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HomeMy WebLinkAbout041315_ca02615 Sheridan Street Port Townsend, WA 98368 &son vltl-� t*�'! www.jeffersonCountyPublicHealth.org 'Inty P ublic Healt Consent Agenda March 26, 2015 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: jean Baldwin, Director DATE: SUBIECT- Agenda Item — Contract Agreement between Kitsap Public Health District (KPHD) and Jefferson County Public Health (JCPH); January 1, 2015 — September 30, 2015• $27,500.00 STATEMENT flF ISSUE: Jefferson County Public Health, Community Health, requests Board approval of the Contract Agreement with Kitsap Public Health District and Jefferson County Public Health; January 1, 2015 — September 30, 2015; $27,500-00, AN GOALSIPRO'S and CON'S: This contract agreement is funded by the Centers for Disease Control State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (1422), KPHD subcontracts JCPH to adopt, identify, meet with, monitor, and participate in policies to increase physical activity in Jefferson County; to identify clients with high blood pressure and track referrals to community resources; to meet with community pharmacists with the intention of convincing at least one pharmacist to participate in medication management tracking; to monitor progress for each activity and report as requested; to participate in conference calls and an annual in-person meeting; to track and respond to activity assessments/surveys. The goal of the program is to reduce by improving prevention, management, and tracking of hypertension, obesity, and pre-diabetes conditions especially among the poor, persons with mental illness, and tribal communities within Olympic community of Health, the planned Accountable Community of Health for Kitsap, Jefferson, and Clallam Counties. FI BENEFIT ANALYSIS: This contract agreement is fully funded by the State and Local Public Health Actions to Prevent Obesity, Diabetes, Health Disease, and Stroke which is a Federal Grant through the Department of Health and Human Services, Centers for Disease Control and Prevention. (,"onimunity HeciMl DeveGoprrenkfl 360 - 385..9400 360-385-940] (fi Always working for a safer and helaffhier community Environmentcil Health Water Quality 360 385-9444 (f) 360-3/9 4487 REg )MMENDATION: 3CPH management requests approval of contract Agreement with Kitsap Public Health District and 3efferson County Public Health for obesity, diabetes, heart disease and stroke prevention; 3ainuary 1, 2015 -- September 30, 2015; $27,500-00. REVIEWED BY: PhUp*M1 r1ey, du ty Administrator.__ Date Contract No. No. Subrecipient* N21102 Z Yes E:1 NO Agreement between Community Lead Organization (CLO) and their Subcontractors Contract Number - 1168 Healthy Communities Obesity, Diabetes, Heart Disease and Stroke Prevention Program for the Washington State Department of Health Between the Kitsap Public Health District And Jefferson County Public Health AGREEMENT Between KITSAP PUBLIC HEALTH DISTRICT And JEFFERSON COUNTY PUBLIC HEALTH Agreement — Jefferson County Public Health — 1371 Healthy Communities Obesity, Diabetes, Heart Disease and Stroke Prevention Program This Agreement ("Agreement") is made and entered into between the Kitsap Public Health District, hereinafter referred to as "District", and Jefferson County Public Health, hereinafter referred to as "Subcontractor". The parties mutually agree as follows: 1. Period of Performance: The period of performance of this Agreement shall begin January 1, 2015 and be completed no later than September 30, 2015, unless terminated sooner or extended as provided for herein. 11. Purpose: The District requires the expertise of this Subcontractor to improve the prevention, management, and tracking of hypertension, obesity, and prediabetes conditions, especially among the poor, persons with mental illness, and tribal communities within the Olympic Community of Health, the planned Accountable Community of Health for Kitsap, Jefferson, and Clallarn Counties. Federal Source of Funds: The funding sources for this Agreement are: Federal $27,500 State $0 Other $0 CFDA# CFDA Title Federal —Grant Fed Federal Grant Federal Agency Amount Award # Award Narne Name 93.757 F Centers for --TU-58DPOO5521- State and Local —Department of $27,500 Disease Control 01 Public Health Health and Human and Prevention Actions to Prevent Services, CDC Obesity, Diabetes, Heart Disease, and Stroke Subcontractor agrees to comply with applicable rules and regulations associated with these federal funds. IV. Program Management and Billings: The assigned District staff will monitor the performance of this contract, approve billings submitted by the Subcontractor, and determine the acceptability of any reports provided by the Subcontractor, DOH staff will provide and facilitate assistance and guidance to the Subcontractor, as necessary. Katie filers Kitsap Public Health District 345 6"' Street, Suite 300 Bremerton, WA 98337 (360) 337-5215 Upon expiration of the Agreement, any claim for payment not already made shall be submitted within 60 days after the expiration date. V. Statement of Work anti ...Bud get: The Subcontractor shall furnish the necessary personnel, equipment material, and/or services and otherwise do all things necessary for or incidental to the performance of the work set forth in Exhibit A, attached hereto and incorporated herein. V1. Compensation: The