HomeMy WebLinkAboutCONSENT Consolidated Contracts Amend 9 ,�= ^ 615 Sheridan Street
j \ Port Townsend, WA 98368
Amason www.JeffersonCountyPublicHealth.org
Public Healt Consent Agenda
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Josh D. Peters, County Administrator
FROM: Apple Martine, JCPH Director
Veronica Shaw, JCPH Deputy Director
DATE: 11 i I/n /2 S
/
SUBJECT: Agenda Item — Consolidated Contracts Amendment #9 with the Department
of Health; January 1, 2025 — December 31, 2027; $193,087 additional
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #9
between JCPH and State of Washington Department of Health (DOH); January 1, 2025 — December 31, 2027;
additional funding of $193,087 for a total to date of $6,000,696.
ANALYSIS/STRATEGIC GOALS/PROS and CONS:
The purpose of this agreement is to provide public health services to the people of Washington State. This
Amendment adds and/or amends statements of work (SOW) and funding for the following programs:
• Foundational Public Health Services: these funds are to build governmental public health system's
capacity and increase the availability of FPHS services statewide; revision corrects allocation, removes
tasks and edits language (reduces funding by $75,000)
• Maternal & Child Health Block Grant: supports local interventions impacting target population (reduces
funding by $33,324)
• Office of Immunizations-ELC: provides funding for health education and promotion (funding of $10,000)
• Office of People Services-HR-Public Health Infrastructure Grant: provides funding to establish, expand,
train and sustain local health jurisdiction (LHJ) public health workforce (additional funding of $200,000)
• Office of Resiliency & Health Security-PHEP: this SOW sets funding and tasks for LHJs to prepare for,
respond to, and recover from public health threats and emergencies (additional funding of $14,857)
• OSS LMP Implementation: funds on-site sewage system implementation local management plan;
amendment adds task-level budgets and complete goals and objectives table
• Sexual & Reproductive Health Program: this revision adds additional funds (additional $62,713)
• WIC (Women, Infants, and Children) Nutrition Program; amendment adds funds and revises program
specific requirements (additional $13,841)
Community Health
Developmental Disabilities Environmental Public Health
360-385-9400 360-385-9444
360-385-9401 (f) (f) 360-379-4487
Always working for a safer and healthier community
CC-25-001-A9
FISCAL IMPACT/COST BENEFIT ANALYSIS:
Total consideration for this Contract Amendment is $193,087. The Consolidated Contract is funded by DOH,
and comprises both Federal and State funds.
RECOMMENDATION:
JCPH Management recommends BoCC approval of Consolidated Contract Amendment #9 between JCPH and
DOH; January 1, 2025 — December 31, 2027; additional funding of $193,087.
REVIEWED BY:
cet&14)
l alb
r,Lti,Josh D. Peters, County Administrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 Always working for a safer and healthier community (f) 360-379-4487
360-385-9401 (f)
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-25-001-A9
Contract For: Consolidated Contracts, Amendment 9 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: $193,087 additional,for a total of$6,000,696 PROCESS: j Exempt from Bid Process
Revenue: $193,087 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 COMPLIA TH t 0 AND CHAPTER 42.23 RCW.
CERTIFIED: N/A:❑■ „'' Nov. 4,2025
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BE DEBARR ANY FEDERAL, STATE, OR LOCAL
AGENCY. /i
CERTIFIED: I J N/A: ❑� ( Nov. 4,2025
Signature Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 11/5/2025.
STEP 4: PROSECUTING ATTORNEY REVIEW(will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 11/4/2025.
Amendment No. 9 with prior amendments and original attached.
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
1
Page 1 of 50
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 9
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:
!lups.-%stateof ca.sharenoint com'sites,doh-ofsfundincresources'snepaaes horrne.asnx''=e1.9a94688da2d94d3ea80ac7fbc32e4d7c
® Adds Statements of Work for the following programs:
Office of Immunizations—ELC-Effective July 1,2025
® Amends Statements of Work for the following programs:
Foundational Public Health Services-Effective July 1,2025
Maternal&Child Health Block Grant—Effective January 1,2025
Office of People Services-HR-Public Health Infrastructure Grant-Effective January 1,2025
Office of Resiliency&Health Security-PHEP-Effective July I,2025
OSS LMP Implementation-Effective July 1,2025
Sexual&Reproductive Health Program-Effective January 1,2025
WIC Nutrition Program-Effective January 1,2025
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-9 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-8 Allocations as follows:
® Increase of$193,087 for a revised maximum consideration of$6,000,696.
❑ 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 O FORM ONLY APPROVED AS TO FORM ONLY
Assistant Attorney General
for 11/04/2025
hilip .H nsucker, Date
Chief Civil Deputy Prosecuting Attorney Page 1 of I
CC-25-00 I-A9
EXHIBIT B-9 Page 2 of 50
Jefferson County Public Health ALLOCATIONS Contract Number. CLH32053
Contract Term:2025-2027 Date: October 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 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 Amd 9 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 ($722) $21,455 $27,516
FFY25 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 Amd 8 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 (S6,061)
FFY25 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WAI Amd 4,8 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 $28,238
FFY24 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WAI Amd 8 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 $6,061 $6,061
FFY24 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 Amd 4 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 ($28,238) $0
FFY24 Brstfdg Peer Cn Pr Mgmt USDA 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 S144,669
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
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 9 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/27 $14,563 $14,563 514,563
FFY25 FarmMktNtrProg Mgmt USDA 7WA810WA7 Amd4 10.572 333.10.57 01/01/25 09/30/25 10/01/24 09/30/25 $637 $637 $637
FFY25 SWIMMING BEACHACTIAR(ECY) 01J74301 Amd2 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 NU9OTU000055 Amd 9 93.069 333.93.06 07/01/25 06/30/26 07/01/25 06/30/26 $14,857 $34,384 $48,138
FFY25 PHEP BP2-CDC-LHJ Partners NU9OTU000055 Amd 7 93.069 333.93.06 07/01/25 06/30/26 07/01/25 06/30/26 $19,527
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 0D2A 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 OlD 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 0D2A OLD 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 tined 9 93.217 333.93.21 04/01/25 03/31/26 04/01/25 03/31/26 521,049 $38,072 $55,038
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
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 PPHF0ps 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
FFY19 ELC ED Immunizations CDC NU50CK0005115 Amd 9 93.323 333.93.32 07/01/25 06/30/26 07/01/25 07/30/26 $10,000 $10,000 S10,000
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
PH Infrastructure Comp Al-LHJ NE11OE000053 Amd 9 93.967 333.93.96 01/01/25 11/30/27 12/01/22 11/30/27 S200,000 $350,300 $350,300
PH infrastructure Comp Al-LHJ NE110E000053 Amd3 93.967 333.93.96 01/01/25 11/30/27 12/01/22 11/30/27 S150,300
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 S27,525 $27,525 $27,525
Page 1of3
EXHIBIT B-9 Page 3 of 50
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: October 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 MCHBG Special Pr HRSA 2 B04MC54583 Amd 9 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $3,376 $3,376 $3,376
FFY26 MCHBG LHJ Contracts HRSA YRl NGA Not Received Amd 9 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 ($36,700) SO $0
FFY26 MCHBG LHJ Contracts HRSA YRl NGA Not Received Amd 7 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $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 1-Ilth 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
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 Hith Cost Share Amd 9 N/A 334.04.91 01/01/26 06/30/26 07/01/25 06/30/26 $41,664 541,664 S137,061
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
SFY25 Sexual&Rep Filth 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 I 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 ShellfishBiotoxin 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 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 $36,611 $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 9 N/A 336.04.25 07/01/25 06/30/26 07/01/25 06/30/26 ($75,000) $2,128,000 $4,461,000
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
SFY25 FPHS-LHJ Funds-GFS Amd 1 N/A 336.04.25 01/01/25 06/30/25 07/01/24 06/30/25 $2,333,000 $2,333,000
YRl Stimulus-Local Asst(10%of 15%)SS 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
Page 2 of 3
EXHIBIT B-9 Page 4 of 50
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: October 1,2025
Indirect Rate January 1,2025 through December 31,2025:27.38%Public Ilealth
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%)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 $6,000,696 $6,000,696
Total consideration: $5,807,609 GRAND TOTAL $6,000,696
$193,087
GRAND TOTAL $6,000,696 Total Fed $870,061
Total State $5,130,635
*Assistance Listing Number tka Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Page 5 of 50
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: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) D Reimbursement
Period of Performance: July 1,2025 through June 30,2026 ® State ❑ FFATA(Transparency Act) ® Periodic Distribution
❑ Other ❑ Research&Development
Statement of Work Purpose: Per RCW 43.70.512,Foundational Public Health Services(FPHS)funds are for the governmental public health system: local health jurisdictions,
Department of Health,state Board of Health,sovereign tribal nations and Indian health programs. These funds are to build the system's capacity and increase the availability of
FPHS services statewide.
Revision Purpose: Correct allocation,remove task 11,add task 12 and edit language in EPH Core Teams section.
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 Decrease(—) Allocation
SFY26 FPHS-LHJ FUNDS-GFS 99210860 N/A 336.04.25 07/01/25 06/30/26 2,203,000 -75,000 2,128,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 2,203,000 -75,000 2,128,000
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 Reinforcing Capacity—See below in Program Specific See below in Program Specific See below in Program
2 Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $60,000
Deliverables
Assessment—CHA/CHIP—See below in Program Specific Requirements See below in Program Specific See below in Program
3 —Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $30,000
Deliverables
Lifecourse-NEW SFY 24 Full Lifecourse Workforce Capacity—See See below in Program
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 9
Page 6 of 50
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
5 See below in Program Specific Requirements—Activity Special See below in Program Specific Specific Requirements- $75,000
Instructions for details Requirements-Deliverables 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 Specific See below in Program
10 and Capability—See below in Program Specific Requirements—Activity Requirements-Deliverables Specific Requirements- $178,000
Special Instructions for details Deliverables
Coe below:n Program
14 Stieeifte-Requifernents—ieeifie
$440T0(40
Requirements ecial Instructions f_detail Deliverables
EPH-NEW SFY 24 Social Work Support—See below in Program See below in Program Specific See below in Program
11 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $85,000
Deliverables
Assessment—Localized Epidemiology Capacity—General—See below in See below in Program Specific See below in Program
12 Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $75,000
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
See below in Program Specific
15 below in Program Specific Requirements—Activity Special Instructions for Requirements-Deliverables Specific Requirements- $63,000
details 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 finance@doh.wa.gov.
