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HomeMy WebLinkAbout121718_ca17 615 Sheridan Street 4711A Port Townsend, WA 98368 deihson www.JeffersonCountyPublicHealth.org Consent Agenda Public Healt November 1, 2018 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Vicki Kirkpatrick, Director DATE: SUBJECT: Agenda Item — Professional Services Agreement with Kitsap Public Health District; July 1, 2018 — June 30, 2019; $61,000.00 STATEMENT OF ISSUE: Jefferson County Public Health requests Board approval of the Professional Services Agreement with Kitsap Public Health District to develop and implement coordinated tobacco, vapor product, and marijuana prevention and intervention strategies; July 1, 2018 —June 30, 2019; $61,000.00 ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S: The purpose of this contract agreement is to retain JCPH to develop and implement coordinated tobacco, vapor product, and marijuana prevention and intervention strategies to prevent and reduce tobacco, vapor, and marijuana use by youth in Jefferson County. JCPH agrees to conduct outreach to Peninsula College Port Townsend campus and Jefferson Co. Board of Health, educate stakeholders and decision-makers, implement evidence-based health communication interventions (including social media), monitor progress, participate in a regional strategic planning process for the use of the marijuana prevention portion of the contract, etc. This agreement, for $61,000.00, is to pay for the coordinator, supplies, travel expenses, and indirect expenditures. FISCAL IMPACT/COST BENEFIT ANALYSIS: This contract agreement is fully funded by the Kitsap Public Health District through a regional grant received from the Washington State Department of Health. RECOMMENDATION: JCPH management request approval of the Professional Services Agreement with Kitsap Public Health District to develop and implement coordinated tobacco, vapor product, and marijuana intervention strategies; July 1, 2018 —June 30, 2019; $61,000.00 REVIEWED BY: ' / / /2--/C-1‘ Pirr / _ ..es'' i orley, �. ty A . rator 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 1849 Page 1 of 29 PROFESSIONAL SERVICES AGREEMENT Between KITSAP PUBLIC HEALTH DISTRICT And JEFFERSON COUNTY HEALTH & HUMAN SERVICES 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 "Subrecipient." The parties mutually agree as follows: 1. Period of Performance: The period of performance of this Agreement shall begin July 1,2018 and be completed no later than June 30, 2019, unless terminated sooner or extended as provided for herein. 2. Purpose: The District requires the expertise of this Subrecipient to develop and implement coordinated tobacco,vapor product,and marijuana intervention strategies to prevent and reduce tobacco, vapor, and marijuana use by youth in Jefferson County. 3. Qualifications/Eligibility: Subrecipient shall have the qualifications necessary to successfully complete the objectives of this Agreement. The Subrecipient 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: Subrecipient 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 and ATTACHMENT B, attached hereto and incorporated herein. ATTACHMENT A contains the Scope of Work and Budget concerning tobacco and vaping prevention activities. ATTACHMENT B contains the Scope of Work and Budget for marijuana prevention activities. 5. Compensation: This Agreement is funded by state and federal funds. The District agrees to pay Subrecipient a total sum of$61,000 in federal and state funds during the Agreement. The District shall reimburse Subrecipient for travel as applicable at the federally approved rate. Compensation will be based on invoices submitted by Subrecipient itemizing a detailed description of services performed per the agreed upon Scopes of Work and Budgets set forth respectively in ATTACHMENTS A and B. Subrecipient shall submit a Monthly Expenditure Report and Request for Reimbursement(Form A-19) invoice voucher, hereto attached and herein incorporated as ATTACHMENT C,to the District for payment. 6. Performance Requirements and Notices: The assigned District staff shall monitor the performance of this Agreement,approve billings submitted by Subrecipient,and determine the acceptability of any reports provided by Subrecipient. District staff shall provide and facilitate assistance and guidance to Subrecipient as necessary. The District reserves the right to conduct periodic performance and billing reviews after the execution of this Agreement in order to evaluate unspent/unclaimed funds. The District reserves for itself the authority to reallocate funding pending the outcome of such a review. Subrecipient shall send programmatic communications, such as reports,via the communication method established by the District. Formal notices pursuant to this Agreement shall be sent to the staff responsible for project coordination as follows: If to the District: If to the Subrecipient: Kitsap Public Health District Jefferson County Public Health Attn: Yolanda Fong Attn: Vicki Kirkpatrick 345 6`h Street, Suite 300 615 Sheridan Street KPHD 1849 Page 2 of 29 Bremerton, WA 98337 Port Townsend, WA 98368 (360)728-2275 (360)385-9408 Y'olanda.Fong a)kitsappublichealth.org vkirkpal ick;%i-co.jef erson.� a.us 7. Special Billing Requirements: Billings to the District shall be submitted no more frequently than every 30 days and shall be quarterly at a minimum. Billings for services on a monthly fraction of the budget will not be accepted or approved. Billings shall be sent to: Kitsap Public Health District Finance Department 345 6t''Street, Suite 300 Bremerton, WA 98337 (360)728-2227 Authorized and allowable program expenditures will be reimbursed upon receipt and approval of the monthly A-19 must be provided to the District by the 20t1,of each month in order to receive reimbursement for the previous month. If the District does not receive the A-19 by the 20th of the month with the required deliverables,the District may withhold approval and payment at its discretion. The District will pay Subrecipient all allowable costs incurred as evidenced by proper invoice of Subrecipient 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. Backup documentation will be provided to the District with 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 Agreement. This is a subrecipient 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. Unexpended funds in each fiscal year may not be carried forward into the new budget period unless otherwise approved by the District. For information in determining allowable costs, indirect rates and pass through agency requirements, such as fiscal monitoring of Subrecipients,please reference the document titled"Uniform Administrative Requirements, Cost Principles,and Audit Requirements for Federal Awards:"(2 Code of Federal Regulation CFR 200). Email submission of invoices,electronic reports,and deliverables is encouraged. However,original hardcopy of the A-19 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 20 days after the expiration date. 8. Independent Capacity: Subrecipient and its employees or agents who are engaged in the performance of this Agreement shall continue to be employees or agents of Subrecipient and shall not be considered to be employees or agents of the District for any purpose. 