District agrees to pay Subcontractor $27,500.00 during the Agreement. . Compensation will be based on invoices submitted by Subcontractor itemizing description of services performed per the agreed upon scope of work and budget (Exhibit A). The District will pay the Subcontractor all allowable costs incurred as evidenced by proper invoice of the Subcontractor submitted to the District on a timely basis, insofar as those allowable and allocable costs to not exceed the amount appropriated or otherwise available for such purposes as stated herein, or in subsequent amendments. The District will pay for costs under this Agreement up to a total not exceeding the Agreement amount. Costs allowable under this Agreement are based on District-approved budget for period of performance January 1, 2015 to September 29, 2015. Vil, Performance Requirements and Notices: Notices pursuant to this Agreement shall be sent to the District staff designated below who is the District's designated Program Coordinator who is responsible for project coordination: if to the District: Kitsap Public Health District Attn: Katie Eilers 345 6`h Street, Suite 300 Bremerton, WA 98337 (360) 337-5224 If to the Subcontractor: Jefferson County Public Health Attn: Jean Baldwin 615 Sheridan Street Port Townsend, WA 98368 (360) 385-9408, A. The Subcontractor will establish a designated local Program Coordinator who will be responsible for project coordination. B. The Subcontractor will participate in: a. Performance measure data collection activities in collaboration with DOH related to priority populations in the designated Community area; b. As relevant, gain access/share purchasing data from participating retail venues and patient encounter data (for example, electronic health records) from health systems; and, c. Participate in project evaluation activities developed and coordinated by DOH. Data submissions related to these items will be provided mutually agreed upon with DOH. C. The District will require the Program Coordinator and other local project participants as designated, to participate in meetings scheduled and published by the District. Where applicable, the District will reimburse the Subcontractor for travel to and from scheduled meetings. VIII. Community Resources: The Subcontractor will make a reasonable and ongoing effort, throughout the contract period, to secure and/or leverage resources from private and public entities to supplement the administrative, operational, and implementation costs under this program. Documentation of any collaborative efforts and securing of resources that benefit this project will be kept current and on file in the office of the Subcontractor and will be available for review upon request by District staff. IX. Billings: Billings to the District shall be submitted no more frequently than every 30 days, and shall be sent to: Katie Filers Kitsap Public Health District 345 61h Street, Suite 300 Bremerton, WA 98337 (360) 337-5215 Upon expiration of the Agreement, any claim for payment not already made shall be submitted within 60 days after the expiration date. X. Independent Capacity: Subcontractor and its employees or agents who are engaged in the performance of this Agreement shall continue to be employees or agents of Subcontractor and shall not be considered for any purpose to be employees or agents of the District. X1. Rights in Data: Unless otherwise provided, data which originates from this Agreement shall be "works for hire" as defined by the U.S. Copyright Act of 1976 and shall be owned by the Washington State Department of Health (DOH). Data shall include, but not be limited to reports, documents, pamphlets, advertisements, books, magazines, surveys, studies, computer programs, films, tapes, and/or sound reproductions. Ownership includes the right to copyright, patent, register, and the ability to transfer these rights. x1l. indemnification: Subcontractor shall defend, indemnify and hold the District, its officers, officials, employees and volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or resulting from the acts, errors or omissions of the Subcontractor in performance of this Agreement, except for injuries and damages caused by the sole negligence of the District. Solely for the purposes, of this provision, the Subcontractor waives its immunity under Title 51 (Industrial Insurance) of the Revised Code of Washington and acknowledges that this waiver was mutually negotiated by the parties, This provision will survive the expiration or termination of this Agreement. XIII. Insurance: The Subcontractor shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Subcontractor, its agents, representatives, or employees. No Limitation. Subcontractor's maintenance of insurance as required by the Agreement shall not be construed to limit the liability of the Subcontractor to the coverage provided by such insurance, or otherwise limit the District's recourse to any remedy available at law or in equity. A. Minimum Scope of Insurance Subcontractor shall obtain insurance of the types described below: Automobile Liablit insurance covering all owned, non-owned, hired and ]eased vehicles. Coverage shall be written on Insurance Services Office (ISO) form CA 00 01 or a substitute form providing equivalent liability coverage. If necessary, the policy shall be endorsed to provide contractual liability coverage. 2, Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01 and shall cover liability arising from premises, operations, independent Subcontractors and personal injury and advertising injury. 3, Workers' Compensation coverage as required by the Industrial Insurance laws of the State of Washington. 4. Professional Liability insurance appropriate to the Subcontractor's profession. The Subcontractor shall provide the District with proof of liability insurance or professional errors and omissions coverage as appropriate. B. Minimum Amounts of Insurance Subcontractor shall maintain the following insurance limits: 1. Automobile Liabilit insurance with a minimum combined single limit for bodily injury and property damage of $ 1,000,000 per accident. 2. Commercial General LiqhiUiy insurance shall be written with limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate. 1 Professional Liabilitv insurance shall be written with limits no less than $1,000,000 per claim and $1,,000,000 policy aggregate limit. C. Other Insurance Provisions 'rhe insurance policies are to contain, or be endorsed to contain, the following provisions for Automobile Liability, Professional Liability and Commercial General Liability insurance: 1. The Subcontractor's insurance coverage shall be primary insurance as respect the District. Any insurance, self-insurance, or insurance pool coverage maintained by the District shall be excess of the Subcontractor's insurance and shall not contribute with it. 2, The Subcontractor's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the District. D. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best rating of not less than ANIL E. Verification of Coverage Subcontractor shall furnish the District with original certificates and a copy of the amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Subcontractor before commencement of the work. XIV, Safeguarding of Information: The use Or disclosure by Subcontractor of any information or documents obtained by the Subcontractor in the course of contract performance for any purpose not directly connected with Subcontractor's responsibilities under this Agreement is prohibited except as may be required by law. Personal information collected, used or acquired in connection with this Agreement shall be used solely for the purposes of this Agreement. Subcontractor agrees not to release, divulge, publish, transfer, sell or otherwise make known to unauthorized persons personal information without the express written consent of the agency or as provided by law. Subcontractor agrees to implement physical, electronic and managerial safeguards to prevent unauthorized access to personal information. The District reserves the right to monitor, audit or investigate the use of personal information collected, used or acquired by the Subcontractor through this Agreement. The monitoring, auditing, or investigating may include but is not limited to "salting" by the District. Salting is the act of placing a record containing unique but false information in a database that can be used later to identify inappropriate disclosure of data contained in the database. Subcontractor shall certify the return or destruction of all personal information upon expiration of this Agreement. Any breach of this provision may result in termination of the Agreement and the demand for return of all personal information. The Subcontractor: contractor agrees to indemnify and hold harmless the District for any damages related to the Subcontractor's unauthorized use of personal information. XV, Records Maintenance; The parties to this Agreement shall each maintain books, records, documents and other evidence which sufficiently and properly reflect all direct and indirect costs expended by either party in the performance of the services described herein. These records shall be subject to inspection, review or audit by personnel of both parties, other personnel duly authorized by either party, the Office of the State Auditor, and federal officials so authorized by law. All books,, records, documents, and other material relevant to this Agreement will be retained for six years after expiration and the Office of the State Auditor, federal auditors, and any persons duly authorized by the parties shall have full access and the right to examine any of these materials during this period. Records and other documents, in any medium, furnished by one party to this Agreement to the other, party, will remain the property of the furnishing party, unless otherwise agreed. The receiving party will not disclose or make available this material to any third parties without first giving notice to the furnishing party and giving it a reasonable opportunity to respond. Each party will utilize reasonable security procedures and protections to assure that records and documents provided by the other party are not erroneously disclosed to third parties. XVI. Written Policies and Procedures/Documents on File: Written policies and procedures, consistent with federal and state regulations, as applicable, will be kept on file in the office of the Subcontractor and available for review at the request of District staff. Such policies and procedures will include, but not be limited to, as appropriate: • Job Descriptions • Confidentiality Policy • Community Needs Assessment In addition, the Subcontractor will keep on file and make