HomeMy WebLinkAbout121216_ca04�V 615 Sheridan Street
Port Townsend, WA 98368
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Public Healt November 3, 2016
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Karen Obermeyer, Community Health Educator
DATE:
SUBJECT: Agenda Item — Contract Agreement between Kitsap Public Health
District and Jefferson County Public Health; September 30, 2016 —
September 29, 2017; $30,000
STATEMENT OF ISSUE:
Jefferson County Public Health, Community Health, requests Board approval of the Contract
Agreement between Kitsap Public Health District and Jefferson County Public Health; September 30, 2016 —
September 29, 2017; $30,000.
ANALYSIS/ STRATEGIC GOALS/PRO'S and CON'S:
This Agreement allows the JCPH to continue its work toward prevention and management improvements
related to hypertension, obesity, and prediabetes conditions particularly among the poor, persons with
mental illness, and tribal communities within the Olympic Community of Health, the Accountable
Community of Health for Kitsap, Jefferson and Clallam counties. Scope of work includes activities related
engaging local employers to adopt workplace wellness policies, as well as engaging community sectors in
the 5210 project. This work is as a subcontractor of KPHD, JCPH will continue its efforts to coordinate
(and/or contract), promote, develop, refer, and facilitate adoption and insertion of evidence -based wellness
policies, and language to further the mission of public health with area YMCA, Diabetes Prevention Program
organizations, WA Department of PHealth, and will report and attend meetings related to the ongoing
project effort.
FISCAL IMPACT/COST BENEFIT ANALYSIS:
The Contract Agreement is fully funded through KPHD, Centers for Disease Control and Prevention Federal
grant award, through the Department of Health and Human Services, CDC, for State and Local Public
Health Actions to prevent Obesity, Diabetes, Heart Disease, and Stroke.
RECOMMENDATION:
JCPH management request approval of the Contract Agreement between Kitsap Public Health District and
Jefferson County Public Health for Healthy Communities project continuation; September 30, 2016 —
September 29, 2017; $30,000.
REVIEW -013 BY:
ip orley, C unty dministrato Date
Community Health Environmental Health
Developmental Disabilities Water Quality
360-385-9400 360-385-9444
360-385-9401 (f) Always working for a safer and healthier community (f) 360-379-4487
KPHD 1586
Page 1 of 25
PROFESSIONAL SERVICES AGREEMENT
Between
KITSAP PUBLIC HEALTH DISTRICT
And
JEFFERSON COUNTY PUBLIC HEALTH
This Professional Services Agreement ("Agreement") is made and entered into between the Kitsap Public
Health District, a Health District organized pursuant to chapter 70.46 Revised Code of Washington and
Section 9.52 Kitsap County Code, hereinafter referred to as "District," and Jefferson County Public Health,
hereinafter referred to as "Subcontractor." The parties mutually agree as follows:
I . Period of Performance: The period of performance of this Agreement shall begin September 30,
2016, and be completed no later than September 29, 2017, unless terminated sooner or extended as
provided for herein.
2, Purpose: The District requires the expertise of this Subcontractor to improve the prevention,
management, and tracking of hypertension, obesity, and pre -diabetes 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 Clallam counties.
3. qualifications/Eli ibilit : The Subcontractor will have the qualifications necessary to successfully
complete the objectives of this Agreement. The Subcontractor hereby affirms that he/she is eligible
to work in the United States as set forth in the Immigration Reform and Control Act (IRCA).
4. Statement of Work and Budget: 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 Attachment A, attached hereto and incorporated herein.
5. Conimunill 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.
6. Compensation: The District agrees to pay Subcontractor $30,000 during the Agreement.
Compensation will be based on invoices submitted by Subcontractor itemizing a detailed description
of services performed per the agreed upon scope of work and budget (Attachment 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 do 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 a period
of performance of September 30, 2016 to September 29, 2017.
KPHD 1586
Page 2 of 25
Payment for costs allowable in each budget period is contingent on continued DP -1422 funding to
the District for the Healthy Communities Obesity, Diabetes, Heart Disease and Stroke Prevention
Program.
The Subcontractor's proposed budget is listed in Attachment A with the Scope of Work.
