HomeMy WebLinkAbout101314_ca03Hea
Consent A enda
615 Sheridan Streei
Port Townsend, WA 98368
www.JeffersonCountyPublicHealth.org
September 22, 2014
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Jean Baldwin, Director
DATE: ,1, (7) 1
SUBJECT: Agenda Item — Contract Agreement with Public Health of King County
for Breast Cervical & Colon Health Program Services; July 1, 2014 —
June 14, 2015; $1,558.00
STATEMENT OF ISSUE:
Jefferson County Public Health, Community Health, requests Board approval of the Contract Agreement
with Public Health of King County for Breast Cervical & Colon Health Program Services; July 1, 2014 —
June 14, 2015; $1,558.00
ANALYSIS /STRATEGIC GOALS /PRO'S and CON'S:
This is an ongoing agreement between Jefferson County and Public Health Seattle & King County to provide
Breast and Cervical Health Care, (Screening & Referral Services) to a specific segment of the population,
uninsured or underinsured women. Services are available to eligible clients to pay for preventive services
such as health exams, mammograms and pap tests. This includes breast screening and annual exam for
women age 40 -64 with incomes at or below 250% of Federal Poverty Level and mammography and breast
diagnostics available to women below 300% of FPL. These services will also be available to women who
may not be eligible for apple Health (Medicaid). This contract provides for colon health services to certain
counties that contract with Public Health of Seattle & King County, Jefferson County is not one of those
counties. JCPH will continue to do outreach.
Community Health
Developmental Disabilities
360 -385 -9400
360 -385 -9401 if)
Always working for a safer and healthier community
Environmental Health
Water Quality
360 -385 -9444
If) 360- 379 -4487
Consent Agenda
FISCAL IMPACT /COST BENEFIT ANALYSIS:
The agreement provides $1558.00 in State and Federal funding. With the uncertain federal budget this
contract amount represents only six months of this one year contract. No general fund dollars support this
program.
The agreement provides:
$1480.00 in funds for one or more of the following
visit, Pap tests, HPV tests.
$78 for Travel to BCCHP meeting
annual exam, clinical breast exam, problem- focused
RECOMMENDATION:
JCPH management request approval of the Contract Agreement with Public Health of King County for Breast
Cervical & Colon Health Program Services; July 1, 2014 — June 14, 2015; $1,558.00
Date
Public Health
Seattle & King County
King County Contract # P,REV3583
Federal Tax ID 4 91-6001322
Federal Sub-recipient Contract — Yes
2014 COMMUNITY SERVICES CONTRACT
(This form is available in alternate formats for people with disabilities upon request.)
THIS CONTRACT is entered into by KING COUNTY (the "County"), and Jefferson County Public
Health (the "Contractor"), whose address is 615 Sheridan, Port Townsend, WA 98368. The County
department overseeing the work to be performed in this Contract is the Seattle-King County Department
of Public Health (aka, Public Health — Seattle & King County, "PHSKC").
Contract SummarY
PHSKC Division: Prevention
Project Title. Breast, Cervical and Colon Health Program Services
Contract Amount not to exceed: One thousand five hundred fifty-eight dollars and zero cents.
Contract Start Date: 7/1/2014 Contract End Date: 6114/2015
Fund Source Information
FEDERAL $ 1,480-00 COUNTY: $ 0 STATE: $78.00 OTHER: $00.00 �tw
S ecific Fundin Details Award number GFDA Amounts
1) Federal BCHP — Award #C16898 — CFDA No. 93.283 - $1,480-00 — 711/2014 — 6/14/2015
2) State — Award #C16898 — $78.00 — 7/1/2014 — 6/15/2015
WHEREAS, the County has been advised that the foregoing are the current funding source . s, funding
levels and effective dates, and
WHEREAS, the County desires to have certain services performed by the Contractor as described in this
Contract, and as authorized by the 2.014 Annual Budget,
NOW THEREFORE, in consideration of payments, covenants, and agreements hereinafter mentioned,
to be made and performed by the parties hereto, the parties mutually agree as follows:
incur oration of 'Exhibits
The Contractor shall provide services and comply with the requirements set forth in the following
attached exhibits, which are incorporated herein by reference:
Exhibit A'. Funder's Special Terms & Conditions
Exhibit B: Scope of Work
Exhibit C: Budget
Exhibit D: I nvoice
Exhibit E: Contractor's Certificate of Insurance and Additional Insured Endorsement
Exhibit F: Service Authorization Form
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Term and Termination
A. This Contract shall commence on (Contract Start 0ahe), and shall terminate on (Contract End
Daha), unless extended orterminated earlier, pursuant to the terms and conditions of the Contract.
B� This Contract may bo terminated hy the County orthe Contractor without cause, in whole orin
part, prior tnthe date specified in Subsection ||./\. above, by providing the other party thirty (3O)
days advance written notice of the termination, The Contract may be suspended by the County
vv|thnmt oaume, in whole or in pad, prior to the date specified in Subsection KU./\. above, by providing
the Contractor thirty (30) days advance written notice ofthe suspension.
C. The County may terminate or suspend th,is Contract, in whole orin part, upon seven (7) days
advance written notice in the event: (1) the Contractor materially breaches any duty, obligation, or
service required pursuant t0 this Contract, or (2) the duties, obligations, or services required herein
become impossible, illegal, or not feasible. If the Contract is terminated by the County pursuant to
this Subsection ||.C. (1). the Contractor shall be liable for damages, including any additional costs
of procurement of similar services from another source.
If the, termination results from acts or omissions ofthe Contractor, including but not limited &o
misappropriation, nonperformance of required services, or fiscal mismanagement, the Contractor
shall return to the County immediately any funds, misappropriated or unexpemcled, which have
been paid tothe Contractor bv the County.
[]� If County or other expected or actual fuinding is withdrawn, reduced, or limited in any way prior to
the termination date set forth above in, Subsection ]].A., the County may, upon written notification
to the Contractor, terminate or suspend this Contract in vxho|g or in part.
if the Contract is terminated or suspended as provided in this Section: (1) the County will be liable
only for payment in accordance with the terms mf this Contract for services rendered prior tothe
effective date of termination or suspension; and (2) the Contractor shall be released from any
obligation toProvide such further services pursuant to the Contract oo are affected bythe
termination mrsuspension.
Funding or obligation under this Contract beyond the current appropriation year is conditional: upon
appropriation bv the County Council of sufficient funds to support the activities described imthe
Contract. Should such appropriation not be approved, this Contract will terminate at the close of
the current appropriation year.
If the Contract ie suspended mo provided in this Section the County may provide written
authorization to resume activities.
E, Nothing herein shall limit. vvaive, or extinguish any right or remedy provided by this Contract or law
that either party may have inthe event that the obligations, terms, and conditions set forth in, this
Contract are breached by the other party.