available for review by District staff, documents consistent with federal and state regulations that will include but are not limited to the latest agency audit. XVIL Reguired Reports: Due dates outside the Budget Period are for reporting only. Subcontractor may not bill for work done outside the Budget Period. The Subcontractor will submit required reports by the date due using required forms according to procedures issued by the District. XVIII. Statutory and Regulatory Compliance: Subcontractor shall comply with all applicable federal, state, and local laws, regulations, guidelines, and standards in the performance of this Agreement. XIX Compliance with State and Federal Confidentiality Laws: The use or disclosure by any party of any inforrnation concerning a client obtained in providing service under this Agreement shall be subject to Chapter 42.56 RCW and Chapter 70.02 RCW, as well as any other applicable federal and state statutes and regulation. X.X. Non -D sLrimination: Subcontractor shall not discriminate against any employee or applicant for employment because of race, color, sex, religion, national origin, creed, marital status, age, Vietnam era or disabled veteran status, sexual preference, or the presence of any sensory mental or physical handicap. XXI. Amendment: This Agreement may be modified only by a written amendment executed by authorized representatives of both parties. XXII. Termination: This Agreement may be terminated by either party upon giving at least thirty (30) days advance written notice to the other party. If this Agreement is so terminated, the parties shall be liable only for performance rendered or costs incurred in accordance with the terms of this Agreement prior to the effective date of termination. XXIII. Termination for Cause- If for any cause, either party does not fulfill in a timely and proper manner its obligations under this Agreement, or if either party violates any of these terms and conditions, the aggrieved party will give the other party written notice of such failure or violation. The responsible party will be given the opportunity to correct the violation or failure within 15 working days. If the failure or violation is not corrected, this Agreement may be terminated immediately by written notice of the aggrieved party to the other. XXIV, 6 �overnanee: This Agreement is entered into pursuant to and under the authority granted by the laws of the State of Washington and applicable federal laws. The provisions of this Agreement shall be construed to conform to those laws. XXV. ' eerab�iii: if any provision of this Agreement or any provision of any document incorporated by reference shall be held invalid, such invalidity shall not affect the other provisions of this Agreement which can be given effect without the invalid provision, if such remainder conforms to the requirements of applicable law and the fundamental purpose of this Agreement, and to this end the provisions of this Agreement are declared to be severable. XXVI. Subcontracting- The Subcontractor shall not enter into subcontracts for any of the work contemplated under this Agreement without prior written approval of DOH. In no event shall the existence of the subcontract operate to release or reduce the liability of the Subcontractor to the Department for any breach in the performance of the Subcontractor's duties. This clause does not include contracts of employment between the Subcontractor and personnel assigned to work under this Agreement. Additionally, the Subcontractor is responsible for ensuring that all terms, conditions, assurances and certifications set forth in this Agreement are carried forward to any subcontracts. Subcontractor agrees not to release, divulge, publish, transfer, sell or otherwise make known to unauthorized persons personal information without the express written consent of DOH or as provided by law. If, at any time during the progress of the work, the District determines in its sole judgment that any subcontractor is incompetent, the District shall notify the Subcontractor, and the Subcontractor shall take immediate steps to terminate its subcontractor's involvement in the work. The rejection or approval by the District of any subcontractor or the termination of a subcontractor shall not relieve the Subcontractor of any of its responsibilities under the Agreement, nor be the basis for additional charges to the District. XXVII. Suspension of Performance and Resumption of Performance: In the event contract funding from state, federal, or other sources is withdrawn, reduced, or limited in any way after the effective date of this Agreement and prior to normal completion, the District may give notice to Subcontractor to suspend performance as an alternative to termination, The District may elect to give written notice to Subcontractor to suspend performance when the District determines that there is a reasonable likelihood that the funding insufficiency may be resolved in a timeframe that would allow performance to be resumed prior to the end date of this Agreement. Notice may include notice by facsimile or email to Subcontractor's representative. Subcontractor shall suspend performance on the date stated in the written notice to suspend. During the period of suspension of performance each party may inform the other of any conditions that may reasonably affect the potential for