HomeMy WebLinkAboutCONSENT Amend No 14 DOH 615 Sheridan Street
Port Townsend, WA 98368
c9eiTehson www.JeffersonCountyPublicHealth.org
Consent Agenda
Public Healt
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: k/1I ;
SUBJECT: Agenda Item — Consolidated Contracts Amendment #14 with the Department
of Health; January 1, 2025 — December 31, 2027; $12,233 additional
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #134
between JCPH and State of Washington Department of Health (DOH); January 1, 2025 — December 31, 2027;
additional funding of $12,233 for a total to date of $6,292,517.
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 program(s):
• Maternal & Child Health Block Grant (MCHBG) — this revision adds funding which supports interventions
that impact the target population of the MCHBG (additional funding of $12,233).
FISCAL IMPACT/COST BENEFIT ANALYSIS:
Total consideration for this Contract Amendment is $12,233. The Consolidated Contract is funded by DOH,
and comprises both Federal and State funds.
RECOMMENDATION:
JCPH Management recommends BoCC approval of Consolidated Contract Amendment #14 between JCPH and
DOH; January 1, 2025 — December 31, 2027; additional funding of $12,233.
REVIEWED BY:
5i,
Josh D. Peters, County Administrator Date
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-A14
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-25-001-A14
Contract For: Consolidated Contracts, Amendment 14 Term: 1/1/2025 - 12/31/2027
COUNTY DEPARTMENT: Public Health
Contact Person: Apple Martine
Contact Phone: x 443
Contact email: amartine@co.jefferson.wa.us
AMOUNT: $12,233 additional,for a total of$6,292,517 PROCESS' Exempt from Bid Process
Revenue: $12,233 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 COM / CE W 3 080 AND CHAPTER 42.23 RCW.
CERTIFIED: . N/A: !■ � May 13, 2026
Glenn Gilbert Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEEN DEB BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: N/A: G� May 13, 2026
Glenn Gilbert Date
STEP 3: RISK MANAGEMENT REVIEW (will be added electronically through Laserfiche):
Electronically approved by Risk Management on 5/15/2026.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 5/14/2026.
State contract--difficult to change.
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 9
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 14
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:
htlas://stateofwa.sharepoint.com/sites/doh-ofsfundi ngresources/sitepages/horne.aTy? eI:9a9.688da2d94d3ea80ac7tbe32e4d7c
❑ Adds Statements of Work for the following programs:
® Amends Statements of Work for the following programs:
Maternal & Child Health Block Grant—Effective January 1, 2025
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-14 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-13 Allocations
as follows:
® Increase of$12,233 for a revised maximum consideration of$6,292,517.
❑ 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 PUBLIC HEALTH STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
Greg Brotherton,Chair Date Date
APPROVE AS TO ORM ONLY: APPROVED AS TO FORM ONLY
I Assistant Attorney General
( (- C May 14, 2026
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
Page I of 1
CC-25.011-A 1 1
EXHIBIT B-14 Page 2 of 9
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: May 1,2026
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 11 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 $1,994 $23,449 $27,516
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)
FFY25 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WAI Amd 8 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 ($6,061)
FFY25 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 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 7WA700WA1 Amd 11 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 ($1,994) $4,067
FFY24 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 Amd 8 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 $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 $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
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 13 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $62,893 $113,693 $113,693
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 12 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $25,400
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 11 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $10,837
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 9 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $14,563
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
FFY26 Swimming Beach Act IAR(ECY) 03J18701 Amd 12 66.472 333.66.47 03/01/26 10/31/26 07/01/25 11/30/26 $8,000 $8,000 $21,500
FFY25 SWIMMING BEACH ACT IAR(ECY) 01J74301 Amd 2 66.472 333.66.47 03/01/25 10/31/25 01/01/25 11/30/25 $13,500 $13,500
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 BP1-CDC-LHJ Partners NU9OTU000055 Amd 1 93.069 333.93.06 01/01/25 06/30/25 07/01/24 06/30/25 $13,754 $13,754
FFY25 OD2A OID Prevent CDC NU17CE010218 Amd 13 93.136 333.93.1'3 09/01/25 06/30/26 09/01/25 08/31/26 $30,667 $128,667 $248,344
FFY25 OD2A OID Prevent CDC NU17CE010218 Amd 10,13 93.136 333.93.13 09/01/25 06/30/26 09/01/25 08/31/26 $98,000
FFY24 OD2A OID CDC Prevent NU17CE010218 Amd 10 93.136 333.93.13 07/01/25 08/31/25 09/01/24 08/31/25 $21,788 $38,121
FFY24 OD2A OID CDC Prevent NU17CE010218 Amd 6 93.136 333.93.13 07/01/25 08/31/25 09/01/24 08/31/25 $16,333
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 9 93.217 333.93.21 04/01/25 03/31/26 04/01/25 03/31/26 $21,049 $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 PPHF Ops NH23IP922619 Amd 1 93.268 333.93.26 01/01/25 06/30/25 07/01/23 06/30/25 $10,000 $10,000 $10,000
FFY20 ELC EDE LHJs CDC NU50CK000515 Amd 1,7 93.323 333.93.32 01/01/25 12/31/25 01/15/21 07/31/26 $15,580 $15,580 $15,580
Page 1 of 3
EXHIBIT B-14 Page 3 of 9
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: May 1,2026
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
FFY19 ELC ED Immunizations CDC NU5OCK000515 Amd 9 93.323 333.93.32 07/01/25 06/30/26 07/01/25 07/30/26 $10,000 $10,000 $10,000
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 A1-LHJ NE110E000053 Amd 9 93.967 333.93.96 01/01/25 11/30/27 12/01/22 11/30/27 $200,000 $350,300 $350,300
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
FFY25 HRSA MCHBG LHJ Contracts , B04MC54583 Amd 1 93.994 333.93.99 01/01/25 09/30/25 10/01/24 09/30/25 $27,525 $27,525 $27,525
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 YR1 B04MC55473 Amd 14 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 S12,233 S28,736 S28,736
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 Amd 13 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $7,646
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 Amd 12 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $2,140
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 Amd 11 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $6,717
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 Amd 9 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 ($36,700) $0
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 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 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
SFY25 DUH Naloxone DDO HCA IAR Amd 4 N/A 334.04.91 03/01/25 06/30/25 12/10/24 06/30/25 $15,000 $15,000 $15,000
SFY26 Drug User Health Program Amd 6 N/A 334.04.91 07/01/25 06/30/26 07/01/25 06/30/26 $80,500 $80,500 $120,750
SFY25 Drug User Health Program Amd 1 N/A 334.04.91 01/01/25 06/30/25 07/01/24 06/30/25 $40,250 $40,250
SFY26 Sexual&Rep Hlth Cost Share Amd 9 N/A 334.04.91 01/01/26 06/30/26 07/01/25 06/30/26 $41,664 $41,664 $137,061
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 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
Page 2of3
EXHIBIT B-14 Page 4 of 9
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: May 1,2026
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
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
YR 1 Stimulus- Local Asst(10%of 15%)SS Amd 12 N/A 346.26.64 01/01/25 12/31/27 07/01/23 06/30/28 $1,800 $3,850 $3,850
YR1 Stimulus-Local Asst(10%of 15%)SS Amd 11 N/A 346.26.64 01/01/25 12/31/27 07/01/23 06/30/28 $250
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
YR 28 SRF-Local Asst(15%)SS Amd 11 N/A 346.26.64 01/01/25 12/31/27 07/01/24 06/30/29 $200 $200 $200
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)
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 12 N/A 346.26.65 01/01/25 12/31/27 07/01/23 12/31/27 $1,800 $4,050 $4,050
Sanitary Survey Fees SS-State Amd 11 N/A 346.26.65 01/01/25 12/31/27 07/01/23 12/31/27 $450
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)
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
YR 1 Stimulus- Local Asst(10%of 15%)TA Amd 12 N/A 346.26.66 01/01/25 12/31/27 07/01/23 06/30/28 $1,000 $2,000 $2,000
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
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) SO
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 $6,292,517 $6,292,517
Total consideration: $6,280,284 GRAND TOTAL $6,292,517
$12,233
GRAND TOTAL $6,292,517 Total Fed S1,156,382
Total State S5,136,135
*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 9
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) 6 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through September 30, 2026 El 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 add additional FFY26 MCHBG LHJ CONTRACTS HRSA YR1 funding.
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 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 YRl 78101261 93.994 333.93.99 10/01/25 09/30/26 16,503 12,233 28,736
FFY25 MCHBG SPECIAL PR HRSA 2 7810125A 93.994 333.93.99 10/01/25 09/30/26 3,376 0 3,376
0 0 0
0 0 0
0 0 0
TOTALS 47,404 12,233 59,637
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 14
Page 6 of 9
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
I d Report actual expenditures for October 1,2024 through Submit actual expenditures using the MCHBG December 5,2025
September 30,2025. Budget Workbook to DOH Community See Program Specific
Consultant. Requirements and Special
I e 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.
1 f Report annual FTE billed to MCHBG. Submit FTE information on DOH-provided July 1,2026
template.
I g 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.
l 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 14
Page 7 of 9
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@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-CHIFAdoh.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 Help Me Grow's Document in the Administrative box on your September 30,2026
ParentHelp 123 Resource Finder annually for accuracy. MCHBG report that you have updated
Exhibit A. Statement of Work Page 3 of 5 Contract Number CLH32053-Amendment 14
Page 8 of 9
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
information on your local CYSHCN program
with WithinReach/Help Me Grow.
