HomeMy WebLinkAbout121817_ca12615 Sheridan Street
Port Townsend, �46
enda
www.JeffersonCountyPublic -017
Public Heaiti JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Karen Obermeyer, Community Health Educator
DATE: Is 118 />0(-+-
SUBJECT: Agenda Item — Contract Agreement between Kitsap Public Health
District and Jefferson County Public Health; October 1, 2017 —
September 29, 2018; $37,500
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; October 1, 2017 —
September 29, 2018; $37,500.
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 5-2-1-0 project. 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 Health, and will report and attend meetings related to the ongoing project
effort.
FISCAL, IMPACT/COST BENEFIT ANALYSIS:
The Contract Agreement is fully funded through the KPHD from 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; October 1, 2017 — September
29, 2018; $37,500.
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 1731
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:
Period of Performance: The period of performance of this Agreement shall begin October 1, 2017,
and be completed no later than September 29, 2018, unless terminated sooner or extended as
provided for herein.
2. Purpose: The District requires Subcontractor's expertise 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/Eligibility: Subcontractor will have the qualifications necessary to successfully
complete the objectives of this Agreement. Subcontractor hereby affirms that he/she is eligible to
work in the United States as set forth in the Immigration and Control Act (IRCA).
4. Statement of Work and Budget: 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. Subcontractor shall
perform the work specified in Attachment A according to standard industry practice.
5. Community Resources: 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 $37,500 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).
Reimbursement for travel is authorized at the federally established rate if allocated in Attachment A.
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 October 1, 2017 to September 29, 2018.
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.
KPHD 1731
Page 2 of 25
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 Reimbursement must be provided to the District by the
20th of the month in order to receive reimbursement for the previous month. If the District does not
receive the Monthly Expenditure Report and Request for Reimbursement form by the 201h 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.
Item Description
1 Sub -recipient name (Exactly as listed in DUNS):
www.SA M.aov
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 Number:.
www.SAM.gov
A 9 -digit number that can be found on the web address
above.
Federal FundingSource ource #1
Jefferson County Public Health
184826790
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: 09/07/2014
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 budgetperiod).
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:
Increase or decrease in federal funds for this sub -award
agreement only.
7 Total Amount of Federal Funds Obligated to the Sub -
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:
$37,500
TBD annually
$1,235,625
KPHD 1731
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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 offederal 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
For grants awarded directly from the federal government to
of 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.
93.757
13
CFDA Number:
Catalog of Federal Domestic Assistance (CFDA) — a 5 -digit
number i.e. 55.555 found on the notice of award.
14
CFDA Name:
State and Local Public Health
www.cfda.„ov
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
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
Are there any additional requirements imposed by the
Yes
pass-through entity (KPHD) to meet its own
responsibilities to 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.
Rate:
31.66%
[Tnect
k with entity. If your contract allows indirects, you
use the sub -recipient federally approved indirect rate.
KPHD 1731
Page 4 of 25
If the entity has never had a federally approved indirect rate
they may use 10% De Minim is 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 15 days of the end of
the contract.
(2) Submit all required program reports and deliverables
within 15 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).
8. Performance Requirements and Notices: The assigned District staff will monitor the performance
of this contract, approve billings submitted by Subcontractor, and determine the acceptability of any
reports provided by Subcontractor. District staff will provide and facilitate assistance and guidance
to Subcontractor as necessary. Notices pursuant to this Agreement shall be sent to the designated
District Program Coordinator and Subcontractor Project Coordinator who is responsible for project
coordination:
If to the District: If to the Subcontractor:
Kitsap Public Health District
Attn: Yolanda Fong
345 6th Street, Suite 300
Bremerton, WA 98337
(360) 728-2275
Yolaiida.fong(i ),kitsappub1icllealth.org
Jefferson County Public Health
Attn: Karen Obermeyer
615 Sheridan Street
Port Townsend, WA 98368
(360) 385-9417
koberaineyer(c G.) Lwffei-son.wa.us
A. Subcontractor will establish a designated local Program Coordinator to be responsible for project
coordination.
B. Subcontractor will participate in:
a. Performance measure data collection activities in collaboration with the District 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 the District.
Data submissions related to these items will be provided as mutually agreed upon with the District.
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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 Subcontractor for travel to and from scheduled meetings as applicable.
