HomeMy WebLinkAboutState of Washington Department of Health Consolidated Contracts Amendment 15 - 070626 Page 1 of 41
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 15
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:
I. Exhibit A Statements of Work,includes the following statements of work,which are incorporated by this reference and located on
the DOH Finance SharePoint site in the Upload Center at the following URL:
httvs://stateofwa.sharepoint.com/sites/doh-ofsfundingesources/sitepages/home.aspx?_e I:9a94688da2d94d3ea80ac71bc32e4d7c
Ea Adds Statements of Work for the following programs:
Foundational Public Health Services-Effective July I,2026
Infectious Disease Syndemic Prevention Services-SSP-Effective July I,2026
►5 Amends Statements of Work for the following programs:
Recreational Shellfish Activities-Effective July 1,2025
School-Based Health Centers Program -Effective July 1,2025
Sexual&Reproductive Health Program -Effective January I,2025
WIC Nutrition Program-Effective January 1,2025
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-15 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-14 Allocations as follows:
1=+ Increase of$1,916,986 for a revised maximum consideration of$8,209,503.
❑ 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
BOAF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
iamb' [
All" -, ; L° 41/h,l-c , 07/08/2026
rothe .n,Chair to Date
APPROVED AS TO FORM ONLY: APPROVED AS TO FORM ONLY
`# Assistant Attorney General
0- C June 25,2026
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
Page 1 of 1
CC-25-011-A15
EXHIBIT B-15 Page 2 of 41
Jefferson County Public Health ALLOCATIONS Contract Number: CL1132053
Contract Term:2025-2027 Date: June 1,2026
Indirect Rate January 1,2025 through December 31,2025:27.38 6,Public Health
Indirect Rate January 1,2026 through December 31,2026:32.64%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
FFY26 BrstliIg Peer Cn Pr Mgmt USDA 7WA700WA1 Amd 15 10.557 333.10.55 10/01/25 09/30/27 10/01/25 09/30/28 $26,770 $26,770 $54,286
FFY25 Brstfdg Peer Cn Pr Mgmt USDA 7WA700WAI Amd 11 10.557 333.10.55 01/01/25 09/30/27 10/01/24 09/30/27 $1,994 $23,449
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 7WA700WAI 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 7WA700WAI 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 15 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 $25,400 $139,093 $139,093
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
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 S637 $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 S8,000 $21,500
FFY25 SWIMMING BEACH ACT TAR(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 S34,384 $48,138
FFY25 PHEP BP2-CDC-LHJ Partners NU9OTU000055 Amd 7 93.069 333.93.06 07/01/25 06/30/26 07/01/25 06/30/26 $19,527
FFY24 PHEP BPI-CDC-LHJ Partners NU9OTU000055 Amd 1 93.069 333.93.06 01/01/25 06/30/25 07/01/24 06/30/25 $13,754 $13,754
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
FFY26 Title X Fam Plan FPHPA YR5 FPHPA006560 Amd 15 93.217 333.93.21 04/01/26 03/31/27 04/01/26 03/31/27 $25,242 $25,242 $80,280
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
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
Page 1 of 4
EXHIBIT B-15 Page 3 of 41
Jefferson County Public Health ALLOCATIONS Contract Number: CL1132053
Contract Term:2025-2027 Date: June 1,2026
Indirect Rate January 1,2025 through December 31,2025:27.38%Public Health
Indirect Rate January 1,2026 through December 31,2026:32.64"A,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
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 NU5OCK000515 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 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 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 YRI B04MC55473 Amd 14 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 $12,233 $28,736 $28,736
FFY26 MCHBG LHJ Contracts HRSA YRI 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 YRI 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 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 YRI 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
SFY27 Sch Based Hlth Cent 1225 Proviso Amd 15 N/A 334.04.90 07/01/26 06/30/27 07/01/26 06/30/27 $140,000 $140,000 $280,000
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
SFY25 DUH Naloxone DDO HCA IAR Arnd 4 N/A 334.04.91 03/01/25 06/30/25 12/10/24 06/30/25 $15,000 $15,000 $15,000
SFY27 Drug User Health Program Amd 15 N/A 334.04.91 07/01/26 06/30/27 07/01/26 06/30/27 $80,500 $80,500 $201,250
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
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
SFY27 Sexual&Rep Hlth Cost Share Amd 15 N/A 334.04.91 07/01/26 06/30/27 07/01/26 06/30/27 $38,074 $38,074 $175,135
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 S41,664 $41,664
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 I N/A 334.04.93 01/01/25 06/30/25 07/01/24 06/30/25 $31,500
Page 2 of 4
EXHIBIT B-15 Page 4 of 41
Jefferson County Public Health ALLOCATIONS Contract Number: C1,1132053
Contract Term:2025-2027 Date: June 1,2026
Indirect Rate January 1,2025 through December 31,2025:27.38%Public Health
Indirect Rate January 1,2026 through December 31,2026:32.64%Public Health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue I.l1J Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
Rec Shellfish/Biotoxin Amd 15 N/A 334.04.93 07/01/25 06/30/27 07/01/25 06/30/27 $9,000 $16,500 $20,200
Rec Shellfish/Biotoxin Amd 6,15 N/A 334.04.93 07/01/25 06/30/27 07/01/25 06/30/27 $7,500
Rec Shellfsh/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
SFY27 FPHS-LHJ Funds-GFS Amd 15 N/A 336.04.25 07/01/26 06/30/27 07/01/26 06/30/27 $1,572,000 $1,572,000 $6,033,000
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
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
YRl 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 l 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
YRI Stimulus-Local Asst(10%of 15%)TA Amd 6 N/A 346.26.66 01/01/25 12/31/27 07/01/23 06/30/28 $1,000
YR 28 SRF-Local Asst(15%)TA Amd 6 N/A 346.26.66 01/01/25 12/31/27 07/01/24 06/30/29 ($1,000) $0 $0
YR 28 SRF-Local Asst(15%)TA Amd 4 N/A 346.26.66 01/01/25 12/31/27 07/01/24 06/30/29 $1,000
YR 27 SRF-Local Asst(15%)TA Amd 4 N/A 346.26.66 01/01/25 06/30/25 07/01/23 06/30/25 ($1,000) $0
YR 27 SRF-Local Asst(15%)TA Amd 1 N/A 346.26.66 01/01/25 06/30/25 07/01/23 06/30/25 $1,000
Page 3 of 4
EXHIBIT B-15 Page 5 of 41
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: June 1,2026
Indirect Rate January 1,2025 through December 31,2025:27.38%Public Health
Indirect Rate January 1,2026 through December 31,2026:32.64%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
TOTAL $8,209,503 $8,209,503
Total consideration: $6,292,517 GRAND TOTAL $8,209,503
$1,916,986
GRAND TOTAL $8,209,503 Total Fed $1,233,794
Total State $6,975,709
*Assistance Listing Number fka Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 4 of 4
Page 6 of 41
Exhibit A
Statement of Work
Contract Term:2025-2027
DOH Program Name or Title: Foundational Public Health Services- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2026
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance "type of Payment
❑ Federal<Select One> (check if applicable) U Reimbursement
Period of Performance: July 1,2026 through June 30,2027 ® State ❑ FFATA(Transparency Act) ® Periodic Distribution
El Other ❑ Research&Development
Statement of Work Purpose: Per RCW 43.70.512,Foundational Public Health Services(FPHS)funds are for the governmental public health system: local health jurisdictions,
Department of Health,state Board of Health,sovereign tribal nations and Indian health programs. These funds are to build the system's capacity and increase the availability of
FPHS services statewide. Establish FY27 FPHS budget.
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
SFY27 FPHS-LHJ FUNDS-GFS 99210870 N/A 336.04.25 07/01/26 06/30/27 0 1,572,000 1,572,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 1,572,000 1,572,000
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
FPHS funds to each LHJ—See below in Program Specific See below in Program Specific See below in Program
1 Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $520,000
Deliverable s
Assessment Reinforcing Capacity—See below in Program Specific See below in Program Specific See below in Program
2 Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $50,000
Deliverables
Assessment—CHA/CHIP—See below in Program Specific See below in Program Specific See below in Program
3 Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $30,000
Deliverables
Lifecourse-Full Lifecourse Workforce Capacity—See below in See below in Program
See below in Program Specific
4 Program Specific Requirements—Activity Special Instructions for Requirements-Deliverables Specific Requirements- $288,000
details Deliverables
Exhibit A,Statement of Work Page 1 of 6 Contract Number CLH32053-Amendment 15
Page 7 of 41
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
CD-Immunization Outreach,Education& Response—See below See below in Program
See below in Program Specific
5 in Program Specific Requirements—Activity Special Instructions for Specific Requirements- $30,000
details Requirements-Deliverables Deliverables
EPH-Fully fund Environmental Public Health Policy& See below in Program Specific See below in Program
6 Leadership Capacity—See below in Program Specific Requirements— Specific Requirements- $100,000
Activity Special Instructions for details Requirements-Deliverables Deliverables
FC-Strengthening Local Finance Capacity—See below in Program See below in Program Specific See below in Program
7 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $62,000
Deliverables
FC-Public Health Communications—See below in Program See below in Program Specific See below in Program
8 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $160,000
Deliverables
Lifecourse-Illicit Substance Use and Overdose Response—See See below in Program
9 below in Program Specific Requirements—Activity Special See below in Program Specific Specific Requirements- $70,000
Instructions for details Requirements-Deliverables Deliverables
EPR-Emergency Preparedness&Response—Capacity and See below in Program Specific See below in Program
10 Capability—See below in Program Specific Requirements—Activity Requirements-Deliverables Specific Requirements- $130,000
Special Instructions for details Deliverables
Assessment—Localized Epidemiology Capacity—General—See See below in Program
11 below in Program Specific Requirements—Activity Special See below in Program Specific Specific Requirements- $67,000
Instructions for details Requirements-Deliverables Deliverables
EPH-Social Work Support—See below in Program Specific See below in Program Specific See below in Program
12 Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $35,000
Deliverables
EPH Core Team—Climate Change Response—See below in See below in Program
13 Program Specific Requirements—Activity Special Instructions for See below in Program Specific Specific Requirements- $30,000
details Requirements-Deliverables Deliverables
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@doli.wa.gov.
doh.wa.gov.
FPHS staff from DOH and the Washington State Association of Local Public Health Officials(WSALPHO)will coordinate and communicate together to build and assure common
systemwide approaches per FPHS Steering Committee direction and the FPHS framework intent.
• For LHJ questions about the use of funds:
o Chris Goodwin,FPHS Policy Advisor,WSALPHO—cgoodwin(ccwsac.org, 564-200-3166
o Brianna Steere,FPHS Policy Advisor,WSALPHO—bsteere( wsac.org,564-200-3171
The intent of FPHS funding is outlined in RCW 43.70.512.
Foundational Public Health Services Definitions and related information can be found here: www.doh.wa.gov/fphs.