UL Compensation and Method of Payment
A The County shall reimburse the Contractor for satisfactory completion ofthe services and
requirements specified in this Contract, payable upon receipt and approval bv the County ofa
signed invoice in substantially the form of the attached Invoice Exhibit, which complies with the
rates set forth in the Budget Exhibit. The rnaxinmano amount payable under this contract is
$1,5,58.00. The County may, at any time and in its sole discretion, increase or decrease the
amount payable under this contract by providing the contract with a Service Authorization Form.
Such Service Authorization Form will be automatically incorporated into this Contract as a new
Exhibit F,
B The Contractor shall submit an invoice and all accompanying reports as specified in the attached
exhibits not more than 15 Working days after the close of each indicated reporting period. The
County shall make payment tothe Contractor not more than 3D days after o complete and
accurate invoice is received.
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C. The Contractor shall submit its final invoice and all outstanding reports within 30 days of the date
this Contract terminates, If the Contractor's final invoice and reports are not submitted by the day
specified in this subsection, the County will be relieved of all liability for payment to the Contractor
of the amounts set forth in said invoice or any subsequent invoice.
D. When a budget is attached, hereto as an exhibit, the Contractor shall apply the funds received from
the County under this Contract in accordance with said budget. The Contract may contain
separate budgets for separate program components. The Contractor shall request prior approval
from the County for an amendment to this Contract when the cumulative amount of transfers
among the budget categories is expected to exceed 10% of the Contract amount in any Contract
budget, Supporting documents necessary to explain fully the nature and purpose of the
amendment must accompany each request for an amendment.
E. If travel costs are contained in the attached budget, reimbursement of Contractor travel, lodging,
and meal expenses are limited to the eligible costs based on the following rates and criteria,
The mileage rate allowed by King County shall not exceed the current Internal Revenue
Service (IRS) rates per mile as allowed for business related travel. The IRS mileage rate
shall be paid for the operation, maintenance and depreciation of individually owned, vehicles
for that time which the vehicle is used during work hours. Parking, shall be the actual cost.
When rental vehicles are authorized, government rates shall be requested. If the Contractor
does not request government rates, the Contractor shall be personally responsible for the
difference. Please reference the federal web site for current rates: http://www.gsa.gov.
2. Reimbursement for meals shall be limited to the per them rates established by federal travel
requisitions for the host city in the Code of Federal Regulations, 41 CFR § 301, App.A.
Please reference hftp://www.gsa.gov for the current host city per diem rates.
3. Accommodation rates shall not exceed the federal lodging; limit plus host city taxes. The
Contractor shall always request government rates.
4. Air travel shall be by coach class at the lowest possible price available at the time the
County requests a particular trip. In general, a trip is associated with a particular work activity
of limited duration and only one round-trip ticket, per person, shall be billed per trip, Any air
travel occurring as part of a federal grant must be in accordance with the Fly America Act.
IV. Internal Control and Dunting Srrstem
The Contractor shall establish and maintain a system of accounting and internal controls which complies
with generally accepted accounting principles promulgated by the Financial Accounting Standards Board
(FASB), the Governmental Accounting Standards Board (GASB), or both as is applicable to the
Contractor's form of incorporation.
V. pebarrrtent and Sias ion Certification
Entities that are debarred, suspended, or proposed for debarment by the US. Government are excluded
from receiving federal funds and contracting with the County. The Contractor, by signature to this
Contract, certifies that the Contractor is not presently debarred, suspended, or proposed for debarment
by any Federal department or agency. The Contractor also agrees that it will not enter into a subcontract
with a contractor that is debarred, suspended, or proposed for debarment. The Contractor agrees to
notify King County in the event it, or a subcontractor, is debarred, suspended, or proposed for debarment
by any Federal department or agency.
V1. Maintenance of =valuations and inspections
A. The Contractor shall maintain accounts and records, including personnel, property, financial, and
programmatic records and other such records as may be deemed necessary by the County to
ensure proper accounting for all Contract funds and compliance with this Contract.
B. In accordance with the nondiscrimination and equal employment opportunity requirements set forth
in Section XIV. below, the Contractor shall maintain the following:
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1 Records of employment, employment advertisements, application forms, and other pertinent
data, records and information na|abad to employment, applications for employment or the
administration or delivery of services or any other benefits under this Contract� and
Z Records, including written quotes, bids, estimates Qrproposals submitted to the Contractor
by all businesses seeking to participate on this Contract. and any other information
necessary to document the actual! use of and payments tVsubContnsct0rsand suppliers in
this CVntmsct, including employment records.
The County may visit the site of the work and the Contractor's office to review the foregoing
records. The Contractor shall provide every assistance requested bx the County during Such
visits and make the foregoing nenomjS available to the County for inspection and copying
upon request. The Contractor shall provide right of access to its facilities—including those of
any subcontractor assigned any portion of this Contract pursuant to Section XIII—to the
County, the state, and/or federal agencies or officials at all reasonable times in order to
monitor and evaluate the services provided under this Contract. The County will give
advance notice to the Contractor in the case of fiscal audits tobo conducted bv the County,
The Contractor shall comply with all nanond keeping requirements set forth in any federal
rm|em. regulations orstatutes included or referenced in, the contract documents, The
Contractor shall inform the County in writing Of the location, if different from the Contractor
address listed on page one of this Contract, of the aforesaid books, records, documents, and
other evidence and shall notify the County in, writing of any changes in location within ten
(10) working days nf any such relocation.
C. The records listed in A and B above shall be maintained for a period of six (6) years after
termination of this Contract. The records and documents with respect to all matters covered' by this
Contract shall be subject ot all time to inspection, review, or audit by the County and/or
federal/state officials so authorized by law during the performance of this Contract and six (6)
years, after termination hereof, unless a longer retention period is required by law,
D. Medical records shall be maintained and preserved by the Contractor in accordance with state and
federal medical records statutes, including but not limited toRCVV7O.41.19Q, 70.02.180. and
standard medical records practice. If the Contractor ceases operations under this Contract, the
Contractor shall be responsible for the disposition and maintenance of such medical records,
E. TheContractoragineeotoconperetewiththeCnuntyoritsagentiniheexu|uationoffhe
Contractor's performance under this Contract and to make available all information reasonably
required by any such evaluation process. The results and records of said evaluations shall be
maintained and disclosed in accordance with RCyV Chapter 42.56,
F The Contractor agrees that all |nformnation, reonrda, and data onUeot8d in connection with this
Contract shall be protected from unauthorized disclosure in accordance with applicable state and
federal law.