9. 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, KPHD 1849 Page 3 of 29 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. 10. Indemnification: Subrecipient 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 Subrecipient 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, Subrecipient 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. 11. Insurance: Subrecipient 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 Subrecipient, its agents,representatives,or employees. No Limitation. Subrecipient's maintenance of insurance as required by the Agreement shall not be construed to limit the liability of Subrecipient 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 Subrecipient 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 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 Subrecipient's Commercial General Liability insurance policy with respect to the work performed for the District. 3. Workers' Compensation coverage as required by the Industrial Insurance laws of the state of Washington. 4. Professional Liability insurance appropriate to the Subrecipient's profession. Subrecipient shall provide the District with proof of liability insurance or professional errors and omissions coverage as appropriate. B. Minimum Amounts of Insurance Subrecipient 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 Liability 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 KPHD 1849 Page 4 of 29 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. Subrecipient'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 Subrecipient's insurance and shall not contribute with it. 2. Subrecipient'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 Subrecipient 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 Subrecipient before commencement of the work. 12. Safeguarding 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 45 CFR Parts 160 and 164(commonly known as HIPAA)and 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. Subrecipient 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. Subrecipient 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 Privacy Officer at(360)728-2262. 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 Subrecipient 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. Subrecipient shall certify the return or destruction of all personal information upon expiration of the Agreement. 13. Records Retention and Inspection: 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. KPHD 1849 Page 5 of 29 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. 14. 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 Subrecipient 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 • 5-Year Regional Strategic Plan(includes biennial work plan) Special Instructions: a. Subrecipient must conduct criminal background checks for those staff,volunteer,contractor, or subcontractor working directly with youth(ages 0-17). b. Subrecipient must prohibit any staff,volunteer,contractor,or subcontractor with a felony conviction related to their duties from supervising and interacting with minors while performing the duties of this contract. This requirement is consistent with existing RCW 9.96A.020. In addition, Subrecipient 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 Subrecipient agreements. Subrecipient will include these requirements in all approved subcontracts. 15. Required Reports: Subrecipient will submit required reports using required forms according to procedures issued by the District. Subrecipient 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. Subrecipient will include all requirements listed above in all approved subcontracts. Due dates outside the Budget Period are for reporting only. Subrecipient may not bill for work done outside the Budget Period. 16. Statutory and Regulatory Compliance: Subrecipient shall comply with all applicable federal,state,and local laws,regulations,guidelines,and standards in the performance of this Agreement. 17. Compliance with State and Federal Confidentiality Laws: Subrecipient 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 H1PAA, or any regulations enacted pursuant to its provisions. An excerpt of certifications and assurances is herein attached as ATTACHMENT D. 18. Certification Regarding Suspension and Debarment: Subrecipient,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 E), certifies that it is not debarred, suspended,or proposed for debarment by any federal agency. KPHD 1849 Page 6 of 29 19. Federal Funding Restrictions and Limitations: Please see ATTACHMENTS A and B for restrictions and limitations. 20. 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 Subrecipient to suspend performance as an alternative to termination. The District may elect to give written notice to Subrecipient 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 Subrecipient's representative. Subrecipient 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 Subrecipient written notice to resume performance and a proposed date to resume performance. Upon receipt of written notice to resume performance, Subrecipient 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 Subrecipient 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 Subrecipient 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: Subrecipient 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. 22. 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 his Agreement unless stated to be such in writing,signed by an authorized representative of the party and attached to the original Agreement. 23. 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. 