Exhibit A,Statement of Work Page 2 of 6 Contract Number CLH32053-Amendment 15
Page 8 of 41
Stable funding and an iterative decision-making process—The FPHS Steering Committee's roles and responsibilities are outlined in the FPHS Committee&Workgroup
Charter The Steering Committee is the decision making body for FPHS and operates under a consensus-based decision making model,outlined here.The Steering Committee use
an iterative approach to decision making meaning additional tasks and/or funds may be added to a local health jurisdiction's (LHJ)FPHS Statement of Work(SOW)as funding
decisions are made.
Spending of FPHS funds—FPHS funds do not require pre-approval or pre-authorization to spend. FPHS funds are to assure FPHS services are available in each jurisdiction based
on the FPHS Definitions(link)and as reflected in the SOW.Assurance includes providing FPHS as part of your jurisdiction's program operations,contracting with another
governmental public health system partner to provide the service,or receiving the service through a new service delivery model such as cross-jurisdictional sharing or regional
staff. FPHS funds are eligible starting at the beginning of each state fiscal year(July 1)regardless of when funds are received by the LHJ,even if the expenditure
occurred before the LHJ's contract was signed.
These funds are not intended for fee-based services such as select environmental public health services.As state funding for FPHS increases,other funds sources(local revenue,
grants, federal block grants)should be directed to the implementation of additional important services and local/state priorities as determined by each agency/jurisdiction.
Annual Allocations—The legislature appropriates FPHS funding on an annual basis and the FPHS Steering Committee allocates funds annually through the FPHS Concurrence
Process for the State Fiscal Year(SFY):July-June.
The Legislature appropriates FPHS funding amounts for each fiscal year of the biennium. This means that funds must be spent within that fiscal year and cannot be carried
forward. Any funds not spent by June 30th each year must be returned to the State Treasury. Funding allocations reset and begin again at the start of the next fiscal year(July 1).
This Statement of Work is for the period of July 1,2026-June 30,2027 and may be included in multiple Consolidated Contracts(ConCons)which are based on the calendar year
and renewed every three years.
Disbursement of FPHS funds to LHJs—Unlike other ConCon grants,FPHS bill-back to DOH is NOT required. The annual allocation is disbursed all up front.
Deliverables—FPHS funds are to be used to assure FPHS services statewide. The FPHS accountability process measures how funds are spent,along with changes in system
capacity through the FPHS Annual Assessment,system performance indicators,and other data. DOH, SBOH and local health jurisdictions have agreed to complete:
1. Reporting of spending and spending projections. Process timelines and reporting template are provided by the FPHS Steering Committee via FPHS Support Staff.
2. FPHS Annual Assessment is due each July to report on the previous state fiscal year.Process and reporting template are provided by the FPHS Steering Committee via
FPHS Support Staff. System results are published in the annual FPHS Investment Report available at x ww.doh.wa.gov/fphs.
BARS Revenue Code: 336.04.25
BARS Expenditure Coding—provided for your reference
562.xx BARS Expenditure Codes for FPHS activities:see below
10 FPHS Epidemiology& Surveillance
11 FPHS Community Health Assessment
12 FPHS Emergency Preparedness&Response
13 FPHS Communication
14 FPHS Policy Development
15 FPHS Community Partnership Development
16 FPHS Business Competencies
Exhibit A,Statement of Work Page 3 of 6 Contract Number CLH32053-Amendment 15
Page 9 of 41
17 FPHS Technology
20 FPHS CD Data&Planning
21 FPHS Promote Immunizations
23 FPHS Disease Investigation—Tuberculosis(TB)
24 FPHS Disease Investigation—Hepatitis C
25 FPHS Disease Investigation—Syphilis, Gonorrhea&HIV
26 FPHS Disease Investigation—STD(other)
27 FPHS Disease Investigation—VPD
28 FPHS Disease Investigation—Enteric
29 FPHS Disease Investigation—General CD
40 FPHS EPH Data&Planning
41 FPHS Food
42 FPHS Recreational Water
43 FPHS Drinking Water Quality
44 FPHS On-site Wastewater
45 FPHS Solid&Hazardous Waste
46 FPHS Schools
47 FPHS Temporary Worker Housing
48 FPHS Transient Accommodations
49 FPHS Smoking in Public Places
50 FPHS Other EPH Outbreak Investigations
51 FPHS Zoonotics(includes vectors)
52 FPHS Radiation
53 FPHS Land Use Planning
60 FPHS MCH Data&Planning
70 FPHS Chronic Disease,Injury&Violence Prevention Data&Planning
80 FPHS Access/Linkage with Medical,Oral and Behavioral Health Care Services Data&Planning
90 FPHS Vital Records
91 FPHS Laboratory—Centralized(PHSKC Only)
92 FPHS Laboratory
Special References(i.e.,RCWs,WACs,etc.):
FPHS Intent-RCW 43.70.512
FPHS Funding—RCW 43.70.515
FPHS Committee&Workgroup Charter
FPHS Steering Committee Consensus Decision Making Model
Activity Special Instructions:
Investments to Each LHJ:
1. FPHS Funds to Each LHJ
These funds are allocated to be used to provide any programs and services within all of the FPHS Definitions.Each LHJ is empowered to prioritize where and how to use
these funds to maximize equitable,effective and efficient delivery of FPHS to every community in Washington.
Exhibit A, Statement of Work Page 4 of 6 Contract Number CLH32053-Amendment 15
Page 10 of 41
Use BARS expenditure codes from the list above that most closely align with expenditure made.
Targeted Investments to Each LHJ:
2. Assessment Reinforcing Capacity(FPHS definition G.2)
Support LHJ assessment capacity with flexible funds to meet locally identified needs.BARS expenditure codes: 562.10 or 11
3. Assessment—CHA/CHIP(FPHS definitions G.3)
Support any CHA/CHIP activity or service(e.g.,data analysis,focus groups,report writing,process facilitation)and may be used to contract with other agencies for staff
time or services. Use BARS expenditure codes: 562.11
4. Lifecourse-Full Lifecourse Workforce Capacity(FPHS definitions D,E,F)
Infrastructure and workforce investments to each LHJ to meet fundamental needs in three areas:Maternal/Child/Family Health;Access/Linkage with Medical,Oral and
Behavioral Health Services;and Chronic Disease,Injury and Violence Prevention.Use BARS expenditure codes: 562.60,562.70,and/or 562.80
5. CD-Immunization Outreach,Education&Response(FPHS definition C.3)
Promote immunization education and use of the statewide immunization registry through evidence-based strategies. Funding can also be used to support vaccine-
preventable disease response.BARS expenditure codes: 562.21 and/or 562.27
6. EPH-Fully fund Environmental Public Health Policy&Leadership Capacity(FPHS definitions B.2,A.C,J.1-3,K.1-2,L.1)
These funds are to be used for staffing costs for environmental health responsibilities and functions(that are not directly fee-based)within leadership,policy development,
foundational public health services implementation,evaluation,or administration,including(but not limited to)Environmental Health Directors.Examples of funded
roles include work relating to general policy,statewide and/or system-wide,and/or cross jurisdictional work,legislation,and rulemaking, SBOH engagement,leadership
support and/or development,workforce development,leadership within health equity,climate,and environmental justice.Use BARS expenditure codes: 562.14,562.40—
562.53
7. FC-Strengthening Local Finance Capacity(FPHS definitions L.2-4,L.6,L.8)
Capacity and infrastructure to assure fiscal management and contract and procurement policies and procedures are effectively implemented to support programs and
services.Use BARS expenditure codes:562.16
8. FC-Public Health Communications(FPHS definitions I.1-2)
Capacity to enhance the frequency,accuracy,and accessibility of public health communications to diverse populations via various media to support programs and
services.Use BARS expenditure codes: 562.13
9. Lifecourse-Illicit Substance Use and Overdose Response(FPHS definitions D.1-2,D.4,F.1-3,G.1-3,1.1-2,J.1-J.3,K.1-2)
Capacity and infrastructure related to addressing overdose crisis.This includes but is not limited to:Overdose response trainings,convening stakeholders or coordination
groups,data analysis,and community education.Use BARS expenditure codes:562.13, 562.14, 562.15,562.60,562.70, 562.80
10. EPR-Emergency Preparedness&Response—Capacity and Capability(FPHS definitions H.1-4)
Capacity and infrastructure to support and enhance the local delivery of FPHS Emergency Preparedness and Response services and activities across critical subject matter
areas.Use BARS expenditure codes: 562.12
Targeted Investments to Select LHJs—Assuring FPHS Available for/in Multiple Jurisdictions:
11. Assessment—Localized Epidemiology Capacity—General(Assessment/Surveillance,CHA/CHIP)(FPHS definitions G.1,2)
Provide general assessment epidemiology focused on local public health assessment needs.Use BARS expenditure codes: 562.10 or 11
Exhibit A,Statement of Work Page 5 of 6 Contract Number CLH32053-Amendment 15
Page 11 of 41
Targeted Investments to Select LHJs—Assuring FPHS Available in Own Jurisdiction
12. EPH-Social Work Support(FPHS definitions B.1-3,B.6-7,D.1,D.2,D.4.E.2,E.4,F.2-3,J.1-2,K.1-2,L.3,L.5)
This investment is intended to support non-traditional responses to environmental health complaints and challenges in the context of social work support and care
coordination with social service providers.Activities include:assessment of complaints and challenges; identifying cases and circumstances for engaging in social work
support and care coordination;and engagement with social service providers.Funds may be used to support these activities,as well as related staffing and training
expenses.Use BARS expenditure codes:562.14,562.15,562.40, 562.47,562.48
EPH—Core Teams(Applies to all EPH Core Team FPHS Investments)(FPHS definition B.1-7)
Each EPH Core Team investment is for LHJ staff to participate in a cross jurisdictional topic-specific Core Team.The Core Teams are each tasked with developing one or
more model program(s),intended to offer guidance for scalable environmental public health responses relating to their specific sub-topic area(s).Where it makes sense to
do so,the Core Teams may also work on implementation of these model programs.The content and output of these model programs will vary depending on the needs and
approaches specific to each sub-topic area.
Recipients of these Core Team FPHS funds are required to participate in the associated Core Team for each investment.Recipients may spend these funds towards
staffing time necessary to participate and on FPHS-qualifying activities for the specific sub-topic area(s)attached to its associated investment.Each Core Team FPHS
investment is distinctive from all other Core Team FPHS investments.
Core Teams exist outside the FPHS structure,in partnership between LHJs and WA DOH,with one co-lead from each.Model programs developed through Core Team
work will be made available to all Washington public health agencies.
There are currently four EPH Core Teams.They are listed below,with their sub-topic area(s),as applicable.
• System-Wide Data Management Improvement
• Climate-Change Response
• Lead Exposure
• Safe&Healthy Communities
Jefferson is receiving funds to participate in these EPH Core Teams:
13. EPH Core Team—Climate-Change Response
This Core Team will address environmental health concerns related to climate and the effects of climate change.
• Model program development will start with Wildfire Smoke and Harmful Algal Blooms,and may include other priorities and topics.
Exhibit A,Statement of Work Page 6 of 6 Contract Number CLH32053-Amendment 15
Page 12 of 41
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 1,2026
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance T le of Payment
❑ Federal<Select One> (check if applicable) /1 Reimbursement
Period of Performance: July 1,2026 through June 30,2027 ® State ❑FFATA(Transparency Act) ❑ Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide Syndemic Prevention Services for infectious diseases(HIV, STI,and Adult Viral
Hepatitis),supporting the Office of Infectious Disease(OID)within Department of Health(DOH).