\Hi Compliance with the Health Insurance Portability and Accountability Act of 199:6 (HIPAA)
The Contractor shall not use protected health information created or shared under this Contract in any
manner that would constitute a violation of HIPAA and any regulations enacted pursuant to its
provisions. Contractor shall read and certify compliance with all H|PAA requirements at
VUi
A. If the Contractor, for-profit or non-profit, receives in excess of $100,000 in funds during its fiscal
year from the County, b shall provide a fiscal year financial statement prepared bvanindependent
Certified Public Accountant or Accounting Firm within six (6) months subsequent to the close ofthe
Contractor's fiscal year.
B, Addiflona� audit or review requirements which may be imposed on the County will be passed on to
the Contractor and the Contractor will be required to comply with any such requirements.
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IX, Corrective Action
If the County determine . s that a breach of contract has occurred, that is, the Contractor has failed to
comply with any terms or conditions of this Contract or the Contractor has failed to provide in any
manner the work or services agreed to herein, and if the County deems said breach to warrant corrective
action, the following sequential procedure will apply:
A. The County will notify the Contractor in writing of the nature of the breach;
The Contractor shall respond in writing within three (3) working days of its receipt of such
notification, which response shall indicate the steps being taken to correct the specified
deficiencies. The corrective action plan shall specify the proposed completion date for bringing the
Contract into compliance, which date shall not be more than ten (1 Q) days from the date of the
Contractor's response, unless the County, at its sole discretion, specifies in writing an extension in
the number of days to complete the corrective actions;
B, The County will notify the Contractor in writing of the County's determination as to the sufficiency
of the Contractor's corrective action plan. The determination of sufficiency of the Contractor's
corrective action plan shall be at the sole discretion of the County;
C. In the event that the Contractor does not respond within the appropriate time with a corrective
action plan, or the Contractor's corrective action plan is determined by the County to be
insufficient, the County may commence termination or suspension of this Contract in whole or in
part pursuant to section 11, C.;
D. In addition, the County may withhold any payment owed the Contractor or prohibit the Contractor
from incurring additional obligations of funds until the County is satisfied that corrective action has
been taken or completed; and
E. Nothing herein shall be deemed to affect or waive any rights the parties may have pursuant to
Section 11., Subsections B, C, D, and E.
X. pis ute Resolution
The parties shall use their best, good-faith efforts to cooperatively resolve disputes and problems that
arise in connection with this Contract. Both parties will make a good faith effort to continue without delay
to carry out their respective responsibilities under this Contract while attempting to resolve the dispute
under this section-
X1. Indemnification
A. In providing services under this Contract, the Contractor is an independent Contractor, and neither
it nor its officers, agents, or employees are employees of the County for any purpose. The
Contractor shall be responsible for all federal and/or state tax, industrial insurance, and Social
Security liability that may result from!, the performance of and compensation for these services and
shall make no claim of career service or civil service rights which may accrue to a County
employee under state or local law.
The County assumes no responsibility for the payment of any compensation, wages, benefits, or
taxes, by, or on behalf of the Contractor, its employees, and/or others by reason of this Contract,
The Contractor shall protect, indemnify, defend, and save harmless the County, its officers, agents,
and employees from and against any and all claims, costs, and/or losses whatsoever occurring or
resulting from (1) the Contractor's failure to pay any such compensation, wages, benefits, or taxes,
and/or (2) the supplying to the Contractor of work, services, materials, or supplies by Contractor
employees or other suppliers in connection with or support of the performance of this Contract.
B. The Contractor further agrees that it is financially responsible for and will repay the County all
indicated amounts following an audit exception which occurs due to the negligence, intentional act,
and/or failure, for any reason, to comply with the terms of this Contract by the Contractor, its
officers, employees, agents, and/or representatives. This duty to repay the County shall not be
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diminished orextinguished b« the prior termination ofthe Contract pursuant hDthe Term and
Termination section,
C, The Contractor shall protect, defend, indemnify, and save harmless the County, its officers,
employees, and agents from any and all costs, claims, judgments, and/or awards ofdamages,
arising out of, or in any way nasm]Ung frnnn' the negligent acts or omissions of the Contractor, its
officers, employees, subcontractors and/or agents, in its Performance and/or non-performance of
its obligations Linder this Contract. The Contractor agrees that its obligations under this
subparagraph extend 10 any claim, demand, and/or cause of action brought by, orun behalf of,
any of its employees or agents. For this purpose, the Contractor. by 0u1ue[ negotiation, hereby
waives, as respects the County only, any immunity that would otherwise be available against such
claims under the Industrial Insurance provisions of Title 51 F<CVV. in the event the County
judgment, �ny �m�g�nt. award, and/or cost arising therefrom including attorneys, fees to enforce - e
provisions of this article, all such fees, expenses, and costs shall be recoverable from the
Contractor.
D. The County shall protect, defend, indemnify, and save harmless the Contractor, its offimsma,
employees, and agents from any and all costs, claims, judgments, and/or awards 0fdamages,
arising out of, or in any way resulting from, the sole negligent acts or omissions mf the County, its
officers, employees, and/or agents, in its performance and/or non-performance of its obligations
under this Contract. The County agrees that its obligations under this subparagraph extend to any
daimm, dennand, and/or cause of action brought by' or on behalf of, any of its employees or agents,
Fmrthiia purpose, the County. by nnutUo| mego(istion. hereby waives, as respects the Contractor
only, any immunity that would otherwise be available against such claims under the Industrial
insurance provisions of Title 51 F<CW. In the event the Contractor incurs any udgment, award,
and/or cost arising therefrom including attorneys' fees to enforce the provisions of this article, all
such fees, expenses, and costs shall be recoverable from the County,
E. Claims shall imc|ude, but not be limited to, assertions that use or transfer of software, boMh,
document, report, film, tape, or sound reproduction or material of any kind, delivered hereunder,
constitutes an infringement of any copyright, pu&ert, tradernark, trade marne, and/or otherwise
results in unfair trade practice.
F. Nothing contained within this provision shall affect and/or after the application of any other
provision contained within this Contract.
G, The indemnification, protection, defense and save harmless obligations contained herein shall
survive the expiration, abandonment or termination of this Agreement,
M. Insurance Reguirements
By the date of execution of this Contract, the Contractor shall procure and maintain for the duration of
this Contract, insurance against claims for injuries topemsonGordarnagestopropertVwhichrnay arise
from, or in connection vitb, the performance of work hereunder by the [:ontnaotor, its agents,
representatives, employees, and/or subcontractors. The costs of such insurance shall be paid by the
Contractor orsubcontractor. The Contractor may furnish separate certificates of insurance and policy
endorsements for each subcontractor as evidence of compliance with the insurance requirements of this
Contract. The Contractor isresponsible for ensuring compliance with all uf the insurance requirements
stated herein, Failure by the Contractnr, its agents, employees, ufMnena, smbnnmtraotoms, providen;,
and/or provider subcontractors to comply with the insurance requirements stated herein shall constitute a
material breach of this Contract. Specific coverages amd'nequirennente are at
http://mmvw.kimgomuOtv.gov/hea|thse[viCes/hea|th/partnershipm/contr8ote; contractors shall read and
provide required insurance documentation prior to the signing of this Contract,
XU|L
A, The Contractor sha,�� not assign orsuboontractanypmrtionmfthis[omtrocturtransferorasoi -m
claim Said consent
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must be sought in writing by the Contractor not less than fifteen (15) days prior to the date of any
proposed assignment.