FPHS staff from DOH and the Washington State Association of Local Public Health Officials(WSALPHO)will coordinate and communicate together to build and assure common
systemwide approaches per FPHS Steering Committee direction and the FPHS framework intent.
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH32053-Amendment 9
Page 7 of 50
• For LHJ questions about the use of funds:
o Chris Goodwin,FPHS Policy Advisor,WSALPHO—cgoodwin@wsac.org, 564-200-3166
o Brianna Steere,FPHS Policy Advisor,WSALPHO—bsteere@wsac.org,564-200-3171
The intent of FPHS funding is outlined in RCW 43.70.512.
Foundational Public Health Services Definitions and related information can be found here: www.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&Workgroup
Charter The Steering Committee is the decision making body for FPHS and operates under a consensus-based decision making model,outlined here.The Steering Committee use
an iterative approach to decision making meaning additional tasks and/or funds may be added to a local health jurisdiction's (LHJ)FPHS Statement of Work(SOW)as funding
decisions are made.
Spending of FPHS funds—FPHS funds do not require pre-approval or pre-authorization to spend. FPHS funds are to assure FPHS services are available in each jurisdiction based
on the FPHS Definitions(link)and as reflected in the SOW.Assurance includes providing FPHS as part of your jurisdiction's program operations,contracting with another
governmental public health system partner to provide the service,or receiving the service through a new service delivery model such as cross jurisdictional sharing or regional
staff.FPHS funds are eligible starting at the beginning of each state fiscal year(July 1)regardless of when funds are received by the LHJ,even if the expenditure
occurred before the LHJ's contract was signed.
These funds are not intended for fee-based services such as select environmental public health services.As state funding for FPHS increases,other funds sources (local revenue,
grants, federal block grants)should be directed to the implementation of additional important services and local/state priorities as determined by each agency/jurisdiction.
Annual Allocations—The legislature appropriates FPHS funding on an annual basis and the FPHS Steering Committee allocates funds annually through the FPHS Concurrence
Process for the State Fiscal Year(SFY):July-June.
The Legislature appropriates FPHS funding amounts for each fiscal year of the biennium. This means that funds must be spent within that fiscal year and cannot be carried
forward. Any funds not spent by June 30`h each year must be returned to the State Treasury. Funding allocations reset and begin again at the start of the next fiscal year(July 1).
This Statement of Work is for the period of July 1,2025-June 30,2026 and may be included in multiple Consolidated Contracts(ConCons)which are based on the calendar year
and renewed every three years.
Disbursement of FPHS funds to LHJs—Unlike other ConCon grants, FPHS bill-back to DOH is NOT required. Half of the annual FPHS funds allocated by the Steering
Committee to each LHJ are disbursed each July and January. The July payments to LHJs and access to FPHS allocation for all other parts of the governmental public health
system occur upon completion of the FPHS Annual Assessment.
Deliverables—FPHS funds are to be used to assure FPHS services statewide. The FPHS accountability process measures how funds are spent,along with changes in system
capacity through the FPHS Annual Assessment,system performance indicators,and other data. DOH,SBOH and local health jurisdictions have agreed to complete:
1. Reporting of spending and spending projections. Process timelines and reporting template are provided by the FPHS Steering Committee via FPHS Support Staff
2. FPHS Annual Assessment is due each July to report on the previous state fiscal year.Process and reporting template are provided by the FPHS Steering Committee via
FPHS Support Staff. System results are published in the annual FPHS Investment Report available at www.doh.wa.gov/fphs.
BARS Revenue Code: 336.04.25
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH32053-Amendment 9
Page 8 of 50
BARS Expenditure Coding—provided for your reference
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 Drinkin Water Quality
44 FPHS a astewater
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.):
FPHS Intent-RCW 43.70.512
FPHS Funding—RCW 43.70.515
FPHS Committee&Workgroup Charter
Exhibit A,Statement of Work Page 4 of 7 Contract Number CLH32053-Amendment 9
Page 9 of 50
FPHS Steering Committee Consensus Decision Making Model
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 1.1-2)
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
Exhibit A,Statement of Work Page 5 of 7 Contract Number CLH32053-Amendment 9
Page 10 of 50
9. Lifecourse-NEW SFY 24 Illicit Substance Use and Overdose Response(FPHS definitions D.1-2,D.4,F.1-3,G.1-3,L1-2,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
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 in Own Jurisdiction
12. EPH-NEW SFY 24 Social Work Support(FPHS definitions B.1-3,B.6-7,D.1,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
13. Assessment—Localized Epidemiology Capacity—General(Assessment/Surveillance,CHA/CHIP)(FPHS definitions G.1,2)
Provide general assessment epidemiology focused on local public health assessment needs. Use BARS expenditure codes: 562.10 or 11
u Core Teams(Appies to all EPH Core Team cone Investments)(cone de fnition 13 1 7)
do so,the Core
J J
estment is distinctive f om ell ,tuner Core Team FPHS estment.-
Cli.nete Change Response
1 ead Exposure
• Saf P. Healthy Communities
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH32053-Amendment 9
Page 11 of 50
is f{crson i ..funds top rticipate in these CDU
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 si*four 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
• Safe&Healthy Communities
Jefferson is receiving funds to participate in these EPH Core Teams:
14. 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
15. 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.
16. 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 9
Page 12 of 50
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) 2 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through September 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 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 remove FFY26 MCHBG LHJ CONTRACTS HRSA YR1 funding as the Department of Health has not received the FFY26
funding,add FFY25 MCHBG SPECIAL PR HRSA 2 funds and change language in task 3f.
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 Decrease(—) Allocation
FFY25 HRSA MCHBG LHJ CONTRACTS 78101251 93.994 333.93.99 01/01/25 09/30/25 27,525 0 27,525
FFY26 MCHBG LHJ CONTRACTS HRSA YR1 78101261 93.994 333.93.99 10/01/25 09/30/26 36,700 -36,700 0
FFY25 MCHBG SPECIAL PR HRSA 2 7810125A 93.994 333.93.99 10/01/25 09/30/26 0 3,376 3,376
0 0 0
0 0 0
0 0 0
TOTALS 64,225 -33,324 30,901
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Maternal and Child Health Block Grant(MCHBG)Administration
la Report actual expenditures for the six-month period Submit actual expenditures using the MCHBG May 16,2025 Reimbursement for actual
from October 1,2024 through March 31,2025. Budget Workbook to DOH Community costs,not to exceed total
Consultant. funding consideration.
lb Develop 2025-2026 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 5,2025 Monthly Reports must only
October 1,2025 through September 30,2026 using Community Consultant. reflect activities paid for
DOH-provided template. with funds provided in this
lc Participate in DOH-sponsored annual MCHBG meeting. LHJ Contract Lead or designee will attend September 30,2025 statement of work for the
meeting. specified funding period.
Exhibit A,Statement of Work Page 1 of 5 Contract Number CLH32053-Amendment 9
Page 13 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Id Report actual expenditures for October 1,2024 through Submit actual expenditures using the MCHBG December 5,2025
September 30,2025. Budget Workbook to DOH Community See Program Specific
Consultant. Requirements and Special
1e Report actual expenditures for the six-month period Submit actual expenditures using the MCHBG May 15,2026 Billing Requirements.
from October 1,2025 through March 31,2026. Budget Workbook to DOH Community
_ Consultant.
if Report annual FTE billed to MCHBG. Submit FTE information on DOH-provided July 1,2026
template.
1g Develop 2026-2027 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 4,2026
October 1,2026 through September 30,2027 using Community Consultant.
DOH-provided template.
1 h 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-funded activities and Submit monthly reports to DOH Community September report due
outcomes using DOH-provided reporting template. As a Consultant.Describe in your updates within October 15,2025
foundation of your MCHBG work determine how each activity of the monthly report how you November 15, 2025
processes and programs can close gaps in health are intentionally focused on closing gaps in December 15,2025
outcomes. health outcomes. January 15,2026
February 15,2026
March 15,2026
April 15,2026
May 15,2026
June 15,2026
July 15,2026
August 15,2026
September 15,2026
Exhibit A,Statement of Work Page 2 of 5 Contract Number CLH32053-Amendment 9
Page 14 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
2d Develop 2026-27 MCHBG Monthly Reporting Submit MCHBG reporting document to DOH Draft—August 14,2026
Template for October 1,2026 through September 30, Community Consultant. Final—September 11,2026
2027 using DOH-provided template.
Children and Youth with Special Health Care Needs(CYSHCN)
3a Complete intake and renewal,per reporting guidance Submit data to DOH per CYSHCN Program January 15,2025 Reimbursement for actual
supplied by DOH,on all infants and children served by guidance. April 15,2025 costs,not to exceed total
the CYSHCN Program as referenced in CYSHCN July 15,2025 funding consideration.
Program guidance. If no CYSHCN care coordination Monthly Reports must only
(enabling service)is provided in a given quarter,email reflect activities paid for
the CHIF administrator at DOH-CHIF a,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 Through 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. If no CYSHCN care coordination July 15,2026
(enabling service)is provided in a given quarter,email
the CHIF administrator at DOH-CHIF a,doh.wa.gov and
indicate that zero clients were served during the quarter.
No spreadsheet is necessary when zero clients are
served.
Exhibit A,Statement of Work Page 3 of 5 Contract Number CLH32053-Amendment 9
Page 15 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
3f Review your program's entry on ParentHelp"' e-R Document in the Administrative box on your September 30,2026
Help Me Grow's ParentHelp123 Resource Finder MCHBG report that you have updated
annually for accuracy. information on your local CYSHCN program
with WithinReach/Help Me Grow.