9. Billines: 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
3456 th Street, Suite 300
Bremerton, WA 98337
(360) 728-2215
Backup documentation must be submitted to the District with each invoice. 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): http://www.ecfr.gov/cgi-bin/text-
idx?SID=6eac521 bb5eae842090f762fed72fb94&mc=true&node=pt21.1.200&rgn=div5
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 is 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 15 days after the expiration date.
10. 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 to be employees or agents of the District for any purpose.
11. Federal Funding Accountability and Transparency Act {FFATA): This statement of work is
supported by federal funds that require compliance with the Federal Funding Accountability and
Transparency Act (FFATA or the Transparency Act). The purpose of the Transparency Act is to
make information available online so the public can see how the federal funds are spent. To comply
with this act and be eligible to perform the activities in this statement of work, Subcontractor must
have a Data Universal Numbering System (DUNS) number.
KPHD 1731
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Information about Subcontractor and this statement of work will be made available on
by DOH as required by PL. 109-282.
Restrictions to funds (what funds can be used for which activities, not direct payments, etc.):
a. Recipients may not use funds for research.
b. Recipients may not use funds for clinical care.
c. Recipients may only expend funds for reasonable program purposes, including personnel,
travel, supplies, and services, such as contractual.
d. Recipients may not generally use HHS/CSC/ATSDR funding for the purchase of furniture or
equipment. However, if equipment purchase is integral to a selected strategy, it will be
considered. Any such proposed spending must be identified in the budget.
e. Recipients may not use funding for construction.
f. The direct and primary recipient in a cooperative agreement program must perform a
substantial role in carrying out project objectives and not merely serve as a conduit for an
award to another party or provider who is ineligible.
g. Reimbursement of pre -award costs is not allowed.
h. Recipients may not use funds for abortions in accordance with Executive Order 13535.
i. If requesting indirect costs in the budget, a copy of the indirect cost rate agreement is
required. If the indirect cost rate is a provisional rate, the agreement should be less than 12
months of age.
12. 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.
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.
13. 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 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, 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.
14. Insurance: 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 Subcontractor, its agents, representatives, or
employees. Subcontractor shall name the District as an additional insured.
No Limitation. Subcontractor's maintenance of insurance as required by the agreement shall not be
construed to limit the liability of 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:
KPHD 1731
Page 7 of 25
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 Liability 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
Subcontractor's Commercial General Liability insurance policy with respect to the work
performed for the District.
3. Workers' C0JDensatian coverage as required by the Industrial Insurance laws of the state of
Washington.
4. Professional l..iability insurance appropriate to Subcontractor's profession. 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 Liability insurance with a minimum combined single limit for bodily injury and
property damage of $1,000,000 per accident.
2. Commercial General Liabilily insurance shall be written with limits no less than $1,000,000
each occurrence, $2,000,000 general aggregate.
3. Professional Liability 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. 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 Subcontractor's insurance and shall not contribute with it.
2. 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 ANII.
E. Verification of Coverage
KPHD 1731
Page 8 of 25
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 Subcontractor before commencement of the work.
15. Safeeuarding of Information and Privacy: 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) 728-2262. Notification must
be made in the most expedient time possible (usually within 24 hours of discovery) and without
unreasonable delay, consistent with 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 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 the Agreement.
16. 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, the awarding agency, and federal officials
so authorized by law. All books, records, documents, and other material relevant to this Agreement
will be retained for six (6) 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. If any litigation, claim or audit is started before the expiration of
the six-year period, the records shall be retained until all litigation, claims, or audit finding involving
the records have been resolved.
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.
17. 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 Subcontractor
and available for review at the request of District staff. Such policies and procedures will include,
but not be limited to, as appropriate:
KPHD 1731
Page 9 of 25
• Job Descriptions
• Confidentiality Policy
• Community Needs Assessment
In addition, 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. Subcontractor will include these requirements in
all approved subcontracts.
18. Required Reports: Subcontractor will submit required reports quarterly using required forms
according to procedures issued by the District.
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.
Subcontractor will include all requirements listed above in all approved subcontracts.
Due dates outside the Budget Period are for reporting only. Subcontractor may not bill for work
done outside the Budget Period.
19. Statutory and Re-gulatory Compliance: Subcontractor shall comply with all applicable federal,
state, and local laws, regulations, guidelines, and standards in the performance of this Agreement.
20. Compliance with State and Federal Confidentiality Laws: 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.
21. Certification Regarding Suspension and Debarment: 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.
22. 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 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.