Subcontractor shall submit a monthly A-19, attached and herein after referenced as Attachment B to
the District for payment. (Note: Subcontractor may elect to bill quarterly, however monthly
Expenditure Report for each month in the quarter must be submitted).
The District will reimburse for actual allowable program costs. Billings for services on a monthly
fraction of the budget will not be accepted or approved.
Authorized and allowable program expenditures will be reimbursed upon receipt and approval of the
Monthly Expenditure Report and Request for Reinribursement must be provided to the District by the
20h of the month in order to receive reimbursement for the l rev OLIS month. If the District does not
receive the Monthly Expenditure Report and Request for Reimbursement form by the 20th of the
month, the District may withhold approval and payment, at its discretion.
7. Federal Source of Funds: The funding source for this Agreement is Federal.
__ ........w
Item Description
W
Federal Funding Source #1
1h
WWv_
Sub -recipient name (Exactly as listed in DUNS):
Jefferson County Public Health
Amq�
Click on web address above and then click on "search
records" tab and enter the sub -recipient's name in the
"Quick Search" box, then press enter.
2
Sub -recipient DUNS Ntunber:
184826790
A 9 digit number that can be found on the web address
above.
3
.........
Federal Award Identification Number (FAIN):
.... .�
NU58DP005531
If a FAIN number is not specifically listed, use "Grant
Number" listed on notice of award.
4
Federal Award Date:
08/07/15
Date the federal grant award was issued or the date in the
"Date of Award" section on the Federal Notice of Award.
(This is not the project or budget period).
5
Start and End Date of the KPHD Contract:
Found in the "Period of Performance" section of the
contract. (If the start date in the period of performance
section is listed as the date of execution (DOE) then refer to
the signature page for the date of the last party so sign).
6
Amount of Federal Funds Obligated by this Action:
$30,000
Increase or decrease in federal funds for this sub -award
agreement only.
7
Total Amount of Federal Funds Obligated to the Sub-
TBD annually
KPHD 1586
Page 3 of 25
......... ..._Wv
recipient by KPHD for this sub -award (per funding
..............
source):
Total amount of all federal funds given to the sub -recipient
for each federal funding source identified.
8
Total amount of Federal award to KPHD:
$915,480
www.ADDS.net
Total of the federal funds awarded to DOH for each federal
funding source identified. For total funds awarded to DOH
go to the Grants Status report available by clicking on the
ADDS.net link above.
9
Project description as Listed on the FFA TA form:
This can be found on the FFATA form
10
Name of federal Awarding Agency:
Department of Health and
List both the federal agency and the awarding division (i.e.
Human Services
HHS/Centers for Disease Control and Prevention) Found in
Centers for Disease Control and
the Notice of Award.
Prevention
11
Name of the pass-through entity:
Washington State Department of
For grants awarded directly from the federal government to
Health
DOH, list "Washington State Department of Health." For
grants sub -awarded to DOH by other state agencies, list the
Kitsap Public Health District
agency's name.
12
Contact information for awarding official — Statement of
Yolanda Fong
Work:
Name of KPHD Program's Contract Manager(s) or project
coordinator.
13
CFDA Number:
93.757
Catalog of Federal Domestic Assistance (CFDA) — a five
digit number (i.e. 55.555) found on the notice of award.
14
CFDA Name:
State and Local Public Health
wmm n'L' - °.f h; . v
Actions to Prevent Obesity,
Click on the web address above, then enter the 5 -digit
Diabetes, Heart Disease and
CFDA number on the right hand side in the "keyword or
Stroke (PPHF)
program number" box and hit enter or "search."
15
Is the Award Research and Development:
No
Usually "no." Check the grant application or notice of
award to see if the award is for research and development.
16
.........�._.. _....._.... __ ....... ..
The Limiting Indirect Cost Rate for the Federal Award, if
...... W W... ...... ........
NA
Any:
Check the grant application or notice of award for an
approved indirect rate.
17
Certifications and assurances — all requirements imposed
on the sub -recipient by the federal awarding agency:
The contract boilerplate covers all standard certifications
and assurances.