B. ,Subcontract" shall mean any agreement between the Contractor and a subcontractor or between
subcontractors that is based on this Contract, provided that the term "Subcontract" does not
include the purchase of (1) support services not related to the subject matter of this Contract, or (2)
supplies.
C. The Contractor shall include Sections IlI.D, III.E., IV, V, VI, VII, X, XI, XIII, XIV, XV, XVI, XVII,
XVIII, XXIV, XXV , XXVI and the Funder's Special Terms and Conditions, if attached, in every
subcontract or purchase agreement for services that relate to the subject matter of this Contract.
D. The Contractor agrees to include the following language verbatim in every subcontract for services
which relate to the subject matter of this Contract:
"Subcontractor shall protect, defend, indemnify, and hold harmless King County, its officers,
employees and agents from any and all costs, claims, judgments, and/or awards of damages
arising out of, or in any way resulting from the negligent act or omissions of subcontractor, its
officers, employees, and/or agents in connection with or in support of this Contract. Subcontractor
expressly agrees and understands that King County is a third party beneficiary to this Contract and
shall have the right to bring an action against subcontractor to enforce the provisions of this
paragraph."
XIV. Nondiscrimination and g._qgual Employment Opportunity
The Contractor shall comply with all applicable federal, state and local laws regarding discrimination,
including those set forth in this Section.
During performance of the Contract, the Contractor agrees that it will not discriminate against any
employee or applicant for employment because of the employee or applicant's sex, race, color, marital
status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or
age except by minimum age and retirement provisions, unless based upon a bona fide occupational
qualification. The Contractor will make equal employment opportunity efforts to ensure that applicants
and employees are treated, without regard to their sex, race, color, marital status, national origin,
religious affiliation, disability, sexual orientation, gender identity or expression or age. Additional
requirements are at http:l/www,kingcounty.gov/healthservices/health/partnerships/contracts; contractors
shall read and certify compliance.
xv. conflict of _Interest
A. The Contractor agrees to comply with applicable provisions of K.C.C. 3,04. Failure to comply with
such requirements shall be a material breach of this contract, and may result in termination of this
Contract pursuant to Section 11 and subject the Contractor to the remedies stated therein, or
otherwise available to the County at law or in equity.
P. The Contractor agrees, pursuant to KCC 3.04.060, that it will not willfully attempt to secure
preferential treatment in its dealings with the County by offering any valuable consideration, thing
of value or gift, whether in the form of services, loan, thing or promise, in any form to any county
official or employee. The Contractor acknowledges that if it is found to have violated the prohibition
found in this paragraph, its current contracts with the county will be cancelled and it shall not be
able to bid on any county contract for a period of two years.
C, The Contractor acknowledges that for one year after leaving County employment, a former County
employee may not have a financial or beneficial interest in a contract or grant that was planned,
authorized, or funded by a County action in which the former County employee participated during
County employment, Contractor shall identify at the time of offer current or former County
employees involved in the preparation of proposals or the anticipated performance of Work if
awarded the Contract. Failure to identify current or former County employees involved in this
transaction may result in the County's denying or terminating this Contract, After Contract award,
the Contractor is responsible for notifying the County's Project Manager of current or former
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County employees who may become involved in the Contract any time during the term of the
Contract.
XVI. Equipment Purchase, Maintenance, and Ownership
A. The Contractor agrees that any equipment purchased, in whole or in part, with Contract funds at a
cost of $5,000 per item or more, when the purchase of such equipment is reimbursable as a
Contract budget item, is upon its purchase or receipt the property of the County andlor
federal/state government. The Contractor shall be responsible for all such property, including the
proper care and maintenance of the equipment.
B, The Contractor shall ensure that all such equipment will be returned to the County or federal/state
government upon termination of this Contract unless otherwise agreed upon by the parties.
XVII, Proprietary Rights
The parties to this Contract hereby mutually agree that if any patentable or copyrightable material or
article should result from the work described herein, all rights accruing from such material or article shall
be the sole property of the County. The County agrees to and does hereby grant to the Contractor,
irrevocable, nonexclusive, and royalty-free license to use, according to law, any imaterial or article and
use any method that may be developed as part of the work under this Contract.
The foregoing products license shall not apply to existing training materials, consulting aids, checklists,
and other materials and documents of the Contractor which are modified for use in the performance of
this Contract.
The foregoing provisions of this section shall not apply to existing training materials, consulting aids,
checklists, and other materials and documents of the Contractor that are not modified for use in the
performance of this Contract.
XVIII, Political Activity Prohibited
None of the funds, materials, property, or services provided directly or indirectly under this Contract shall
be used for any partisan political activity or to further the election or defeat of any candidate for public
office.
XiX, King County Recycled Product Procurement Policy
in accordance with King County Code 18,20, the Contractor shall use recycled paper, and both sides of
sheets of paper whenever practicable, when submitting proposals, reports, and invoices, if paper copies
are required.
XX, Future Support
The County makes no commitment to support the services contracted for herein and assumes no
obligation for future support of the activity contracted herein except as expressly set forth in this
Contract.
XXI, Entire ContractfWaiver of Default
The parties agree that this Contract is the complete expression of the terms hereto and any oral or
written representations or understandings not incorporated herein are excluded. Both parties recognize
that time is of the essence in the performance of the provisions of this Contract, Waiver of any default
shall not be deemed to be a waiver of any subsequent default. Waiver or breach of any provision of the
Contract shall not be deemed to be a waiver of any other or subsequent breach and shall not be
construed to be a modification of the terms of the Contract unless, stated to be such through written
approval by the County, which shall be attached to the original Contract.
XXII. Contract Amendments
Either party may request changes to this Contract. Proposed changes which are mutually agreed upon
shall be incorporated by written amendments to this Contract.
XXII I. Notices
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Whenever this Contract provides for notice to be provided by one party to another, such notice shall be
in writing and directed to the chief executive office of the Contractor and the project representative of the
County department specified on page one of this Contract. Any time within which a party must take some
action shall be computed from the date that the notice is received by said party.