3g Support improvements to the local system of care Submit updates as part of monthly reporting September report due
(public health services and systems/policy,systems,and document. October 15,2025
environment)for CYSHCN. Refer to the Focus of Work
document for example activities and priority areas. November 15, 2025
December 15,2025
January 15,2026
February 15,2026
March 15,2026
April 15,2026
May 15,2026
June 15,2026
July 15,2026
August 15,2026
September 15,2026
MCHBG Assessment and Evaluation
4a As part of the ongoing 5-year MCHBG Needs Submit documentation as requested by DOH. September 30,2025 Reimbursement for actual
Assessment,participate in activities developed and costs,not to exceed total
coordinated by DOH using DOH-provided reporting funding consideration.
template. Monthly Reports must only
4b Provide summary of outcomes of MCHBG-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 financeAdoh.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.
Exhibit A,Statement of Work Page 4 of 5 Contract Number CLH32053-Amendment 9
Page 16 of 50
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:
All training costs and all travel expenses for such training(for example:per diem,hotel,registration fees)must be pre-approved, unless identified in pre-approved Budget
Workbook. Submit a paragraph to your Community Consultant explaining why the training is necessary to implement a strategy in the approved work plan. Details should also
include total cost of the training and a link to or brochure of the training.Retain a copy of the Community Consultant's approval in your records.
Program Manual,Handbook,Policy References:
CYSHCN Information and Resources:
Children and Youth with Special Health Care Needs Website(wa.gov)
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
1. At least 30%of federal Title V funds must be used for preventive and primary care services for children and at least 30%must be used for services for children with
special health care needs. [Social Security Law,Sec.505(a)(3)].
2. Funds may not be used for:
a. Inpatient services,other than inpatient services for children with special health care needs or high-risk pregnant women and infants,and other patient services approved by
Health Resources and Services Administration(I-IRSA).
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 A19-1 A 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 Budget Workbook.
Exhibit A,Statement of Work Page 5 of 5 Contract Number CLH32053-Amendment 9
Page 17 of 50
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Immunizations—ELC-Effective July 1,2025 Local Health Jurisdiction Name: Jefferson County Public Health
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 El 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 funding to conduct activities related to health education and promotion of COVID-19,
long COVID and other vaccine-preventable diseases for at-risk populations,including strengthening bi-directional relationships with health care providers and increasing access to
care.
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY19 ELC ED IMMUNIZATIONS CDC 7431025E 93.323 333.93.32 07/01/25 06/30/26 0 10,000 10,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 10,000 10,000
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
1. Implement communication,health education and other strategies or Written report describing Within 30 days of execution Reimbursement for
other activities,working with health care providers,community- activity/activities expected to be of contract amendment. actual costs incurred,
based organizations or other partners to reach the locally identified implemented on provided document. not to exceed total
population. funding consideration
Implementation plan of activities to be Within 30 days of execution amount.
conducted as part of activity on DOH of contract amendment.
provided document.
Forecast of expected spending of funds Within 30 days of execution
through remainder period of of contract amendment.
performance(June 2025)on provided
document.
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH32053-Amendment 9
Page 18 of 50
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
2. Catalog activities and conduct an evaluation of the strategies used Written report,showing the strategies June 30,2026
to increase access to services. used and the final progress of the reach
(template to be provided)
3. Co-sponsor one mobile health event with Care-a-Van in their Plan to incorporate to be added to June 30,2026
jurisdiction including planning,outreach,and logistics to reach the implementation plan.
locally identified population.
Written report describing the mobile
health event including date,location,
services offered,partners,and number of
attendees.
4. Provide culturally and linguistically appropriate information about Written report describing outreach and June 30,2026
vaccine-preventable diseases and Long COVID to reach locally education strategies.
identified populations.
Copies of any developed materials.
5. Other activities to consider,with support provided by DOH: Written report,showing the strategies June 30,2026
used and the final progress of the reach
• Consider adding activities that assess the need for Long (template to be provided)
COVID screening and treatment,distribute Long COVID
clinical education resources to providers in each
jurisdiction,and support linkages between social care and
clinical care.
• Consider hosting Mental Health First Aid training for the
public health and health care workforce to increase skill
and response capability.
Contact Jennifer Robinson at:jenirobinson@wsu.edu
Website: https://www.mentalhealthfirstaid.org/
• Consider hosting a virtual or in-person training for health
care leaders to support the workforce and reduce burnout.
o Example:Leading in Healthcare:Contributing to
more health within the system
o Description:This workshop focuses on simple
and accessible best-practices for supervisors and
managers on leading through crisis and
developing healthy team/work group culture.
We will cover communication tactics and
strategies during times of adversity or high-
intensity,crisis recovery,and grief and loss.We
will focus on actionable steps that those in
leadership positions can take to improve the
wellness and functionality of their teams from a
behavioral health lens,and the specific strategies
used by highly successful teams during and after
recovery from adverse events.
Exhibit A,Statement of Work Page 2 of 3 Contract Number CLH32053-Amendment 9
Page 19 of 50
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Distribute and promote provider behavioral health and wellbeing
resources from DOH.
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 LW 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
Invoicing:
Invoices must be submitted monthly to include the previous month's reimbursements/costs to DOH using a Contract A19-1A invoice voucher form and required back-up
documentation.Final invoices are due within 45 days of the end of the contract.
Unallowable Costs:
There are limitations from the funding source on allowable costs for this statement of work. If the LHJ is unsure if a cost is allowable,they should contact the DOH contract
manager for approval of the cost prior to making the purchase or charge.
• Advertising costs(e.g.,conventions,displays,exhibits,meetings,memorabilia,gifts,souvenirs)
• Alcoholic beverages
Building,purchases,construction,capital improvements
• Clinical care(non-immunization services)
• Entertainment costs
• Fundraising Cost
• Goods and services for personal use
• Honoraria
• Independent Research
• Land acquisition
• Legislative/lobbying activities
Interest on loans for the acquisition and/or modernization of an existing building
• Payment of a bad debt,collection of improper payments
• Promotional and/or incentive materials(e.g.plaques,clothing,and commemorative items such as pens,mugs/cups,folders/folios,lanyards,magnets,conference bags)
Purchase of food/meals(unless part of required travel per diem costs)
• Vehicle Purchase
• Vaccine Purchase
Exhibit A, Statement of Work Page 3 of 3 Contract Number CLH32053-Amendment 9
Page 20 of 50
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of People Services-HR-Public Health Local Health Jurisdiction Name: Jefferson County Public Health
Infrastructure Grant-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 Trans(Transparency Act ❑ Fixed Price
Period of Performance: January 1,2025 through November 30,2027 El Other ® ( p )
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide funding to establish,expand,train,and sustain the LW public health workforce in
accordance with the Centers for Disease Control and Prevention(CDC)Public Health Infrastructure Grant(PHIG).
Revision Purpose: Purpose of revision is to add second allocation of funding and update Task 2 and 3 due dates.
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
PH INFRASTRUCTURE COMP Al-LHJ 92321223 93.967 333.93.96 01/01/25 11/30/27 150,300 200,000 350,300
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 150,300 200,000 350,300
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
1 Develop a contact list of staff responsible for the Submit to DOH Program Contact names, Submit by email to DOH Reimbursement for actual
statement of work(SOW). position titles,email addresses and phone Program Contact any staff costs not to exceed total
numbers of key LW staff responsible for this change(s)within 30 days funding allocation
statement of work,including management, amount.
program staff,and accounting and/or
financial staff. Invoice Vouchers must be
2 Develop an implementation plan to use these funds for Submit initial implementation plan to the Implementation plans must billed monthly and
one or more of the allowable costs listed below. DOH Program Contact for review and prior be submitted by email to received by DOH within
approval as soon as possible. DOH Program Contact 45 days of the close of the
Funding is intended to establish,expand,train,and sustain before using funds. month in which services
public health staff to support LHJ prevention,preparedness, were provided.
response,and recovery initiatives.These include the
following short-term outcomes: increased retention of
existing public health staff,and improved workforce systems
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH32053-Amendment 9
Page 21 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
and processes.Washington will also move toward the Revisions to the implementation plans are Revised implementation
following intermediate outcome measures as part of this not required to be submitted to DOH for plans are due a month and
Workforce initiative: increased size [and capabilities]of the preapproval. Submit updated implementation 10 days after the end of the
public health workforce,increased job satisfaction,stronger plans at the end of the grant year with an grant year November 30th
public health foundational capabilities,and increased reach overview of those changes. except for the final year of
of public health services.Ultimately,these workforce the grant:
investments will support accelerated prevention, • January 10,2026
preparedness,and response to emerging threats,and • January 10,2027
improved other public health outcomes. • J ars-4-A3-20-28
November 30, 2027
Funding can be used for permanent full-time and part-time
staff,temporary or term-limited staff,fellows,interns,
contractors,and contracted employees.
Allowable costs include:
• Costs,including wages and benefits,related to
recruiting,hiring,and training of new or existing
public health staff
• Purchase of supplies and equipment to support the
expanded and/or current workforce and any training
related to the use of supplies and equipment.
• Training and education(and related travel)for new
and existing staff on topics such as incident
management training,working with underserved
populations,cultural competency,disease
investigations,informatics or data management,or
other needs identified by the LHJ.
• Costs of allowed contractors and contracted staff.
Notes:
• Preapproval from DOH is required to contract with
these funds.
• Preapproval is required for the purchase of
equipment. (Equipment is a tangible item with an
original per-unit cost of$5,000 or more.)
3 Data collection,as applicable,is based on: Data on form provided by DOH Reporting periods are:
• Hiring and Retention goals for the Public Health • December 1,2024—
Infrastructure Grant(PHIG)period. Data collection includes: May 31,2025
• Hiring and retention activities the LW has at the • Number of funded positions filled by • June 1,2025—
end of the reporting period. job classification and program area November 30,2025
since the inception of the grant • December 1,2025—
(December 1,2022),as of the end of May 31,2026
the reporting period.
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment 9
Page 22 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
o Including positions filled with • June 1,2026—
current employees,new hires,and November 30,2026
PHIG funded positions vacated • December 1,2026—
during the reporting period. May 31,2027
• Data Quality and Context • June 1,2027—
o Are the data provided questionable November 30,2027
or low/poor quality?
o Does the data provided adhere to Report due dates are a
the definitions established by CDC month and 10 days after
in the performance measure the end of the reporting
guidance? period except for the final
o Describe any data limitations, reporting period:
including reasons unable to report, • July 10,2025
and steps taken to obtain data • January 10,2026
and/or improve data quality in the • July 10,2026
future. If you reported on these • January 10,2027
data using a definition that was . July 10,2027
different than provided in CDC's •
guidance,please describe. November 30, 2027
o Provide any additional context or
information related to this measure.