18
r _. y tional re uirements impose........... _..�
Are there an adldi q ..�............... d by the pass
....__...��._. _� ......_
Yes
through entity (KPHD ) to meet its own responsibilities to
KPHD 1586
Page 4 of 25
the awarding agency:
If applicable, this is identified by the KPHD program staff
writing the contract. This can also be found in the
"Statement of Work" section of the contract.
�.. ............
19 Indirect Rate: 25.7%
Check with entity. If your contract allows indirects, you
must use the sub -recipient federally approved indirect rate.
If the entity has never had a federally approved indirect rate
they may use 10% De Minimis indirect rate.
20 Access to Sub grantee's accounting records:
All sub -recipients are required to make their accounting
records available and accessible to the awarding agency.
You can find this requirement in the "Records Maintenance"
section of the contract.
21 Closeout Requirement.
(1) Submit all final billings within 30 days of the end of
the contract.
(2) Submit all required program reports and deliverables
within 30 days.
(3) Dispose of property purchased with sub -award funds
and dispose of or return government -furnished
property no longer used for sub -award related
activities (If applicable KPHD must be contacted for
disposal requirements)
(4) Additional KPHd program specific contract closeout
requirements: (If applicable, see SOW for additional
closeout requirements)
Performance Requirements and Notices: : 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. District staff will provide and facilitate assistance and
guidance to the Subcontractor as necessary. Notices pursuant to this agreement shall be sent to the
designated District Program Coordinator who is responsible for project coordination:
If to the District:
Kitsap Public Health District
Attn: Yolanda Fong
345 6th Strect., Shite 300
Bremerton, WA 98337
(360) 337-5275
If to the Subcontractor:
Jefferson County Public Health
Attn: Karen Obermeyer
615 Sheridan Street
Port Townsend, WA 98368
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 the District related to
priority populations in the designated Community area;
KPHD 1586
Page 5 of 25
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 the District.
Data submissions related to these items will be provided as mutually agreed upon with the District.
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. The District will
reimburse the Subcontractor for travel to and from scheduled meetings as applicable.
9, Billings: Billings to the District shall be submitted no more frequently than every 30 days, and shall
be quarterly at a minimum. Billings shall be sent to:
Kitsap Public Health District
Accounts Payable
345 6"' Street, Stflte 300
Bremerton, WA 98337
(360) 337-5215
Backup documentation will be provided to the District within five business days. Backup
documentation can include, but is not limited to: receipts, invoices, billing records, work orders,
positive time and attendance records (timesheets), travel vouchers and accounting expense reports.
Failure to provide the required information may result in nonpayment of invoices or termination of
this contract.
This is a sub -recipient contract. All expenditures incurred and reimbursements made for
performance under this contract will be based on actual allowable costs. Costs can include direct
labor, direct material, and other direct costs specific to the performance of activities or achievement
of deliverables under this contract.
For information in determining allowable costs, indirect rates and pass through agency requirements,
such as fiscal monitoring of sub -recipients, please reference the document titled "Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards:" (2
Code of Federal Regulation CFR 200)
Signed Expenditure Report (A-19) invoices must be received prior to approval and payment.
Email submission of invoices, electronic reports, and deliverables is encouraged. However, original
hardcopy of the invoices are required and shall be mailed to the District.
Upon expiration of the Agreement, any claim for payment not already made shall be submitted to the
District within 20 days after the expiration date.
10. jgggender t t"a acct : 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 to be employees or agents of the District for any purpose.
11. 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 District.
KPHD 1566
Page 6 of 25
Data shall include, but not 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.
The District maintains all rights to the license to publish, translate, reproduce, modify, deliver,
dispose of the data, and to authorize others to do so.
12. 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.
13. Insttrance: 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:
1. Automobile Liability insurance covering all owned, non -owned, hired and leased 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 Ljability insurance shall be written on ISO occurrence form CG 00 01
and shall cover liability arising from premises, operations, independent contractors and
personal injury and advertising injury. The District shall be named as an insured under the
Subcontractor's Commercial General Liability insurance policy with respect to the work
performed for the District.
3. Workers' Coin - risatioii coverage as required by the Industrial Insurance laws of the state of
Washington.