XXIV.Services Provided in Accordance with Law and Rule and Regulation
The Contractor and any subcontractor agree to abide by the laws of the state of Washington, rules and
regulations promulgated thereunder, and regulations of the state and federal governments, as
applicable, which control disposition of funds granted under this Contract, all of which are incorporated
herein by reference.
In the event that there is a conflict between: any of the language contained in any exhibit or attachment to
this Contract, the language in the Contract shall have control over the language contained in the exhibit
or the attachment, unless the parties affirmatively agree in writing to the contrary.
XXV. Ang� l�avrr
This Contract shall be construed and interpreted in accordance with the laws of the State of Washington.
The venue for any action hereunder shall be in the Superior Court for King County, Washington.
XXVI.No Third Part Beneficiaries
Except for the parties to whom this Contract is assigned in compliance with the terms of this Contract,
there are no third party beneficiaries to this Contract, and this Contract shall not impart any rights
enforceable by any person or entity that is not a party hereto.
xxvii. contractor Certification
By signing this Contract, the Contractor certifies that in addition, to agreeing to the terms and conditions
provided herein, the Contractor certifies that it has read and understands the contracting requirements
on the PHSKC website (http://www.kingcounty.gov/health/contracts), and agrees to comply with all of
the contract terms and conditions detailed on that site, including EEO/Nondiscrimination, HIPAA,
insurance, and Credentialing, as applicable.
IN WITNESS WHEREOF, the parties hereby agree to the terms and conditions of this Contract:
KING COUNTY
IM
King County Executive
Date
CONTRACTOR
Signature
Name (Please type or print)
Date
Exhibit A — Special Terms and Conditions
This Contract is funded in whole or in ,part hy the US Government, through DOH, Agreement No.
06898. In addition to King County's general terms and conditions, the Contractor shall also comply
with the terms and conditions of thefunder and the federal certifications and assurances in this Exhibit,
ADDITIONAL TERMS AND CONDITIONS
OMB Circular A-133 Audit
A. If the Contractor or subcontractor is a non-profit organization as defined in OMB Circular A -133, and
expends a total of $500,000 or more in federal financial assistance and has received federal financial
assistance from the County during its fiscal year, then the Contractor or subcontractor shall meet the
respective A -133 requirements described in herein as applicable.
B. lf the Contractor is a non-profit organization, it shall have an independent audit conducted of its
financial statement and condition, which shall comply with the requirements of GRAS (generally
accepted auditing standards); GAO's Standards for Audits of Governmental Organizations, Programs,
Activities, and Functions; and OMB Circular A- -133, as amended, and as applicable. The Contractor
shall provide a copy of the audit report to each County division providing financial assistance to the
Contractor no later than nine (9') months subsequent to the end of the Contractor's fiscal year, The
Contractor shall provide to the County its response and corrective action plan for all findings and
reportable conditions contained in its audit. When reference is made in its audit to a "Management
Letter" or other correspondence made by the auditor, the Contractor shall provide copies of those
communications and the Contractor's response and corrective action plan. Submittal of these documents
shall constitute compliance with this requirement,
C. If the Contractor is a Washington state municipal entity or other government institution or jurisdiction, it
shall submit to the County a copy of its annual report of examination /audit, conducted by the
Washington State Auditor, within thirty (30) days of receipt, which Submittal shall constitute
compliance with this requirement.
U.S. Department of Health and Human Services (HHS) Requirements
'This Contract is sub . ject to the requirements of the 1414S Grants Policy Statement (HITS GPS) that arc
applicable based on recipient type and purpose of award. The HHS GPS is available at
STANDARD FEDERAL CERTIFICATIONS AND ASSURANCES
Following are the Assurances, Certifications, and Special Conditions that apply to all federally funded (in whole or in
part) agreements administered by the Washington State Department of Health.
1. FEDERAL CJRCULARS: The following compliance matrix identifies the Off-ice of Management and Budget's
Mrytgn tk fe�q ttil;ep
Circular's _fp oBich govern expenditure of federal funds. These requirements apply to
0 e
the Department of Health and then for, �'w the funds to the subrecipient. The federal Circulars which provide the
applicable administrative requirements, cost principles and audit requirements are identified by subrecipient
orlganizAtWhlype.
Exhibit F
r2ervice Authorization Form-
BCCHP Program
Contract #
Contractor: Address line I
Address line 2
Address line 3
EXHIBIT F
Service Authorization Effective Date:
Public Health Seattle & King County hereby amends the not to exceed amount in the hereby authorizes the
following not-to-exceed amount for the services Provided in the Scope of Work Exhibit under the above referenced
—tv rt at the rates set forth in the Budget Exhibit:
The total reimbursement shall not exceed the amount set forth in this Service Authorization Form
FUNDING SOURCES FUNDING LEVELS EFFECTIVE DATES
FEDERAL $
Fedeeel Cat to u,e Nca. $
STATE $
KOMEN TOTAL $
Public Health Signature Date
Name
4/2014
Original not to exceed
Description
amount
Amended to exceed amount
Fees
LEEP Conization Fees,
Client Consults, ,
$0.00
Gynecological Fees (Col,pos, etc.)
Tntnl reimbursable contract amount
$0'-00
The total reimbursement shall not exceed the amount set forth in this Service Authorization Form
FUNDING SOURCES FUNDING LEVELS EFFECTIVE DATES
FEDERAL $
Fedeeel Cat to u,e Nca. $
STATE $
KOMEN TOTAL $
Public Health Signature Date
Name
4/2014
EXHIBIT E
idfergon county,'WashLrIgon Washington Coundeslisk Pool
'kttc� Lesj[e, L'ocke ��rihr�.Road SW j &dto 106
Tumwatc�r, WasM bix 98512-6,103
PC) Box 1220
port Townsend, WA 9V68
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MR Y TaA T13B UA'13 'eOucy=lMD HIS BEEN ISSUED TO, TH9,PARTTr-1PXTa,10 MEMB ER
Tim Is To CER-MY TIMT T13B
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poliCY PERIOD INDICAtkb NOIVITEWA101NO ANY RE MkAEN�T, T��OR
NA,�ABOVEVQ,RTHE
ON of WITH RESPECT TO WHId4THIS CERTIFICAM MA)t BE
CONDrrION OF ANY Cojq,� OR OMR DOCWEW
MAY PER
77
FORDED Jay TM POLICY DESCRIB115D NEREINISSURn= TO ALL
ISSUED OR MAY PMTAJNI T'E'COVERAGES Al
TERMS ExC;UJ8J 'C
T�M TERMS, EXCLW1101qS AND CONDMONS OF SUCH POLICY,
POLICY E"UJATJ0fqr PAT
t.
MMSOF LIABILITY EACH OCCURPLEWC
AMP-M;
Inctading-,
Including;.