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When District determines that the funding insufficiency is resolved, 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.
23. 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.
24. No 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.
25. Assignment: 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.
26. Amendment: This Agreement may be modified only by a written amendment executed by
authorized representatives of both parties.
27. 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.
28. 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 fifteen (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.
29. Governance: The Agreement has been and shall be construed as having been made and delivered
within the State of Washington and it is agreed by each party hereto that the Agreement shall be
governed by the laws of the State of Washington, both as to its interpretation and performance. Any
action at law, suit in equity, or judicial proceeding arising out of the Agreement shall be instituted
and maintained only in any of the courts of competent jurisdiction in Kitsap County, Washington.
30. 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
KPHD 1731
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31. 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.
32. dispute Resolution: In the event that a dispute or conflict arises under the Agreement that the
Parties are unable to resolve with good faith efforts, they shall allow the dispute to be decided by a
Dispute Panel in the following manner: A Mediator shall be mutually appointed by both parties, and
each party shall appoint an additional member to the Dispute Panel. The Dispute Panel shall review
the facts, contract terms and applicable statutes and rules and make a determination of the dispute.
The determination of the Dispute Panel shall be final and binding on the Parties hereto. The Parties
shall equally share the costs, if any, for the services of the Dispute Panel.
33. Subcontracting: 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 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.
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.
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.
34. Survival: Those provisions of the Agreement that by their sense and purpose should survive
expiration or termination of the Agreement shall so survive. Those provisions include, but are not
necessarily limited to the following: Indemnification, Termination, Disputes, Confidentiality,
Choice of Law, No Waiver, Records Inspection and Retention, and Severability.
35. 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.
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the date set forth below.
KITSAP PUB C H 11 DISTRICT
By:
Kith Grelln/er, Ad inistrator
Date: 4�9 l ��
JEFFERSON COUNTY PUBLIC HEALTH
Date:
Kathleen Kler, Commissioner
KPHD 1731
Page 12 of 25
ATTACHMENT A
Scope of Work and Budget
Jefferson County Public Health
October 1, 2017 — September 29, 2018
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.
Strategy
Activity
1.1
Implement community wide 5-2-1-0 including worksites and other community
sectors, to encourage improved food and beverage guidelines.
1.2
Continue to promote public benefits in farmers markets and local food retailers.
Explore improving health service pricing, placement, and promotion strategies
through continued partnership with Jefferson Healthcare and their 5210 team.
1.3
Strengthen community promotion of physical activity though signage, worksite
policies and social support.
Continue to expand signage at local hiking trails.
1.4
Continue to follow county comp plan revision process and assist as needed.
1.7
Explore availability of Sound Health coverage for DPP programs and use the annual
health assessment event to promote available resources.
2.5
Explore establishing additional sites to increase access to worksite blood pressure
monitoring stations.
2.6
Identify CHWs in the community, engage and support them in creating connections
to community health systems and community resources that support lifestyle change
for adults with high blood pressure and/or prediabetes.
Continue to ensure JCPH medical assistants and volunteer CHWs complete DOH
CHW modules on HTN and prediabetes.
2.7
Engage at least 2 of the 5 county pharmacies in supporting self-management for
adults with high blood pressure and prediabetes screening
2.8
Improve the referral system to increase participation in evidence based lifestyle
change programs. Explore working with Jefferson Healthcare to support
participation in DPP.
Identify policies and process changes needed to accommodate transmission of
information between referral sources, community health workers, evidence -based
programs, and primary care for more widespread implementation with partner
organizations.
Monitoring and
Monitor progress for each activity as appropriate; submit quarterly narrative and
Reporting
data reports as requested by KPHD on January 15, 2018; April 16, 2018; July 16,
2018 and October 15, 2018.
KPHD 1731
Page 13 of 25
Calls/Meetings
Participate in scheduled conference calls and annual in-person meeting; review
Description
correspondences related to 1422 from the Department of Health; respond to activity
7,781.17
assessments/surveys administered by KPHD as appropriate per scope of work.
Invoicing
Submit timely monthly invoices or quarterly invoices on January 15, 2018; April 16,
2018; July 16, 2018 and October 15, 2018. Invoices must include supporting
4,208.19
documentation such as time cards for staff time and copies of invoices paid for
Goods & Services
goods and services.