Note:6-month Reporting periods see Due
Date/Time Frame
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 financega 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 LW 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
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 eCFR:: 2 CFR Part 200--Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal
Awards.
The following expenses are not allowable with these funds:
• Clothing(except for vests to be worn during exercises or response)
Exhibit A, Statement of Work Page 3 of 4 Contract Number CLH32053-Amendment 9
Page 23 of 50
• Equipment not primarily used by or for public health employees.
• Food or beverages(unless employee is in travel status)
• Incentives(except for retention incentives)
• Items to be given to community members(members of the public)
• Salaries at a rate more than Executive Level II(Federal Pay Scale)
• Vehicles(with preapproval,funds may be used to lease vehicles)
• Capital expenses
Preapproval from DOH is required to use these funds for:
• Contracting.
• Purchasing equipment.(Equipment is a tangible item with an original per-unit cost of$5,000 or more.)
• Disposition of equipment with a current value of$5,000 or more.(Equipment is a tangible item with an original per-unit cost of$5,000 or more.)
• Leasing vehicles.
• Out-of-state travel.
Note: See also DOH A19 Documentation Matrix for additional expenses that may require preapproval.
Billing Requirements:
All expenses on invoices must be related to statement of work tasks.
Submit invoices monthly on a signed A19 with backup documentation appropriate for risk level. DOH will provide Al9 and risk level.
• If your invoice includes indirect costs,you must have an indirect rate cost agreement approved by DOH.
• If you have no expenses related to this statement of work for a month,let your DOH Primary Point of Contact know via email.
• Submit final billing within 45 days of the end of the period of performance for this statement of work.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH32053-Amendment 9
Page 24 of 50
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: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: July 1,2025 through June 30,2026 El State ® FFATA(Transparency Act) El Fixed Price
El Other El 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(PHEP)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: The purpose of this revision is to add the remaining PHEP BP2 funds.
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 PHEP BP2-CDC-LHJ PARTNERS 31602254 93.069 333.93.06 07/01/25 06/30/26 19,527 14,857 34,384
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 19,527 14,857 34,384
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 9
Page 25 of 50
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 BP1 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
PHEP FFY24 BP1 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 9
Page 26 of 50
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 PHEP Cooperative Agreement.
DOH uses the Multi-Year Preparedness Activities Calendar(MYPAC)to demonstrate that sub-recipients of the PHEP funding are participating
in,or leading exercises.Local Jurisdictions and Tribes may use PHEP funding for any exercise that furthers their preparedness.
6.1 If DOH participation is requested,complete the WA DOH Exercise Exercise Notification Form As soon as the LHJ is
Notification Form prior to conducting an exercise that was not aware of the exercise
previously identified in the LHJ's MYPAC or led by DOH. date and details.
6.2 Conduct,or participate in,at least one emergency response exercise by Submit a Completed After-Action For AARs that the LHJ
June 30,2026. Report/Improvement Plan(AAR/IP) are responsible for,90
days after exercise
LHJs should coordinate preparedness exercises with local partners, completion.For others,
including Tribes,emergency management,healthcare facilities,and when the AAR is
first responder agencies. Participation in exercises hosted by other publicly available.
organizations within the jurisdiction or geographic region is also
strongly encouraged to support regional coordination and strengthen
multi-agency response capabilities.
Note:A real-world response would meet this deliverable.
7 Public Health Emergency Response Planning
A core component of every public health preparedness and response program is maintaining an up-to-date and complete emergency response
plan that describes how the jurisdiction will respond to the public health impacts of the most likely threats faced by the jurisdiction.
7.1 Update or develop LHJ identified sections of the Comprehensive Describe progress to date in the mid-year December 31,2025
Emergency Response Plan addressing gaps/needs identified from an report on template provided by DOH. June 30,2026
After Action Report from an exercise or a real world response
Exhibit A,Statement of Work Page 3 of 10 Contract Number CLH32053-Amendment 9
Page 27 of 50
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*doh.wa.gov for any incident that involves the activation of
emergency response plans and/or the implementation of an incident
command structure.
Exhibit A,Statement of Work Page 4 of 10 Contract Number CLH32053-Amendment 9
Page 28 of 50
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 9
Page 29 of 50
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 9
Page 30 of 50
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 9
Page 31 of 50
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
15 Build Highly Qualified PHEP 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 finance@doh.wa.gov.
Exhibit A,Statement of Work Page 8 of 10 Contract Number CLH32053-Amendment 9
Page 32 of 50
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 LW 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."PIMP 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 9
Page 33 of 50
• 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 A 19 Documentation Matrix for additional expenses that may require preapproval.
BILLING
Please refer to the Billing Instructions in the 2025—2027 Consolidated Contract.
All expenses on invoices must be related to the Statement of Work Tasks.
Submit invoices monthly on a signed A19-1A invoice voucher form with backup documentation appropriate for risk level. DOH will provide A19 form and risk level.
• Submit invoices monthly within 60 days of the end of the month of service(unless the related ConCon amendment has not been executed,in that case submit invoices as
soon as possible after the amendment is executed).
• Please do not submit invoices until the ConCon amendment including the funds has been executed.
• If invoices include indirect costs,there must be a DOH-approved indirect rate cost agreement.
• If there are no expenses related to this Statement of Work for a month,let the DOH Contact via email.
• If you are submitting a supplemental, revised,corrected,or any additional invoice for a month,please clarify your intentions in the email with the invoice.
• Submit final billing within 60 days of the end of the funding period.
Exhibit A,Statement of Work Page 10 of 10 Contract Number CLH32053-Amendment 9
Page 34 of 50
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: Revision Revision#(for this SOW) 1 Funding Source r 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) 0 Fixed Price
0 Other 0 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: Add task-level budgets and complete goals and measurable objectives table.
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 None Allocation
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 07/01/25 06/30/26 36,611 0 36,611
SFY27 WASTEWATER MANAGEMENT-GFS 26701170 N/A 334.04.93 07/01/26 06/30/27 31,822 0 31,822
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 07/01/26 06/30/27 6,571 0 6,571
0 0 0
0 0 0
0 0 0
TOTALS 75,004 0 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 741 992
OSS compliant with inspections countywide Number of OSS 2,52" 2,914
Number of OSS failures identified/
OSS failures identified/corrected in MRA number of OSS failures with completed 12/2 12/6
repairs
Number of OSS failure identified/
OSS failures identified/corrected countywide number of OSS failures with completed 33/9 33/17
repairs
Exhibit A, Statement of Work Page 1 of 3 Contract Number CLH32053-Amendment 9
Page 35 of 50
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. $3,754 based on actual
within 60 days of completing work.Local or County Health costs.
subrecipients will submit invoices through the ConCon
process and will send progress reports and deliverables to the
LMP Contract Manager. Invoices must be submitted at least
bi-monthly(per ConCon requirements)but no more
frequently than monthly. Invoices will be reviewed for
consistency with progress.The LMP Contract Manager may
require monthly invoices.
1.2 Semi-Annual Progress Reports Data about the following: Due July 15 for the
Reporting periods are semiannually from January 1— • Qualitative: duration of the contract
June 30 and July 1—December 31. Progress reports include o Summary of work. period.
data described in the outcome column. o Barriers to LMP Implementation.
• Quantitative:
o OSS inventory metrics.
o Enforcement actions.
o Outreach and Education efforts.
Task 2: Local Management Plan Implementation This task includes all work done to implement the county's LMP excluding grant management tasks and inspection
rebates/incentives.
2.1 Database Maintenance and Quality Assurance/Quality a.Provide narrative of data clean-up tasks a-d. Report in semi-annual Reimbursement up to$X
Control completed and in-progress. progress report in Subtask $18,750 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 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 9
Page 36 of 50
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 SX
The LHJ will provide rebates to homeowners for pumping, documents to DOH. rebates. $52,500 based on actual
inspection and minor repairs.Rebates issued will be up to costs.
$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 finance a,doh.wa.zov.
Exhibit A,Statement of Work Page 3 of 3 Contract Number CLH32053-Amendment 9
Page 37 of 50
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) 4 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through June 30,2026 ® State ® FFATA(Transparency Act) ❑ Fixed Price
❑ Other E 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 1-5 of the contract,which runs January 1,2022—March 31,2027.
For state funding,due dates after June 30,2026 are for reporting only.LHJs may not bill under this contract for work done after June 30,2026.
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$21,049 in FFY25 FPHPA Title X Family Planning funds for the period of 04/01/25-03/31/26,add$$41,664 in SFY26
Sexual and Reprouctive Health Cost Share funds for the period of 01/01/26-06/30/26,and extend the period of performance through June 30,2026.
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 21,049 38,072
SFY26 SEXUAL&REP HLTH COST SHARE _ 78431160 N/A 334.04.91 07/01/25 12/31/25 47,404 0 47,404
SFY26 SEXUAL&REP HLTH COST SHARE 78431160 N/A 334.04.91 01/01/26 06/30/26 0 41,664 41,664
0 0 0
TOTALS 129,386 62,713 192,099
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 9
Page 38 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
state and federal laws.Also see Program DOH will authorize
Manual,Handbook,Policy References under • Other data and documentation in format requested by payment only upon
Reporting Requirements(below). DOH. (Includes copies of program and financial audits satisfactory completion
and reviews including summaries conducted by other and acceptance of
B. Complete required Agency Information entities.) deliverables and for
Request including Title X Assurance of
allowable costs as
Compliance and National Provider Identifier • Site review directed by DOH SRHP. Follow-up site outlined in the statement
(NPI)billing numbers visits as needed until identified issues are resolved. of work and/or budget.
*SEE INVOICES and
C. Provide medical services,community • Submit documentation to DOH SRHP as requested for PAYMENTS that
education and outreach,and staff training, a desk review prior to site visit.
consistent with state requirements: follows this table for
• Appropriate staff and documentation readily available details.