4. Professional l.� g[ ili®tpy 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:
KPHD 1586
Page 7 of 25
1. Autoirnobilc Liability insurance with a minimum combined single limit for bodily injury and
property damage of $1,000,000 per accident
2. Comnicrcial General lJgL)Jlity insurance shall be written with limits no less than $1,000,000
each occurrence, $2,000,000 general aggregate.
3. Profcssional [Jabilit^y 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
The 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 A:VII.
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.
14. Safeguarding of Iiforma,tion and P!•i ac : The use or disclosure by any party of any information
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
regulations. 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. Any unauthorized access or use of confidential
information must be reported to the District Security Officer at (360) 337-5262. The notification
must be made in the most expedient time possible (usually within 24 hours of discovery) and without
unreasonable delay, consistent with the legitimate needs of law enforcement, or any measures
necessary to determine the scope of the breach and restore the reasonable integrity of the data
system.
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,
KPHD 1586
Page 8 of 25
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
the Agreement.
15. 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 the 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 that party 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.
16. 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 and subcontractor agreements. The Subcontractor will include these
requirements in all approved subcontracts.
1T Reg uuired Reports: The Subcontractor will submit required reports quarterly using required forms
according to procedures issued by the District.
The Subcontractor will be obligated to submit required reports after the close of the contract period,
during the transfer of obligations to another contractor, or upon termination of the contract for any
reason.
The Subcontractor will include all requirements listed above in all approved subcontracts.
KPHD 1586
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Due dates outside the Budget Period are for reporting only. Subcontractor may not bill for work
done outside the Budget Period.
18. 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.
19. Com fiance with State and Federal Confidentiality Laws: The Subcontractor shall not use
protected health information created or shared under this Agreement in any manner that would
constitute a violation of RCW 70.02, RCW 42.56, the Health Information Portability and
Accountability Act, commonly known as HIPAA, or any regulations enacted pursuant to its
provisions. An excerpt of certifications and assurances is herein attached as Attachment C
20, Certification Ike ardin j xSus ension and Debarnier t: The Subcontractor, by completing and
returning to the District the "Debarment, Suspension, Ineligibility or Voluntary Exclusion
Certification Form," and completing, signing and returning to the District the "Certification
Regarding Debarment, Suspension, Ineligibility or Voluntary Exclusion for Lower Tier Covered
Transactions" form, (to be supplied to lower tier participants; see Attachment C), certifies that it is
not debarred, suspended, or proposed for debarment by any federal agency.
21. Sus pension of Performance and Resumption tion 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 occur 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.
21 Non -Discrimination: 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.
KPHD 1586
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23. 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 writing, signed by an authorized representative of
the party and attached to the original Agreement.
24. Ais n cnen : The work to be provided under this Agreement and any claim arising there under, 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.
25. Amendment: This Agreement maybe modified only by a written amendment executed by
authorized representatives of both parties.
26. Termination: This Agreement may be terminated by either party upon giving at least thirty (20)
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.
27. 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 part to the other.
28. Governance: 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.
29. Severability: 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.
30. S contractin : The Subcontractor shall not enter into subcontracts for any of the work
contemplated under this Agreement without prior written approval of the District. 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, 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 the District or as provided by
law.
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If at any time during the progress of the work, the District determines in its sole judgment that any
contractor is incompetent, the District shall notify Subcontractor, and 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
Subcontractor of any of its responsibilities under the Agreement, nor be the basis for additional
charges to the District.
31. Entire Agreement: This Agreement 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 PU .I STH DISTRICT
Kith Grellner
Administrator
Date: 7
Fundine Source
Program
Federal Contract/Grant
JEFFERSON COUNTY PUBLIC HEALTH
Date:
Kathleen Kler
Commissioner
KPHD 1586
Page 12 of 25
ATTACHMENT A
Scope of Work and Budget
Jefferson County Public Health
September 30, 2016 — September 29, 2017
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.
Strate v
Activity
1.1
Facilitate adoption of updated policies with food and beverage standards in
Chimacum School District 49, Quilcene School District 48, Brinnon School
District 46.
Implement Worksite Wellness program: Use Best Practice framework,
Health Links, to assist employers in implementing evidence based worksite
wellness strategies including programs, communications and policies to
increase access to healthy food and beverages options.
Implement community wide 5-2-1-0 including worksites and other
community sectors, to encourage improved food and beverage guidelines.