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY27 DRUG USER HEALTH PROGRAM 12405170 N/A 334.04.91 07/01/26 06/30/27 0 80,500 80,500
0 0 0_
_ 0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 80,500 80,500
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 Reimbursement of
services and tracking: the DOH/OID issued actual costs incurred,
Provide comprehensive Syringe Services Programs(SSP)to • number of sterile syringes distributed database for tracking SSP not to exceed$80,500
people who use drugs(PWUD). This plan of action is • number of naloxone kits distributed activities by the 15th of
directed to distribute syringes to communities that use drugs • number of participant encounters each month following
to prevent transmission of infectious disease. SSPs will • number of referrals to health and social service.
operate during scheduled hours to provide all required harm services
reduction supplies,naloxone,and syringes to prevent
transmission of disease and overdose. SSPs will offer Submit Performance Objectives and Work Submit Performance
referrals to address social determinants of health. Plan that will include: Objectives and Work Plan
• Outcomes aligned with program by September 1,2026.
Priority populations for Syringe Services Programs include strategies and activities.
people who use drugs,with a focus on:
Exhibit A,Statement of Work Page 1 of 9 Contract Number CLH32053-Amendment 15
Page 13 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
• People systemically marginalized and underserved • SMART objectives aligned with
due to racism—Black/African American, performance targets
Latino/Latina/Latine/Latinx,American • Activities aligned with program
Indian/Alaska Native people and other communities outcomes
for whom there are documented health disparities in • Timeline for implementation(including
your region. staffing of the proposed program,
• People who are unhoused or unstably housed. training,etc.)
• People engaged in sex work. • Anticipated capacity building or
• People involved in the criminal legal system. technical assistance needs.
• Gender expansive/transgender individuals.
• Gay,bi,and other men who have sex with men. NOTE: See Special Requirements,Terms
and Conditions—Section 7 Performance
NOTE: See Special Requirements,Terms and Conditions Objectives&Workplans for additional
—Section 4 Syringe Services Programs: Support for deliverable information
Operations Program Requirements for additional task
information.
Syringe Services Programs:Clinical Services
Provide direct access to clinical services to improve the SSP Clinical services outcomes may include,
health and well-being of people who use drugs.At but are not limited to,delivering services and
minimum, services must include onsite,low-barrier access to tracking:
wound care,infectious disease testing, STI and hepatitis C • Number of wound care sessions
treatment,and medications for opioid use disorder. • Number of infectious disease tests
Additional services can include mental health services, conducted(hepatitis C, HIV,gonorrhea-
sexual and reproductive health care,and other primary care chlamydia,syphilis)
and psychosocial support services. • %positive of infectious disease tests
(hepatitis C,HIV,gonorrhea-chlamydia,
NOTE: See Special Requirements,Terms and Conditions syphilis)
—Section 6 Syringe Services Program,Clinical Services • Number of participants started on
Requirements for additional task information. hepatitis C treatment
• Number of participants inducted on
medications for opioid use disorder
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance())doh.wa.gov.
Program Specific Requirements
Special Requirements,Terms and Conditions
1. Definitions
Exhibit A,Statement of Work Page 2 of 9 Contract Number CLH32053-Amendment 15
Page 14 of 41
a. ANONYMOUS SERVICES-HIV Prevention services including condom distribution,outreach and light touch.
b. CAPACITY BUILDING-The process by which individuals and organizations obtain,improve,and retain the skills,knowledge,tools,equipment,and
other resources needed to do their jobs competently.
c. CONTRACTOR—For the purposes of this Statement of Work Only,the entity receiving funds directly from Washington State Department of Health
(DOH)for client services to prevent or treat conditions named in the statement of work will be referred to as contractor.
d. HARM REDUCTION-Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.
e. INTEGRATED TESTING-For the purpose of this Statement of Work,Integrated Testing includes Human Immunodeficiency Virus(HIV),Gonorrhea
(GC),Chlamydia(CT),Syphilis,Hepatitis C(HCV)and Hepatitis B(HBV).
f. SOCIAL DETERMINANTS OF HEALTH-Social determinants of health(SDOH)are the conditions in the environments where people are born,live,
learn,work,play,worship,and age that affect a wide range of health,functioning,and quality-of-life outcomes and risks.
g. YOUTH-For purposes of this agreement,the term"youth"applies to persons under the age of 18.
2. Submission of Invoice Vouchers—
a. On a monthly basis,the CONTRACTOR shall submit complete and correct Al 9 invoice vouchers with amounts billable to DOH under this statement of work
and the corresponding OID Expense Summary backup form.All A19 invoice vouchers must be submitted by the 25th of the following month. Prior approval is
required for a different frequency of billing.
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 31,2027.DOH will pay belated
claims at its discretion,contingent upon the availability of funds.
c. The CONTRACTOR will be placed on a three-month Corrective Action Plan(CAP)if invoice submissions are past due by 90 days.
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
Exhibit A,Statement of Work Page 3 of 9 Contract Number CLH32053-Amendment 15
Page 15 of 41
outreach settings). Programs should also anticipate the potential of needlestick injury and have a"post-exposure-prophylaxis"protocol included in this document.
j. All staff and volunteers working directly with participants/clients must complete CPR certification within the first 3 months after contract start date(if not
already complete).
5. Syringe Services Program,Harm Reduction Care Navigation Requirements
a. Includes all requirements for Syringe Service Program operations(see above)
b. Attend Harm Reduction Care Navigation training provided by DOH.
c. Support participant transportation(e.g.,through the provision of bus passes,cab vouchers,or direct transportation).
d. Accompany participants to appointments or provide"warm hand-offs."
e. Full-time care navigators(1.0 FTE)shall not exceed a case load greater than 25 individuals.
f. Submit monthly outcome data in accordance with DOH standards.
6. Syringe Services Program,Clinical Services Requirements
a. Includes all requirements for Syringe Service Program operations(see above)
b. Must have clinical staff licensed to practice in the state of Washington to provide clinical services (e.g., RN,PA,ARNP, LCSW).
c. If providing advanced level clinical services(e.g.,PA,ARNP, CNM), programs must have appropriate clinical oversight.
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
Exhibit A,Statement of Work Page 4 of 9 Contract Number CLH32053-Amendment 15
Page 16 of 41
services. Proposed work plan activities may be adjusted in collaboration with OID staff to better address the overarching goals of the funded services.OID will
provide a template that must be used in developing the work plan.
b. The applicant should address the following outline in their work plan:
i. Contract Year 3 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 and Work Plans should be submitted by September 1,2026.
d. OID staff are available to support in developing Performance Objectives&Work Plans in collaboration with funded agencies.
e. Performance Objectives and 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. 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.
11. 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.
12. 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)
13. 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
Exhibit A,Statement of Work Page 5 of 9 Contract Number CLH32053-Amendment 15
Page 17 of 41
v. Mail-order naloxone distribution program
vi. Fiscal Monitoring—To be scheduled by the DOH Fiscal Monitoring Unit
b. Corrective Action Plans—DOH may exercise the following options if the CONTRACTOR does not come into compliance or resolution with programmatic
and/or fiscal monitoring corrective action plan by the due date(s)identified in the CAP.i. §200.339 Remedies for noncompliance.
If a non-Federal entity fails to comply with the U.S.Constitution,Federal statutes,regulations or the terms and conditions of a Federal award,the Federal
awarding agency or pass-through entity may impose additional conditions,as described in §200.208.If the Federal awarding agency or pass-through entity
determines that noncompliance cannot be remedied by imposing additional conditions,the Federal awarding agency or pass-through entity may take one or more
of the following actions,as appropriate in the circumstances:
(a)Temporarily withhold cash payments pending correction of the deficiency by the non-Federal entity or more severe enforcement action by the Federal
awarding agency or pass-through entity.
(b)Disallow(that is,deny both use of funds and any applicable matching credit for)all or part of the cost of the activity or action not in compliance.
(c)Wholly or partly suspend or terminate the Federal award.
(d) Initiate suspension or debarment proceedings as authorized under 2 CFR part 180 and Federal awarding agency regulations(or in the case of a pass-through
entity,recommend such a proceeding be initiated by a Federal awarding agency).
(e)Withhold further Federal awards for the project or program.
(f)Take other remedies that may be legally available
14. 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.
Exhibit A,Statement of Work Page 6 of 9 Contract Number CLH32053-Amendment 15
Page 18 of 41
It is the understanding of DOH that Supervision funded under the direct program portion of this contract include at minimum the provision of at least
two of the three functions detailed here:administrative,educational or supportive supervision.Supervision that encompasses only administrative
functions will not be considered billable under Direct Program.To that end,it is the expectation of DOH that those personnel identified as Supervisors
have no more than one degree of separation from direct client care. Exceptions to this rule can be presented and considered to and by DOH Contract
Management. It will fall to the requesting organization to satisfactorily demonstrate that any Supervisory positions falling within the scope of Direct
Program are meeting the expectation of provision of educational or supportive supervision with the aim of directly impacting client experiences, quality
of services,and adherence to best practices and Statewide Standards.
viii. Small and Attractive items—Each Contractor shall perform a risk assessment(both financial and operational)on the agency's assets to identify those
assets that are particularly at risk or vulnerable to loss. Operational risks include risks associated with data security on mobile or portable computing
devices that store or have access to state data.Assets so identified that fall below the state's capitalization policy are considered small and attractive
assets.The Contractor shall develop written internal policies for managing small and attractive assets.Internal policies should take into consideration
the WaTech IT Security Standard SEC-04,which includes SEC-04-06-S Mobile Device Security Standard and SEC-04-01-G Media Handling and Data
Disposal Best Practices-https://watech.wa.gov/policies.
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 t Washington State Department of Health
when purchasing food and refreshments for approved meetings.
2. Food for staff meetings/training is unallowable.
PLEASE NOTE: If meals/refreshments are purchased for allowable meetings,food can only be
purchased for clients at the per diem rate.Any expenses over per diem will be denied. U.S. General Services Administration Per Diem
Look Up
x. Reimbursement of disallowed costs—The CONTRACTOR agrees to reimburse DOH for expenditures billed to the DOH for costs that are later
determined through audit or monitoring to be disallowed under the requirements of 2 CFR Part 200—Uniform Administrative Requirements,Cost
Principles,and Audit Requirements for Federal Audits.
b. Contract Modifications
i. Notice of Change in Services—The CONTRACTOR shall notify DOH program staff,within 45 days,if any situations arise that may impede
implementation of the services contained in the statement of work.DOH and the CONTRACTOR will agree to strategies for resolving any shortfalls.
DOH retains the right to withhold funds in the event of substantial noncompliance.