1. LHJ is responsible for making sure all to DOH SRHP prior to and during site visit.
staff have the knowledge to carry out Payment is limited to the
the requirements of the SOW. maximum funds
available for funding
2. Medical,laboratory,and other services source. DOH will
related to abortion are not covered by reimburse for actual
this task. allowable costs as
3. Community education services must be calculatedthe R&E
(s workbook
based on the needs of the community. (see
LHJ must have an Information& Reporting Requirements
Education(I&E)committee with five table)
(5)or more members that is broadly
representative of the population or All services must be
community for which materials are billed within 40 days of
intended.The committee must review a the budget period,60
batch of patient-facing materials days for all other billing.
annually(at least 15 products or 15%of Specific dates noted in
the total number of materials,whichever
Reporting Requirements,
is smaller);meet at least annually and Activity 5,Revenue and
establish a written record of its Expense Reports.
determination.(42 CFR 59[59.6])
4. Outreach is to ensure all populations in
your community understand the services
available.Focus your outreach efforts
on increasing equity.
Exhibit A, Statement of Work Page 2 of 8 Contract Number CLH32053-Amendment 9
Page 39 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Washington State Sexual and
Reproductive Health Network priority
populations are:
• Teens
• People who are uninsured or
underinsured,and/or low-
income(at or below 250%of
the federal poverty line)
• Rural communities
• Hispanic
• Black,Indigenous,People of
Color
Extra efforts should be made to provide
information and services to people who
intersect with multiple priority
population 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 CVR data submitted to DOH data contractor(Ahlers& The 15th of the following
each family planning clinic visit as defined Associates)electronically in a format compatible with month. Within thirty(30)
in the SRH CVR Manual. Ahlers software. days of receiving
1. Maintain a computer system that
includes safety precautions against loss error/rejection report or
of information. • Data for each month request from DOH Sexual
2. Ensure data entry personnel protect and Reproductive Health
confidentiality of CVR data. • Corrected CVR data data manager.
3. Have ability to retrieve all information
for auditing and monitoring by DOH or
its designee.
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.
Exhibit A, Statement of Work Page 3 of 8 Contract Number CLH32053-Amendment 9
Page 40 of 50
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 30(h during each year of
all members of the SRHP Network to ensure this contract. Requested information will include: AND
accurate records of LHJ's organization and the
services it provides. Information about your agency contacts and your As needed or requested to
organization's staffing maintain accuracy of
In addition,elements of this report allow DOH to A. Head of Organization information.
ensure that SRHP&Title X requirements B. Head of Finance
including client fees and required services are C. Medical Director
met.The updated information also assists DOH D. NPI numbers used to bill Medicaid
to manage this SOW and the Sexual& E. The following(one person might fill more than one
Reproductive Health Network as a whole. role)
a. Contract Coordinator
b. Clinical representative
c. Billing contact
d. Outreach and education contact
e. Contact for CVR data
f. Contact for EHR information
Information regarding sexual and reproductive health
related services offered at each clinic site:
A. Cost analysis:How LHJ determines what it costs
to provide services. LHJ uses this to help construct
its fee schedule.A cost analysis must be
performed by LHJ within three years prior to the
start date of this SOW.If contractor cost analysis
was approved by DOH at the beginning of the
contract period,LHJ does not have to resubmit
unless changes are made.LHJ must email DOH
contract manager informing them that no changes
were made.
Exhibit A, Statement of Work Page 4 of 8 Contract Number CLH32053-Amendment 9
Page 41 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
B. Sliding fee schedule that includes all services
required in the SRH Manual.Additional SRH-
related services as outlined in Task 1 may also be
included on LHJ's sliding fee schedule.
a. Sliding fee schedule must be based on cost
analysis described above.
b. Fee schedule must be resubmitted for
reapproval anytime there are any significant
changes,which may include changing of
services,fees,etc.
c. LHJ must not implement a revised fee
schedule until it has been approved in writing
by DOH.
d. Income conversion tables must be updated Submit an updated
annually and approved by DOH income conversion table
by March 15 of each year
Information related to current Community Outreach Plan: of the contract.
LHJ's community outreach plan follows a 5-year cycle.
This process must include the following steps:
A. Utilize the state level priority populations,county
level demographic data,and agency profile to
identify unmet need in the community served.
B. Determine objectives and activities to expand
sexual and reproductive health to reach
populations in need of services in the community
served.
C. Measure completion of the objectives and
activities.
2 Program Updates This information must be reported using the template During quarterly check
or format provided by DOH. It will include information ins and as requested by
Summary of ongoing activities related to the SRH about contractor's work during current and past DOH
Program.This informs quality improvement of SOWs:
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 9
Page 42 of 50
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.
h ttps://www.doh.wa.gov/Portals/1/Doc um ents/Pu bs/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 9
Page 43 of 50
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 financena,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
Program Manual,Handbook,Policy References:
LHJ must comply with all state,federal,DOH SRHP,and Title X requirements,policies,and regulations and with their DOH approved Agency Information Dashboard.
Reference documents include:
• DOH SRHP Manual(DOH publication 930-122,available at 930-122-FPRHManualComplete.pdf(wa.gov)Some provisions of this manual are highlighted in this SOW,
but all provisions of the manual must be complied with.
• Clinic Visit Record Manual(https://doh.wa.gov/sites/default/files/2024-10/930-139-CVRManual.pdf)
• LHJ's approved Agency Information Request.
Billing Requirements:
See Payment column of Tasks and Deliverables table and R&E report description in Reporting Requirements table
Billing must be based on a current cost analysis approved by DOH(see Reporting Requirements table).
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 budget/funding
period(s)that end during the contract period of performance.DOH must receive correct and complete FINAL invoices no later than 45 days after the contract expiration date.
Invoices must reference the contract number and provide detailed information as required.All invoices must be approved by DOH prior to payment;approval will not be
unreasonably withheld.
DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for allowable costs as outlined in the statement of work and/or budget.DOH
will return all incorrect or incomplete invoices and will not pay for services that occur outside the period of performance.The Contractor will not invoice for services if they are
entitled to payment,have been,or will be paid,by any other source for that service.
DOH will issue payment within 30 days of receiving a correct and complete invoice and approving the deliverable(s).Late invoices will be paid at the discretion of DOH and are
contingent upon the availability of funds.Failure to submit a properly completed IRS form W-9 may result in delayed payments.
Exhibit A, Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment 9
Page 44 of 50
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.
DOH will reimburse for:
• Actual allowable costs according to your approved cost analysis(see Reporting Requirements table)and as calculated by the R&E workbook.
Special Instructions:
Accessibility of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to priority populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible,services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal, State,and local governments,including local fire,building,and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis.Acceptance of SRH services must not be a prerequisite to eligibility for,or receipt of,services in any non-SRH
programs of the LHJ.
Availability of Emer!ency 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 9
Page 45 of 50
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) 4 Funding Source Federal Compliance Type of Payment
Z Federal Subrecipient (check if applicable) Z Reimbursement
Period of Performance: January 1,2025 through December 31,2027 ❑ State ® FFATA(Transparency Act) ❑ 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 add funds to FFY26 WIC CLIENT SVS CONTRACTS USDA,reduce FFY25 BRSTFDG PEER CN PR MGMT USDA,and revise 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 USDA WIC CLIENT SVS CONTRACTS 76101251 10.557 333.10.55 01/01/25 09/30/25 144,669 0 144,669
FFY24 BRSTFDG PEER CN PR MGMT USDA 7621424A 10.557 333.10.55 01/01/25 09/30/26 6,061 0 6,061
FFY25 BRSTFDG PEER CN PR MGMT USDA 76214250 10.557 333.10.55 01/01/25 09/30/27 22,177 -722 21,455
FFY25 FARM MKT NTR PROG MGMT USDA 76540251 10.572 333.10.57 01/01/25 09/30/25 637 0 637
FFY26 WIC CLIENT SVS CONTRACTS USDA 76101261 10.557 333.10.55 10/01/25 09/30/26 0 14,563 14,563
0 0 0
TOTALS 173,544 13,841 187,385
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
2. Reallocations are necessary to redistribute caseload through September 2026=
statewide. 300
3. Caseload declines.
Exhibit A,Statement of Work Page 1 of 6 Contract Number CLH32053-Amendment 9
Page 46 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
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
See"Billing
2 Breastfeeding Promotion 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. Documentation must be available for
• Work with employers who likely employ low-income review by WIC monitor staff. Biennial WIC Monitor
people to create worksite environments that support
breastfeeding.
Exhibit A,Statement of Work Page 2 of 6 Contract Number CLH32053-Amendment 9
Page 47 of 50
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• 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 Biennial WIC Monitor
30 of the current year. benefits were issued. Set the end date to
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.
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
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
Exhibit A,Statement of Work Page 3 of 6 Contract Number CLH32053-Amendment 9
Page 48 of 50
• 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(i.e.,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.
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
Exhibit A,Statement of Work Page 4 of 6 Contract Number CLH32053-Amendment 9
Page 49 of 50
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 financial 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."
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
Exhibit A,Statement of Work Page 5 of 6 Contract Number CLH32053-Amendment 9
Page 50 of 50
October 1,2025,through September 30,2026
October 1,2026,through September 30,2027
October 1,2027,through December 31,2027
2. Billing Information:
a. Billings are submitted on an A19-IA invoice. These invoices are provided by the Department in the WIC Budget Workbook and include accounting codes for different
budget categories.
b. A19s are submitted monthly and must be received by the Department within 30 68 days following the close of each calendar month.Additional Al 9s may be submitted at
any time but must be received within 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.
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 6 of 6 Contract Number CLH32053-Amendment 9
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:
'.ta9468$41a2d94d3eak0ac7tb 32e4d7c
►� Adds Statements of Work for the following programs:
OSS LMP Implementation -Effective July I,2025
® Amends Statements of Work for the following programs:
OSS LMP Implementation -Effective January I,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:
41 Increase of$71,556 for a revised maximum consideration of$5,807,609.
❑ Decrease of for a revised maximum consideration of .