3g Support improvements to the local system of care Submit updates as part of monthly reporting September report due
(public health services and systems/policy,systems,and document. October 15,2025
environment)for CYSHCN.Refer to the Focus of Work November 15,2025
document for example activities and priority areas. December 15,2025
January 15,2026
February 15,2026
March 15,2026
April 15, 2026
May 15,2026
June 15,2026
July 15,2026
August 15,2026
September 15,2026
MCHBG Assessment and Evaluation
4a As part of the ongoing 5-year MCHBG Needs Submit documentation as requested by DOH. September 30,2025 Reimbursement for actual
Assessment,participate in activities developed and costs,not to exceed total
coordinated by DOH using DOH-provided reporting funding consideration.
template. Monthly Reports must only
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 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.
Exhibit A, Statement of Work Page 4 of 5 Contract Number CLH32053-Amendment 14
Page 9 of 9
Program Specific Requirements
Special Requirements:
All training costs and all travel expenses for such training(for example: per diem,hotel,registration fees)must be pre-approved,unless identified in pre-approved Budget
Workbook. Submit a paragraph to your Community Consultant explaining why the training is necessary to implement a strategy in the approved work plan. Details should also
include total cost of the training and a link to or brochure of the training. Retain a copy of the Community Consultant's approval in your records.
Program Manual,Handbook,Policy References:
CYSHCN Information and Resources:
Children and Youth with Special Health Care Needs Website(wa.gov)
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
1. At least 30%of federal Title V funds must be used for preventive and primary care services for children and at least 30%must be used for services for children with
special health care needs. [Social Security Law, Sec. 505(a)(3)].
2. Funds may not be used for:
a. Inpatient services,other than inpatient services for children with special health care needs or high-risk pregnant women and infants,and other patient services approved by
Health Resources and Services Administration(HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land,the purchase,construction,or permanent improvement of any building or other facility, or the purchase of major medical
equipment.
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. Payment for any services furnished by a provider or entity who has been excluded under Title XVIII(Medicare),Title XIX(Medicaid),or Title XX(social services block
grant).[Social Security Law, Sec 504(b)].
3. If any charges are imposed for the provision of health services using Title V(MCH Block Grant)funds, such charges will be pursuant to a public schedule of charges;will not
be imposed with respect to services provided to low-income mothers or children;and will be adjusted to reflect the income,resources,and family size of the individual
provided the services. [Social Security Law, Sec. 505(1)(D)J.
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 pre-approved Budget Workbook.
Exhibit A, Statement of Work Page 5 of 5 Contract Number CLH32053-Amendment 14
Page 1 of 27
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLU32053 AMENDMENT NUMBER: 13
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:
httos://state.fiva.sharelxoint.conllsites/doh-ofsfundinuresottrces/sitettages/home-asos? e1:9a94688da2dc)4d3ea8Oac7fbc32e=4d7c
❑ Adds Statements of Work for the following programs:
Q Amends Statements of Work for the following programs:
Infectious Disease Syndemic Prevention Services-SSP- Effective July I, 2025
Maternal & Child Health Block Grant— Effective January 1, 2025
WIC Nutrition Program - Effective January 1, 2025
El Deletes Statements of Work for the following programs:
2. Exhibit B-13 Allocations, attached and incorporated by this reference,amends and replaces Exhibit B-I2 Allocations
as follows:
Q Increase of$101,206 fora revised maximum consideration of S6,280,284.
❑ 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.
JEFFERS N COUNTY WASHINGTON STATE OF WASHINGTON
BOARD F COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
05/12/2026
rel, rot erton,Chair Da i —� Date
APPROVED AS TO FORM ONLY: APPROVED AS TO FORM ONLY
� 04/29/2026 Assistant Attorney General
fy
Jeremia . L rer, Date
Deputy Prosecuting Attorney
Page 1 of
CC-25-0I I-AI ti
EXHIBIT B-13 Page 2 of 27
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: April 1,2026
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 11 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 $1,994 $23,449 $27,516
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)
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 ($6,061)
FFY25 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 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 7WA700WA1 Amd 11 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 ($1,994) $4,067
FFY24 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 Amd 8 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 $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 $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 Mid 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 7WA700Vi a` Amd 13 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $62,893 $113,693 $113,693
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 12 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $25,400
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 11 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $10,837
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 9 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $14,563
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
FFY26 Swimming Beach Act IAR(ECY) 03J18701 Amd 12 66.472 333.66.47 03/01/26 10/31/26 07/01/25 11/30/26 $8,000 $8,000 $21,500
FFY25 SWIMMING BEACH ACT IAR(ECY) 01J74301 Mid 2 66.472 333.66.47 03/01/25 10/31/25 01/01/25 11/30/25 $13,500 $13,500
FFY25 PHEP BP2-CDC-LHJ Partners NU90TU000055 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 NU90TU000055 Amd 7 93.069 333.93.06 07/01/25 06/30/26 07/01/25 06/30/26 $19,527
FFY24 PHEP BP1-CDC-LHJ Partners NU90TU000055 Amd 1 93.069 333.93.06 01/01/25 06/30/25 07/01/24 06/30/25 $13,754 $13,754
FFY25 OD2A OID Prevent CDC NU17CE010218 Amd 13 93.136 333.93.13 09/01/25 06/30/26 09/01/25 08/31/26 $30,667 $128,667 $248,344
FFY25 OD2A OID Prevent CDC NU17CE010218 Amd 10,13 93.136 333.93.13 09/01/25 06/30/26 09/01/25 08/31/26 $98,000
FFY24 OD2A OID CDC Prevent NU17CE010218 Amd 10 93.136 333.93.13 07/01/25 08/31/25 09/01/24 08/31/25 $21,788 $38,121
FFY24 OD2A OID CDC Prevent NU17CE010218 Amd 6 93.136 333.93.13 07/01/25 08/31/25 09/01/24 08/31/25 $16,333
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 9 93.217 333.93.21 04/01/25 03/31/26 04/01/25 03/31/26 $21,049 $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 Mid 3 93.217 333.93.21 01/01/25 03/31/25 04/01/24 03/31/25 $8,345 $16,966
FFY24 FPHPA Title X Family Plan FPHPA006560 Amd 21 93.217 333.93.21 01/01/25 03/31/25 04/01/24 03/31/25 $8,621
FFY24 CDC PPHF Ops NH23IP922619 Amd 1 93.268 333.93.26 01/01/25 06/30/25 07/01/23 06/30/25 $10,000 $10,000 $10,000
FFY20 ELC EDE LHJs CDC NU50CK000515 Amd 1,7 93.323 333.93.32 01/01/25 12/31/25 01/15/21 07/31/26 $15,580 $15,580 $15,580
Page 1 of 3
EXHIBIT B-13 Page 3 of 27
Jefferson County Public health ALLOCATIONS Contract'Sumber: C1.1132053
Contract Term:2025-2027 Date: April 1,2026
Indirect Rate January 1,2025 through December 31,2025:27.38%Public Health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding ('hart of
Federal Award Assist Revenue 1.11.1 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
FFY19 ELC ED Immunizations CDC NU5OCK000515 Amd 9 93.323 333.93.32 07/01/25 06/30/26 07/01/25 07/30/26 $10,000 $10,000 $10,000
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 $200,000 $350,300 $350,300
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
FFY25 HRSA MCHBG LHJ Contracts B04MC54583 Amd 1 93.994 333.93.99 01/01/25 09/30/25 10/01/24 09/30/25 $27,525 $27,525 $27,525
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 YR1 B04MC55473 Amd 13 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $7,646 $16,503 $16,503
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 Amd 12 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $2,140
FFY26 MCHBG LHJ Contracts HRSA YRI B04MC55473 Amd 11 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $6,717
FFY26 MCHBG LHJ Contracts HRSA YRl B04MC55473 Amd 9 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 ($36,700) $0
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 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 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
SFY25 DUH Naloxone DDO HCA IAR Amd 4 N/A 334.04.91 03/01/25 06/30/25 12/10/24 06/30/25 $15,000 $15,000 $15,000
SFY26 Drug User Health Program Amd 6 N/A 334.04.91 07/01/25 06/30/26 07/01/25 06/30/26 $80,500 $80,500 $120,750
SFY25 Drug User Health Program Amd 1 N/A 334.04.91 01/01/25 06/30/25 07/01/24 06/30/25 $40,250 $40,250
SFY26 Sexual&Rep Hlth Cost Share Amd 9 N/A 334.04.91 01/01/26 06/30/26 07/01/25 06/30/26 $41,664 $41,664 $137,061
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 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) $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
Page 2 of 3
EXHIBIT B-13 Page 4 of 27
Jefferson County Public Health ALLOCATIONS Contract Number: C1,1132053
Contract Term:2025-2027 Date: April 1,2026
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
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
YR 1 Stimulus- Local Asst(10%of 15%)SS Amd 12 N/A 346.26.64 01/01/25 12/31/27 07/01/23 06/30/28 $1,800 $3,850 $3,850
YR1 Stimulus-Local Asst(10%of 15%)SS Amd 11 N/A 346.26.64 01/01/25 12/31/27 07/01/23 06/30/28 $250
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
YR 28 SRF-Local Asst(15%)SS Amd 11 N/A 346.26.64 01/01/25 12/31/27 07/01/24 06/30/29 $200 $200 $200
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)
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 12 N/A 346.26.65 01/01/25 12/31/27 07/01/23 12/31/27 $1,800 $4,050 $4,050
Sanitary Survey Fees SS-State Amd 11 N/A 346.26.65 01/01/25 12/31/27 07/01/23 12/31/27 $450
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)
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
YR 1 Stimulus- Local Asst(10%of 15%)TA Amd 12 N/A 346.26.66 01/01/25 12/31/27 07/01/23 06/30/28 $1,000 $2,000 $2,000
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
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 $6,280,284 $6,280,284
Total consideration: $6,179,078 GRAND TOTAL $6,280,284
$101,206
GRAND TOTAL $6,280,284 Total Fed $1,144,149
Total State $5,136,135
*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 27
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Infectious Disease Syndemic Prevention Services- Local Health Jurisdiction Name: Jefferson County Public Health
SSP-Effective July 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: July 1,2025 through June 30,2026 [2] 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 Syndemic Prevention Services for infectious diseases(HIV,STI,and Adult Viral
Hepatitis), supporting the Office of Infectious Disease(OID)within Department of Health(DOH)
Revision Purpose: Add additional funds to FFY25 OD2A for a start date of 9/1/25.