1.2
Continue technical support for "Re -think Your Drink" project, for placement
and promotion strategies.
Continue to promote public benefits in farmers market.
1.3
Implement Worksite Wellness program: Use Best Practice framework,
Health Links, to assist employers in implementing evidence based worksite
wellness strategies including programs, communications and policies to
increase physical activity.
In alignment with Jefferson County's CHIP plan, outreach and engage major
employers in adopting worksite wellness policies to promote physical
activity utilizing 5210 messaging and Health Links model.
Continue to improve referral system to increase participation in evidence
based lifestyle change programs.
1.4
Complete recommendations to insert health language into Jefferson County
Comp Plan for adoption in comp plan update.
2.4
Continue to ensure medical assistants and volunteers complete CHW
modules on HTN and prediabetes.
2.5
Continue to increase access to worksite blood pressure monitoring stations.
2.8
Identify and enhance new and existing referral relationships to support
transmission and receiving of referrals. Share information collected in
strategies 1.2 and 1.3, as well as locations for accurate measurement of blood
pressure and screenings for high blood pressure in CLO areas with regional
211 entities to enhance listings and access.
KPHD 1586
Page 13 of 25
Budget October 1, 2016 — September 29, 2017
Component I
p changes needed to accommodate transmission
dentify policies and rocesscrages
Description
f information between referral sources, community health workers,
$9,238.39
[evidence-basedprograms, and primary care, for more widespread
Benefits
mplementation with partner organizations.
Benefits - Karen Obermeyer, 6.5 hrs/wk
Utilize DOH contract with 2-1-1 call center, to identify tracking,
$3,545.10
enhancements or relationships needed to provide comprehensive, multi-
directional referrals between referral specialists, community health workers,
5210 webpa ga ..... ..
d promotion support, point of purchase
community-based organizations, and primary care practices.
$1000.00
Improve referral system to increase participation in evidence based lifestyle
Total$17,339.24
�.2
change programs.
Monitoring
Monitor progress for each activity as appropriate; submit quarterly narrative
and Reporting
and data reports as requested by KPHD on January 16, 2017; April 17, 2017;
Staff Salary
July 17, 2017 and October 13, 2017.
Calls/Meetings
Participate in scheduled ___.W._____ .............:...................................
duled co
p nference calls and annual in-person meeting;
$2,735.20
..........
review correspondences related to 1422 from the Department of Health;
Indirect
respond to activity assessments/surveys administered by KPHD as
25.7%
appropriate per scope of work.
Invoicing
Submit timely monthly invoices or quarterly invoices on January 20, 2017;
April 20, 2017; July 20, 2017 and October 20, 2017. Invoices must include
prediabetes. . .............. — __�.....m
supporting documentation such as time cards for staff time and copies of
$12,660.76
......... ...............
invoices paid for goods and services.
Budget October 1, 2016 — September 29, 2017
Component I
Cost
Description
Staff Salary
$9,238.39
Salary - Karen Obermeyer, 6.5 hrs/wk
Benefits
$3,555.76
Benefits - Karen Obermeyer, 6.5 hrs/wk
Indirect
$3,545.10
25.7%
.. mm..........
5210 webpa ga ..... ..
d promotion support, point of purchase
Goods & Services
$1000.00
display support, public benefit promotions supplies
Total$17,339.24
�.2
...
....... .._ ...............
.......
Component
cost
Description
Staff Salary
$6,540.95
..................................................................._..............
Salary - Karen Obermeyer, 5 hrs/wk
Benefits
$2,735.20
..........
Benefits - Karen Obermeyer, 5 hrs/wk
Indirect
$2,588.56
25.7%
Goods & Services
$796.05
......... ._ .... .........._
worksite blood pressure monitoring stations, HTN and
prediabetes. . .............. — __�.....m
Total
..................
$12,660.76
......... ...............
_... ................ ..............
.....................
Total Jefferson
$30,000
Federol I.D. NO. Or 88N NO.:
Federal Tax ID #
DATE
Billing for Labor and Expenses for Period of:
Budget Item
Comp 1: Strategies
Salaries
Benefits
Travel
Equipment
Goods & Services
Indirect
SUBTOTAL
Comp 2: Strategies
Salaries
Benefits
Travel
Equipment
Goods & Services
Indirect
SUBTOTAL
Prepared By: '.Telephone Number: Date:
Dom Date: Current Doc. No. '.Ref. Doc. No.
