittatioe-is-nt proyitlee{wialt -30 s ftt re t H13+eot-request--t4
reimbursement:
Payment is-limited 4e-theitioxitttttfftt€ttttd>- '10444e-fef€its ing tree
Exhibit A,Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment 7
Page 44 of 44
4,----: tual-idl l k ¢ee s g-to-y f- € t-; yes-{r. R imt4 efeme s ithlt*
.;.-......._lie-amonn4 mini;tinktl SCW--livid i•b}+-thelien.l - rm li:
E s ynieiit-wil-il .ale thitedprttat by-ICI t;ter- el crtiisg-Requirement- i l )
14 reinilAuseifienufequesty--# -c le4e41-viint t tivities...fiiiast-lie-i eiveil nix-approve tfort =merit-by-ll lTl-within-45..isys-cif E4 e euttok te-=%SOW-pefiat e€ titt tiiiat e,
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 budgetifinuting periods)that
end during the contract period ofpertormance. DOH must receive correct and complete FINAL invoices no later than-1 S days after the contract expiration date. Invoices must
reference the contract number and provide detailed information as required.All invoices must he approved by DOH prior to payment:approval will not be unreasonably withheld.
DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and Or allowable costs as outlined in the statement of work and/or budget. DOH
will return all incorrect or incomplete invoices and will not pay Jr 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 funds. 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 a way accepted by DOH.
Payment is limited to the maximum funds available for funding source.
DO/I 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 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 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
Page of 19
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 6
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:
hops://stateofwa.sharcnoint.corn/sites/doh-ofsfundingresources/sitcpaxcs/home aspx?=e1:9a946RSda2d94d3eaR0ac7tbc32c4d7c
® 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$3,289.422.
❑ 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 WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
OA— 4hikzi/44----)14.: 08/05/2025
H dt. is ur-Chair-- d Date Date
A APPROVED AS TO FORM ONLY
APPROVED AS TO FORM ONLY
Assistant Attorney General
- July 24, 2025
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney Page I of I
CC-25-001-A6
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 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 7WA700WA1 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 7WA700WA1 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) 01J74301 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 PREP BP1-CDC-LHJ Partners NU9OTU000055 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 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 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 06/30/25 $51,330 $51,330 $51,330
FFY22 PH Infrastructure Comp Al-LHJ NE110E000053 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 07/01/25 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
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 Page 3 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
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/Biotozin 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 1 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
YR1 Stimulus-Local Asst(10%of 15%)SS Amd 6 N/A 346.26.64 01/01/25 12/31/27 07/01/23 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 01/01/25 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
YR1 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 01/01/25 12/31/27 07/01/24 06/30/29 ($1,000) $0 $0
YR 28 SRF-Local Asst(15%)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
Page 4 of 19
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Infectious Disease Syndemic Prevention Services- Local Health Jurisdiction Name: Jefferson County Public Health
SSP-Effective July 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: July 1,2025 through June 30,2026 ® 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
Master Assistance BARS Allocation
LHJ Funding Period Change
Index Listing Revenue CurrentTotal
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) 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 • 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
Page 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/Latina/Latine/Latinx, • Timeline for implementation(including
American Indian/Alaska Native people and staffing 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:Harm 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
Page 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, • 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@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.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,functioning,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 Al 9 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.
£ 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.
7. 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. Supervisors 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 financial 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-04-01-G Media
Handling and Data Disposal Best Practices-https://watech.wa.gov/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,Infrared 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 I 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 intemet/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.Barnes@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 https://www.cdc.gov/hiv/pdf/funding/announcements/ps12-1201/cdc-hiv-ps12-1201-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.federalregister.gov/documents/2013/12/26/2013-30465/unifonn-adtninistrative-
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
Page 14 of 19
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Drinking Water Group A Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
® Federal Contractor (check if applicable) ❑ Reimbursement
Period of Performance: January 1,2025 through December 31,2027 ® 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.
Master Assistance ; BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Decrease(—) 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
YR1 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
YR1 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 5,400 -800 4,600
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
1 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 LW 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. Sanitary Survey Report,the LHJ shall be
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH32053-Amendment 6
Page 15 of 19
Task Activity 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 LHJ 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
Page 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). http://www.ofm.wa.goviresources/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 financenu,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.gov 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$43480-$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 A19-1A 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
Page 18 of 19
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Recreational Shellfish Activities- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: July 1,2025 through June 30,2026 ® State ❑FFATA(Transparency Act) El 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
Master Assistance BARS Allocation
LHJ Funding Period Change
Index Listing Revenue CurrentTotal
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) 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
Page 19 of 19
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 finance@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/shellfi sh/recreational-shellfish
https://doh.wa.gov/about-us/programs-and-services/environmental-public-health/environmental-health-and-safety/about-shellfish:program/about-biotoxins-and-illness-prevention-
program
Special Instructions:
Report for work performed in 2025 must be submitted via email to Liz Maier(liz.maier(c!)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: CL1132053 AMENDMENT NUMBER: 5
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"LI-IJ",
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:
l. 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:
hues:/stateofwa.sharepoint.con::sitesidoh-ofsfiindincresourcesisiteoat;es;home,asnx?=eI:9a94688da2d94d3ea8Uac7tbc32e4d7e
❑ 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,amends and replaces Exhibit B-4 Allocations as
follows:
® Increase of$17,023 for a revised maximum consideration of$3,185,889.