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 DRUG USER HEALTH PROGRAM 12405160 N/A 334.04.91 07/01/25 06/30/26 80,500 0 80,500
FFY24 OD2A OID CDC PREVENT 12405241 93.136 333.93.13_ 07/01/25 08/31/25 38,121 0 38,121
FFY25 OD2A OID PREVENT CDC 12405252 93.136 333.93.13 09/01/25 06/30/26 98,000 30,667 128,667
0 0 0
0 0 0
0 0 0
TOTALS 216,621 30,667 247,288
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Syringe Services Programs: Support for Operations: SSP operations outcomes include delivering Enter deliverable data into the Reimbursement of
services and tracking: DOH/OID issued database for actual costs incurred,
Provide comprehensive Syringe Services Programs(SSP) • number of sterile syringes distributed tracking SSP activities by the not to exceed$80,500
to people who use drugs(PWUD). This plan of action is • number of naloxone kits distributed 15th of each month following for 07/01/25—06/30/26
directed to distribute syringes to communities that use • number of participant encounters service.
drugs to prevent transmission of infectious disease. SSPs • number of referrals to health and social
will operate during scheduled hours to provide all services
required harm reduction supplies,naloxone,and syringes
to prevent transmission of disease and overdose. SSPs Submit Performance Objectives&Work
will offer referrals to address social determinants of Plan within the first six months of contract
health. period that will include:
• Outcomes aligned with program
strategies and activities.
Exhibit A,Statement of Work Page 1 of 11 Contract Number CLH32053-Amendment 13
Page 6 of 27
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Priority populations for Syringe Services Programs • SMART objectives aligned with
include people who use drugs,with a focus on: performance targets
• People systemically marginalized and • Activities aligned with program
underserved due to racism—Black/African outcomes
American,Latino/Latina/Latine/Latinx, • Timeline for implementation(including
American Indian/Alaska Native people and staffing of the proposed program,
other communities for whom there are training,etc.)
documented health disparities in your region. • Anticipated capacity building or
• People who are unhoused or unstably housed. technical assistance needs.
• People engaged in sex work.
• People involved in the criminal legal system. NOTE: See Special Requirements,Terms
• Gender expansive/transgender individuals. and Conditions—Section 7 Performance
• Gay,bi,and other men who have sex with men. Objectives&Workplans for additional
deliverable information
NOTE: See Special Requirements,Terms and
Conditions—Section 4 Syringe Services Programs:
Support for Operations Program Requirements for
additional task information.
Syringe Services Programs:Clinical Services SSP Clinical services outcomes may
include,but are not limited to,delivering
Provide direct access to clinical services to improve the services and tracking:
health and well-being of people who use drugs.At • Number of wound care sessions
minimum,services must include onsite,low-barrier • Number of infectious disease tests
access to wound care,infectious disease testing,STI and conducted(hepatitis C,HIV,
hepatitis C treatment,and medications for opioid use gonorrhea-chlamydia,syphilis)
disorder.Additional services can include mental health • %positive of infectious disease tests
services,sexual and reproductive health care,and other (hepatitis C,HIV,gonorrhea-
primary care and psychosocial support services. chlamydia,syphilis)
• Number of participants started on
NOTE: See Special Requirements,Terms and hepatitis C treatment
Conditions—Section 6 Syringe Services Program, • Number of participants inducted on
Clinical Services Requirements for additional task medications for opioid use disorder
information.
2 Syringe Services Programs:Harm Reduction Service Harm reduction care navigation outcomes Enter deliverable data into the Reimbursement of
Navigation include delivering services and tracking: DOH/OID issued database for actual costs incurred,
• number of participants enrolled in care tracking SSP activities by the not to exceed$38,121
Provide appropriate referrals to SSP participants; navigation services 15th of each month following for
facilitate access to receive health care and medical • number of care navigation sessions service. 07/01/25—08/31/25
services,social services,behavioral health counseling and • number of referrals to health and social
other services including substance use treatment services
Exhibit A,Statement of Work Page 2 of 11 Contract Number CLH32053-Amendment 13
Page 7 of 27
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
(including medications for opiate use disorder, or • number of linkages to care for health Reimbursement of
MOUD);housing;and advocacy,including but not and social services actual costs incurred,
limited to criminal legal involvement,medical providers, • number of outreach attempts per not to exceed$984104
benefits navigation,and family reunification. participant $128,667 for 09/01/25—
06/30/26
NOTE: See Special Requirements,Terms and
Conditions—Section 5 Syringe Services Program,
Harm Reduction Care Navigation Requirement for
additional task information
3 The LHJ will engage in OD2A-S evaluation activities for Quarterly submission of collected data and Enter quarterly data into the
work completed using OD2A-S funds. Evaluation answers to qualitative questions(as it DOH/OID issued template on
activities will involve: applies to your OD2A-S activities)on a the following dates:
• As applicable,collecting data on CDC performance DOH-provided template • For reporting period
measures to support DOH evaluation plan. 9/1/25-11/30/25
o Total number of harm reduction service December 1,2025
encounters(e.g., in-person,mail,telephone, • For reporting period
online) 12/1/25-2/28/26
o Zip code where harm reduction services
March 1, 2025
were provided(list"unknown"when • For reporting period
location is unknown)
o Total number of navigators located in a 3/1/26-5/31/26
harm reduction setting or other setting June 1,2026
o Number of referrals to harm reduction • For reporting period
services for each race ethnicity 6/1/26-8/31/26
o If possible,total number of hours spent by September 1,2026
each navigator on linkage to care or referral
efforts
o Type of organization where naloxone was
distributed(SSP, faith-based organizations,
schools,etc.)
o Zip code where naloxone was distributed
(list"unknown"when unknown)
o Number of naloxone doses distributed at
each type of organization
o Number of service encounters involving
drug checking
o Zip code for drug checking encounters(list
"unknown"when unknown)
o Number of referrals to MOUD for each
race/ethnicity
Exhibit A, Statement of Work Page 3 of 11 Contract Number CLH32053-Amendment 13
Page 8 of 27
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
o Number of referrals to behavioral health
treatment only(without MOUD)for each
race/ethnicity
o Number of other referrals,if not to MOUD
and behavioral health,with a description of
the type of referral
• Providing answers to contextual performance
measures questions.
o How has access to care or treatment has
been improved,and what new/existing
community assets were leveraged?
o What are the barriers for people accessing
harm reduction services in your
jurisdiction?
o What are barriers to accessing or receiving
naloxone?
o Describe what types of navigators are
included in the data reported
o Describe methods to support navigators
• Collaborating with the DOH evaluator on a Targeted
Evaluation Project(TEP)that will provide a greater
understanding of navigation activities.
• Supporting other evaluation tasks as requested,to
meet overall CDC evaluation 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.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Special Requirements,Terms and Conditions
1. Definitions
a. ANONYMOUS SERVICES-HIV Prevention services including condom distribution,outreach and light touch.
Exhibit A,Statement of Work Page 4 of 11 Contract Number CLH32053-Amendment 13
Page 9 of 27
b. CAPACITY BUILDING-The process by which individuals and organizations obtain,improve,and retain the skills,knowledge,tools,equipment,and
other resources needed to do their jobs competently.
c. CONTRACTOR—For the purposes of this Statement of Work Only,the entity receiving funds directly from Washington State Department of Health
(DOH)for client services to prevent or treat conditions named in the statement of work will be referred to as contractor.
d. HARM REDUCTION-Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.
e. INTEGRATED TESTING-For the purpose of this Statement of Work, Integrated Testing includes Human Immunodeficiency Virus(HIV), Gonorrhea
(GC),Chlamydia(CT),Syphilis,Hepatitis C(HCV)and Hepatitis B(HBV).
f. SOCIAL DETERMINANTS OF HEALTH-Social determinants of health(SDOH)are the conditions in the environments where people are born, live,
learn,work,play,worship,and age that affect a wide range of health, functioning,and quality-of-life outcomes and risks.
g. YOUTH-For purposes of this agreement,the term"youth"applies to persons under the age of 18.
2. Submission of Invoice Vouchers—
a. On a monthly basis,the CONTRACTOR shall submit complete and correct A19 invoice vouchers with amounts billable to DOH under this statement of work
and the corresponding OID Expense Summary backup form.All A19 invoice vouchers must be submitted by the 25th of the following month. Prior approval is
required for a different frequency of billing.
i. The CONTRACTOR must provide all backup documentation as required based on the assigned risk level and/or as identified by DOH program staff
to determine allowability of billed expenses. Risk assessments are completed at the beginning of a new contract for all sub-recipient contracts.
Contact your contract manager if you are unaware of your assigned risk level.
ii. DOH may ask for additional backup information to pay invoices based on the needs of the funding sources supporting the work.
b. The CONTRACTOR shall submit all final claims for payment for costs due and payable under this statement of work by July 31,2026. DOH will pay belated
claims at its discretion,contingent upon the availability of funds.