E 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
-, � /0 /2 _, 10/07/2025
ei ' ,isenhour,Chair Date Date
APPROVED TO FORM ONLY APPROVED AS TO FORM ONLY
' :` Assistant Attorney General
j 404i for 09129/7025
`Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney Page 1 of I
CC-25-ool•as
EXHIBIT B-8 Page 2 of 17
Jefferson County Public Health ALLOCATIONS Contract Number:0 CL1132053
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# I.ist#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY25 USDA BFPC Prog Mgmt 7WA700WAI Amd 8 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 ($6,061) S22,177 $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) S0
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 09/3025 (S3,448) $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) 0IJ74301 Amd 2 66.472 333.66.47 03/01/25 10/31/25 01/01/25 11/30/25 S13,500 S13,500 S13,500
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 BPI-CDC-LHJ Partners NU90TU000055 Amd 1 93.069 333.93.06 01/01/25 06/30/25 07/01/24 06/30/25 S13,754 $13,754
FFY24 OD2A OID CDC Prevent NU17CE010218 Amid 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 NU 17CE010218 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 PPHFOps NH231P922619 Amd I 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 S15,580
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 I 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 YRI 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 1 of 3
EXHIBIT B-8 Page 3 of 17
Jefferson County Public Health ALLOCATIONS Contract Number: ('1.1132053
Contract Term:2025-2027 Date: September 1,2025
Indirect Rate January 1,2025 through December 31,2025:27.38%Public Health
DO11 Use Only
BARS Statement of Work Chart of Accounts Funding ('hart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# I,ist#* 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 I 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 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 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 $36.611 $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) 525,018
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 $8,763 518,002
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-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
YRI Stimulus-Local Asst(10%of15%)SS Amd6 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 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 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-8 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 1 N/A 346.26.66 01/01/25 06/30/25 07/01/23 06/30/25 $1,000
TOTAL 55,807,609 S5,807,609
Total consideration: S5,736,053 GRAND TOTAL S5,807,609
S71,556
GRAND TOTAL 55,807,609 Total Fed S643,638
Total State S5,163,971
*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
0 Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through June 30,2025 ® State El FFATA(Transparency Act) ❑ 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
Index Listing Revenue LHJ Funding Period Current Change Total
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(e.g.,"OSS compliance") Units StartingTargets
(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 tinancea,doh.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) ❑ 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
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
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 26701 170 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.
Units Starting
Description(e.g.,"OSS compliance") (e.g."systems") Amount Targets
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.
I 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)hem een
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 finance(udoh.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) ❑ 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
See"Billing
1 WIC Nutrition Program 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 I 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
See"Billing
2 Breastfeeding Promotion 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 FAINP benefits to eligible WIC participants by September Document in a Family Alert that FMNP
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
F1.1NP benefits at authorised farmers markets and farm stores. alert to dismiss at the end of the season. All sent by Oct. 1,2025 and
by Oct. 1.2026
:tio., Program benefts t and by Oct. 1.2027
el 'une an`i September 30 of chock registers to State WIC office on a
current year. Biennial WIC Monitor
pods
review by WIC monitor staff.
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.Qov 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(i.e.,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 financial 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. A19s 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 64 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 112144
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATE!)CONTRACT
CONTRACT NUMBER: CLR32053 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"LW",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:
Into." w .s / ' a c i 't /h xh- d da2d4443C/180a .ti1:0 t17,
® 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 52,446,631 for a revised maximum consideration of$5.736,053,
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations are attached only for informational purposes.
3. Exhibit C Federal Grant Awards Index,incorporated by this reference,and located in the ConCon, Funding&BARS library at
the URL provided above.
Unless designated otherwise herein,the effective date of this amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force and effect.
IN WITNESS WHEREOF,the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
409/09/2025
Heidi Eisenhour,Chair Date Date
APPROVED A$ FORM ONLY APPROVED AS TO FORM ONLY
Assistant Attorney General
- for 08/22/2025
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
CC-25-051-A7 Page 1 of 1
EXHIBIT B-7 Page 2 of 44
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: August 1,2025
Indirect Rate January 1,2025 through December 31,2025:27.38%Public Health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal
Total
FFY25 USDA BFPC Prog Mgmt 7WA700WA1 Amd 4 10.557 333.10.55 01/01/25 09/30/26 10/01/24 09/30/26 $28,238 $28,238 $28,238
FFY24 USDA BFPC Prog Mgmt 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 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
FFY25 PIJEP BP2-CDC-1.,IJ,J Partners NU9OTU000055 Mud 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 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 NUI7CE010218 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 1,7 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 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 S150,300
FFY25 HRSA MCHBG LHJ Contracts B04MC54583 Amd l 93.994 333.93.99 01/01/25 09/30/25 10/01/24 09/30/25 $27,525 $27,525 $27,525
FFY26131CHBG LHJ Contracts HRSA YR1 NCA Not Received Amd 7 93.994 333,93.99 10/01/25 09/30/26 10/01/25 09/30126 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 S59,000 $59,000
SFY26 Sch Based filth 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
SFY25 DUH Naloxone DDO HCA JAR 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
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 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
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 S40,250 $40,250
SFY26 Sexual&Rep filth Cost Share ,1nrd 7 NIA 334.04.91 07/01/25 12/31/25 07//01125 06/30/26 547.404 S47.404 $95,397
SFY25 Sexual&Rep Hlth Cost Share Amd I 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 LH1 Opioid Campaign Proviso Amd I 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 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 01/01/25 06/30/25 07/01/24 06/30/25 ($1,363) $9,239 $9,239
SFY25 Wastewater Management-GFS Amd 3 N/A 334.04.93 01/01/25 06/30/25 07/01/24 06/30/25 $10,602
SFY26 FPHS-I,H,1 Funds-GFS irnd', \:A 336.04.25 07/01/25 06/30/26 07/01/25 06/30/26 $2,203,00(1 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 $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 Fccs 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 31,2025:2738%Public Health
DOH use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Fending 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 55,736,053
Total consideration: 53,289,422 GRAND TOTAL 55,736,053
52,446,631
GRAND TOTAL $5,736,053
Total Fed 5647,086
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 El 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
Index Listing Revenue LHJ Funding Period Current Change Total
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 Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Participate in public health emergency preparedness and response activities for COVID-19.This may include surveillance,epidemiology,laboratory capacity,infection control,
mitigation,communications and/or other preparedness and response activities for COVID-19.
Examples of key activities include:
• Incident management for the response
• Testing
• Case Investigation/Contact Tracing
• Sustainable isolation and quarantine
• Care coordination
• Surge management
• Data reporting
Exhibit A,Statement of Work Page 1 of 6 Contract Number CLH32053-Amendment 7
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 12/31/25
must conduct the following activities in accordance with the Quarterly performance fr.=34=2)5
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 t of 44
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Work with DOH to develop a corrective action
plan if unable to meet metrics.
ii. Case investigation
1. Strive to maintain the capacity to conduct
targeted investigations as appropriate.
2. Enter all case investigation and outbreak data in Enter all case investigation data in WDRS
WDRS following DOH guidance. following guidance from-DOH.
a) Strive to enter all case investigation and
outbreak data into CREST as directed by
DOH.
b) Ensure all staff designated to utilize WDRS
have access and are trained in the system.
c) Include if new positive cases are tied to a
known existing positive case or indicate
community spread.
d) Conduct targeted case investigation and
monitor outbreaks.
e) Coordinate with Tribal partners in
conducting case investigations for tribal
members.
3. Ensure contact tracing and case investigation
activities meet DOH Case and Contact Tracing
Metrics.(Metrics to be determined
collaboratively by DOH,LHJs,and Tribes.)
Work with DOH to develop a corrective action
plan if unable to meet metrics.
b. Testing
i. Work with partners and Tribes to ensure testing is
available to every person within the jurisdiction
meeting current DOH criteria for testing and other
local testing needs.
ii. Work with partners and Tribes to ensure testing is
provided in a culturally and linguistically responsive
manner with an emphasis on making testing
available to disproportionately impacted
communities and as a part of the jurisdiction's
contact tracing strategy.
iii. Maintain a current list of entities providing COVID- Maintain a current list of entities
19 testing and at what volume. Provide reports to providing COVID-19 testing and at what
DOH on testing locations and volume as requested. volume.Provide reports to DOH Contract
manager on testing locations and volume
as requested.
Exhibit A,Statement of Work Page 3 of 6 Contract Number CLH32053-Amendment 7
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
Page9of44
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 I&Q quarantine,and confirmation of
operations identified and confirmed.This location appropriate planning and coordination as
should be sufficient for supporting I&Q services that required.
are adequate for the population for your jurisdiction
and have an ability to expand if needed.This can be
through contract/formal agreement;alternatively,the
jurisdiction may establish with an adjacent
jurisdiction a formal agreement to provide the
isolation and quarantine capacity adequate to the
population for your jurisdiction with the ability to
expand.
ii. Maintain ongoing census data for isolation and Report census numbers to include historic
quarantine for your population. total by month and monthly total for
current quarter to date
Exhibit A,Statement of Work Page 5 of 6 Contract Number CLH32053-Amendment 7
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(idoh.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.ov 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.govRtrants/documents/General-Terrns-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 A19-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
E Federal<Select One> (check if applicable) ❑ Reimbursement
Period of Performance: July 1,2025 through June 30,2026 El State ❑FFATA(Transparency Act) ®Periodic Distribution
❑ 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 ProgramSpecific See below in ProgramSee below in Program
2 P h — P Specific Specific Requirements- $60,000
Requirements—Activity Special Instructions for details Requirements-Deliverables Deliverables
Assessment—CHA/CHIP—See below in Program Specific Requirements See below in ProgramSee below in Program
3 p q Specific Specific Requirements- $30,000
—Activity Special Instructions for details Requirements-Deliverables Deliverables
Lifecourse-NEW SFY 24 Full Lifecourse Workforce Capacity—See See below in Program Specific See below in Program
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
5 See below in ProgramSpecific Requirements—ActivitySpecial See below in Program Specific
p q P Requirements-Deliverables Specific Requirements- $75,000
Instructions for details Deliverables
EPH-NEW SFY 24 Fully fund Environmental Public Health Policy& See below in Program
See below in Program Specific
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
10 and Capability See below in ProgramSee below in Program Specific
p ty— Specific Requirements—Activity Requirements-Deliverables Specific Requirements- $178,000
Special Instructions for details Deliverables
_Special
—Shared Regional Epidemiology—General See below in Program
See below in Program Specific
11 (Assessment/Surveillance,CHA/CHIP)—See below in Program Specific Requirements-Deliverables Specific Requirements- $150,000
Requirements—Activi S S.-cial Instructions for details Deliverables
EPH-NEW SFY 24 Social Work Support—See below in Program See below in 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
See below in Program Specific
15 below in Program Specific Requirements—Activity Special Instructions for Requirements Deliverables Specific Requirements- $63,000
details 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 finance a;doh.wa.cov.