❑ 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 WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
Heidi Eisenhour.Chair ;)ate Date
APPROVED AS TO FORM ONLY APPROVED AS TO FORM ONLY
Assistant Attorney General
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
CC-25-001-Ai Page 1 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
11011 Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue 1111 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 10.557 333.1055 01/01/25 09/30/25 10/01/24 09/30/25 $144,142
FFY25 USDA FMNP Mgmt 7WA810WA7 Amd 4 10.572 333.1057 01/01/25 09/30/25 10/01/24 09/30/25 $637 $637 $637
FFY25 SWIMMING BEACH ACT JAR(ECY) 01J74301 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 BP I-CDC-LHJ Partners NU90T1.1000055 Amd 1 93.069 333.93.06 01/01/25 06/30/25 07/01124 06/3025 $13,754 $13,754 $13.754
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 $81,556
FFY24 OD2A OID CDC Prevent NU 17CE010218 Amd 1 93.136 333.93.13 01/01/25 06/30125 09/01/24 08/31/25 $49,000
FFY25 FPHPA Title X Finally Plan FPHPA006S60 Amd 5 93.217 333.93.21 04/01/25 03/31/26 04/01/25 03/31/26 517,023 $17,023 S33.989
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 FPFIPA006560 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 N11231P922619 Amd 1 93.268 33393.26 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 COV1D-19 PHWFD-LILT 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 NE110E000053 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 I N/A 334.04.90 01/01/25 06/30/25 07/0124 06/30/25 $59,000 $59,000 $59,000
SFY25 DUH Naloxone DDO HCA 1AR 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
SFY25 Drug User Health Program Amd I N/A 334.04.91 01/01/25 06/30/25 07/01/24 (06/30125 $40,250 $40,250 S40,250
SFY25 Sexual&Rep Hlth Cost Share Amd 1 N/A 334.04.91 01/01/25 06/30/25 07/0124 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
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 I N/A 334.04.93 01/01/25 06/30/25 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
Rec Shelltish/Biotoxin Amd 1 N/A 334.04.93 01/01/25 06/30/25 07/01/23 06/30'25 $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) 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 Amd4 N/A 334.04.93 01/0:1/25 06/30/25 07/01/24 06/30r25 ($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
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(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 I N/A 346.26.64 01/01/25 06/30/25 07/01/23 06/30/25 $2,200
Sanitary Survey Fees SS-State Amd 1 N/A 346.26 65 01/01/25 06/30/25 07/01/23 12/31/27 $2,200 $2,200 $2,200
YR28 SRF-Local Asst(15%)TA Amd 4 N/A 346.26.66 01/01/25 12/31/27 07/01/24 06/30/29 $1,000 $1,000 $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 $3,185,889 S3,185,889
Total consideration: $3,168,866 GRAND TOTAL S3.185,889
S17,023
GRAND TOTAL $3,185,889 Total Fed $574,526
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"334".
Page 2 of 2
Page 4 of 11
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Sexual& Reproductive Health Program - Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1, 2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 2 Funding Source - Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
® State ® FFATA (Transparency Act) ❑ Fixed Price
Period of Performance: January 1,2025 through March 31.2026 ❑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 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 performance
from 06/30/2025 to 03/31/2026,and revise language in task table and Program Specific Requirements section.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) 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 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 • A 19 invoice vouchers submitted in a timely manner \-o more than monthly Billing must be based
(SRHP)&Title X(TX)Services—excluding accompanied by an R&E workbook showing revenue and no ia;than on a current cost
abortion and other surgical procedures related to and expenses for the month billed and any other quorted). 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
federal Title X requirements and all state and I below. Reports in the
Exhibit A,Statement of Work Page 1 of 8 Contract Number CLH32053-Amendment 5
Page 5 of 11
Task 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 SCCriuI: 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.
• Al9backup
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 i 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 Reporting
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
Washington State Sexual and Reproductive months remaining
P 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
Page 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
Color All services through the
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 15'h of the
SRH CVR Manual.