Covers all Jeffermil County Employees
Agrr,enle
,r1t to provide broast and, boM
'cRrePrQ9r9=: King COURV
During the NiicY Per'od 10101113-10101/14
Seaffic-King couu�y Dept of 'Public, IlVdtli
aka Public flenl(fl, SieUttle, &-r 'C"a"COunty
October 1, 2014
General Uabilltyr
Bodily Injury
Personal Injury
Property Dmake
Fn r�, onSIp f
_OiS and Omml�ia To eSsional
Advm-tising Injury
Contractual
Automobile Liability
Owned, nonow , 36d 4nd hired autos
SHOUt,p T1mAaoVtDE5CRJp?n MIX? BECANCR-RD
5NDEA'YOPm mA46 3oDAys wari'm No-me Ta'rm,
r-MIMATS KOWEnt, Wr FAMI=TO MABAUCKNOME
,SHALL, IMPOSE NO OBLIGA11ON 0R UA10LITY, OF ANY KIND
UPON TIM 15M OR ITS AGPXTS OR REURF,5ENTAIWES,
Public Health
Seattle & King County
Please review, sign and MAIL this invoice within 10
days receipt.
Attenton: Amber Roche @ Address
below
Call W/ Qrjesticns Tel: 206-263-8205
Thursday, July 24, 2014
Contract/CPA #i
Receipt #
Purchase Order #
Supplier
JEFFERSON COUNTY
Supplier #
6649
Site
PUBLIC HEALTH
Invoice Date
71112014
Invoice #:
PREV 3583JEF July'14
Amount to Pay
Note to AP
Pay Immediately
Print on Remittance
Jefferson County Public Health
615 Sheridan,
Port Townsend,
WA 98368
Areast Ccrvical and Colon "calth Program
401 `�rtn A-,m6o, Sure -.XJE
15- dvre"Oo" 961c'.
206,263-8205 Fn :Ica 79F�'3;'IH
bJy ".Lav" h I
Current Billing Period July 2014 Exhibit ID contract Veriod 01/2014 to 6/14/2015
IContracted Line Items Current Contracted Accumulated Available
Expenses Budget Expense Balance
Bulp clinical Services $1,4WOO $1,48000
Travel to BCCITP Annual Meeting $78.00 $7800
Total $1,558.00 $1,558.00
i certify that the fees itemized above were incurred for the period: July 2014
and that the reimbursement amount reflects, as reasonably as possible, the contractual value of the fees being charged,
X X
Date
Provider Agency Authorized Signature
X
Please Print Name Below Signature
----------------- — -------------- FOR HEALTH DEPART MILN I WSIL UNLY L3L-LUVV I 111;j LIINL --------------------------------------
Pay Contracted Accumulated Available
Expense Summary - ORGIPROJ: 800107 / 1123492 Current Budget Expense Balance
Federal BCCHP 101.562 $1,480.00 $1,490,00
Stale 13C( 'HP 1:0 614 $78,00 $78,0�O
Total $1,558.0o $1,558,00
PH-SIKC - BCCHP Monitor Date
Exhibit C: Budget
Jefferson County Public Health
615 Sheridan
July 1, 2�014 - June 1.4, �2011
BUJDGET DETAIL
TOTAL FUNDS
ALLOCATED
Breast and Cervical Health Services
includes one or
more of the following: annual exam with
Clinical Breast Exam (CBE), problem-focused $1,480.00
Pa
visit, '0
777,77-77M,
Travel 7
Total Fundi
$1,558.00
;rvlices will be paid by CPT code according to the rates listed on the most current Breast,
ervical, and Colon Health Program Fee Schedule , The fee schedule changes annually on
]IV 1.
Anticipated #s
BCHP L
10 JBCHP services average $1148/client
prev3583 - Jefferson County Public Health
REIMBURSEMENT PROCEDURES
BCCHP at Public (Health will,
• Pay for services provided within the corresponding contract period,
• Send the current Fee Schedules for Breast and Cervical Cancer Screening to the
Contractor, as well as any subsequent revisions. Revisions will replace earlier
versions.
• Pay for CPT-coded services at rates listed on the Fee Schedule. When applicable,
payment will include facility fee costs, as described on the Fee Schedule. We
reimburse clinic services at "Professional non-facility office" rates.
• Pay for Client Support Services (case management) based on the BCCHP rate per
client enrolled and screened (Exhibit C).
• Monitor contracted funds.
• Generate monthly clinical services billing reports for the contractor, based on forms the
contractor submits. The reports will detail client names, dates of service, CPT codes,
and fees.
• Create a monthly invoice from the billling reports and send to the Contractor to review
and approve.
• Pay the Contractor based on the approved invoice.
The Contractor will not bill BCCHP clients for any differences between service
charges and BCCHP reimbursement.
Prev3583 Jefferson County Public Heallh Page 4 of 4
Client support Services at Jefferson
The contra—ctOOL.
� VYL
1. Track BCCHP clients to make sure they receive timely follow-up after abnormal breast
or cervical cancer findings. Monitor clients until they receive a diagnosis.
2. implement a re-screening reminder system for BCCHP clients,
3. Document scheduling for appropriate follow-up tests and return appointments.
4. Review and give test results to clients in a timely manner.
5. Document all findings and send to Public Health.
REIMBURSEMENT PROCESS:
The Contra—rtOrOlL
Complete exam and reimbursement forms and, if applicable, diagnostic forms. Forms
0
are available online at: c/ c 10 w 0 x
np•_ . - . - rrrr-rhP _q-
,/IWWw kioggo—u—O-!Y.�g�vLhp..p,lthservic,es/hea�thi/chroni b
• Make best efforts to submit reimbursement forms to BCCHP at Public Health within 10
businesLs das from the date of service. listed on the current BCCHP Fee
• Accept the amounts for CPT-coded services
Schedule. contract does not duplicate any work to, be
• Certify that work to be performed under this
charged against any other contract, subcontract, or other funding source.
• Monitor funds spent and clients scheduled, to stay within the total budget.
• In the case of any overpayment, contact BCCHP staff before Lakin any action to
discuss how to correct the error.
Review BCCHP-generated invoices promptly, and approve by mailing a signed original to
BCCHP.
BCCHP will not pay for services if we receive reimbursement forms later than 45 days from
the service date. We will evaluate exceptions on a case-by-case basis. We may impose
an earlier deadline to submit forms for June services, to achieve timely fiscal year-end
close out,
REIMBURSEMENT LIMITS: contract amouriLLExbibit C.
Exhibit C shows the "anticipated number of clients (sometimes called "slots") that the
clinical fundincJ may cover for each type of service. These are estimates based on
average histar %cal costs per type of clinical service. Since costs may vary, these estimates
are only a u e ine to show a possible mix of services that the Contractor could provide
with total available funds. Please carefully review Exhibit C.