Work class
Sub Sub o.r
a.r o.w APPN I PROGRAM
°"" rwure INDEX INDEX I Obj Sub All -
u Gbj
Signature must be an authorized agent for the agency (director, owner, etc,) and slgnod In Ink.
Slgnedt
Signatory Name (typed)
Date:
...._.................. __.�................... ..........�.� ..,,.....�.-..
Received By: Date Received:
Description
Description Cost For KPHD Accounting use
$0.00
$0.00
TOTAL $0.00
uee Vendor Meeeage:
"
ATTACHMENT B
KPHD 1586
Request for Reimbursement Form A-19
Page 14 of 25
Inv -la. Numb -
FORM;" STATE OF WASHINGTON
AGENCY USE ONLY
A19 -1E , INVOICE VOUCHER
AgencyNumbee LocallanCode PR ORAUTH.NO.
... .....,�..,�.�,.,.....,�„�,
QRV 1MN99
WSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claimpayment for materials,
ncBNOw NAME
merchandise or services. Show complete detail for each item. Sections highlighted In yellow are
Kitsap Public Health District
required.
Margaret Hilliard, Accounting Assistant
345 - 6th Street, Suite #300
Sub -Recipient's Cerlflcatlon. I hereby certify under penalty of perjury that theitems and totals listed
herein are proper charges for materials, merchan-dise or services furnished to the State of Washington,
Bremerton, WA 98337-1866
and that all goodsfurnished and/or services rendered have been provided without discrimina-tion
because of age, sex, marital status, race, creed, color, national origin, handicap, religion, or Vietnam era
or diabled veterans status.
Federol I.D. NO. Or 88N NO.:
Federal Tax ID #
DATE
Billing for Labor and Expenses for Period of:
Budget Item
Comp 1: Strategies
Salaries
Benefits
Travel
Equipment
Goods & Services
Indirect
SUBTOTAL
Comp 2: Strategies
Salaries
Benefits
Travel
Equipment
Goods & Services
Indirect
SUBTOTAL
Prepared By: '.Telephone Number: Date:
Dom Date: Current Doc. No. '.Ref. Doc. No.
Work class
Sub Sub o.r
a.r o.w APPN I PROGRAM
°"" rwure INDEX INDEX I Obj Sub All -
u Gbj
Signature must be an authorized agent for the agency (director, owner, etc,) and slgnod In Ink.
Slgnedt
Signatory Name (typed)
Date:
...._.................. __.�................... ..........�.� ..,,.....�.-..
Received By: Date Received:
Description
Description Cost For KPHD Accounting use
$0.00
$0.00
TOTAL $0.00
uee Vendor Meeeage:
"
JUBI Number:
Pruj.s Ra,.y Ph..
AMOUNT
Inv -la. Numb -
KPHD 1586
Page 15 of 25
ATTACHMENT C
FEDERAL COMPLIANCE
AND STANDARD 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 II. Standard
Federal Assurances and Certifications. In the instance of inclusion of federal funds as
a result of an amendment, the Contractor may be designated as a subrecipient and the
effective date of the amendment shall also be the date at which these requirements go
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 contract. (Refer to Catalog of Domestic
Assistance number(s) cited in the "Payment" section of this contract for requirements specific to
that fund source.) For clarification regarding any of these elements or details specific to the
federal funds in this contract, contact:
Compliance and Internal Control Officer
Office of Financial Services
Department of Health
Post Office Box 47901
Olympia, Washington 98504-7901
1. UNIFORM ADMINISTRATIVE GUIDANCE — The Uniform Administrative Guidance (Supercircular)
became effective December 26, 2014 and combines numerous OMB Circulars into one document.
This document establishes 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 Uniform Administrative Guidance provides the applicable
administrative requirements, cost principles and audit requirements are identified by subrecipient
organization type.
COMPLIANCE MATRIX
OMB CIRCULAR
_...