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 LHJ questions about the use of funds:
o Chris Goodwin,FPHS Policy Advisor,WSALPHO—cgoodwinl)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—hstectelry sac.or2,564-200-3171
The intent of FPHS funding is outlined in RCW 43.70.512.
Foundational Public Health Services Definitions and related information can be found here: ww w.doh.wa.gov/tphs.
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.eov!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
FP11S Steering Committee Consensus Decision Making Nilotic!
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 FPHS Available in Own Jurisdiction
12. EPH-NEW SFY 24 Social Work Support(FPHS definitions B.1-3,B.6-7,D.1,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
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to support local interventions that impact the target population of the Maternal and Child Health
Block Grant.
Revision Purpose: The purpose of this revision is to provide additional funding,add activities and deliverable due dates,and extend the period of performance and funding
period from September 30,2025 to September 30,2026,for continuation of MCHBG related activities,and update Program Specific Requirements.
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 YR1 78101261 93.994 333.93.99 10/01/25 09/30/26 0 36,700 36,700
0 0 0
- 0 0 0
'0 0 0
0 0 0
TOTALS 27,525 36,700 64,225
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Maternal and Child Health Block Grant(MCHBG)Administration
l 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
Ic 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
it Report actual expenditures for October 1, 2024 through Submit actual expenditures using the MCHBG December 5,2025 See Program Specific
September 30, 2025. Budget Workbook to DOH Community Requirements and Special
Consultant. Billing Requirements.
it 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 DON Community
Consultant.
if. Report annual FTE billed to MCHBG. Submit FTE information on DOH-provided July 1. 2026
template.
Ig Develop 2026-2027 MCHBG Budget Workbookfor Submit MCHBG Budget Workbook to DOH September 4, 2026
October 1, 2026 through September 30,2027 using Community Consultant.
DOH provided template.
Ili Participate in DON-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.
2E Report 2025-26 MCHBG-fiurded activities and Submit monthly reports to DOH Community September report due
outcomes using DOH provided reporting template.As a Consultant. Describe in your updates within October 15, 2025
foundation of your MCHBG work determine how each activity of the monthly report how you November 15. 2025
processes and programs can close gaps in health are intentionally.focused on closing gaps in December 15, 2025
outcomes. health outcomes. January 15, 2026
February 15, 2026
March 15, 2026
April 15, 2026
May 15, 2026
June 15, 2026
July 15, 2026
August 15, 2026
_ September 15, 2026
Exhibit A,Statement of Work Page 2 of 5 Contract Number CLH32053-Amendment 7
Page 20 of 44
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
2d Develop 2026-27 MCHBG Monthly Reporting Template Submit MC IBG reporting document to DO/I Draft--August 14, 2026
tar October 1, 2026 through September 30, 2027 using Community Consultant. Final September 11,2026
DOH-provided template.
Children and Youth with Special Health Care Needs(CYSHCN)
3a Complete intake and renewal,per reporting guidance Submit data to DOH per CYSHCN Program January 15,2025 Reimbursement for actual
supplied by DOH,on all infants and children served by guidance. April 15,2025 costs,not to exceed total
the CYSHCN Program as referenced in CYSHCN July 15,2025 funding consideration.
Program guidance.If no CYSHCN care coordination Monthly Reports must only
(enabling service)is provided in a given quarter,email reflect activities paid for
the CHIP administrator at DOH-CI-IIF0I doh.wa.{ov 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 17 rough 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 13, 202.
supplied by DOH, on all infants and children served by guidance. January 15. 2026
the CYSHCN Program as referenced in CYSHC/V April 15,2026
Program guidance. If no CYSHCN care coordination July 15, 2026
(enabling service)is provided in a given quarter, email
the CHIP administrator at DOH-C111F(a)dolt.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 ParentHelp123.org Document in the Aclnrinistrative box on your September 30, 2026
annually jar 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 CISHCNprogram
with WithinReach/lfelp Me Grow.
_i,,> 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 CYSIICN. Refer to the Focus of Work November 15, 2025
document for example activities and priority areas. December 15, 2025
January 15, 2026
February 15, 2026
March 15,2026
April 15,2026
May 15, 2026
June 15, 2026
July 15, 2026
August 15, 2026
September 15, 2026
MCHBG Assessment and Evaluation
4a As part of the ongoing 5-year MCHBG Needs Submit documentation as requested by DOH. September 30,2025 Reimbursement for actual
Assessment,participate in activities developed and costs,not to exceed total
coordinated by DOH using DOH-provided reporting funding consideration.
template. Monthly Reports must only
1b Provide summary of outcome:of.11CHBG 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
r,':'5 using DOH-provided reporting template. statement of work for the
tis part of-the ongoing 5-year A1CHBG Needs Submit documentation as requested by DOH. September 3a. 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 SharePoiin site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financc(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 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 USASLending.gov 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:
C4 l t-;ttr1 °iautb b-St al-l-1ea4t#r12are Needs W #eta A::
14ealth Setmees-Atttiterizaiseo 4 448Afizorm
Children and Youth tiith ral Health Care r c .< ; ft Itebsitenta.froo
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 A19-1A 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 pc-approved Bbudget If 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 ❑ State ®FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work is to establish funding and tasks for LHJs to strengthen their capacity and capability around the Public
Health Response Readiness Framework(CDC)to prepare for,respond to,and recover from public health threats and emergencies through a continuous cycle of planning,
organizing,training,equipping,exercising,evaluating,and implementing corrective actions as described in the Public Health Emergency Preparedness(PREP)Cooperative
Agreement.Many LHJs support a position responsible for public health emergency preparedness and response.LHJs use different titles for these positions.DOH wants to be
respectful of this diversity and refers to the people who fill these important roles as Public Health Emergency Response Coordinators.
This statement of work includes a partial allocation of PHEP funds because DOH has received a partial allocation from the CDC.DOH will add the remaining funds to the
statement of work when they are received.If they are not received,DOH will review the statement of work and adjust actvities as needed.
Guidance Documents-LHJs are strongly encouraged to use the Guidance Documents listed in the Program Specific Requirements in the bottom section of this Statement of Work.
Revision Purpose: NA
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 PHEP BP2-CDC-LHJ PARTNERS 31602254 93.069 333.93.06 07/01/25 06/30/26 0 19,527 19,527
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 19,527 19,527
Task 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 BP1 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
PHEP FFY24 BPI 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.
PHEP funding may be used to support additional public health
emergency response trainings identified by the LHJ.
6 Exercising
Both state and local health departments follow the Homeland Security Exercise and Evaluation Program(HSEEP)principles.Assessing the
effectiveness of our emergency response plans and the training of those who might respond to the public health impacts of disasters,is a core
component of the preparedness cycle.The act of exercising combined with the learning as demonstrated by an After-Action Report(AAR)
drives future planning and training.It is DOH's responsibility to meet the exercise requirements under our CDC PREP Cooperative Agreement.
DOH uses the Multi-Year Preparedness Activities Calendar(MYPAC)to demonstrate that sub-recipients of the PREP funding are participating
in,or leading exercises.Local Jurisdictions and Tribes may use PREP funding for any exercise that furthers their preparedness.
6.1 If DOH participation is requested,complete the WA DOH Exercise Exercise Notification Form As soon as the LHJ is
Notification Form prior to conducting an exercise that was not aware of the exercise
previously identified in the LHJ's MYPAC or led by DOH. date and details.
6.2 Conduct,or participate in,at least one emergency response exercise by Submit a Completed After-Action For AARs that the LHJ
June 30,2026. Report/Improvement Plan(AAR/IP) are responsible for,90
days after exercise
LHJs should coordinate preparedness exercises with local partners, completion.For others,
including Tribes,emergency management,healthcare facilities,and when the AAR is
first responder agencies.Participation in exercises hosted by other publicly available.
organizations within the jurisdiction or geographic region is also
strongly encouraged to support regional coordination and strengthen
multi-agency response capabilities.
Note:A real-world response would meet this deliverable.
7 Public Health Emergency Response Planning
A core component of every public health preparedness and response program is maintaining an up-to-date and complete emergency response
plan that describes how the jurisdiction will respond to the public health impacts of the most likely threats faced by the jurisdiction.
7.1 Update or develop LHJ identified sections of the Comprehensive Describe progress to date in the mid-year December 31,2025
Emergency Response Plan addressing gaps/needs identified from an report on template provided by DOH. June 30,2026
After Action Report from an exercise or a real world response
Exhibit A,Statement of Work Page 3 of 10 Contract Number CLH32053-Amendment 7
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.gov for any incident that involves the activation of
emergency response plans and/or the implementation of an incident
command structure.
Exhibit A,Statement of Work Page 4 of 10 Contract Number CLH32053-Amendment 7
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 29of44
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,optimises 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 PREP workforce is essential for ensuring operational readiness and effective emergency response.Ongoing
participation in communities of practice fosters shared learning,supports the dissemination of best practices,and strengthens workforce
competencies needed to execute critical public health preparedness functions.
15.1 Engage in at least one community of practice(CoP)group that Mid-and end-of-year reports on template December 31,2025
identifies problems,solutions,and best practices in public health provided by DOH.
emergency preparedness.This can be a community of practice led by June 30,2026
DOH,CDC,or Northwest Center for Evidence-Based Public Health
Emergency Preparedness and Response.
Note:Attending the MCM CoP(Task 16.2)meets this activity also.
16 Medical Countermeasures—All LHJs,including non-Cities Readiness Initiative(CRI)*LHJs,must be able to meet medical countermeasure
(MCM)capabilities to ensure timely protection of their communities during public health emergencies.Building and maintaining this capability
supports equitable access to life-saving interventions and strengthens the overall statewide response system.