Prev3583 jefferSon CCunty PUblic Health Page 3 of 4
ENROLLMENT
Some populations have lower screening and/or higher morbidity or mortality rates.
Jefferson will focus enrollment efforts on clients who:
• Have never or rarely received breast or cervical services
• Are ages 50 or older (breast services) or 40-49 (cervical services)
• Are new to BCCHP
• Are from a racial or ethnic minority population, including African American, Asian,
Pacific Islander, American Indian/Alaskan Native, and Hispanic/Latina
• Are lesbian, gay, bisexual, or transgender
• Have a disability (as defined by the client)
• Have a strong famiily history or other high risk, including ages 40-49 for breast services
The contractor will obtain informed consent before performing Services, and mail
completed enrollment and consent forms to BCCHP (within the timeframe listed below
under "reimbursement process").
. i
Clinical Services
The Contractor Will',
• Make best efforts to comply with CDC and DOH Performance Indicators:
* Assist the client to complete the diagnostic work-up within 60 days of a
documented abnormal breast finding,
* Assist the client to start breast cancer treatment within 60 days of a
documented diagnosis of breast cancer or breast pre-cancer.
* Assist the client to start cervical cancer treatment within 90 days of a
documented diagnosis of cervical cancer or pre-cancer.
• Document attempts to contact each client for follow-up services per BCCHP
protocol. It is the contractor's responsibility to get clients in for timely follow-up.
• Review and follow instructions in the Contractor's Procedure Manual, available at:
http:�/ww Ki.�lRq�Qgi!tY,.g-gv/healthservices/health/chronic/bcl,I
— wJ -
• Document that administrative and health care personnel who work with BCCHP
clients review the DOH online BCCHP training modules that correspond to their
work. See: bj!p,,//dpmedia.doh a.,g(?V/bcchp
- - media_ . _- -___-
• Maintain HIPAA regulated confidentiality of all BCCHP client data and medical
records.
• Provide effective, understandable, and respectful care to clients in their preferred
language, Make reasonable efforts to provide care that is compatible with clients'
cuiltural health beliefs and practices.
• Maintain documentation of current WA State licensure and/or certification for all
health care professionals who perform medical procedures under this contract.
Present documentation to BCCHP staff upon request,
• Send a representative to the annual BCCHP mandatory meeting and a minimum of
two other meetings and/or trainings as scheduled by the DOH or Public Health.
• Work with BCCHP staff to distribute educational materials, upon request,
Prev3583 Jefferson County Pubfic Healthi Page 2 of 4
Exhibit B: Scope of Work Prev3583
PUBLIC HEALTH
CLINICAL and CLIENT SUPPORT SERVICES, OUTREACH & RECRUITMENT
July 1, 2014 through June 14, 2015
BACKGROUND
The Breast, Cervical, and Colon Health Program (BCCHP) helps eligible clients get
screened for breast, cervical, and colorectal cancers, and connects clients with diagnostic
services and treatment when needed. The program serves clients with low incomes and
who lack health insurance coverage for cancer screening. BCCHP improves access to
services, especially foir people who face extra barriers to getting health care.
PURPOSE
Jefferson County Public Health will enroll BCCHP eligible clients and provide
recommended cancer screening services. They will refer BCCHP enrolled clients with
abnormal cancer screening results to other BCCHP contracted providers for appropriate
follow-up services. They will also use outreach activities outlined below to recruit clients
for the BCCHP.
SERVICES
Enrollment Site:
Annual exam with Clinical Breast Exam (CBE)
Problem-focused visit
Pap tests
HPV tests
ELIGIBLE POPULATION
Women — all services;
Breast screenin & annual exam Cervical"
40-64, or If last pap normal & > 3 years or co-
35-39, if being seen for breast testing (Pap normal and HPV
symptoms, or negative) > 5 years:
64+ if ineligible for Medicare 0 40-64
• 35-39, if being seen for breast I
Prio I for Mamrn symptoms
tit��Mo �r� �m
• Ages 50 or older, and last A A USPSTF 2012 Cervical Cancer
mammogram > 2 years s per
Screening Guidelines. If not eligible for Pap
• Suspicious breast findings Test, pelvic exam paid only if done as pad of
• Strong family history or other visit for breast screeninglannual exam
high risk
At or below 250% of Federal Poverty Level (FPL)*
Uninsured or Underinsured (deductible over $500)
Ineligible for Apple Health (Medicaid) — documentation required
WashiqR
ton State Reside - nts
"mammography and breast diagnostics available to clients at or below 300 % APL
Prev3583 Jefferson County pub[ic Health Page 1 o6
Exhibit A — Special Terms and Conditions
assurance of project consistency with the approved State management program developed under the Coastal Zone
Management Act of 1972 (16 U.S.C. 1451 et seq.); (t) conformity of Federal actions to State (Clear Air)
Implementation Plans Linder Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. 7401 et seq.);
(g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended,
(P.L, 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended,
(P.L.. 93-205),
12 Will comply with the Wild and Scenic Rivers Act of 1.968 (16 [J,S,C. 1721 et seq.) related to protecting
components or potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act
of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a -1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and
related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.t— 89-544, as amended, 7 U.S.C. 2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other
activities supported by this award of assistance,
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.) which prohibits the use
of lead- based paint in construction or rehabilitation of residence structures.
IT Will cause to be Performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Circular No, A-133, Audits of States, Local Governments, and Non-Profit
organizations.
18, will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies
governing this program.
Exhibit A — Special Terms and Conditions
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through
any authorized representative, access to and the right to examine all records, books, papers, or documents, related to
the award-, and will establish a proper accounting system in accordance with generally accepted accounting standards
or agency directives.
1 Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents
the appearance of personal or organizational conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728-4763) relating to prescribed
standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A
of OpM,s Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI
of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national
origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. 1681-1683, and 1685-1686),
which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29
U,S.C. 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 Us . C. 6101
-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (RL, 91-616),
as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) 523 and 527 of the Public
i-lealth Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and
drug abuse patient records; (h) Title Vill of the Civil Rights Act of 1968 (42 U.S.C, 3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in
the specific statute(s) Linder which application for Federal assistance is being made; and 0) the requirements of any
Other nondiscrimination statutc(s) which may apply to the application.
7. Will comply, or has already complied, with the requirements of Titles It and III of the uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable
treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs.
These requirements apply to all interests in real property acquired for project purposes regardless of Federal
participation in purchases.
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. 1501-1508 and 7324-7328) which limit
the political activities of employees whose principal employment activities are funded in whole or in part with
Federal funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. 276a to 276a-7), the Copeland
Act (40 U.S.C. 276c and 18 U.S.C. 874) and the Contract Work Hours and Safety Standards Act (40 U,S,C. 327-
333), regarding labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or
more.