3. Program Organization—CONTRACTOR must
a. The CONTRACTOR must provide a full updated organizational chart,including Board of Directors with contact information if applicable, and staffing plan
referencing positions described in the budget narrative.
b. The CONTRACTOR must provide job descriptions for any new or changed positions in the updated organizational chart.
i. Any new positions funded through the original contract funds,must have prior DOH approval.
c. The CONTRACTOR must notify their DOH contract manager within 30 days of any staff vacancies related to contracted positions and provide an updated
budget.
i. Any new fiscal staff responsible for invoicing on this contract will need to meet with the assigned OID Contract Manager within 60 days for DOH
invoice overview and training.
4. Syringe Services Program: Support for Operations Program Requirements
a. Operate for a minimum of 8 hours per week and 2 days per week.
b. Provide mobile and/or street outreach(note:programs must have a vehicle for mobile outreach.)
c. Offer safer injection supplies(see list of required safer injection supplies below).
d. Submit monthly SSP data in accordance with DOH standards.
e. Attend required capacity building/training opportunities provided by DOH.
f. Participate in annual site visits with DOH staff.
g. Demonstrate structure for receiving and incorporating participant feedback about services.
h. Partner with relevant local agencies to ensure effective outreach and service provision. (See Scope of Work narrative below for details on MOUs required.)
i. Develop and maintain a Universal Precautions and Sharps Handling policy and procedure,including clear,written policies on handling biohazardous waste,
avoiding unnecessary handling of sharps,and potential needle stick injuries to staff,volunteers,and participants.Programs should follow the universal precaution
guidelines established by the CDC and OSHA. SSPs may need to adapt those precautions to accommodate the circumstances of their work(e.g.,mobile and
outreach settings). Programs should also anticipate the potential of needlestick injury and have a"post-exposure-prophylaxis"protocol included in this document.
Exhibit A,Statement of Work Page 5 of 11 Contract Number CLH3 2053-Amendment 13
Page 10 of 27
j. All staff and volunteers working directly with participants/clients must complete CPR certification within the first 3 months after contract start date(if not
already complete).
5. Syringe Services Program,Harm Reduction Care Navigation Requirements
a. Includes all requirements for Syringe Service Program operations(see above)
b. Attend Harm Reduction Care Navigation training provided by DOH.
c. Support participant transportation(e.g.,through the provision of bus passes,cab vouchers,or direct transportation).
d. Accompany participants to appointments or provide"warm hand-offs."
e. Full-time care navigators(1.0 FTE) shall not exceed a case load greater than 25 individuals.
f. Submit monthly outcome data in accordance with DOH standards.
6. Syringe Services Program,Clinical Services Requirements
a. Includes all requirements for Syringe Service Program operations(see above)
b. Must have clinical staff licensed to practice in the state of Washington to provide clinical services(e.g.,RN, PA,ARNP,LCSW).
c. If providing advanced level clinical services(e.g., PA,ARNP,CNM),programs must have appropriate clinical oversight.
Note: Clinical services can be provided through sub-contractor arrangement or MOU with a Federally Qualified Health Center or other clinical
partner if there is a justification the relationship will support efforts to reach people who use drugs and provide onsite and/or mobile clinical services.
Clinical services can also be provided using telemedicine services with appropriate description of why in-person services cannot be provided and who
the telemedicine partner(s)will be.
NOTE: Funds from this contract may not be used to purchase basic safer injection supplies(listed below)—Instead,DOH will provide Contractors with supplies.
Below is the list of required supplies for SSP to be provided to Contractors by DOH:
a. Syringes(1 cc 27 gauge 1/2",28 gauge 1/2",and 29 gauge 1/2"; 1 cc 30 gauge 5/16";3 cc 25G 1"and 1.5")
b. Alcohol pads
c. Non-latex tourniquets
d. Sterile water
e. Sterile saline
f. Cookers
g. Cottons and/or cellulose filters
h. Bandages/gauze
i. Sharps containers(1 quart and 2 gallon for distribution, 8 gallon for program use)
j. Naloxone
k. Amber bags
The exceptions to these supplies are vendor or manufacturer supply shortages. If a program expects to run out of one of these items,please contact DOH immediately.
7. Performance Objectives&Work Plan:
a. Funded Syndemic Prevention Services agencies are required to submit Performance Objectives and Work Plan that provides both a high-level overview of the
period of performance and a detailed description of the first year of the contract period.The work plan should incorporate related program strategies and
activities.Applicants should propose specific,measurable,achievable,realistic,and time-based(SMART)process and/or outcome objectives for each activity
aligned with performance outcomes. The work plan should include training,capacity building,and TA needs to support the implementation of the funded
services.Proposed work plan activities may be adjusted in collaboration with OID staff to better address the overarching goals of the funded services. OID will
provide a template that must be used in developing the work plan.
b. The applicant should address the following outline in their work plan:
Exhibit A, Statement of Work Page 6 of 11 Contract Number CLH32053-Amendment 13
Page 11 of 27
i. Contract Year 2 Detailed Work Plan(For each funded service category)
ii. Program strategies and activities
iii. Outcomes aligned with program strategies and activities
iv. SMART objectives aligned with performance targets
v. Activities aligned with program outcomes
vi. Timeline for implementation(including staffing of the proposed program,training,etc.)
vii. Anticipated capacity building or technical assistance needs.
c. Performance Objectives&Work Plans should be submitted by December 31,2025.
d. OID staff are available to support in developing Performance Objectives&Work Plans in collaboration with funded agencies.
e. Performance Objectives&Work Plans will be reviewed between OID staff and funded agencies at least quarterly.Performance Objectives& Work Plans can be
adjusted throughout the period of performance.
8. Participation in program evaluation activities—The Contractor is expected to participate in program evaluation activities,including evaluation planning,and collecting
and reporting qualitative and quantitative program data,as deemed necessary by OID staff.
9. Participation in Capacity Building and Technical Assistance Activities designed to increase efficacy of Syndemic Services
a. Opportunities for capacity building and technical assistance for contractor will be offered throughout the contract year by WA DOH and other regional or
national capacity building organizations.
b. Contractors will be expected to meet with WA DOH OID staff on an annual basis to discuss training and will work with DOH to track shared completion of
Capacity Building Needs
c. All contracted staff will be required to complete training in respect to their role. DOH staff and contracted staff will work together to track completion of required
trainings.
10. CLAS Standards—The CONTRACTOR will comply with the National Standards for Culturally and Linguistically Appropriate Services(CLAS)standards(1,5-9).
National Standards for Culturally and Linguistically Appropriate Services(CLAS) in Health and Health Care(allianceforclas.org)
11. Participation in Program Monitoring Activities—
a. DOH will conduct semi-annual or annual performance site visits in the following areas:
i. Integrated testing
ii. Syndemic service navigation
iii. PrEP Housing
iv. Syringe Service Programs
v. Mail-order naloxone distribution program
vi. Fiscal Monitoring—To be scheduled by the DOH Fiscal Monitoring Unit
b. Corrective Action Plans—DOH may exercise the following options if the CONTRACTOR does not come into compliance or resolution with programmatic
and/or fiscal monitoring corrective action plan by the due date(s)identified in the CAP.i. §200.339 Remedies for noncompliance.
If a non-Federal entity fails to comply with the U.S.Constitution,Federal statutes,regulations or the terms and conditions of a Federal award,the Federal
awarding agency or pass-through entity may impose additional conditions,as described in§200.208.If the Federal awarding agency or pass-through entity
determines that noncompliance cannot be remedied by imposing additional conditions,the Federal awarding agency or pass-through entity may take one or more
of the following actions,as appropriate in the circumstances:
Exhibit A,Statement of Work Page 7 of 11 Contract Number CLH32053-Amendment 13
Page 12 of 27
(a)Temporarily withhold cash payments pending correction of the deficiency by the non-Federal entity or more severe enforcement action by the Federal
awarding agency or pass-through entity.
(b)Disallow(that is,deny both use of funds and any applicable matching credit for)all or part of the cost of the activity or action not in compliance.
(c)Wholly or partly suspend or terminate the Federal award.
(d)Initiate suspension or debarment proceedings as authorized under 2 CFR part 180 and Federal awarding agency regulations(or in the case of a pass-through
entity,recommend such a proceeding be initiated by a Federal awarding agency).
(e)Withhold further Federal awards for the project or program.
(f)Take other remedies that may be legally available
12. Contract Management—
a. Fiscal Guidance
i. Indirect-If charging indirect costs,the CONTRACTOR must have a current federally negotiated rate or De Minimis certification of file with DOH.
DOH is not able to reimburse indirect costs without an approved indirect cost rate or De Minimis certification of file.
ii. Advance Payments Prohibited—DOH funds are"cost reimbursement"funds. DOH will not make payment in advance or in anticipation of services
or supplies provided.This includes payments of"one-twelfth"of the current fiscal year's funding.
iii. Duplication of EIP Services—The CONTRACTOR shall not use contract funds to provide a parallel medication service to EIP. CONTRACTOR's
providing case management services shall make every effort to enroll clients in EIP.
iv. Payment of Cash or Checks to Clients Not Allowed—Where direct provision of service is not possible or effective,vouchers or similar programs,
which may only be exchanged for a specific service(e.g.,transportation),shall be used to meet the need for such services. CONTRACTOR shall
administer gift cards voucher programs to assure that recipients cannot readily convert vouchers into cash.
1. Store gift cards that can be redeemed at one merchant or an affiliated group of merchants for specific goods or services are allowable as
incentives for eligible program participants.
2. General-use prepaid cards are considered"cash equivalent"and are therefore unallowable. Such cards generally bear the logo of a payment
network,such as Visa,MasterCard,or American Express,and are accepted by any merchant that accepts those credit or debit cards as payment.