ENTITY TYPE
ADMINISTRWATIVE
COSTWW�m
AUDIT
REQUIREMENTS
PRINCIPLES
REQUIREMENTS
State. Local and Indian Tribal
2 CFR 200
2 CFR 200
2 CFR 200
Governments & Governmental
Subpart D
Subpart E
Subpart F
Hospitals
Non -Profit Organizations
_
2 CFR 200
2 CFR 200
2 CFR 200
...Subpart D
Subpart E
_ ..�..WW.
Subpart F
..� w
Hospitals-...�_
2 CFR 200
45 CFR 74
2 CFR 200
Subpart D
Appendix E
Subpart F
Colleges or Universities & Affiliated
2 CFR 200
2 CFR 206-1
2 CFR 200
Hospitals
Subpart D
Subpart E
_ Subpart F
KPHD 1586
Page 16 of 25
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. PL 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
Contractor 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 (PL 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
VIII 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 Uniform Administrative Guidance (subpart F) as well as all
applicable federal and state statutes and regulations. A subrecipient who expends $750,000 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 2 CFR 200 Subpart F
II. 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 contracting organization) certifies to the best of his
or her knowledge and belief, that the contractor, defined as the primary participant in accordance with
45 CFR Part 76, and its principals:
KPHD 1586
Page 17 of 25
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 contract 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 contract had one or more public transactions
(Federal, State, or local) terminated for cause or default.
Should the contractor not be able to provide this certification, an explanation as to why should be
placed after the assurances page in the contract.
The contractor agrees by signing this contract 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 contracting organization) 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
The dangers of drug abuse in the workplace;
ii. The contractor's policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
KPHD 1586
Page 18 of 25
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 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—
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 agency in writing within ten calendar days after receiving notice under 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 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—
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
iii, 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
WA State Department of Health
PO Box 47905
Olympia, WA 98504-7905
KPHD 1586
Page 19 of 25
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 undersigned (authorized official signing for the contracting 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, 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
$100,000 for each such failure.
4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA)
The undersigned (authorized official signing for the contracting 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 contracting
organization will comply with the Public Health Service terms and conditions of award if a contract is
awarded.
KPHD 1586
Page 20 of 25
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 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 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 contractor 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 contractor 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 contractor 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 contractor 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 contractor shall provide immediate written notice to the department or agency
to whom this contract is submitted if at any time the prospective contractor learns that its
KPHD 1586
Page 21 of 25
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
contract is submitted for assistance in obtaining a copy of those regulations.
E. The prospective contractor agrees by submitting this contract 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 contractor further agrees by submitting this contract 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).
H. 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.
I. 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, DOH may terminate this
transaction for cause or default.
KPHD 1586
Page 22 of 25
7. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS -- PRIMARY COVERED TRANSACTIONS
A. The prospective contractor certifies to the best of its knowledge and belief, that it and its
principals:
i. Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any Federal department or
agency;
fl, Have not within a three-year period preceding this contract 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;
Iii, Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State or local) with commission of any of the offenses
enumerated in paragraph (1)(b) of this certification; and
iiv. Have not within a three-year period preceding this contract had one or more public
transactions (Federal, State or local) terminated for cause or default.
B. Where the prospective contractor is unable to certify to any of the statements in this certification,
such prospective contractor shall attach an explanation to this contract.
CONTRACTOR'S SIGNATURE IIS REQUIRED
SIGNATUREmmOFmAUTHORIZED CERTIFYING OFFICIAL TITLEm
Please also print or type name:
ORGANIZATION NAME: (if applicable) DATE
KPHD 1586
Page 23 of 25
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 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:
1. 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. [1114728-
4763)
❑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
KPHD 1586
Page 24 of 25
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. 0794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.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 (P.L. 91-
616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Fill 523 and 527 of the Public Health 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 VIII 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) 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 Titles 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 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. 0276c 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 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) 11514; (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 under the Coastal Zone Management Act of 1972 (16 U.S.C.
❑ ❑ 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation
Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C.
El 07401 et seq.); (g) protection of underground sources of drinking water under the
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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 (16 U.S.C. 11E] 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.L. 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. ❑04801 et
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.
CONTRACTOR'S SIIGINArURE IS REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
Please also print or type name:
ORGANIZATION NAME: (if applicable) DATE