11. Will cornply with environmental standards which may be prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of
,,Vet4an& pursuant to EO I 1990; (d) evaluation of flood hazards in floodplains in accordance with E0 11988; (e)
Exhibit A — Special Terms and Conditions
The Contractor certifies that the statements herein are true, complete, and accurate to the best of his or her
knowledge, and that he or she is aware that any false, fictitious, or fraudulent statements or claims may subject him
or her to criminal, civil, or administrative penalties, The Contractor agrees that the contracting organization will
comply with the Public Health Service terms and conditions of award if a contract is awarded.
5, CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Public Law 103227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in
any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for
the provision of health, day care, early childhood development services, education or library services to children
under the age of 18, if the services are funded by Federal programs either directly or through State or local
governments, by Federal grant, contract, loan, or loan guarantee, The law also applies to children's services that
are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds, The law
does not apply to children's services provided in private residence, portions of facilities used for inpatient drug or
alcohol treatment, service providers whose sole source of applicable Federal funds is Medicare or Medicaid, or
facilities where WIC coupons are redeemed.
Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to
$ 1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.
The Contractor certifies that the contracting organization will comply with the requirements, of the Act and will not
allow smoking within any portion of any indoor facility used for the provision of services for children as defined
by the Act.
The contracting organization agrees that it will require that the language of this certification be included in any
subcontracts which contain provisions for children's services and that all subrecipients shall certify accordingly,
The Public Health Services (PHS) strongly encourages all recipients to provide a smoke-free workplace and
promote the non-use of tobacco products. This is consistent with the PHS mission to protect and advance the
physical and mental health of the American people.
ASSURANCES — NON CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
cornpleting and reviewing the collection of information. Send comments regarding the burden estimate or ally other
aspect of this collection of information, including Suggestions for reducing, this burden, to the Office of Management
and Budget, Paperwork Reduction Project (0348-004-0), Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please
contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances, if such is the case, you will be notified.
As the duly authorized representative of the contractor, I certify that the Contractor:
Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability
( including funds Sufficient to pay the non-Federal share of project cost) to ensure proper planning, management, and
completion of the project described in this application.
Exhibit A — Special Terms and Conditions
g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f)-
For purposes of paragraph (e) regarding agency notification of criminal drug convictions, DOH has designated
the following central point for receipt of such notices:
Compliance and Internal Control officer
Office of Grants Management
WA State Department of Health
PO Box 47905
Olympia, WA 98504-7905
3. CERTIFICATION REGARDING LOBBYING
Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence certain
Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative
agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the
Federal Government in connection with a SPECIFIC grant or cooperative agreement, Section 1352 also requires
that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying
undertaken with non-Federal (nonappropriated) funds. These requirements apply to grants and cooperative
agreements EXCEEDING $100,000 in total costs (45 CFR Part 93),
The Contractor certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the Contractor, to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of'Congress in connection with the awarding of
any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement,
(2) If any funds other than Federally appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer
or employee of'Congress, or an employee of a Member of Congress in connection with this Federal contract,
grant, loan, or cooperative agreement, the Contractor shall complete and submit Standard Form-LLL,
"Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, Standard Form-LLL,
"Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this
application form.)
(3) The Contractor shall require that the language of this certification be included in the award documents for all
subcontracts at all tier's (including subcontracts, subcontracts, and contracts under grants, loans and
cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
'this certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by Section 1352, U.S. Code, Any person who fails to file the
required certification shall be subject to a civil penalty of not less than $10,000 and not more than
$ I oo,OpO for each such faikire,
4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT(PFCRA)
Exhibit A — Special Terrns and Conditions
COMPLIANCE AIL11TWX
2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
The Contractor certifies that the Contractor will, or will continue to, provide a drug-free workplace in accordance
with 45 CFR Part 76 by:
a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession
or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be
taken against employees for violation of such prohibition;
b) Establishing an ongoing drug-free awareness program to inform employees about
(1) The dangers of drug abuse in the workplace;
(2) The contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
c) Making it a requirement that each employee to be engaged in the performance of the contract be given a copy
of the statement required by paragraph (a) above;
d) Notifying the employee in the statement required by paragraph (a), above, that, as a condition of employment
under the contract, the employee will—
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring
in the workplace no later than five calendar days after such conviction;
e) Notifying the agency in writing within ten calendar days after receiving notice Linder paragraph (d)(2) from an
employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must
provide notice, including position title, to every contract officer or other designee on whose contract activity
the convicted employee was working, unless the Federal agency has designated a central point for the receipt
of such notices. Notice shall include the identification nurnber(s) of each affected grant;
f) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with
respect to any ernployce who is so convicted -
(1) Taking. appropriate personnel action against such an employee, up to and including termination, consistent with
the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation prograrn
approved for Such purposes by a Federal, State, or local health, law enforcement, or other appropriate
agency;
OMB CIRCULAR
ENTITY TYPE
ADMINISTRATIVE
REQUIREMENTS
COST PRINCIPLES
AUDIT REQUIREMENTS
State, Local and Indian
Tribal Governments &
A-] 02 & Common Rule
2 CFR 225 (A-87)
A-133
Governmental Hospitals
Non-Profit Organizations
A-110
2 CFR 230 (A -122)
A-133
& Non-Profit Hospitals
Colleges or Universities
A-] 10
2 CFR 220 (A-21)
A-133
& Affiliated Hospitals
2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
The Contractor certifies that the Contractor will, or will continue to, provide a drug-free workplace in accordance
with 45 CFR Part 76 by:
a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession
or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be
taken against employees for violation of such prohibition;
b) Establishing an ongoing drug-free awareness program to inform employees about
(1) The dangers of drug abuse in the workplace;
(2) The contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
c) Making it a requirement that each employee to be engaged in the performance of the contract be given a copy
of the statement required by paragraph (a) above;
d) Notifying the employee in the statement required by paragraph (a), above, that, as a condition of employment
under the contract, the employee will—
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring
in the workplace no later than five calendar days after such conviction;
e) Notifying the agency in writing within ten calendar days after receiving notice Linder paragraph (d)(2) from an
employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must
provide notice, including position title, to every contract officer or other designee on whose contract activity
the convicted employee was working, unless the Federal agency has designated a central point for the receipt
of such notices. Notice shall include the identification nurnber(s) of each affected grant;
f) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with
respect to any ernployce who is so convicted -
(1) Taking. appropriate personnel action against such an employee, up to and including termination, consistent with
the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation prograrn
approved for Such purposes by a Federal, State, or local health, law enforcement, or other appropriate
agency;