BBudeet October 1, 2017 — September 29, 2018
Component 1
Cost
Description
Staff Salary
7,781.17
0.13 FTE 5.32 hrs/wk
Benefits
3,010.64
Indirect
4,208.19
31.66%
Goods & Services
2,500
Signs for walking trails, travel
Total
17,500.00
Component 2
Cost
Description
Staff Salary
10,592.33
0.18 FTE 7.24 hrs/wk
Benefits
4,098.31
Indirect
4,809.36
Indirect calculated on total costs at 31.66%
Goods & Services
500
Mobile BP Kit (teaching materials, supplies), travel
Total
20,000.00
Total Jefferson
County Public
Health
$37,500.00
ATTACHMENT B
KPHD 1731 REQUEST FOR REIMBURSEMENT FORM A-19
Page 14 of 25
FORMSTATE
A19 -1E
(REV 3195)
OF WASHINGTON
INVOICE VOUCHER
AGENCY USE ONLY
de
Agency Number Location CoP.R. OR AUTH. NO.
INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claimpayment for materials,
merchandise or services. Show complete detail for each item Sections highlighted in yellow are
required.
Sub-Reclplent's Cerification. 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,
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.
Signature must be an authorized agent for the agency (director, owner, etc.) and signed in ink.
AGENCY NAME
Kitsap Public Health District
Accounts Payable
345 - 6th Street, Suite #300 Bremerton,
WA 98337-1666
VENDOR OR CLAIMANT arrant Is to be payable to
Signed:
Signatory Name (lypedj Date:
Federal I D. NO. Or SSN NO:
Federal Tax ID #
Received By: Date Received:
DATE Description
Billing for Labor and Expenses for Period of.•
Budget Item Description Cost For KPHD Accounting use only
Comp 1: Strategies
Salaries
Benefits
Travel
Equipment
Goods & Services
Indirect
SUBTOTAL $0.00
Comp 2: Strategies
Salaries
Benefits
Travel
Equipment
Goods & Services
Indirect
SUBTOTAL $0.00
TOTALI $0.00
Prepared By: Telephone Number: Date: Date:
Doc, Date: Current Doc. No. Ref. Doc. No. Use Vendor Message: UBI Number:
Work class
Sub Sub
cue y,.
APPN PROGRAM
nine INDEX INDEX Obj sub ma.. Allo. r"oJ-1
Obj
r.ol rn.. AMOUNT
Invoice Number
Grant Approval for Payment Warrant Total
Invoice No 71
KPHD 1731
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 ADMINISTRATIVE COST 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
Subpart F
Hospitals
2 CFR 200
45 CFR 74
2 CFR 200 y
Subpart D
Appendix E
Subpart F
Colleges or Universities & Affiliated
2 CFR 200
2 CFR 200
2 CFR 200
Hospitals
Subpart D
Subpart E
Subpart F
KPHD 1731
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
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 1731
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;
The contractor's policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
KPHD 1731
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—
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 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
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
WA State Department of Health
PO Box 47905
Olympia, WA 98504-7905
KPHD 1731
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 1731
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 1731
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 1731
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:
Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any Federal department or
agency;
ii. 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
iv. 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 IS REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL I TITLE
Please also print or type name:
KaAian I6-0--<
ORGAN{ZATION NAME: (if applicable) DATE
� on (' cun4# ?�)codd 0�
OxA,nr nr-,x.SSiM.2.['S
KPHD 1731
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. ! ! 11728-
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 1731
Page 24 of 25
Education Amendments of 1972, as amended (20 U.S.C. ! i! 11681-1683, 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. 11794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. I !1 16101-6107), 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) I F 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.
I 1 i-, 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. ! 1 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. I i 11501-1508
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.
1276a to 276a-7), the Copeland Act (40 U.S.C. 11276c and 18 U.S.C. 111 1874) and
the Contract Work Hours and Safety Standards Act (40 U.S.C. i 11 327-333), 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.
I 11451 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.
1 11':7401 et seq.); (g) protection of underground sources of drinking water under the
KPHD 1731
Page 25 of 25
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. I -111721 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. 11470), EO 11593
(identification and protection of historic properties), and the Archaeological and Historic
Preservation Act of 1974 (16 U.S.C. i 1469a-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. 11 ,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. I-11-4801 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 SIGNATURE IS REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
TITLE
W O L r
Please also print or type name
ORGANIZATION NAME: (if applicable)
Lo" '3)Wc0(
DATE
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