Gift cards that are cobranded with the logo of a payment network and the logo of a merchant or affiliated group of merchants are general-use
prepaid cards,not store gift cards,and therefore are unallowable.
3. The CONTRACTOR must ensure that a policy for managing gift cards with strong internal controls is in place.
v. Funds for Needle Exchange Programs Not Allowed with Federal Funding—CONTRACTOR shall not expend contract federal funds to support
needle exchange programs using funds from HIV Community Services Tasks.
vi. Travel—Out of staff travel requires prior approval from DOH and must follow GSA guidelines and reimbursement rates.
vii. Supervision,under DOH Community Programs contracts,will be understood as the delivery of a set of interrelated functions encompassing
administrative,educational and supportive roles that work collectively to ensure clinical staff(i.e.case managers,navigators,coordinators,assistants,
coaches)are equipped with the skills necessary to deliver competent and ethical services to clients that adhere to best practices within applicable
fields as well as all relevant Statewide Standards. Supervisors must meet the criteria set forth within the WA State HIV Case Management Standards
and provide the level of interaction and review detailed in that document.
It is the understanding of DOH that Supervision funded under the direct program portion of this contract include at minimum the provision of at least
two of the three functions detailed here:administrative,educational or supportive supervision.Supervision that encompasses only administrative
Exhibit A,Statement of Work Page 8 of 11 Contract Number CLH32053-Amendment 13
Page 13 of 27
functions will not be considered billable under Direct Program.To that end,it is the expectation of DOH that those personnel identified as Supervisors
have no more than one degree of separation from direct client care.Exceptions to this rule can be presented and considered to and by DOH Contract
Management.It will fall to the requesting organization to satisfactorily demonstrate that any Supervisory positions falling within the scope of Direct
Program are meeting the expectation of provision of educational or supportive supervision with the aim of directly impacting client experiences,
quality of services,and adherence to best practices and Statewide Standards.
viii. Small and Attractive items—Each Contractor shall perform a risk assessment(both financial and operational)on the agency's assets to identify
those assets that are particularly at risk or vulnerable to loss. Operational risks include risks associated with data security on mobile or portable
computing devices that store or have access to state data.Assets so identified that fall below the state's capitalization policy are considered small and
attractive assets.The Contractor shall develop written internal policies for managing small and attractive assets. Internal policies should take into
consideration the WaTech IT Security Standard SEC-04,which includes SEC-04-06-S Mobile Device Security Standard and SEC-04-01-G Media
Handling and Data Disposal Best Practices-https://watech.wa.gov/policies.
The Contractor shall implement specific measures to control small and attractive assets in order to minimize identified risks. Periodically,the
Contractor should perform a follow up risk assessment to determine if the additional controls implemented are effective in managing the identified
risks.
Contractor must include,at a minimum,the following assets with unit costs of$300 or more:
1. Laptops and Notebook Computers
2. Tablets and Smart Phones
Agencies must also include the following assets with unit costs of$1,000 or more:
1. Optical Devices,Binoculars,Telescopes,Infrared Viewers,and Rangefinders
2. Cameras and Photographic Projection Equipment
3. Desktop Computers(PCs)
4. Television Sets,DVD Players,Blu-ray Players,and Video Cameras(home type)
ix. Food and Refreshments—Food and refreshments are not allowable direct costs,unless provided in conjunction with allowable meetings,whose
primary purpose is the dissemination of technical information. Pre-approval is required when food and refreshments are purchased for these
meetings.A sign in sheet with the clients' ID number from the DOH approved data system as well as an agenda is required to receive reimbursement
for these charges.
1. The CONTRACTOR shall follow Healthy Nutrition Guidelines for Meetings and Events[Washington State Department of Health
when purchasing food and refreshments for approved meetings.
2. Food for staff meetings/training is unallowable.
PLEASE NOTE: If meals/refreshments are purchased for allowable meetings,food can only be
purchased for clients at the per diem rate. Any expenses over per diem will be denied. U.S. General Services Administration Per Diem
Look Up
x. Reimbursement of disallowed costs—The CONTRACTOR agrees to reimburse DOH for expenditures billed to the DOH for costs that are later
determined through audit or monitoring to be disallowed under the requirements of 2 CFR Part 200—Uniform Administrative Requirements,Cost
Principles,and Audit Requirements for Federal Audits.
Exhibit A,Statement of Work Page 9 of 11 Contract Number CLH32053-Amendment 13
Page 14 of 27
b. Contract Modifications
i. Notice of Change in Services—The CONTRACTOR shall notify DOH program staff,within 45 days,if any situations arise that may impede
implementation of the services contained in the statement of work.DOH and the CONTRACTOR will agree to strategies for resolving any shortfalls.
DOH retains the right to withhold funds in the event of substantial noncompliance.
ii. Contract Amendments—Effective Date—The CONTRACTOR shall not begin providing services authorized by a contract amendment until the
CONTRACTOR has received a signed and fully executed copy of the contract amendment from DOH.
1. Local Health Jurisdiction(LHJ)Contractors—Request for contract amendments must be received no less than 60 days prior to the Draft Due
Date identified by the CON CON SOW Schedule on the CON CON Dashboard.
2. Non-LHJ Contractors—Request for contract amendments must be received no later than 60 days prior to the end of the Federal Fiscal Year
(FFY)and 90 days prior to end of the State Fiscal Year(SFY).
a. Amendments must be signed prior to the end of the FFY or SFY end date.
EX.FFY end date is 12/31,contract amendment request due to contract manager by 11/1
13. Youth and Peer Outreach Workers
All programs,including CONTRACTORS,using youth(either paid or volunteer)in program activities will use caution and judgment in the venues/situations where
youth workers are placed. Agencies will give careful consideration to the age appropriateness of the activity or venue.Agencies will also ensure that organizational staff
and youth comply with all relevant laws and regulations regarding entrance into adult establishments and environments.Agencies will also maintain and implement
appropriate safety protocols that include clear explanation of the appropriate laws and curfews and clearly delineate safe and appropriate participation of youth in program
outreach activities.
14. Whistleblower
a. Whistleblower statue,41 U.S.C.&4712,applies to all employees working for CONTRACTOR,subcontractors,and subgrantees on federal grants and contracts.
The statue(41 U.S.C.&4712)states that an"employee of a CONTRACTOR,subcontractor,grantee,or subgrantee,may not be discharged,demoted,or
otherwise discriminated against as a reprisal for"whistleblowing."In addition,whistleblower protections cannot be waived by an agreement,policy, form,or
condition of employment.
b. The National Defense Authorization Act(NDAA)for Fiscal Year 2013 (Pub. L. 112-239,enacted January 2,2013)mandates a pilot program entitled"Pilot
Program for Enhancement of Contractor Employee Whistleblower Protections."This program requires all grantees,their subgrantees,and subcontractors to:
i. Inform their employees working on any federal award they are subject to the whistleblower rights and remedies of the pilot program
ii. Inform their employees in writing of employee whistleblower protections under 41 U.S.C. &4712 in the predominant native language of the
workforce;and,
iii. CONTRACTOR and grantees will include such requirements in any agreement made with a subcontractor or subgrantee.
15. Allowable Costs
All expenditures incurred and reimbursements made for performance under this statement of work shall be based on actual allowable costs.Costs can include direct labor,
direct material,and other direct costs specific to the performance of activities or achievement of deliverables under this statement of work.
For information in determining allowable costs,please reference OMB Circulars:
2 CFR200(State,Local and Indian Tribal governments)at:https://www.federalregister.gov/documents/2013/12/26/2013-30465/uniform-administrative-
requ irements-cost-principles-and-audit-requirements-for-federal-awards.
**Disclosure of information is governed by the Washington Administrative Code(WAC)246-101-120,520 and 635,and the Revised Code of Washington(RCW)
70.24.080,70.24.084,and 70.24.105 regarding the exchange of medical information among health care providers related to HIV/AIDS or STI diagnosis and treatment.
Exhibit A,Statement of Work Page 10 of 11 Contract Number CLH32053-Amendment 13
Page 15 of 27
Please note that CONTRACTORs fit under the definition of"health care providers"and"individuals with knowledge of a person with a reportable disease or condition"
in the WAC and RCW.
DOH statutory authority to have access to the confidential information or limited Dataset(s)identified in this agreement to the Information Recipient: RCW 43.70.050
Information Recipient's statutory authority to receive the confidential information or limited Dataset(s) identified in this Agreement: RCW 70.02.220(7)
Exhibit A, Statement of Work Page 11 of 11 Contract Number CLH32053-Amendment 13
Page 16 of 27
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) 5 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) ❑ 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 add additional FFY26 MCHBG LHJ CONTRACTS HRSA YR l funding.
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
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 8,857 7,646 16,503
FFY25 MCHBG SPECIAL PR HRSA 2 7810125A 93.994 333.93.99 10/01/25 09/30/26 3,376 0 3,376
0 0 0
0 0 0
0 0 0
TOTALS 39,758 7,646 47,404
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 13
Page 17 of 27
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
1 e 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.
l f Report annual FTE billed to MCHBG. Submit FTE information on DOH-provided July 1,2026
template.
lg 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.
lh 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 13
Page 18 of 27
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@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
3 e 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-CH1F@,doh.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 Help Me Grow's Document in the Administrative box on your September 30,2026
ParentHelp123 Resource Finder annually for accuracy. MCHBG report that you have updated
Exhibit A,Statement of Work Page 3 of 5 Contract Number CLH32053-Amendment 13
Page 19 of 27
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
information on your local CYSHCN program
with WithinReach/Help Me Grow.