*Non-CRI LHJs are LHJs that do not receive Cities Readiness Initiative(CRI)funding.In Washington State,the LHJs that receive CRI funding
are Clark County Public Health,Public Health—Seattle&King County,Snohomish County Health Department,and Tacoma—Pierce County
Health Department.
16.1 Update MCM plan between July 1,2025,and June 30,2026,to reflect Updated MCM plan(submit once by December 31,2025
current capabilities,procedures,and resources,to demonstrate ongoing June 30,2026,or sooner). June 30,2026
medical countermeasure(MCM)readiness.
If the Plan is not submitted by
If the MCM plan does not include jurisdiction's ability to receive, December 31,2025,describe progress to
stage,store,and distribute MCM,provide a comprehensive date in the mid-year report on template
supplemental report on these capabilities.This report should include: provided by DOH.
• The process for receiving,staging,storing,and distributing
MCM. End-of-year report on template provided
by DOH.
16.2 Attend one of the MCM quarterly meetings for the non-CRI LHJs and Mid-and end-of-year reports on template December 31,2025
one MCM community of practice meeting throughout the performance provided by DOH.
period. June 30,2026
Note:Participation in the MCM community of practice also meets the
requirement of Task 15.1.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance<udoh.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 USA pending.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 Al 9-lA 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) Z Reimbursement
Period of Performance: July 1,2025 through June 30,2026 El State ❑FFATA(Transparency Act) ❑Fixed Price
❑ Other [J 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 Current g Total
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
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.
l b 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 Payment Information
# Activity Deliverables/Outcomes Due Date/Time Frame 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
Rage 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 fnanceer aAdoh.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) 0 Fixed Price
0 Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide sexual and reproductive health services(SRH)to Washington State residents.These
services will comply with all state,federal,and DOH SRHP Manual requirements.It highlights specific requirements,but all must be complied with. Budgets are based on an
approved allocation formula with funds available.
This Statement of Work spans Years 1-4 of the contract,which runs January 1,2022—March 31,2026.
For state funding,due dates after December 31,2025 are for reporting only.LHJs may not bill under this contract for work done after December 31,2025.
For federal funding,due dates after March 31,2026 are for reporting only.LHJs may not bill federal funds under this contract for work done after March 31,2026.
Revision Purpose: The purpose of this revision is to add$47,404 in Sexual and Reprouctive Health Cost Share funding for the period of 07/01/2025- 12/31/2025 and to update
billing and payment language.
Master Assistance BARS Allocation
LHJ Funding Period Chan e
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 1,01re+evv-the-right
Manual,Handbook,Policy References under • Other data and documentation in format requested by ter-wi#b#xrldrtti
Reporting Requirements(below). DOH. (Includes copies of program and financial audits trrrtil=
and reviews including summaries conducted by other +- -L-it`
B. Complete required Agency Information entities.) or-et-fr;r es-SOW
Request including Title X Assurance of fife reNnved Brie
Compliance and National Provider Identifier ..._.._.-I-efaeili T }I1;>1 ,k.t'ev3t`WS _,w li,e,;tetl eel.
(NPI)billing numbers t1r e at , le-to. _y1I- 4 ffl DOH{
• Crerrent-data is
C. Provide medical services,community ---{ ,. Lalitiate I 311 l" ,ate-vim:,- atiswc•prio - lI` s rrtiued to,...and
education and outreach,and staff training, trr,er trti,t-_mild-i y ilal3l t±+iOr..tc-artlii r ir,.4,k1 .
consistent with state requirements: dining-revit.- • AP)&irk Ili
documentation
1. LHJ is responsible for making sure all IX I{- ...i _..p riv ur_si ,:i s..apeemmired-k-DOH
staff have the knowledge to carry out { ont-il„it i- ".•• ,-tifeit444veti, has been-submitted
the requirements of the SOW. and, o:
• Site review directed by DOH SRHP. Follow-up site • Other dcliz etwhks
2. Medical,laboratory,and other services visits as needed until identified issues are resolved. have.,-been-met-
related to abortion are not covered by
this task. • Submit documentation to DON SRHP as requested for P-En
a desk review prior to site visit. ?moth +er ts
3. Community education services must be rwfilfrbk-irt=-Nerrelirrg
based on the needs of the community. . Appropriate stall and documentation readily available s ee.
• LHJ must have an Information& to DOH SRHP prior to and during site visit.
Education(I&E)committee with five D( f- ill4wi lrrer:ye-fir
(5)or more members that is broadly •
representative of the population or
community for which materials are
intended.The committee must review a totorotorrpprr
batch of patient-facing materials 14.,p r
orsting
annually(at least 15 products or 15%of Rem
the total number of materials,whichever
1)4830,
is smaller);meet at least annually and
establish a written record of its trr
determination.(42 CFR 59[59.6]) • � '
fenttri rrg-i -fhe
4. Outreach is to ensure all populations in
your community understand the services ftrrnrbet+ ,mitotflrs
reYfkti fing-tef fire
available.Focus your outreach efforts {etirrgatere r,
on increasing equity.
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 ,F remit-will-4e
Reproductive Health Network priority t trim #, :-R
populations are: , :o -it -{, '1#.-t � =
• Teens i 4-e :rt s
• People who are uninsured or l lYter}
underinsured,and/or low-
income(at or below 250%of 41/-seo-vietilwem �y
the federal poverty line)
• Rural communities Iere et-mrr.t-Fie-bill d
• Hispanic
• 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 Jbllows
• Reporting Requirements(see this table for details.
below)
D. Collect,maintain,and provide data about Payment is limited to Hu
each family planning clinic visit as defined CVR data submitted to DOH data contractor(Ahlers& The 15thof the following maximum funds
in the SRH CVR Manual. Associates)electronically in a format compatible with month.Within thirty(30) available fir.funding
1. Maintain a computer system that Ahlers software. days of receiving source. DOII will
includes safety precautions against loss error/rejection report or reimburse_ br actual
of information. • Data for each month request from DOH Sexual allowable costs as
and Reproductive Health calculated by the R&E
2. Ensure data entry personnel protect • Corrected CVR datadata
confidentiality of CVR data. manager. workbook(see Reporting
3- Have ability to retrieve all information Requirements table)
for auditing and monitoring by DOH or
its designee. All services must be
billed within 40 days of
E. Notify DOH contract manager of all: the budget period, 60
Email brieflydescribin chap e. As needed to keep
• Key staff and organizational changes. g g days for all other billing.
• Proposed clinic site additions.New information current. Specific dates noted in
clinic sites must be approved by DOH Reporting Requirements.
before offering services supported by Activity 5, Revenue and
SRHP/Title X funding. Expense Reports.
Exhibit A,Statement of Work Page 3 of 8 Contract Number CLH32053-Amendment 7
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 306 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 1 may also be
included on LHJ's sliding fee schedule.
a. Sliding fee schedule must be based on cost
analysis described above.
b. Fee schedule must be resubmitted for
reapproval anytime there are any significant
changes,which may include changing of
services,fees,etc.
c. LHJ must not implement a revised fee
schedule until it has been approved in writing
by DOH.
d. Income conversion tables must be updated Submit an updated
annually and approved by DOH income conversion table
by March 15 of each year
Information related to current Community Outreach Plan: of the contract.
LHJ's community outreach plan follows a 5-year cycle.
This process must include the following steps:
A. Utilize the state level priority populations,county
level demographic data,and agency profile to
identify unmet need in the community served.
B. Determine objectives and activities to expand
sexual and reproductive health to reach
populations in need of services in the community
served.
C. Measure completion of the objectives and
activities.
2 Program Updates This information must be reported using the template During quarterly check
or format provided by DOH.It will include information ins and as requested by
Summary of ongoing activities related to the about contractor's work during current and past DOH
SRH Program.This informs quality improvement SOWs:
of the Washington State SRH Network.
A. Community education and outreach strategies and
activities and a discussion of their effectiveness.
B. Staff training.
4 Family Planning Annual Report(FPAR) Organization-level data on clinical services emailed to Data to be collected
DOH SRH data manager annually through the end
Information DOH is requesting to develop trend Number of: of the grant(2027).
data. All information is for the calendar year A. Pap tests with an ASC or higher result
(January through December).The subsequent B. Pap tests with an HSIL or higher result
Exhibit A,Statement of Work Page 5 of 8 Contract Number CLH32053-Amendment 7
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 15`h of the following
in the Clinic Visit Record(CVR)Manual available at: month.
https:/Iwww.doh.wa.got/Portalsili[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
Page 43 of 44
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 financelrildob.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual,Handbook,Policy References:
LHJ must comply with all state,federal,DOH SRHP,and Title X requirements,policies,and regulations and with their DOH approved Agency Information Dashboard.
Reference documents include:
• DOH SRHP Manual(DOH publication 930-122,available at 930-122-FPRHManualCompletc.pdf(wa.guv)Some provisions of this manual are highlighted in this SOW,
but all provisions of the manual must be complied with.
• Clinic Visit Record Manual(blips].d lt.u.a.gm;sttesidefault}filet`2024-10J930-I39-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).
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Exhibit A,Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment 7
Page 44 of 44
DOH will-reimburse for:
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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 budget/fending period(s)that
end during the contract period of perfbrmance. DOH must receive correct and complete FINAL invoices no later than 45 days after the contract expiration date. Invoices must
reference the contract number and provide detailed information as required.All invoices must be approved by DOH prior to payment:approval will not be unreasonably withheld.
DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for allowable costs as outlined in the statement of work and/or budget. DOH
will return all incorrect or incomplete invoices and will not pay for services that occur outside the period ofperformance. 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 titnds. 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.
DOH will reimburse for.:
• Actual allowable costs according to your approved cost analysis(see Reporting Requirements table)and as calculated by the R&E workbook
Special Instructions:
Accessibility of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to priority populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible,services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal, State,and local governments,including local fire,building,and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis.Acceptance of SRH services must not be a prerequisite to eligibility for,or receipt of,services in any non-SRH
programs of the LHJ.
Availability of 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:
Sce SRHP Manual for close out requirements and resources.
Exhibit A,Statement of Work Page 8 of 8 Contract Number CLH32053-Amendment 7