Exhibit A,Statement of Work Page 7 of 9 Contract Number CLH32053-Amendment 15
Page 19 of 41
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
15. Content Review and Website Disclaimer Notice
In accordance with all federal guidance,contractors receiving funds through DOH will submit all proposed written materials requiring review for HIV-related scientific or
medical accuracy including written materials,audio visual materials,and pictorials, including social marketing and advertising materials,educational materials,social
media communications(e.g.,Facebook,twitter)and other electronic communications,such as intemet/webpages to the OID Content Review Committee.CONTRACTOR
shall submit all materials to be reviewed for scientific or medical accuracy to:
Michael Barnes,Washington State Department of Health
PO Box 47841
Olympia,WA 98504-7841
Phone: 360-810-1880
Email: Michael.Barnes@doh.wa.gov
16. 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.
17. 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.
18. 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:
Exhibit A, Statement of Work Page 8 of 9 Contract Number CLH32053-Amendment 15
Page 20 of 41
2 CFR200(State,Local and Indian Tribal governments)at: https://www.federalregister.gov/documents/20 1 3/1 2/26/20 1 3-3 0465/uniform-administrative-
requi rem ents-cost-pri nc i p l es-and-aud i t-requirem ents-fo r-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.
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 9 of 9 Contract Number CLH32053-Amendment 15
Page 21 of 41
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Recreational Shellfish Activities- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: July 1,2025 through June 30,2027 Z State ❑ FFATA(Transparency Act) ID Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide funds for shellfish harvesting safety.
Revision Purpose: The purpose of this revision is to extend the period of performance and funding end date from 06/30/26 to 06/30/27,add funds,and revise task delieverable
due date and payment information,and special instructions.
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
REC. SHELLFISH/BIOTOXIN 26402600 N/A 334.04.93 07/01/25 06/30/27 7,500 9,000 16,500
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 7,500 9,000 16,500
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
1 Biotoxin Monitoring Submit annual report on DOH approved Email Reports to DOH by S7.000 S15,500
• Collect monitoring samples on schedule according to format of activities for the year,including the February 15,2026 and
Department of Health(DOH)Biotoxin Monitoring Plan, number of sites monitored and samples /ebruari />. 2027
coordinate deviations from the schedule with DOH,notify collected,and number and names of beaches
DOH in advance if samples cannot be collected. posted with signs. (See Special Instructions
• Conduct emergency biotoxin sampling when needed. below.)
• Post/remove recreational shellfish warning and/or
classification signs on beaches and restock cages as
needed.
• Issue biotoxin news releases during biotoxin closures in
Jefferson County. _
Exhibit A,Statement of Work Page 1 of 2 Contract Number CLH32053-Amendment 15
Page 22 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• This task may also include recruiting,training,and
coordination of volunteers,and fuel reimbursement funds
for volunteer biotoxin monitoring.
2 Outreach Submit annual report including the number Email Reports to DOH by S-594$1,000
• Staff educational booths at local events. of events staffed and amount of educational February 15,2026 and
• Distribute safe shellfish harvesting information. materials distributed. February 15, 2027
(See Special Instructions
below.)
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@doh.wa.gov.
Program Specific Requirements
Program Manual,Handbook,Policy References:
Department of Health's Biotoxin Monitoring Plan
Special References(i.e.,RCWs,WACs,etc.):
Chapter 246-280 WAC
h ttps://doh.wa.gov/community-and-environment/shel lfish/recreational-shellfish
https://doh.wa.gov/about-us/programs-and-services/envi ronmental-publ ic-health/environmental-health-and-safety/about-shell fish-program/about-biotox i n s-and-i I Ine ss-prevention-
program
Special Instructions:
Report for work performed in 2025 must be submitted via email to Liz Maier(liz.maiera,doh.wa.gov)by February 15,2026.Report for work performed in 2026 must be submitted
via email to Li- lfaier(li_.maienc4doh.wa.gov)by Februan 15, 2027.
The report format will be provided by DOH and may be modified throughout the period of performance via email announcement.
Exhibit A,Statement of Work Page 2 of 2 Contract Number CLH32053-Amendment 15
Page 23 of 41
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: School-Based Health Centers Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) Z Reimbursement
Period of Performance: July 1,2025 through June 30,2027 ® State ❑ FFATA(Transparency Act) ❑ Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to fulfill the legislative mandate, RCW 43.70.825,and formalize a grant award to Jefferson
County Public Health for a school-based health center(SBHC)operations grant.A school-based health center is defined in the law as"a student-focused health center located in or
adjacent to a school that provides integrated medical,behavioral health,and other health care services such as dental care."
Jefferson County Public Health will complete infrastructure and capacity building tasks and activities outlined in the contract to operate,expand,and/or improve a school-based
health center at Quilcene,Chimacum,and Port Townsend School Districts.Activities include participation in trainings,technical assistance,and contract meetings;expanding,
sustaining,and/or improving SBHC services;and reporting on performance. This contract will be the fourth year of the grant award.
This is exempt from the budget freeze,as it is for existing SBHCs and the contract is for services that were legislatively supported.
Revision Purpose: This revision extends the period of performance through state fiscal year 2027,adds funds for an additional grant year,and updates deliverable due dates.
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY26 SCH BASED HLTH CENT 1225 PROVISO 78310860 N/A 334.04.90 07/01/25 06/30/26 140,000 0 140,000
SFY27 SCH BASED HLTH CENT 1225 PROVISO 78310870 _ N/A 334.04.90 07/01/26 06/30/27 0 140,000 140,000
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 140,000_ 140,000 280,000
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
la Develop or update a grant implementation plan for SBHC operations grant implementation September 30,2025 $15,000
maintaining,expanding,or improving SBHC services. workplan September 30. 2026
Create a workplan that outlines tasks and activities for the
project,including the due date,staff that will work on each
task,and staffs role for each task. _
1 b Provide services in accordance with the SBHC Grant Quarterly report—implementation Quarterly, $20,000($5,000 per
Requirements before or within three(3)months of the grant October 15 report)
period. January 15
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH32053-Amendment 15
Page 24 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
April 15
Provide updates to DOH on progress of SBHC operations July 15
and workplan completion.
•Include status report of SBHC operations(hours of
operation,staffing model,and services provided)and grant
spending
•Include milestones,successes,challenges,and barriers
2a Attend bimonthly contract meetings,starting within two(2) Quarterly report that includes list of dates of Quarterly, $10,000($2,500 per
months of contract execution,with DOH to discuss progress, contract meetings attended during the October 15 report)
support needs,barriers/challenges. reporting period January 15
April 15
Provide updates on grant implementation,including grant July 15
spending,relevant staffing changes,etc.
2b Participate in at least one key training,support,and/or Quarterly report that includes: Quarterly, $10,000($2,500 per
technical assistance activity per quarter,as recommended by •List of trainings and TA meetings attended October 15 report)
DOH or WA School-Based Health Alliance(WA SBHA). during the reporting period January 15
•List of any additional resources or training April 15
Identify additional resources or training needed;collaborate needed July 15
with DOH to participate in and/or get access to resources,if
needed.
3a Update the community engagement and/or communications Community engagement plan September 30,2025 $15,000
plan for the 2025 2026 school year.Plan should include September 30. 2026
relationship-building activities,youth engagement,
parent/guardian engagement,and advisory group meetings.
3b Provide updates on implementation of community Quarterly report—community engagement Quarterly, $10,000($2,500 per
engagement and communications plans. October 15 report)
January 15
April 15
July 15
4a Provide integrated medical and behavioral health services Quarterly performance measure report Quarterly, $20,000($5,000 per
that,at minimum,meet the DOH SBHC Grant October 15 report)
Requirements. January 15
April 15
Collect and report on required performance measures,using July 15
provided DOH performance measure spreadsheet,for each
SBHC site.
5a Identify SBHC operations goals and draft or urpu/ate Evaluation plan September 30,2025 $15,000
evaluation plan,in collaboration with DOH SBHC Septet/the, 30, 2026
epidemiologist.The plan will include,at minimum, goals
addressing financial sustainability and health equity.
5b Provide updates on progress of identified SBHC operations Quarterly report—evaluation Quarterly, $10,000($2,500 per
goals and implementation of evaluation plan.Participate in October 15 report)
January 15
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment 15
Page 25 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
DOH SBHC grant program evaluation activities,as April 15
applicable. July 15
5c Submit report on SBHC evaluation using measures and goals Evaluation report June 30,2026 $15,000
outlined in evaluation plan. Use provided DOH report June 30, 2027
template.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW,or any other
finance-related inquiry,may be sent to tinanceii>,doh.wa.gov.
Program Specific Requirements
Special Requirements: Quarterly progress reports will be submitted to the DOH contract manager through an online link provided by DOH.
• Reports should include progress on deliverables to date, budget to actual report,successes, barriers/challenges,and support needs.
• Specific or separate reports should be submitted separately by email and on the specified due date.
Special References(i.e., RCWs,WACs,etc.): In accordance with RCW 43.70.825:Concerning School Based Health Centers(2021),the Washington State Department of Health
(DOH)contemplates awarding a contract to Jefferson County Public Health(LHJ)to operate their school-based health centers.
Definitions: A school-based health center is defined in the law as"a student-focused health center located in or adjacent to a school that provides integrated medical, behavioral
health,and other health care services such as dental care." Upon execution of the contract,the SBHC must meet the minimum requirements,including:
• Be open during regular school hours
• Provide on-site primary care services by a nurse practitioner,physician's assistant,medical doctor,and/or doctor of osteopathy,at least once a week
• Coordinate clinic services
• Provide behavioral health care services by a behavioral health provider that is on-site,through telehealth,and/or through mobile units.If a behavioral health provider is
not licensed,they must be supervised by a licensed behavioral health provider.
Billing Requirements:
• The grantee will invoice no later than 30 days after the month of service,or the submission date of deliverables with an associated cost,as specified in the Statement of
Work(SOW).All invoices for the budget period must be submitted no later than 45 days after the end of the budget period.
• Due dates and deliverables can be negotiated on and changed,as needed,with prior approval from the contract manager.
• Invoices will be submitted on the DOH A-19 form. Invoices must reference this contract number and provide detailed information as requested.
• All invoices must be approved by DOH prior to payment;approval will not be unreasonably withheld.DOH reserves the right to withhold payment until grantee meets
SBHC grant requirements or until an action plan is agreed upon.DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for
allowable costs as outlined in the statement of work and/or budget.DOH will issue payment within 30 days of receiving a correct and complete invoice and approving the
deliverable(s).
• DOH will return all incorrect or incomplete invoices and will not pay for services that occur outside the period of performance.
• The grantee will not invoice for services if they are entitled to payment,have been,or will be paid by any other source for that service.
• The grantee may bill incrementally for progress on objectives, but the entire product will be delivered for the amount specified regardless of time spent on the tasks for each
objective.