3g Support improvements to the local system of care Submit updates as part of monthly reporting September report due
(public health services and systems/policy,systems,and document. October 15,2025
environment)for CYSHCN.Refer to the Focus of Work November 15,2025
document for example activities and priority areas. December 15,2025
January 15,2026
February 15,2026
March 15,2026
April 15,2026
May 15,2026
June 15,2026
July 15,2026
August 15,2026
September 15,2026
MCHBG Assessment and Evaluation
4a As part of the ongoing 5-year MCHBG Needs Submit documentation as requested by DOH. September 30,2025 Reimbursement for actual
Assessment,participate in activities developed and costs,not to exceed total
coordinated by DOH using DOH-provided reporting funding consideration.
template. Monthly Reports must only
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 finance(a,doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Exhibit A,Statement of Work Page 4 of 5 Contract Number CLH32053-Amendment 13
Page 20 of 27
Program Specific Requirements
Special Requirements:
All training costs and all travel expenses for such training(for example:per diem,hotel,registration fees)must be pre-approved,unless identified in pre-approved Budget
Workbook. Submit a paragraph to your Community Consultant explaining why the training is necessary to implement a strategy in the approved work plan. Details should also
include total cost of the training and a link to or brochure of the training. Retain a copy of the Community Consultant's approval in your records.
Program Manual,Handbook,Policy References:
CYSHCN Information and Resources:
Children and Youth with Special Health Care Needs Website(wa.gov)
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
1. At least 30%of federal Title V funds must be used for preventive and primary care services for children and at least 30%must be used for services for children with
special health care needs. [Social Security Law,Sec.505(a)(3)].
2. Funds may not be used for:
a. Inpatient services,other than inpatient services for children with special health care needs or high-risk pregnant women and infants,and other patient services approved by
Health Resources and Services Administration(HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land,the purchase,construction,or permanent improvement of any building or other facility,or the purchase of major medical
equipment.
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. Payment for any services furnished by a provider or entity who has been excluded under Title XVIII(Medicare),Title XIX(Medicaid),or Title XX(social services block
grant).[Social Security Law,Sec 504(b)].
3. If any charges are imposed for the provision of health services using Title V(MCH Block Grant)funds, such charges will be pursuant to a public schedule of charges;will not
be imposed with respect to services provided to low-income mothers or children;and will be adjusted to reflect the income,resources,and family size of the individual
provided the services. [Social Security Law, Sec. 505(1)(D)].
Monitoring Visits(i.e.,frequency,type,etc.):
Check-ins with DOH Community Consultant as needed.
Billing Requirements:
Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable A19-lA 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 13
Page 21 of 27
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) 7 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through December 31,2027 El State FFATA(Transparency Act) El Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: To provide Women, Infants,and Children(WIC)Nutrition Program services by following WIC federal regulations, WIC state office policies and
procedures,WIC directives,and other rules. Refer to the Program Specific Requirements section of this document.
Revision Purpose: To add funds to FFY26 WIC CLIENT SVS CONTRACTS USDA and update caseload.
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 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 4,067 0 4,067
FFY25 BRSTFDG PEER CN PR MGMT USDA 76214250 10.557 333.10.55 01/01/25 09/30/27 23,449 0 23,449
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 50,800 62,893 113,693
0 0 0
TOTALS 223,622 62,893 , 286,515
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
2. Reallocations are necessary to redistribute caseload through September 2026=
statewide. 300
3. Caseload declines.
Exhibit A, Statement of Work Page 1 of 7 Contract Number CLH32053-Amendment 13
Page 22 of 27
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Authorized participating
caseload for October 2025
through September 2026 =
350
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
Exhibit A,Statement of Work Page 2 of 7 I, Contract Number CLH32053-Amendment 13
Page 23 of 27
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
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.
• 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.
Exhibit A, Statement of Work Page 3 of 7 Contract Number CLH32053-Amendment 13
Page 24 of 27
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.
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:
Exhibit A,Statement of Work Page 4 of 7 Contract Number CLH32053-Amendment 13
Page 25 of 27
• 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."
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.
Exhibit A,Statement of Work Page 5 of 7 Contract Number CLH32053-Amendment 13
Page 26 of 27
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 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. Al 9s are submitted monthly and must be received by the Department within 30 days following the close of each calendar month.Additional A19s 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.
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH32053-Amendment 13
Page 27 of 27
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
I
Exhibit A,Statement of Work Page 7 of 7 Contract Number CLH32053-Amendment 13
Page 1 of 21
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 12
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:
tittps:,;siate«kka.charepoiutsprR sites!t oh-tifsfundinaresourecx'sit naPeeh/tr.me,amx? c1 944688cia2d9-1d3gatitl ic7fbc32e ld7c
Adds Statements of Work for the following programs:
BEACH Program - Effective March 1,2026
® Amends Statements of Work for the following programs:
Maternal&Child Health Block Grant—Effective January I, 2025
Office of Drinking Water Group A Program -Effective January 1,2025
WIC Nutrition Program - Effective January 1, 2025
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-12 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-11 Allocations
as follows:
® Increase of S40,140 for a revised maximum consideration of$6,179,07$.
❑ 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 OUNTY COMMISSIONERS DEPARTMENT OF HEALTH
'Lb 'catibUk.
03/11/2026
Greg rotherton,Chair Dale V Date
AP, @V,ED S TO FORM ONLY APPROVED AS TO FORM ONLY
Jeremiah B.Luther,DPA Assistant Attorney General
-- %' 02/27/2026
hi p'C. H isucker, Date Page 1 of l
ief Civ' eputy Prosecuting Attorney
CC 25-OO1•Al:
EXHIBIT B-12 Page 2 of 21
.lefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: February 1,2026
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 11 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 $1,994 $23,449 $27,516
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)
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 ($6,061)
FFY25 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 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 7WA700WA1 Amd 11 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 ($1,994) $4,067
FFY24 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WA1 Amd 8 10.557 333.10.55 01/01/25 09/30/26 10/01/23 09/30/26 $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 $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
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 kind 12 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $25,400 $50,800 $50,800
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 11 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $10,837
FFY26 WIC Client Svs Contracts USDA 7WA700WA7 Amd 9 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $14,563
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
FFY26 Swimming Beach Act IAR(ECY) 03J18701 Amd 12 66.472 333.66.47 03/01/26 10/31/26 07/01/25 11/30/26 $8,000 $8,000 $21,500
FFY25 SWIMMING BEACH ACT IAR(ECY) 01J74301 Amd 2 66.472 333.66.47 03/01/25 10/31/25 01/01/25 11/30/25 $13,500 $13,500
FFY25 PHEP BP2-CDC-LHJ Partners NU90TU000055 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 NU90TU000055 Amd 7 93.069 333.93.06 07/01/25 06/30/26 07/01/25 06/30/26 $19,527
FFY24 PHEP BP1-CDC-LHJ Partners NU90TU000055 Amd 1 93.069 333.93.06 01/01/25 06/30/25 07/01/24 06/30/25 $13,754 $13,754
FFY25 OD2A OID CDC Prevent NU17CE010218 Amd 10 93.136 333.93.13 09/01/25 06/30/26 09/01/25 08/31/26 $98,000 $98,000 $217,677
FFY24 OD2A OID CDC Prevent NU17CE010218 Amd 10 93.136 333.93.13 07/01/25 08/31/25 09/01/24 08/31/25 $21,788 $38,121
FFY24 OD2A OID CDC Prevent NU17CE010218 Amd 6 93.136 333.93.13 07/01/25 08/31/25 09/01/24 08/31/25 $16,333
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 9 93.217 333.93.21 04/01/25 03/31/26 04/01/25 03/31/26 $21,049 $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 PPHF Ops NH23IP922619 Amd 1 93.268 333.93.26 01/01/25 06/30/25 07/01/23 06/30/25 $10,000 $10,000 $10,000
FFY20 ELC EDE LHJs CDC NU50CK000515 Amd 1,7 93.323 333.93.32 01/01/25 12/31/25 01/15/21 07/31/26 $15,580 $15,580 $15,580
FFY19 ELC ED Immunizations CDC NU50CK000515 Amd 9 93.323 333.93.32 07/01/25 06/30/26 07/01/25 07/30/26 $10,000 $10,000 $10,000
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
Page 1 of 3
EXHIBIT B-12 Page 3 of 21
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: February 1,2026
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
PH Infrastructure Comp A1-LHJ NE110E000053 Amd 9 93.967 333.93.96 01/01/25 11/30/27 12/01/22 11/30/27 $200,000 $350.300 $350,300
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
FFY25 HRSA MCHBG LHJ Contracts B04MC54583 Amd 1 93.994 333.93.99 01/01/25 09/30/25 10/01/24 09/30/25 $27,525 $27,525 $27,525
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 YR1 B04MC55473 Amd 12 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $2,140 $8,857 S8,85'
FFY26 MCHBG LI-U Contracts HRSA YR1 B04MC55473 Amd 11 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $6,717
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 Amd 9 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 ($36,700) $0
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 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 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
SFY25 DUH Naloxone DDO HCA IAR Amd 4 N/A 334.04.91 03/01/25 06/30/25 12/10/24 06/30/25 $15,000 $15,000 $15,000
SFY26 Drug User Health Program Amd 6 N/A 334.04.91 07/01/25 06/30/26 07/01/25 06/30/26 $80,500 $80,500 $120,750
SFY25 Drug User Health Program Amd 1 N/A 334.04.91 01/01/25 06/30/25 07/01/24 06/30/25 $40,250 $40,250
SFY26 Sexual&Rep Hlth Cost Share Amd 9 N/A 334.04.91 01/01/26 06/30/26 07/01/25 06/30/26 $41,664 $41,664 $137,061
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 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) $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
Page 2 of 3
EXHIBIT B-12 Page 4 of 21
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: February 1,2026
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 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
YR 1 Stimulus- Local Asst(10%of 15%)SS Amd 12 N/A 346.26.64 01/01/25 12/31/27 07/01/23 06/30/28 $1,800 $3,850 $3.8511
YR1 Stimulus-Local Asst(10%of 15%)SS Amd 11 N/A 346.26.64 01/01/25 12/31/27 07/01/23 06/30/28 $250
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
YR 28 SRF-Local Asst(15%)SS Amd 11 N/A 346.26.64 01/01/25 12/31/27 07/01/24 06/30/29 $200 $200 $200
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)
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 12 N/A 346.26.65 01/01/25 12/31/27 07/01/23 12/31/27 $1,800 $4,050 $4,050
Sanitary Survey Fees SS-State Amd 11 N/A 346.26.65 01/01/25 12/31/27 07/01/23 12/31/27 $450
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)
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
YR 1 Stimulus- Local Asst(10%of 15%)TA Amd 12 N/A 346.26.66 01/01/25 12/31/27 07/0I/23 06/30/28 $1,000 $2,000 $2,000
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
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 $6,179,078 $6,179,078
Total consideration: $6,138,938 GRAND TOTAL S6,179,078
$40,140
GRAND TOTAL $6,179,078 Total Fed $1,042,943
Total State $5,136,135
*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 21
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: BEACH Program-Effective March 1,2026 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: March 1,2026 through October 31,2026 ❑ State ® FFATA(Transparency Act) ❑ Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The Beach Environmental Assessment,Communication,and Health(BEACH)Program works with LHJ to monitor water at marine swimming
beaches for bacteria and provide public notification when levels are unsafe.This work is funded by an interagency agreement issued by Department of Ecology(ECY) for
administration by DOH. Reference DOH Contract#GVS32430.