resumption of performance. When the District determines that the funding insufficiency is resolved, the District may give Subcontractor written notice to resume performance and a proposed date to resume performance. Upon receipt of written notice to resume performance, Subcontractor will give written notice to the District as to whether it can resume performance, and, if so, the date upon which it agrees to resume performance. If Subcontractor gives notice to the District that it cannot resume performance, the parties agree that the Agreement will be terminated retroactive to the original date of termination. If the date Subcontractor gives notice it can resume performance is not acceptable to the District, the parties agree to discuss an alternative acceptable date. If an alternative date is not acceptable to the District, the parties agree that the Agreement will be terminated retroactive to the original date of termination. Xxvill. Waiver: A failure by either party to exercise its rights under this Agreement shall not preclude that party from subsequent exercise of such rights and shall not constitute a waiver of any other rights under this Agreement unless stated to be such in a writing signed by an authorized representative of the party and attached to the original Agreement. XXIx, A1ggBMgRt: The work to be provided under this Agreement, and any claim arising thereunder, is not assignable or delegable by either party in whole or in part, without the express prior written consent of the District, which consent shall not be unreasonably withheld. X)(. Entire A : This Agreement including Exhibit A and Attachment 1, Federal Compliance Entire Standard Federal Certifications and Assurances, constitutes the entire agreement between the parties regarding its subject matter. Any oral or written representations not expressly incorporated in this Agreement are specifically excluded. KITSAP PUBLIC HEALTH DISTRICT_ By: — Scott Daniels Administrator Date: SUBCONTRACTOR 0 David Sullivan Chairperson, BOCC Date: NOTE, SUBCONTRACTOR SIGNATURES ALSO REQUIRED ON ATTACHMENT 1, SECTIONS I AND 2 FEDERAL CERTIFICATIONS AND ASSURANCES. Exhibit A Scope of Work and Budget Jefferson County Public Health January 1— September 29, 2015 As a subcontractor of KPHD under the Centers for Disease Control funded State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (1422), Jefferson County Public Health agrees to the following activities funded in full or part by the associated budget. Jefferson County Public Health Subcontract: January I September 29, 2015 Component I . . . ....... Acd iy'' 3 Adopt worksite wellness policy to increase physical activity in Jefferson Benefits County Public Health. 8 Identify Jefferson County Public Health clients with high blood pressure and Indirect track referrals to community resources 14 Meet with community pharmacists from local entities (Dons, Safeway, QFC, Tri Area, or Jefferson Healthcare) to identify at least I pharmacists willing to engage in hvvertension management Monitoring Monitor progress for each activity as appropriate; submit timely program and R �tjn reports as requested by KPHD Calls/Meetings Participate in scheduled conference calls and annual in-person meeting; review correspondences related to 1422 from the Department of Health; respond to activity assessments/surveys administered by KPHD as appropriate per scope of work Invoicing Submit timely monthly invoicing for expenses incurred according to the approved subcontractor budget Jefferson County Public Health Subcontract: January I September 29, 2015 Component I cost Salaries $8,301 Benefits $3,174 Goods $ Services $1,000 Indirect $2,525 Subtotal $15,000 Component 2 Salaries $6,8 18 Benefits $2,608 Goods $ Services $1,000 Indirect $2,074 Subtotal $12,500 Total JCHD $27,500 Attachment I FEDERAL COMPLIANCE AND STANDARI[) FEDERAL CERTIFICATIONS AND ASSURANCES In the event federal funds are included in this Agreement, added by future amendment(s), or redistributed between fund sources resulting in the provision of federal funds, the following sections apply. I. Federal Compliance and 11. Standard Federal Assurances and Certifications. In the instance of inclusion of federal funds as a result of an amendment, the Subcontractor may be designated as a subrecipient and the effective date of the amendment shall also be the date at which these requirements go into effect. I. FEDERAL COMPLIANCE - The use of federal funds requires additional compliance and control mechanisms to be in place. The following represents the majority of compliance elements that may apply to any federal funds provided under this Agreement. (Refer to Catalog of Domestic Assistance number(s) cited in the "Payment" section of this Agreement for requirements specific to that fund source.) For clarification regarding any of these elements or details specific to the federal funds in this Agreement, contact: Compliance and Internal Control Officer Office of Financial Services Washington State Department of Health Post Office Box 47901 Olympia, Washington 98504-7901 1. CIRCULARS 'COMPLIANCE MATRIX' - The following compliance matrix identifies the OMB Circulars that contain the requirements which govern expenditure of federal funds. These requirements apply to the Department of Health, as the primary recipient of federal funds, and then follow the funds to the subrecipient. The