• Report due dates and invoice amounts are as follows(invoice amount listed below is an estimate and is flexible based on deliverables completed):
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH32053-Amendment 15
Page 26 of 41
o Q1 deliverables(July-September)due by October 15,2025:$65,000
o Q2 deliverables(October-December)due by January 15, 2026: $20,000
o Q3 deliverables(January-March)due by April 15, 2026: $20,000
o Q4 deliverables(April-June)due by July 15, 2026: $35,000
• DOH must receive correct and complete invoices within 45 days of the budget period. Late invoices will be paid at the discretion of DOH and are contingent upon the
availability of funds.Failure to submit a properly completed IRS form W-9 may result in delayed payments.
o Submit all final billings within 45 days of the end of the contract
o Submit all required program reports and deliverables within 45 days
Exhibit A,Statement of Work Page 4 of 4 Contract Number CLH32053-Amendment 15
Page 27 of 41
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Sexual&Reproductive Health Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 5 Funding Source Federal Compliance T pe of Payment
® Federal Subrecipient (check if applicable) Reimbursement
Period of Performance: January 1,2025 through June 30,2027 ® State ® FFATA(Transparency Act) ❑ Fixed Price
❑ Other ❑Research&Development
Statement of Work Purpose: Provide sexual and reproductive health services to Washington State residents.These services will comply with all state and DOH Sexual&
Reproductive Health Manual requirements.It highlights specific requirements,but all must be complied with.Budgets are based on an approved allocation formula with funds
available.
This statement of work(SOW)supports the Title X family planning service grant(FPHPA006560),which runs on a 5-year grant cycle(1/14/2022 to 3/31/2027)with a revised
SOW issued each grant year.The SOW includes both federal and state budgets,where the federal Title X budget period runs from April to March and the state Title X budget
period runs from July to June annually.
For federal funding,due dates after 03/31/27 are for reporting purposes only.LHJ may not bill federal funding under this SOW for work done after 03/31/27.
For state funding,due dates after 06/30/27 are for reporting purposes only.LHJ may not bill state funds under this SOW for work done after 06/30/27.
Revision Purpose: The purpose of this revision is to add$38,074 in SFY27 SEXUAL&REP HLTH COST SHARE funding for the period of 07/01/26-06/30/27,add$25,242 in
FFY26 TITLE X FAM PLAN FPHPA YR5 funding for the period of 04/01/26-03/31/27,extend the period of performance through June 30,2027,clarify language in the
Statement of Work Purpose,and revise task and Program Specific language.
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY24 FPHPA TITLE X FAMILY PLAN 78430240 93.217 333.93.21 01/01/25 03/31/25 16,966 0 16,966
SFY25 SEXUAL&REP HLTH COST SHARE 78430150 N/A 334.04.91 01/01/25 06/30/25 47,993 0 47,993
FFY25 FPHPA TITLE X FAMILY PLAN , 78430250 93.217 333.93.21_ 04/01/25 03/31/26 38,072_ 0 38,072
SFY26 SEXUAL&REP FILTH COST SHARE 78431160 N/A _ 334.04.91 07/01/25 !12/31/25 47,404 0 47,404
SFY26 SEXUAL&REP HLTH COST SHARE 78431160 N/A 334.04.91 01/01/26 06/30/26 41,664 0 41,664
SFY27 SEXUAL&REP HLTH COST SHARE 78431170 N/A 334.04.91 07/01/26 06/30/27 0 38,074 38,074
FFY26 FPHPA TITLE X FAMILY PLAN 78430260 93.217 333.93.21 04/01/26 03/31/27 0 25,242 25,242
0 0 0
0 0 0
TOTALS 192,099 63,316 255,415
Exhibit A, Statement of Work Page 1 of 8 Contract Number CLH32053-Amendment 15
Page 28 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
1 Sexual and Reproductive Health Program • A 19 invoice vouchers submitted in a timely manner As described in Task 6: Billing must be based on
(SRHP)&Title X(TX) Services—excluding accompanied by an R&E workbook showing revenue Revenue and Expense a current cost analysis
abortion and other surgical procedures related and expenses for the month billed and any other Reports in the Reporting approved by DOH(see
to SRHP. required back-up documentation per DOH policy. Requirements section Reporting Requirements
below. below).
A. Comply with Washington State SRHP • All reports described in Reporting Requirements
Manual,federal Title X requirements and all below. As requested by DOH
state and federal laws. Also see Program DOH will authorize
Manual,Handbook,Policy References under • Other data and documentation in format requested by payment only upon
Reporting Requirements(below). DOH. (Includes copies of program and financial audits satisfactory completion
and reviews including summaries conducted by other and acceptance of
B. Complete required Agency Information entities.) deliverables and for
Request including Title X Assurance of allowable costs as
Compliance and National Provider Identifier • Site review directed by DOH SRHP.Follow-up site outlined in the statement
(NPI)billing numbers visits as needed until identified issues are resolved. of work and/or budget.
*SEE INVOICES and
C. Provide medical services,community • Submit documentation to DOH SRHP as requested for
PAYMENTS that
education and outreach,and staff training, a desk review prior to site visit. follows this table for
consistent with state requirements: details.
• Appropriate staff and documentation readily available
1. LHJ is responsible for making sure all to DOH SRHP prior to and during site visit.
staff have the knowledge to carry out Payment is limited to the
the requirements of the SOW. maximum funds
available for funding
2. Medical, laboratory,and other services source. DOH will
related to abortion are not covered by reimburse for actual
this task. allowable costs as
cal3. Community education services must be workbookok(see
the R&E
see
based on the needs of the community. Reporting Requirements
LHJ must have an Information&
Education(I&E)committee with five table)
(5)or more members that is broadly
representative of the population or All services must be
community for which materials are billed within 40 days of
intended.The committee must review a the budget period,40 30
days for all other billing.
batch of patient-facing materials
annually (at least 15 products or 15%of Specific dates noted in
Reporting Requirements,
the total number of materials,whichever Activity 5,Revenue and
is smaller);meet at least annually and Expense Reports.
establish a written record of its
determination.(42 CFR 59[59.6])
Exhibit A,Statement of Work Page 2 of 8 Contract Number CLH32053-Amendment 15
Page 29 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
4. Outreach is to ensure all populations in
your community understand the services
available.Focus your outreach efforts
on increasing equity.
Washington State Sexual and
Reproductive Health Network priority
populations are:
• Teens
• People who are uninsured or
underinsured,and/or low-
income(at or below 250%of
the federal poverty line)
• Rural communities
• Hispanic
• Black, Indigenous,People of
Color
Extra efforts should be made to provide
information and services to people who
intersect with multiple priority
population categories.
5. Provide all services in accordance with:
• DOH SRHP&Title X Manual
• Other state and federal
requirements
• Reporting Requirements(see
below)
D. Collect,maintain,and provide data about CVR data submitted to DOH data contractor t--a-I}tefs& The 15`h of the following
each family planning clinic visit as defined Associates)electronically in a format compatible with month.Within thirty(30)
in the SRH CVR Manual Milers their software. days of receiving
1. Maintain a computer system that
includes safety precautions against loss error/rejection report or
of information. • Data for each month request from DOH Sexual
and Reproductive Health
2. Ensure data entry personnel protect • Corrected CVR data data manager.
confidentiality of CVR data.
3. Have ability to retrieve all information
for auditing and monitoring by DOH or
its designee.
As needed to keep
E. Notify DOH contract manager of all:
• Key staff and organizational changes.
Email briefly describing change. information current.
Exhibit A,Statement of Work Page 3 of 8 Contract Number CLH32053-Amendment 15
Page 30 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
• Proposed clinic site additions.New
clinic sites must be approved by DOH
before offering services supported by
SRHP/Title X funding.
• Expected clinic site closures.Note:
DOH may,at its sole discretion,
recalculate LHJ's funding allocation if it
closes a clinic site.
• Any other change that might affect
LHJ's ability to provide the sexual and
reproductive services described in this
SOW.
Reporting Requirements
1 Agency Information Request This information must be reported using the template April 30th during each
or format provided by DOH.All signatures and forms year of this contract.
DOH SRHP requires updated information from must be completed by April 30th during each year of
all members of the SRHP Network to ensure this contract.Requested information will include: AND
accurate records of LHJ's organization and the
services it provides. Information about your agency contacts and your As needed or requested to
organization's staffing maintain accuracy of
In addition,elements of this report allow DOH to A. Head of Organization information.
ensure that SRHP&Title X requirements B. Head of Finance
including client fees and required services are C. Medical Director
met.The updated information also assists DOH D. NPI numbers used to bill Medicaid
to manage this SOW and the Sexual& E. The following(one person might fill more than one
Reproductive Health Network as a whole. role)
a. Contract Coordinator
b. Clinical representative
c. Billing contact
d. Outreach and education contact
e. Contact for CVR data
f. Contact for EHR information
Information regarding sexual and reproductive health
related services offered at each clinic site:
A. Cost analysis:How LHJ determines what it costs
to provide services. LHJ uses this to help construct
its fee schedule. A cost analysis must be
performed by LHJ within three years prior to the
start date of this SOW. If contractor cost analysis
was approved by DOH at the beginning of the
Exhibit A,Statement of Work Page 4 of 8 Contract Number CLH32053-Amendment 15
Page 31 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
contract period,LHJ does not have to resubmit
unless changes are made.LHJ must email DOH
contract manager informing them that no changes
were made.
B. Sliding fee schedule that includes all services
required in the SRH Manual.Additional SRH-
related services as outlined in Task 1 may also be
included on LHJ's sliding fee schedule.
a. Sliding fee schedule must be based on cost
analysis described above.
b. Fee schedule must be resubmitted for
reapproval anytime there are any significant
changes,which may include changing of
services,fees,etc.
c. LHJ must not implement a revised fee
schedule until it has been approved in writing
by DOH.
d. Income conversion tables must be updated Submit an updated
annually and approved by DOH income conversion table
by March 15 of each year
Information related to current Community Outreach Plan: of the contract.
LHJ's community outreach plan follows a 5-year cycle.
This process must include the following steps:
A. Utilize the state level priority populations,county
level demographic data,and agency profile to
identify unmet need in the community served.
B. Determine objectives and activities to expand
sexual and reproductive health to reach
populations in need of services in the community
served.
C. Measure completion of the objectives and
activities.
2 Program Updates This information must be reported using the template During quarterly check
or format provided by DOH.It will include information ins and as requested by
Summary of ongoing activities related to the SRH about contractor's work during current and past DOH
Program.This informs quality improvement of SOWs:
the Washington State SRH Network.
A. Community education and outreach strategies and
activities and a discussion of their effectiveness.
B. Staff training.
Exhibit A,Statement of Work Page 5 of 8 Contract Number CLH32053-Amendment 15
Page 32 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
4 Family Planning Annual Report(FPAR) Organization-level data on clinical services emailed to Data to be collected
DOH SRH data manager annually through the end
Information DOH is requesting to develop trend Number of: of the grant(2027).
data. All information is for the calendar year A. Pap tests with an ASC or higher result
(January through December). The subsequent B. Pap tests with an HSIL or higher result
agreements sent to the agency will request that C. HIV Positive confidential tests
these data be collected and reported on within the D. HIV Anonymous tests
statement of work period of performance. E. FTE required to provide sexual and reproductive
health services:
• Physicians
• Physician assistants+nurse practitioners+
certified nurse midwives
• Registered nurses with expanded scope of practice
who are trained and permitted by state specific
regulations to perform all aspects of the physical
assessment.
Financial data emailed to DOH Contract Manager
R&E showing Other Revenue through the end of the grant
as described below.