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
FFY26 SWIMMING BEACH GRANT IAR(ECY) 26505926 66.472 333.66.47 03/01/26 10/31/26 0 8,000 8,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 8,000 8,000
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 BEACH Program Administration and Annual Meeting: Time Summarize time spent on administrative Annual meeting held in Reimbursement for actual
spent on administrative duties related to the BEACH duties in annual report. March 2026. Annual report costs up to$8,000 for
Program and the 2026 Annual meeting. due October 31,2026. tasks 1-3. Sub-recipient
2 Bacteria Monitoring&Public Notification 1. Enter data into Department of Ecology's 1. Enter data results into may use their discretion in
• Collect samples and field observations in BEACH Program Database. database by Friday each prioritizing which task(s)
accordance with BEACH Program Quality week of sample collection. to pay with this award.
Assurance Project Plan(QAPP).Notify BEACH 2. Email copies of laboratory analytical
Program Coordinator in advance if samples cannot reports to BEACH Program Coordinator. 2. Email copies of reports
be collected. Coordinate deviations from the QAPP upon receipt.
and/or schedule with the BEACH Program 3. Include a list of swimming advisories in
Coordinator. annual report. 3. Annual report due
• Post and/or remove swimming advisory signs as October 31,2026.
needed. Provide public education about beach water
Exhibit A, Statement of Work Page 1 of 2 Contract Number CLH32053-Amendment 12
Page 6 of 21
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
quality.Notify BEACH Program Coordinator of
swimming advisories as soon as possible.
3 Illness Pollution Investigations 1. Provide notification via telephone to 1. Within fourteen(14)
Notify BEACH Program Coordinator of any illness reports BEACH Program Coordinator. business days.
related to recreational swimming beaches.Conduct illness
investigations as needed. 2. Summarize illness investigation in annual 2. Annual report due
report. October 31,2026.
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.\}a.t_o\.
Federal Funding Accountability and Transparency Act(FFATAI(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
The funds for this project are being provided by an Environmental Protection Agency grant,Agreement Number CU-03J 18701-0,Catalog of Federal Domestic Assistance Number
66.472—Beach Monitoring and Notification Program Implementation Grants.
Program Manual,Handbook,Policy References:
Quality Assurance Project Plan https://apps.ecology.wa.gov/publications/SummaryPages/1903119.html
Exhibit A, Statement of Work Page 2 of 2 Contract Number CLH32053-Amendment 12
Page 7 of 21
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) 4 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 add additional FFY26 MCHBG LHJ CONTRACTS HRSA YR1 funding.
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 6,717 2,140 8,857
FFY25 MCHBG SPECIAL PR HRSA 2 7810125A 93.994 333.93.99 10/01/25 09/30/26 3,376 0 3,376
0 0 0
0 0 0
0 0 0
TOTALS 37,618 2,140 39,758
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Maternal and Child Health Block Grant(MCHBG)Administration
1 a Report actual expenditures for the six-month period Submit actual expenditures using the MCHBG May 16,2025 Reimbursement for actual
from October 1,2024 through March 31,2025. Budget Workbook to DOH Community costs,not to exceed total
Consultant. funding consideration.
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 12
Page 8 of 21
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
1 e 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.
1 f Report annual FTE billed to MCHBG. Submit FTE information on DOH-provided July 1,2026
template.
I g 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.
lh 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 12
Page 9 of 21
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-CHIFadoh.wa.gov and with funds provided in this
indicate that zero clients were served during the quarter. statement of work for the
No spreadsheet is necessary when zero clients are specified funding period.
served.
3b Identify unmet needs for CYSHCN on Medicaid and Submit completed Health Services 30 days after forms are See Program Specific
refer to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment completed. Requirements and Special
Diagnostic and Treatment funds as needed. Fund requests directly to the CYSHCN Through September 30, Billing Requirements.
Program as needed. 2025
3c Review your program's entry on ParentHelpl23.org Document in the Administrative box on your September 30,2025
annually for accuracy. MCHBG report that you have updated
information on your local CYSHCN program
with WithinReach/Help Me Grow.
3d Support improvements to the local system of care Submit updates as part of monthly reporting January 15,2025
(public health services and systems/policy,systems,and document. February 15,2025
environment)for CYSHCN.Refer to the Focus of Work March 15,2025
document for example activities and priority areas. April 15,2025
May 15,2025
June 15,2025
July 15,2025
August 15,2025
September 15,2025
3e Complete intake and renewal,per reporting guidance Submit data to DOH per 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( doh.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 Help Me Grow's Document in the Administrative box on your September 30,2026
ParentHelp123 Resource Finder annually for accuracy. MCHBG report that you have updated
Exhibit A,Statement of Work Page 3 of 5 Contract Number CLH32053-Amendment 12
Page 10 of 21
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
information on your local CYSHCN program
with WithinReach/Help Me Grow.
3g Support improvements to the local system of care Submit updates as part of monthly reporting September report due
(public health services and systems/policy,systems,and document. October 15,2025
environment)for CYSHCN.Refer to the Focus of Work November 15,2025
document for example activities and priority areas. December 15,2025
January 15,2026
February 15,2026
March 15,2026
April 15,2026
May 15,2026
June 15,2026
July 15,2026
August 15,2026
September 15,2026
MCHBG Assessment and Evaluation
4a As part of the ongoing 5-year MCHBG Needs Submit documentation as requested by DOH. September 30,2025 Reimbursement for actual
Assessment,participate in activities developed and costs,not to exceed total
coordinated by DOH using DOH-provided reporting funding consideration.
template. Monthly Reports must only
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 finance(a,doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Exhibit A,Statement of Work Page 4 of 5 Contract Number CLH32053-Amendment 12
Page 11 of 21
Program Specific Requirements
Special Requirements:
All training costs and all travel expenses for such training(for example:per diem,hotel,registration fees)must be pre-approved,unless identified in pre-approved Budget
Workbook. Submit a paragraph to your Community Consultant explaining why the training is necessary to implement a strategy in the approved work plan.Details should also
include total cost of the training and a link to or brochure of the training.Retain a copy of the Community Consultant's approval in your records.
Program Manual,Handbook,Policy References:
CYSHCN Information and Resources:
Children and Youth with Special Health Care Needs Website(wa.gov)
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
1. At least 30%of federal Title V funds must be used for preventive and primary care services for children and at least 30%must be used for services for children with
special health care needs. [Social Security Law, Sec. 505(a)(3)].
2. Funds may not be used for:
a. Inpatient services,other than inpatient services for children with special health care needs or high-risk pregnant women and infants,and other patient services approved by
Health Resources and Services Administration(HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land,the purchase,construction,or permanent improvement of any building or other facility, or the purchase of major medical
equipment.
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. Payment for any services furnished by a provider or entity who has been excluded under Title XVIII(Medicare),Title XIX(Medicaid),or Title XX(social services block
grant).[Social Security Law,Sec 504(b)].
3. If any charges are imposed for the provision of health services using Title V(MCH Block Grant)funds,such charges will be pursuant to a public schedule of charges;will not
be imposed with respect to services provided to low-income mothers or children;and will be adjusted to reflect the income,resources,and family size of the individual
provided the services. [Social Security Law,Sec. 505 (1)(D)].
Monitoring Visits(i.e.,frequency,type,etc.):
Check-ins with DOH Community Consultant as needed.
Billing Requirements:
Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable 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 pre-approved Budget Workbook.