1. Maintain a computer system that includes Ahlers software. following month.
safety precautions against loss of • Data for each month Within thirty (30)days
information. j
2. Ensure data entry personnel protect of receiving
confidentiality of CVR data. • Corrected CVR data error/rejection report or
3. Have ability to retrieve all information for request from DOH
auditing and monitoring by DOH or its Sexual and
designee. Reproductive Health
data manager.
E. Notify DOH contract manager of all:
• Key staff and organizational changes. Email briefly describing change. As needed to keep
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
may,at its sole discretion,recalculate
LHJ's finding allocation if it closes a clinic
site.
Exhibit A, Statement of Work Page 3 of 8 Contract Number CLH32053-Amendment 5
Page 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
Agency Information Request This information must be reported using the template April 30°i 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 30th 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
prov ides. 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 F. 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
start date of this SOW. If contractor cost anal sis
was approved by DOH at the becinninu of the
contract period. LHJ does not have to resubmit
unless changes are made. LHJ must email DOH
contract manager informing them that no chances
\A ere 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
Page 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.
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:
• Physicians
Exhibit A,Statement of Work Page 5 of 8 Contract Number CLH32053-Amendment 5
Page 9 of 11
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• 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 Brant
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
in the Clinic Visit Record(CVR)Manual available at: following month.
h ttps://www.doh.wa.2ov/Portals/1/Documents/Pubs/930-
139-CVR\lanual.pdf. 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
h ,
6 Revenue and Expense Reports(R&E) Completed R&E for time period that shows all revenue Sdbinittxl
(including program income)that support Task I SRH 4n\oice(.\10)•- --'
Services and all expenses related to providing those triorc than n onthly and
services. R&E workbook will be provided by DOH. n„ !e than quarterly
A. Expenses must match General Ledger. R&E showing all
B. Other revenue/program income must reflect revenue sources of revenge that
actually received in the reporting month. support services nwa
be hilted‘‘ithin 15
All entries on"Other"rows must be accompanied by a {sty s of the budget
description of the revenue source or expense,including any pc i3•, r
calculations uses.
submitted b February
Invoices(A 19's)and
RX'Es that support
Exhibit A,Statement of Work Page 6 of 8 Contract Number CLH32053-Amendment 5
Page 10 of 11
Task Activity Deliverables/Outcomes Due Date/lime Frame Payment Information
and/or Amount
Se
end uJ IIu thi
must he billed
following the required
deadlines:
• .11arch/nvoic•es
and R&;Es are doe
bt'htay 10th
* June invoices and
R&Es are due bi
.4 ugust loth
• December
Invoices and
R&Es are due by
February loth
• All remaining
months inns!he
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 aJdoh.wa.aov.
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 USASpendine.2ow 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-FPRHManualCo mplete.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 (https://doh.wa.gosisites/default;tiles/2024-I0/930-I39-CVR Man ualpdt)
• LHJ's approved Agency Information Request.
Exhibit A, Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment 5
Page 11 of 11
Billing Requirements:
See Payment column of Tasks and Deliverables table and ROE report description in Reporting Requirements table
Billing must he based on a current cost ana1vsis approved by DOH(see Reporting Rcquirerru r:r
DOH reserves the right to withhold paynn'm until.
• Compliance issues or a lx eriurrs SOII.are resolved in a way accepted by DOI
• Current data is submined to, and accepted by, Ahler.s.
• .J 1.9 back up documentation required by DOH has been submitted and approved.
• Other deliverables have been li/el
Billing invoicing for reimbursement shall happen rto more than monthly as costs are incurred and no less than quarterly to best monitor spending plans.
Billings invoices shall include copies at backup documentation lor all expenses according to the contract's risk level as defined by.419 Backup Documentation,Matrix.
Backup documentation can include. but is not limited to; receipts, invoices. killing records. Work nrai'r+. l,nsiIive time and attendance records inntesheets,. travel vouchers
and acemrnting expense reports.
• Additional backup documentation may be requested if needed.
• Payments will not be made, and invoices will he returned to von if sufficient backup documeniatian is not provided within 30 days(Our receipt ofvour request far
re lln burst'mew.
Payment is limited to the maximum pouts available Jar innding source.
DOH will reimburse for:
• Actual allowable costs according to your approved cost analysis (see Reporting Requirements tablet. Or
• The an aunt remaining in the.S'DII divided by the number of months remaining in the,fnndiag source,plus one. whichever is less.
Payment will he calculated by Ji -1:provided by DOH(see Reporting Requirements tablet.
Final reimbursement requests for completed contract activities must be received and approved for paynrcnt by UGH within l5 days of the end of the .SOII'period of periornr,nr.e.
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 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 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 5
Signature: Signature:
Email: ggilbert@co.jefferson.wa.us Email: Brenda.Henrikson@DOH.WA.GOV