Subsequent agreements will request that data be collected
and reported on during the appropriate contract period of
performance.(FPAR due 01-31 annually through 2027)
5 Clinic Visit Reports(CVRs) Clinic visit records must include all elements specified The 15th of the following
in the Clinic Visit Record(CVR)Manual available at: month.
https://waporta/.org/
Within thirty(30)days of
receiving error or
rejection report or request
CVR data must be submitted to DOH data contractor from DOH SRH data
(Ahlers&Associates}electronically in a format compatible manager.
with Ahlers their software.
- Each month's CVR data
- Corrected CVR data
6 Revenue and Expense Reports(R&E) Completed R&E for time period that shows all revenue Invoices(A19's)and
(including program income)that support Task 1 SRH R&Es that support
Services and all expenses related to providing those services through the end
services. R&E workbook will be provided by DOH. of this contract must be
billed following the
A. Expenses must match General Ledger. required deadlines:
B. Other revenue/program income must reflect revenue • March Invoices and
actually received in the reporting month.
R&Es are due by
May 10th
Exhibit A,Statement of Work Page 6 of 8 Contract Number CLH32053-Amendment 15
Page 33 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
All entries on"Other"rows must be accompanied by a • June Invoices and
description of the revenue source or expense,including any R&Es are due by
calculations uses. August 10th
• December Invoices
and R&Es are due
by February 10th
• All remaining
months must be
billed within(4 30
days.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site. Questions related to this SOW,or any other
finance-related inquiry,may be sent to tinance(udoh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA) (Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual,Handbook,Policy References:
LHJ must comply with all state,federal,DOH SRHP,and Title X requirements, policies,and regulations and with their DOH approved Agency Information Dashboard.
Reference documents include:
• DOH SRHP Manual,available at https ir'aportal.oag- (DOH publication 930 122,available at 930 122 FPRHManualComplete.pdf(wa.gov)Some provisions of this
manual are highlighted in this SOW,but all provisions of the manual must be complied with.
• (VR.t lantral, available at blip,+: ucaparla/or;g
• LHJ's approved Agency Information Request.
Billing Requirements:
See Payment column of Tasks and Deliverables table and R&E report description in Reporting Requirements table
Billing must be based on a current cost analysis approved by DOH(see Reporting Requirements table).
INVOICES AND PAYMENT: Contractor will submit invoices to the DOH Contract Manager for all amounts to be paid within 30 days of the month of service,or the
submission date of deliverables with an associated cost,as specified in the Statement of Work(SOW). Refer to the SOW,Exhibit A,for invoice due dates on any budget/funding
period(s)that end during the contract period of performance.DOH must receive correct and complete FINAL invoices no later than 45 days after the contract expiration date.
Invoices must reference the contract number and provide detailed information as required.All invoices must be approved by DOH prior to payment;approval will not be
unreasonably withheld.
Exhibit A,Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment 15
Page 34 of 41
DOH will authorize payment only upon satisfactory completion and acceptance of deliverables and for allowable costs as outlined in the statement of work and/or budget.DOH
will return all incorrect or incomplete invoices and will not pay for services that occur outside the period of performance.The Contractor will not invoice for services if they are
entitled to payment,have been,or will be paid,by any other source for that service.
DOH will issue payment within 30 days of receiving a correct and complete invoice and approving the deliverable(s).Late invoices will be paid at the discretion of DOH and are
contingent upon the availability of funds. Failure to submit a properly completed IRS form W-9 may result in delayed payments.
DOH reserves the right to withhold payment until:
• Compliance issues or a previous SOW are resolved in a way accepted by DOH.
Payment is limited to the maximum funds available for funding source.
DOH will reimburse for:
• Actual allowable costs according to your approved cost analysis(see Reporting Requirements table)and as calculated by the R&E workbook.
Special Instructions:
Accessibility of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to priority populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible,services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal,State,and local governments, including local fire,building,and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis. Acceptance of SRH services must not be a prerequisite to eligibility for,or receipt of,services in any non-SRH
programs of the LHJ.
Availability of Emergency Services
The LHJ must have written plans and procedures for the management of on-site medical emergencies, including emergencies that require transport and after-hours management of
contraceptive emergencies. (See DOH SRH Manual)
If LHJ or DOH discontinues this contract:
See SRHP Manual for close out requirements and resources.
Exhibit A,Statement of Work Page 8 of 8 Contract Number CLH32053-Amendment 15
Page 35 of 41
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) 8 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through December 31,2027 ID State ® FFATA(Transparency Act) D 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 FFY26 BRSTFDG PEER CN PR MGMT 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 09/30/26 113,693 25,400 139,093
FFY26 BRSTFDG PEER CN PR MGMT USDA 76214260 10.557 333.10.55 10/01/25 09/30/27 0 26,770 26,770
0 0 0
TOTALS 286,515 52,170 338,685
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 15
Page 36 of 41
Task Payment Information
# Activity Deliverables/Outcomes Due Date/Time Frame 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
2 Breastfeeding Promotion See"Billing ��
Requirements below.
2.1 Provide breastfeeding promotion activities in accordance with Status report of chosen activities in First year due 11/30/25
federal and state requirements. Nutrition Services Plan. Second year due 11/30/26
Third year due 11/30/27
Documentation must be available for
review by WIC monitor staff. Biennial WIC Monitor
Exhibit A, Statement of Work Page 2 of 7 Contract Number CLH32053-Amendment 15
Page 37 of 41
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
See"Billing
3 Breastfeeding Peer Counseling Program(BFPC) 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(ddoh.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 15
Page 38 of 41
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 15
Page 39 of 41
• 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 15
Page 40 of 41
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 A19-1A 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 A 19s 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 15
Page 41 of 41
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
Exhibit A,Statement of Work Page 7 of 7 Contract Number CLH32053-Amendment 15
615 Sheridan Street
Port Townsend, WA 98368
(*ehson 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: Jjtyr
Li 6)-o1(,
SUBJECT: Agenda Item — Consolidated Contracts Amendment #15 with the Department
of Health; January 1, 2025 — December 31, 2027; $1,916,986 additional
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #15
between JCPH and State of Washington Department of Health (DOH); January 1, 2025 — December 31, 2027;
additional funding of $1,916,986 for a total to date of $8,209,503.
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):
• Foundational Public Health Services (FPHS) funds are to build the public health system's capacity and
increase the availability of FPHS services statewide (additional funding of $1,572,000).
• Infectious Disease Syndemic (occurring when two or more infectious diseases or health conditions
cluster and interact within a population) Prevention Services (additional funding of $80,500).
• Recreational Shellfish Activities; this SOW provides funds for shellfish harvesting safety (additional
$9,000).
• School-Based Health Centers Program: this SOW formalizes a grant award to JCPH for school-based
health center operations (additional $140,000).
• Sexual & Reproductive Health Program: this revision adds funds (additional $63,316).
• WIC Nutrition Program — this revision updates adds funds within the Women, Infants, and Children
Nutrition Program (additional $52,170).
FISCAL IMPACT/COST BENEFIT ANALYSIS:
Total consideration for this Contract Amendment is $1,916,986. The Consolidated Contract is funded by DOH,
and comprises both Federal and State funds.
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-A 15
RECOMMENDATION:
JCPH Management recommends BoCC approval of Consolidated Contract Amendment #15 between JCPH and
DOH; January 1, 2025 — December 31, 2027; additional funding of $1,916,986.
REVIEWED BY:
6/46k4
Josh D. Peters, County Administrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 Always working for a safer and healthier community (f) 360-379-4487
360-385-9401 (f)
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-25-001-A15
Contract For: Consolidated Contracts, Amendment 15 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: $1,916,986 additional for a total of$8,209,503 PROCESS. if Exempt from Bid Process
Revenue: $1,916,986 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 COMP E WIT 5.080 AND CHAPTER 42.23 RCW.
�""�
CERTIFIED: N/A: ■ l��'3� / June 25, 2026
Glenn Gilbert Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEEN DEBARRED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: I 1 N/A: �C lac June 25,2026
Glenn Gilbert Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 6/25/2026.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 6/25/2026.
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:
Irtlp.y/tstateofwa.sharepoint comisitesldoh-ofsfundingesouices/sitegages/home.02x? eI:9a94688da2d94d3ea8Oac7lbc32e ld7c
❑ 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$6492,517.
❑ 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 - F COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
05/28/2026
Jreg rot erton, atr Date Date
APPROVE AS TO ORM ONLY: APPROVED AS TO FORM ONLY
C Assistant Attorney General
May 14, 2026
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
Page I of I
t:C-25-01 I-AI I
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 7WA700WAI 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 $28,236
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 10/0I/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 S14,563
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 I0/31/26 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 PREP BP2-CDC-LHJ Partners NU90T0000055 Amd 7 93.069 333.93.06 07/01/25 06/30/26 07/01/25 06/30/26 $19,527
FFY24 PHEP BPI-CDC-LHJ Partners NU9OTU000055 Amd I 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 NUI7CE010218 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 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 Pale 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 NU50CK000515 Amd 9 93.323 333.93.32 07/01/25 06/30/26 07/01/25 07/30/26 $10,000 510,000 $10,000
FFY2I 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 NE110E000053 Amd 9 93.967 333.93.96 01/01/25 11/30/27 12/01/22 11/3027 $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 11/3027 $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 YRI B04MC55473 .Amd 14 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 S12,233 S28,736 $28,736
FFY26 MCHBG LHJ Contracts HRSA YRI 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 YRI B04MC55473 Amd 12 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/3026 $2,140
FFY26 MCHBG LHJ Contracts HRSA YR1 B04MC55473 Amd 11 93.994 333.93.99 10/0125 09/30/26 10/01/25 09/30/26 $6,717
FFY26 MCHBG LHJ Contracts HRSA YRI 604MC55473 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 YRI 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 S140,000
SFY25 DUH Naloxone DDO HCA IAR Amd 4 N/A 334.04.91 03/01/25 06/30/25 12/1024 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 S47,404
SFY25 Sexual&Rep Hlth Cost Share Amd 1 N/A 334.04.91 01/01/25 06/30/25 07/01/24 06/3025 $47,993 S47,993
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 S24,500 $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 ShellfishBiotoxin Amd6 N/A 334,04.93 07/01/25 06/30/26 07/01/25 06/30/26 $7,500 $7,500 $11,200
Rec Shellfish/Biotoxin Amd I N/A 334.04.93 01/01/25 06/30/25 07/01/23 06/30/25 $3,700 $3,700
Small Onsite Management(ALEA) Amd 8 N/A 334,04.93 07/01/26 06/30/27 07/01/25 06/30/27 $6,571 $6,571 S68,200
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 2 of 3
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 S2,203,000
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
YRI 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
YRI 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 S6,292,517 S6,292,517
Total consideration: S6,280,284 GRAND TOTAL S6,292,517
S12,233
GRAND TOTAL S6,292,5I7 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) El Fixed Price
0 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 f 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 16,503 12,233 28,736
FFY25 MCHBG SPECIAL PR HRSA 2 78I0125A 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
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
I c 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
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
le 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.
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.
1 h Participate in DOH-sponsored MCHBG fall regional LHJ Contract Lead or designee will attend September 30,2026
meeting. regional meeting.