Exhibit A,Statement of Work Page 5 of 5 Contract Number CLH32053-Amendment 12
Page 12 of 21
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Drinking Water Group A Program - Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 4 Funding Source Federal Compliance Type of Payment
® Federal Contractor (check if applicable) ❑ Reimbursement
Period of Performance: January 1,2025 through December 31,2027 ® State ® FFATA(Transparency Act) ® Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non-community Group A water systems
Revision Purpose: Correct total allocation column to reflect cumulative funding amount for SS and TA 2025 and 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
SANITARY SURVEY FEES SS-STATE 24112522 N/A 346.26.65 01/01/25 12/31/27 2,250 1,800 4,050
YR 27 SRF-LOCAL ASST(15%)SS 24119227 N/A . 346.26.64 01/01/25 12/31/25 0 0 0
YR 27 SRF-LOCAL ASST(15%)TA 24119227 N/A 346.26.66 01/01/25 12/31/25 0 0 0
YR 28 SRF-LOCAL ASST(15%)SS 24119228 N/A 346.26.64 01/01/25 12/31/27 200 0 200
YR1 STIMULUS -LOCAL ASST(10%OF 15%)SS 24144240 N/A 346.26.64 01/01/25 12/31/27 2,050 1,800 3,850
YR 28 SRF-LOCAL ASST(15%)TA 24119228 N/A 346.26.66 01/01/25 12/31/27 0 0 0
YR1 STIMULUS -LOCAL ASST(10%OF 15%)TA 24144240 N/A 346.26.66 01/01/25 12/31/27 1,000 1,000 2,000
0 0 0
0 0 0
TOTALS 5,500 4,600 10,100
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
1 Trained LHJ staff will conduct sanitary surveys of Provide Final* Sanitary Survey Reports Final Sanitary Survey Upon ODW acceptance of the Final
small community and non-community Group A to ODW Regional Office. Complete Reports must be Sanitary Survey Report,the LHJ shall be
water systems identified by the DOH Office of Sanitary Survey Reports shall include: received by the ODW paid$1,000 for each sanitary survey of a
Drinking Water(ODW)Regional Office. 1. Cover letter identifying significant Regional Office within Transient Non-Community(TNC)system.
deficiencies, significant findings, 30 calendar days of
See Special Instructions for task activity. observations,recommendations,and conducting the sanitary Upon ODW acceptance of the Final
referrals for further ODW follow- survey. Sanitary Survey Report,the LHJ shall be
The purpose of this statement of work is to provide up. paid$1,500 for each sanitary survey of a
funding to the LHJ for conducting sanitary surveys 2. Completed Small Water System non-Transient Non-Community(NTNC)
and providing technical assistance to small checklist.
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH32053-Amendment 12
Page 13 of 21
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
community and non-community Group A water 3. Updated Water Facilities Inventory and Community systems with 499 and less
systems. (WFI). connections.
4. Photos of water system with text
identifying features Payment is inclusive of all associated costs
5. Any other supporting documents. such as travel,lodging,per diem.
*Final Reports reviewed and accepted by Payment is authorized upon receipt and
the ODW Regional Office. acceptance of the Final Sanitary Survey
Report within the 30-day deadline.
Late or incomplete reports may not be
accepted for payment.
2 Trained LHJ staff will conduct Special Purpose Provide completed SPI Report and any Completed SPI Reports Upon acceptance of the completed SPI
Investigations(SPI)of small community and non- supporting documents and photos to must be received by the Report,the LHJ shall be paid$750 for each
community Group A water systems identified by ODW Regional Office. ODW Regional Office SPI on Transient Non-Community(TNC)
the ODW Regional Office. within 2 working days system.
of the service request.
See Special Instructions for task activity. Payment is inclusive of all associated costs
such as travel,lodging,per diem.
Payment is authorized upon receipt and
acceptance of completed SPI Report within
the 2-working day deadline.
Late or incomplete reports may not be
accepted for payment.
3 Trained LHJ staff will provide direct technical Provide completed TA Report and any Completed TA Report Upon acceptance of the completed TA
assistance(TA)to small community and non- supporting documents and photos to must be received by the Report,the LHJ shall be paid$250 per hour
community Group A water systems identified by ODW Regional Office. ODW Regional Office for each technical assistance activity.
the ODW Regional Office. within 30 calendar
days of providing Payment is authorized upon receipt and
See Special Instructions for task activity. technical assistance. acceptance of completed TA Report within
the 30-day deadline.
Late or incomplete reports may not be
accepted for payment.
4 LHJ staff performing the activities under tasks 1,2 For training attended in person,prior to Annually For training attended in person,LHJ shall
and 3 attend periodic required survey training as attending the training,submit an be paid mileage,per diem,lodging,and
directed by DOH. "Authorization for Travel(Non- registration costs as approved on the pre-
Employee)"DOH Form 710-013 to the authorization form in accordance with the
See Special Instructions for task activity. ODW Program Contact for approval(to current rates listed on the OFM Website
ensure enough funds are available). http://www.ofm.wa.gov/resources/travel.asp
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment 12
Page 14 of 21
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DC)H 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
Data Sharing
The Office of Drinking Water will share water system information and files with the local health jurisdiction to support the work identified in this statement of work. To request
water system data please contact the regional office with the name of the water system,water system ID#,specific information being requested and any timeline requirements.If
allowable,please give administrative staff 3 to 5 business days to provide records.
Program Manual, Handbook,Policy References: Field Guide(DOH Publication 331-486).
Special References:
Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work,ODW contracts with the LHJ to conduct sanitary surveys(and SPIs and
provide technical assistance)for small community and non-community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys(and
SPIs and provide technical assistance)for small community and non-community water systems with surface water sources, large water systems,and systems with complex
treatment.
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4,below.
Special Billing Requirements
The LW shall submit monthly invoices within 30 days following the end of the month in which work was completed,noting on the invoice the month and year being billed for.
Payment cannot exceed a maximum accumulative fee of$4300$8,100 for Task 1,and S000$2,000 for Task 2,Task 3 and Task 4 combined during the contracting period,to
be paid at the rates specified in the Payment Method/Amount section above. When invoicing for sanitary surveys,bill half to BARS Revenue Code 346.26.64 and half to BARS
Revenue Code 346.26.65.
When invoicing for Task 1, submit the list of WS Name,ID#,Amount Billed,Survey Date and Letter Date for which you are requesting payment.
When invoicing for Task 2-3,submit the list of WS Name,ID#,TA Date and description of TA work performed,and Amount Billed.
When invoicing for Task 4,submit receipts and the signed pre-authorization form for non-employee travel to the ODW Program Contact below and a signed A 19-I A Invoice
Voucher to DOH Grants Management,billing to BARS Revenue Code 346.26.66 under Technical Assistance(TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW. Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance(Field Guide). The sanitary survey will include an
evaluation of the following eight elements: source;treatment;distribution system;finished water storage;pumps,pump facilities and controls;monitoring,reporting and data
verification;system management and operation;and certified operator compliance. If a system is more complex than anticipated or other significant issues arise,the LHJ may
request ODW assistance.
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH32053-Amendment 12
Page 15 of 21
• No more than 3 surveys of non-community systems with three or fewer connections be completed between January 1,2025, and December 31,2025.
• No more than 3 surveys of non-community systems with four or more connections and all community systems to be completed between January 1, 2025,and
December 31,2025.
• No more than 3 surveys of Transient Non-Community(TNC)systems to be completed between January 1,2026,and December 31,2026.
• No more than 1 surveys of Non-Transient Non-Community(NTNC)and Community systems with 499 and less connections to be completed between January 1,
2026,and December 31,2026.
The process for assignment of surveys to the LHJ,notification of the water system,and ODW follow-up with unresponsive water systems;and other roles and responsibilities of
the LHJ are described in the Field Guide.
Task 2
Trained LHJ staff will perform Special Purpose Investigations(SPIs)as assigned by ODW. SPIs are inspections to determine the cause of positive coliform samples or the cause of
other emergency conditions. SPIs may also include sanitary surveys of newly discovered Group A water systems. Additional detail about conducting SPIs is described in the Field
Guide. The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staff will conduct Technical Assistance as assigned by ODW.Technical Assistance includes assisting water system personnel in completing work or verifying work
has been addressed as required,requested, or advised by the ODW to meet applicable drinking water regulations. Examples of technical assistance activities are described in the
Field Guide. The ODW Regional Office must authorize in advance any technical assistance provided by the LHJ to a water system.
Task 4
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work.
If required trainings,workshops or meetings are not available,not scheduled,or if the LW staff person is unable to attend these activities prior to conducting assigned tasks,the
LHJ staff person may,with ODW approval, substitute other training activities to be determined by ODW. Such substitute activities may include one-on-one training with ODW
staff,co-surveys with ODW staff,or other activities as arranged and pre-approved by ODW.LHJ staff may not perform the activities under tasks 1,2,and 3 without completing
the training that has been arranged and approved by ODW.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH32053-Amendment 12
Page 16 of 21
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) 6 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 add funds to FFY26 WIC CLIENT SVS CONTRACTS USDA.
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 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 4,067 0 4,067
FFY25 BRSTFDG PEER CN PR MGMT USDA 76214250 10.557 333.10.55 01/01/25 09/30/27 23,449 0 23,449
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 25,400 25,400 50,800
0 0 0
TOTALS 198,222 25,400 223,622
Task Payment Information
Activity Deliverables/Outcomes Due Date/Time Frame 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 12
Page 17 of 21
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).
I.8a Submit entire WIC and Breastfeeding Peer Counseling Budget Budget Workbook First year due 9/30/25
Workbook for each year of the contract Second year due 9/30/26
Third year due 9/30/27
1.8b Submit Rev-Exp Report spreadsheet from the WIC Budget Revenue and Expense Report and A-19 First year due monthly
Workbook monthly with A-19 through September 30,2025
Second year due monthly
through September 30,2026
Third year due monthly
through September 30,2027
2 Breastfeeding Promotion See"Billing
Requiremente 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 12
Page 18 of 21
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 tinance@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
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• 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
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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
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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 Al 9-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 30 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.
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