federal Circulars which provide the applicable administrative requirements, cost principles and audit requirements are identified by subrecipient organization type. COMPLIANCE, MATRIXOMB CIRCULAR ENTITY TYPE ADMINISTRATIVE COST PRINCIPLES AUDIT REQUIREMENTS REQUIREMENTS State, Local and A-102 & A-87 A-133 Indian Tribal Common Rule Governments & Governmental Non-Profit A- I I _0 A- 122 A-133 Organizations & Non-Profit ijos itals Colleges or A-110 A-21 A-133 Universities & Affiliated Hospitals 2. CITIZENSHIP/ALIEN VERIFICATION/DETERMINATION - The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 (PL 104-193) states that federal public benefits should be made available only to U.S. citizens and qualified aliens. Entities that offer a service defined as a "federal public benefit" must make a citizenship/qualified alien determination/ verification of applicants at the time of application as part of the eligibility criteria. Non-US citizens and unqualified aliens are not eligible to receive the services. PI, 104-193 also includes specific reporting requirements. Exemptions from the determination/verification requirement is afforded the following programs offered by the Department of Health: Family Planning, Breast & Cervical Health Program (BCHP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), WIC Farmers Market Program, Immunization Programs, and Ryan White CARE Act programs and other communicable disease treatment and diagnostic programs. 3. CIVIL RIGHTS AND NONDISCRIMINATION - During the performance of this Agreement, the Subcontractor shall comply with all current and future federal statutes relating to nondiscrimination. These include but are not limited to: Title VI of the Civil Rights Act of 1964 (PL 88-352), Title IX of the Education Amendments of 1972 (20 U.S.C. §§ 1681-1683 and 1685-1686), section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794), the Age Discrimination Act of 1975 (42 U.S.C. §§ 6101-6107), the Drug Abuse Office and Treatment Act of 1972 (PI, 92-255), the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290dd-3 and 290ee-3), Title Vill of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), and the Americans with Disability Act (42 U.S.C., Section 12101 et seq.). 4. SINGLE AUDIT ACT - A subrecipient (including private, for-profit hospitals and non-profit institutions) shall adhere to the federal Office of Management and Budget (OMB) Circular A -133, as well as all applicable federal and state statutes and regulations. A subrecipient who expends $500,000 or more in federal awards during a given fiscal year shall have a single or program - specific audit for that year in accordance with the provisions of OMB Circular A -133. 11. 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. CERTIFICATIONS 1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION The undersigned (authorized official signing for the subcontracting organization) certifies to the best of his or her knowledge and belief, that the Subcontractor, defined as the primary participant in accordance with 45 CFR Part 76, and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal Department or agency; B. Have not within a 3-year period preceding this Agreement been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and D. Have not within a 3-year period preceding this Agreement had one or more public transactions (Federal, State, or local) terminated for cause or default. Should the Subcontractor not be able to provide this certification, an explanation as to why should be placed after the assurances page in the Agreement. The Subcontractor agrees by signing this Agreement that it will include, without modification, the clause titled Certification Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion--Lower Tier Covered Transactions in all lower tier covered transactions (i.e., transactions with sub- grantees and/or contractors) and in all solicitations for lower tier covered transactions in accordance with 45 CFR Part 76. 2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS The undersigned (authorized official signing for the subcontracting organization) certifies that the Subcontractor 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 i. The dangers of drug abuse in the workplace; ii, The Subcontractor's policy of maintaining a drug-free workplace; iii. Any available drug counseling, rehabilitation, and employee assistance programs; and iv. 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 Agreement 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 Agreement, the employee will- i. Abide by the terms of the statement; and ii. 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 District in writing within ten calendar days after receiving notice under paragraph (D) 00 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 number(s) of each affected grant; F. Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (D) (ii), with respect to any employee who is so convicted- i. 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 ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; 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 Washington State Department of Health PO Box 47905 Olympia, WA 98504-7905 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 (non-appropriated) funds, These requirements apply to grants and cooperative agreements EXCEEDING $ 100,000 in total costs (45 CFR Part 93). The undersigned (authorized official signing for the subcontracting organization) certifies, to the best of his or her knowledge and belief, that: A. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, 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, B. 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 undersigned 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.) C. The undersigned shall require that the language of this certification be included in the award documents for all subcontracts at all tiers (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, LT'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 $100,000 for each such failure. 4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA) The undersigned (authorized official signing for the subcontracting organization) 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 undersigned agrees that the subcontracting 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 103-227, 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. By signing the certification, the undersigned certifies that the subcontracting 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 subcontracting 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 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. 6, 'CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS INSTRUCTIONS FOR CERTIFICATION By signing and submitting this proposal, the prospective Subcontractor is providing the certification set out below. A. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective Subcontractor shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective Subcontractor to furnish a certification or an explanation shall disqualify such person from participation in this transaction. B. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective Subcontractor knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause of default. C. The prospective Subcontractor shall provide immediate written notice to the department or agency to whom this Agreement is submitted if at any time the prospective Subcontractor learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. D. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the person to whom this Agreement is submitted for assistance in obtaining a copy of those regulations. E. The prospective Subcontractor agrees by submitting this Agreement that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by DOH. F. The prospective Subcontractor further agrees by submitting this Agreement that it will include the clause titled Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - - Lower Tier Covered Transaction, provided by HHS, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. G. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List (of excluded parties). 11. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 1. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, District may terminate this transaction for cause or default. SUBCONTRACTOR'S SIGNATURE IS REQUIRED Signature of Authorized Certifying Official Title 1?—Iease Also Print or Type Name Organization Name Date FEDERAL 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 completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503 PLEASE DO NOT RETURN YOUR COMPLETED FORM 'TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY. Note: Certain of these assurances may not be applicable to your projector 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 duty authorized representative of the Subcontractor, I certify that the Subcontractor: I , 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. 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. 3. 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 ame- 168,3, and 1685-1686), which prohibits discrimination on the which prohibits discrimination on the basis of handicaps; (d) the Age Discrim-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and'freatment 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 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol (42 -3 and 290 ee 3), as amended, relating to confidentiality of alcohol and seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and 0) the requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of ritles II 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 applic- 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 -276a- -333), regarding labor standards for federally assisted construction subagreements. lo. 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. 1. Will comply 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) 1 1 514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed of Federal actions to State (Clear Air) Implen-ientation Plans under Section 176(c) of the 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 1968 (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 and protection of historic properties), and the Archaeological and Historic Preservation Act -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.L. 89-544, as amended, 7 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. 460let seq.) which prohibits the use of lead-based paint in construction or rehabilitation of residence structures. 17. 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. SUBCONTRACTOR'S SIGNATURE IS REQUIRED Title of Authorized Certifying Official TitLU, Please Also Print or Type Name Organization Name Date