Implementation
2a Report 2024-25 MCHBG-funded activities and Submit monthly reports to DOH Community January 15,2025 Reimbursement for actual
outcomes using DOH-provided reporting template. As a Consultant.Describe in your updates within February 15,2025 costs,not to exceed total
foundation of your MCHBG work determine how each activity of the monthly report how you March 15,2025 funding consideration.
processes and programs can close gaps in health are intentionally focused on closing gaps in April 15,2025 Monthly Reports must only
outcomes. health outcomes. May 15,2025 reflect activities paid for
June 15,2025 with funds provided in this
July 15,2025 statement of work for the
August 15,2025 specified funding period.
September 15,2025
2b Develop 2025-26 MCHBG reporting document for Submit MCHBG reporting document to DOH Draft-August 15,2025 See Program Specific
October 1,2025 through September 30,2026 using Community Consultant. Final-September 12,2025 Requirements and Special
DOH-provided template. Billing Requirements.
2c Report 2025-26 MCHBG-funded activities and Submit monthly reports to DOH Community September report due
outcomes using DOH-provided reporting template. As a Consultant. Describe in your updates within October 15,2025
foundation of your MCHBG work determine how each activity of the monthly report how you November 15,2025
processes and programs can close gaps in health are intentionally focused on closing gaps in December 15,2025
outcomes. health outcomes. January 15,2026
February 15,2026
March 15,2026
April 15, 2026
May 15,2026
June 15,2026
July 15,2026
August 15,2026
September 15,2026
Exhibit A, Statement of Work Page 2 of 5 Contract Number CLH32053-Amendment 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-CHIFr7a,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 ParentHelpI 23.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-CH IFc 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
ParentHelp I23 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 financerdoh.wa.go‘.
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)].
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 A 19-1 A invoice voucher.Payment to completely expend the"Total Consideration"for
a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly by the 30th of each month following
the month in which the expenditures were incurred and must be based on actual allowable program costs.Billing for services on a monthly fraction of the"Total Consideration"
will not be accepted or approved.
Special Instructions:
Contact DOH Community Consultant for approval of expenses not reflected in pre-approved Budget Workbook.
Exhibit A,Statement of Work Page 5 of 5 Contract Number CLH32053-Amendment 14
Page 1 of 27
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 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:
I. Exhibit A Statements of Work, includes the following statements of work, which are incorporated by this reference
and located on the DOH Finance SharePoint site in the Upload Center at the following URL:
baps//stateellvasharepoint.cunt/sites/doh-ofsfundinwesources/sitepages/home.aspx? e I:9a94688da24194d3ea80ac7tbc32e td7c
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 1, 2025
Maternal & Child Health Block Grant - Effective January 1, 2025
WIC Nutrition Program - Effective January I, 2025
r 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:
Increase of$101,206 for a revised maximum consideration of$6,280,284.
7 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.
ALI. 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 F COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
� _ ��1 4�� 05/12/2026
re rot erton, Chair Dat Date
APPROVED AS TO FORM ONLY: APPROVED AS TO FORM ONLY
l;ar _ 04/29/2026 Assistant Attorney General
4
Jeremia'. 1.11r er. Date
Deputy Prosecuting Attorney
Page 1ol' I
cc ?c.ntt All
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 7WA700WAI 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 10/0123 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
FF1•26 WI( Client Sss Contracts 1'SDA "Ni ti'u!lti i- Amd 13 10.557 333.1(1.55 10/0125 09/30/26 10/01/25 09/3026 7'562.8'13 S113.693 S113.693
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 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 BPl-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 OM Prevent CD(' NI l'7('}010218 kind 13 93.136 333.93.13 09/0125 06/3026 09/0125 08/31/26 S30,667 S128,667 S248,344
FFY25 OD2A OID i'revent('I)( 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 OLD 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 OLD CDC Prevent NU17CE010218 Amd 2 93.136 333.93.13 0I/0125 06/30/25 09/01/24 08/31/25 $32,556 $81,556
FFY24 OD2A OLD CDC Prevent NU17CE010218 Amd 1 93.136 333.93.13 01/01/25 06/30/25 09/01/24 08/31/25 $49,000
FFY25 FPHPA Title X Family Plan FPHPA006560 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 NH231P922619 Amd 1 93.268 333.93.26 01/01/25 06/30/25 07/01/23 06/30/25 $10,000 $10,000 $10,000
FFY20 ELC EDE LHJs CDC NU50CK000515 Amd 1,7 93.323 333.93.32 01/01/25 12/31/25 01/15/21 07/31/26 $15,580 $15,580 $15,580
Page 1 of 3
EXHIBIT B-I3 Paae 3 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
FFYI9 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 NEI 10E000053 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 NE1 IOE000053 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 YRI 1404,414'55473 Amd 13 93,994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 S7,646 S16,503 S16,503
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 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 YRI 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 I N/A 334.04.90 01/01/25 06/30/25 07/01/24 06/30/25 $59,000 $59,000 S59,000
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 5140,000
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 HIM Cost Share Amd 9 N/A 334.04.91 01/01/26 06/30/26 07/01/25 06/3026 $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 07/0123 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: 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 if Amend# List i#* 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 S10,602
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 S4,461,000
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 I 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
YRl 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
YRI 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 I 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
YRl 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 S6,280,284 S6,280,284
Total consideration: S6,179,078 GRAND TOTAL S6,280,284
S 101,206
GRAND TOTAL S6,280,284 Total Fed S1,144,149
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 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 ® State ❑ FFATA(Transparency Act) D 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 5918:000
benefits navigation,and family reunification. participant Si 2'8,6O?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 finance a doh.wa.gox.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.go‘ by DOH as required by P.L. 109-282.
Program Specific Requirements
Special Requirements,Terms and Conditions
I. 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 Al 9 invoice vouchers with amounts billable to DOH under this statement of work
and the corresponding OID Expense Summary backup form.All A19 invoice vouchers must be submitted by the 25th of the following month.Prior approval is
required for a different frequency of billing.
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 CLH32053-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 Health Nutrition Guidelines for Meetings and Events I Washington State Department of Health
when purchasing food and refreshments for approved meetings.
2. Food for staff meetings/training is unallowable.
PLEASE NOTE: If meals/refreshments are purchased for allowable meetings,food can only be
purchased for clients at the per diem rate. Any expenses over per diem will be denied. U.S. General Services Administration Per Diem
Look Up
x. Reimbursement of disallowed costs—The CONTRACTOR agrees to reimburse DOH for expenditures billed to the DOH for costs that are later
determined through audit or monitoring to be disallowed under the requirements of 2 CFR Part 200—Uniform Administrative Requirements,Cost
Principles,and Audit Requirements for Federal Audits.
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-
re uirenlents-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
Z 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 YRl 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 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
I 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.
I 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 I,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 usin&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:d;doh.wa.go‘ 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 a doh.wa.go‘ 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.‘A a.go .
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.go‘ by DOH as required by P.L. 109-282.
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 VVebsite(wa.govl
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(I)(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 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 T pe of Payment
® Federal Subrecipient (check if applicable) 1101 Reimbursement
Period of Performance: January 1,2025 through December 31,2027 ❑ State ® FFATA(Transparency Act) ❑ Fixed Price
0 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
I ut nu'i_e>d 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 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 financeadoh.wa.go‘..
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 t'SASoending.go' 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. AI9s are submitted monthly and must be received by the Department within 30 days following the close of each calendar month. Additional Al9s 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.
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:
!hairs: statcoliv.t.ibareprunt.carn%sitesidlift-e fsfunii rs:resource,i'siie:iacc inic .as i c 1:9446iiiida?d94d>ca2tt ac7ibc32e 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 1, 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-1 1 Allocations
as follows:
® Increase of$40,140 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
C—A" 'cbtukktfik3i,j3,4)52-J 03/11/2026
Greg rotherion,Chair Dade
Date
A t3V,ED S TO FORM ONLY APPROVED AS TO FORM ONLY
Jeremiah B.Luther,DPA Assistant Attorney General
02/27/2026
/ hi `p C.H sucker, Date Page 1 of 1
ief Ci puty Prosecuting Attorney
CC-25-OO 1•A 12
EXHIBIT B-12 Page 2 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
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 7WA700WAI 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 7WA700W':k7 Amd 12 10.557 333.10.55 10/01/25 09/30/26 10/01/25 09/30/26 S25,400 S50,800 S50,800
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 >,md 12 66.472 333.66.47 03/01/26 10/31/26 07/01/25 11/30/26 S8,000 S8,000 S21,500
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 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 AI-LHJ NE11OE000053 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 MCHBC LHJ Contracts HRSA YRI B04MC55473 Amd 12 93.994 333.93.99 10/01/25 09/30/26 10/01/25 09/30/26 S2,140 $8,857 $8,857
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 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 $3,850
YRI 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 Sl,800 S4,050 S4,050
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 1,md 12 N/A 346.26.66 01/01/25 12/31/27 07/01/23 06/30/28 SL000 S2,000 $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 $6,179,078
$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) El 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 CurrentTotal
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 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
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) ❑ Fixed Price
E 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 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 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
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 12
Page 8 of 21
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
ld 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.
if 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 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-CHIFna,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-CHIFna,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
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 12
Page 10 of 21
Task Payment Information
# Activity Deliverables/Outcomes Due Date/Time Frame 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 Al 9-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 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 Chang
e
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,LW shall
and 3 attend periodic required survey training as attending the training,submit an be paid mileage,per diem,lodging,and
directed by DOH. "Authorization for Travel(Non- registration costs as approved on the pre-
Employee)"DOH Form 710-013 to the authorization form in accordance with the
See Special Instructions for task activity. ODW Program Contact for approval(to current rates listed on the OFM Website
ensure enough funds are available). htt�://www.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 DOH Finance SharePoint site. Questions related to this SOW,or any other
finance-related inquiry,may be sent to financea,doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Data Sharing
The Office of Drinking Water will share water system information and files with the local health jurisdiction to support the work identified in this statement of work. To request
water system data please contact the regional office with the name of the water system,water system ID#,specific information being requested and any timeline requirements.If
allowable,please give administrative staff 3 to 5 business days to provide records.
Program Manual,Handbook,Policy References: Field Guide(DOH Publication 331-486).
Special References:
Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work,ODW contracts with the LHJ to conduct sanitary surveys(and SPIs and
provide technical assistance)for small community and non-community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys(and
SPIs and provide technical assistance)for small community and non-community water systems with surface water sources, large water systems,and systems with complex
treatment.
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4,below.
Special Billing Requirements
The LHJ shall submit 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 S4,500$8,100 for Task 1,and$47000$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 19-1 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 LHJ staff person is unable to attend these activities prior to conducting assigned tasks,the
LHJ staff person may,with ODW approval, substitute other training activities to be determined by ODW. Such substitute activities may include one-on-one training with ODW
staff,co-surveys with ODW staff,or other activities as arranged and pre-approved by ODW.LHJ staff may not perform the activities under tasks 1,2,and 3 without completing
the training that has been arranged and approved by ODW.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH32053-Amendment 12
Page 16 of 21
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: WIC Nutrition Program - Effective JanuarLL 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 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.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY25 USDA WIC CLIENT SVS CONTRACTS 76101251 10.557 333.10.55 01/01/25 09/30/25 144,669 0 144,669
FFY24 BRSTFDG PEER CN PR MGMT USDA 7621424A _ 10.557 333.10.55 01/01/25 09/30/26 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 Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 WIC Nutrition Program See"Billing Requirements"below.
1.1 Maintain authorized participating caseload at 100%based on Outcomes based on monthly participation Authorized participating
quarterly average as determined from monthly caseload data from state WIC caseload caseload for March 2025
management reports generated at state WIC office. management reports. through September 2026=
The Department of Health(Department) State WIC Nutrition 280
Program has the option of reducing authorized participating
caseload and corresponding funding when: Authorized participating
1. Unanticipated funding situations occur. caseload for March 2025
2. Reallocations are necessary to redistribute caseload through September 2026=
statewide. 300
3. Caseload declines.
Exhibit A, Statement of Work Page 1 of 6 Contract Number CLH32053-Amendment 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).
1.8a Submit entire WIC and Breastfeeding Peer Counseling Budget Budget Workbook First year due 9/30/25
Workbook for each year of the contract Second year due 9/30/26
Third year due 9/30/27
1.8b Submit Rev-Exp Report spreadsheet from the WIC Budget Revenue and Expense Report and A-19 First year due monthly
Workbook monthly with A-19 through September 30,2025
Second year due monthly
through September 30,2026
Third year due monthly
through September 30,2027
2 Breastfeeding Promotion See"Billing
Requirements" below.
2.1 Provide breastfeeding promotion activities in accordance with Status report of chosen activities in First year due 11/30/25
federal and state requirements. Nutrition Services Plan. Second year due 11/30/26
Third year due 11/30/27
Documentation must be available for
review by WIC monitor staff. Biennial WIC Monitor
2.2 Work with community partners to improve practices that affect Status report of chosen activities in First year due 8/30/25
breastfeeding. Choose one or more of the following projects: Nutrition Services Plan. Second year due 8/30/26
• Provide staff,health care providers and community partners Third year due 8/30/27
virtual breastfeeding training resources. 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 finance(c doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual,Handbook,Policy References:
The local agency shall be responsible for providing services according to rules,regulations and other information contained in the following:
• WIC Federal Regulations, USDA,and FNS 7CFR Part 246.
• Washington State WIC Nutrition Program Policy and Procedure Manual
Exhibit A, Statement of Work Page 3 of 6 Contract Number CLH32053-Amendment 12
Page 19 of 21
• Office of Management and Budget, Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards, 2 CFR 200
• Farmers Market Nutrition Program Federal Regulations,USDA,FNS 7CFR Part 248
• Other directives issued during the term of the contract
Staffing Requirements:
The local agency shall:
• Use Competent Professional Authority staff,as defined by WIC policy,to determine participant eligibility,prescribe an appropriate food package and offer nutrition
education based on the participants' needs.
• Use a Registered Dietitian(RD)or other qualified nutritionist to provide nutrition services to high-risk participants,to include development of a high-risk care plan. The
RD is also responsible for quality assurance of WIC nutrition services. See WIC Policy for qualifications for a Registered Dietitian and other qualified nutritionist.
• Assign a qualified person to be the Breastfeeding Coordinator to organize and direct local agency efforts to meet federal and state policies regarding breastfeeding
promotion and support. The Breastfeeding Coordinator must be an International Board-Certified Lactation Consultant or attend an intensive lactation management
course,or other state approved training.
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
The local agency shall follow the instructions found in the Policy and Procedure Manual under WIC Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,
Cost Principles,and Audit Requirements for Federal Awards.
Special References(i.e.,RCWs,WACs,etc.):
What is the WIC program?
1. The WIC program in the state of Washington is administered by the Department of Health.
2. The WIC program is a federally funded program established in 1972 by an amendment to the Child Nutrition Act of 1966.The purpose of the program is to provide nutrition
and health assessment;nutrition education;nutritious food;breastfeeding counseling;and referral services to pregnant,breastfeeding,and postpartum women,infants,and
young children in specific risk categories.
3. Federal regulations governing the WIC program(7 CFR Part 246)require implementation of standards and procedures to guide the state's administration of the WIC program.
These regulations define the rights,responsibilities,and legal procedures of WIC employees,participants,persons acting on behalf of a participant,and retailers.They are
designed to promote:
a. High quality nutrition services;
b. Consistent application of policies and procedures for eligibility determination;
c. Consistent application of policies and procedures for food benefit issuance and delivery;and
d. WIC program compliance.
4. The WIC program implements policies and procedures stated in program manuals,handbooks,contracts, forms,and other program documents approved by the USDA Food
and Nutrition Service.
5. The WIC program may impose sanctions against WIC participants for not following WIC program rules stated on the WIC rights and responsibilities.
6. The WIC program may impose monetary penalties against persons who misuse WIC benefits or WIC food but who are not WIC participants.
Monitoring Visits(i.e.,frequency,type,etc.):
Program and fiscal monitoring are done on a biennial(every two years)basis and are conducted onsite.
The local agency must maintain on file and have available for review,audit and evaluation:
• All criteria used for certification,including information on income,nutrition risk eligibility and referrals
• Program requirements
• Nutrition education
• All financial records
Exhibit A,Statement of Work Page 4 of 6 Contract Number CLH32053-Amendment 12
Page 20 of 21
Assurances/Certifications:
1. Computer Equipment Loaned by the Department of Health WIC Nutrition Program
In order to perform WIC program activities,the Department requires computer equipment,such as computers,signature pads,document scanners,card readers and printers to
be in local WIC clinics or to be transported to mobile clinics. This equipment("Loaned Equipment")is owned by the Department and loaned to the local agency(Contractor).
The Loaned Equipment is supported by the Department. This equipment shall be used for WIC business only or according to WIC Policy and Procedures.
An inventory of Loaned Equipment is kept by the Department. Each time Loaned Equipment is changed,the parties shall complete the Equipment Transfer Form and the
Department updates the inventory. A copy of the Transfer Form will be provided to the contractor. Copies of the updated inventory list may be requested at any time.
The local agency agrees to:
a. Defend,protect and hold harmless the Department or any of its employees from any claims, suits or actions arising from the use of this Loaned Equipment.
b. Assume responsibility for any loss or damage from abnormal wear or use,or from inappropriate storage or transportation. The Department may enforce this by:
1) Requiring reimbursement from the local agency of the value of the Loaned Equipment at the time of the loss or damage.
2) Requiring the local agency to replace the Loaned Equipment with equipment of the same type,manufacturer,and capabilities(as pre-approved by the Department),or
3) Assertion of a lien against the Contractor's property.
c. Notify the Department immediately of any damage to Loaned Equipment.
d. Notify the Department prior to moving or replacing any Loaned Equipment.
The Department recommends Contractors carry insurance against possible loss or theft.
2. Civil Rights Assurance
a. The local agency shall perform all services and duties necessary to comply with federal law in accordance with the following Civil Rights Assurance.
b. "The Program applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964(42 U.S.C.2000d et seq.),Title IX of the Education Amendments
of 1972(20 U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.794),Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.);all provisions
required by the implementing regulations of the Department of Agriculture;Department of Justice Enforcement Guidelines,28 CFR 50.3 and 42;and FNS directives and
guidelines,to the effect that,no person shall, on the ground of race,color,national origin,sex,age or handicap,be excluded from participation in,be denied benefits of,or
otherwise be subject to discrimination under any program or activity for which the Program applicant receives Federal fmancial assistance from FNS;and hereby gives
assurance that it will immediately take measures necessary to effectuate this agreement.
c. "By accepting this assurance,the Program applicant agrees to compile data,maintain records and submit reports as required, to permit effective enforcement of the
nondiscrimination laws and permit authorized USDA personnel during normal working hours to review such records,books and accounts as needed to ascertain
compliance with the nondiscrimination laws. If there are any violations of this assurance,the Department of Agriculture,Food and Nutrition Service,shall have the right
to seek judicial enforcement of this assurance.This assurance is binding on the Program applicant,its successors,transferees,and assignees,as long as it receives
assistance or retains possession of any assistance from the Department.The person or persons whose signatures appear on the contract are authorized to sign this
assurance on behalf of the Program applicant."
3. 2CFR 200
The local agency shall comply with all the fiscal and operations requirements prescribed by the state agency as directed by Federal WIC Regulations(7CFR part 246.6),2CFR
part 200,the debarment and suspension requirements of 2CFR part 200.213,if applicable,the lobbying restrictions of 2CFR part 200.245,and FNS guidelines and instructions
and shall provide on a timely basis to the state agency all required information regarding fiscal and program information.
Billing Requirements:
1. Definitions
Contract Period: January 1,2025—December 31,2027
Contract Budget Periods:The time periods for which the funding is budgeted.
• There are four federal budget periods
January 1,2025,through September 30,2025
Exhibit A, Statement of Work Page 5 of 6 Contract Number CLH32053-Amendment 12
Page 21 of 21
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-lA invoice. These invoices are provided by the Department in the WIC Budget Workbook and include accounting codes for different
budget categories.
b. Al9s are submitted monthly and must be received by the Department within 30 days following the close of each calendar month. Additional Al9s may be submitted at
any time but must be received within 45 days of the close of the federal budget period.
c. Funds are allocated by budget categories and by federal budget periods(refer to the budget spreadsheet).
d. Funds are encumbered or spent only during the budget period;no carry forward from previous time periods or borrowing from future time periods is allowed.
e. Payments are limited to the amounts allocated for the budget period for each budget category.
f. Billings are based on actual costs for completed activities. Advance payments are not allowed. Back-up documentation must be retained by the local agency and available
for inspection by the Department or other appropriate authorities.
g. Payments will be made only for WIC approved expenditures. Refer to the Washington State WIC Nutrition Program Policy and Procedure Manual Volume 2,Chapter 4—
Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards.
h. If billing for indirect costs,a Cost Allocation Plan or Federal Indirect Cost Agreement must be submitted prior to payment.
Special Instructions:
The local agency shall:
1. Maintain complete,accurate,and current accounting of all local,state,and federal program funds received and expended.
2. Provide,as necessary,a single audit in accordance with the provisions of 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles,and Audit Requirements for
Federal Awards. This circular requires all recipients and sub-recipients of federal funds to have a single audit performed should they spend$750,000 or more of federal grants
or awards from all sources. Contractors spending less than$750,000 in federal grants or awards may also be subject to audit.
3. Use Breastfeeding Peer Counseling(BFPC)Program funds only to support the peer counseling program. Once the program is established and peer counselors are trained,the
majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs see Volume 2,Chapter 4—Allowable
Costs. The priority use of BFPC funds is to hire and train peer counselors to provide breastfeeding peer counseling services to WIC participants.
SPECIAL REQUIREMENTS
Contract Budget Period Time Period special requirement Amount Special Requirement Description
funds are available
January 1,2025—September 30, January 2025—September 2025 $2,500 For general training funds. This funding is for all WIC staff to participate in
2025 WIC-related training.Added in the USDA WIC Client Services Contracts
category to cover training registrations,travel expenses, staff time to
participate in training(salary/benefits for part time or contractor),and other
approved training expenses.
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
Exhibit A,Statement of Work Page 6 of 6 Contract Number CLH32053-Amendment 12