24. Amendments and Changes in Work: This Agreement may be modified only by a written amendment executed by authorized representatives of both parties. In the event of any errors or omissions by Subrecipient in the performance for any work required under this Agreement, Subrecipient will make all necessary corrections without additional compensation.All work submitted by Subrecipient will be certified by Subrecipient and checked by Subrecipient for errors and omissions. Subrecipient will continue to be responsible for the accuracy of work even after the work is accepted by the District. 25. Termination: This Agreement may be terminated by either party upon giving at least 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. 26. 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 KPHD 1849 Page 7 of 29 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. 27. Termination for Funding: If funding for the Agreement or matter is withdrawn,reduced or limited in any way after the Agreement is signed or becomes effective,the Parties may summarily terminate the Agreement notwithstanding any other termination provision in the Agreement. Termination under his provision will be effective upon the date specified in the written notice of termination. No costs incurred after the effective date of the termination will be paid. 28. Choice of Law: This Agreement is entered into pursuant to and under the authority granted by the laws of the State of Washington and applicable federal laws,both as to its interpretation and performance. The provisions of this Agreement shall be construed to conform to those laws. Any action t law,suit in equity, or judicial proceeding arising out of this Agreement shall be instituted and maintained only in any of the courts of competent jurisdiction in Kitsap County, Washington. 29. 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. 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 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. 31. 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, Waiver, Records Inspection and Retention,and Severability. 32. Subcontracting: Subrecipient shall not enter into subcontracts for any of the work contemplated under his 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 Subrecipient to the Department for any breach in the performance of Subrecipient's duties. This clause does not include contracts of employment between Subrecipient and personnel assigned to work under this Agreement. Subrecipient is responsible for ensuring that all terms, conditions, assurances and certifications set forth in this Agreement are carried forward to any subcontracts. Subrecipient 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 Subrecipient,and Subrecipient shall take immediate steps to terminate its Subrecipient's involvement in the work. The rejection or approval by the District of any Subrecipient or the termination of a Subrecipient shall not relieve Subrecipient of any of its responsibilities under the Agreement, nor be the basis for additional charges to the District. 33. 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. KPHD 1849 Page 8 of 29 IN WITNESS WHEREOF,the Parties have executed this Agreement as of the date set forth below. KITSAP PUBLIC HEALTH DISTRICT JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS By: By: Keith Grellner David Sullivan Administrator Chair Date: Date: Approved to orm: c. '2 /L /6° Philip Hunsucker, Chief Civil Deputy Prosecutor Attest: Clerk of the Board Funding Source Program: CH Federal Contract/Grant: DOH Con Con CLH 18248 (KPHD 1749) KPHD 1849 Page 9 of 29 ATTACHMENT A-TOBACCO Scope of Work and Budget Jefferson County Public Health July 1,2018—June 30,2019 As a subrecipient of KPHD under the Washington Department of Health funded Tobacco& Vapor Product Prevention&Control Program, Jefferson County Public Health agrees to the following activities funded in full or part by the associated budget. ctiurt3v' 1.1 Work with Decision-makers(Board of Health)to implement"No Vaping in Public Places" ordinance in Jefferson County. 1.2 Follow up on proposed tobacco/vape policy that has been postponed by Jefferson County government. Conduct outreach to Jefferson Co. Board of Health,encourage consideration of including vapor product language in local SIPP ordinance. 2.1 Educate stakeholders/board members about tobacco-related disparities, evidence- based and promising interventions to address health equity, and local level policies and programs that can be designed to eliminate disparities at one Chimacum Prevention Coalition Meeting. 3.1 Provide education and WA quitline(2MorrowQuit app)cards to stakeholders at local coalitions,community events,and prevention gatherings. Create and implement a cession campaign targeted directly at pregnant women and women of child-bearing age in Jefferson County. Establish connections with organizations who work with this population and ensure they are equipped with education and resources for tobacco cessation. *(PHBG Special Project) 3.2 Provide education and WA quitline(2MorrowQuit app)cards to local WIC locations. 4.1 Educate decision-makers via presentations on PSE strategies for tobacco prevention to 4 school boards: Port Townsend, Chimacum,Quilcene, and Brinnon. 5.1 Educate at least 3 decision-makers and stakeholders groups listed below, on the value of a comprehensive tobacco vapor product prevention program and best practices:Jefferson County Board of Health, Board of County Commissioners,City of Port Townsend City Council,local groups representing disparities. 6.1 Using social media,post no fewer than 6 posts aimed at evidence-based health communications to prevent youth initiation and promote cessation. 8.1 Provide outreach and technical assistance to Peninsula College as they reinforce their vaping in public places policy on campus. 8.2 Disseminate information regarding the evidence-based impact of flavors and menthol in Vapor Products on youth initiation. 8.3 Wait for DOH guidance on 8.3iii: Providing TA to public housing authorities and residents in the implementation and enforcement of smoke-free policies per HUD's Smoke-Free Public Housing Rule. Monitoring and Monitor progress for each activity as appropriate;submit monthly narrative and data Reporting reports as requested by KPHD on the 5'''of every month. Calls/Meetings Participate in bi-monthly conference calls and webinars as scheduled; participate in strategic planning meeting hosted/facilitated by KPHD; review correspondences related to TVPPCP from the Department of Health;respond to activity assessments/surveys administered by KPHD as appropriate per scope of work. KPHD 1849 Page 10 of 29 Invoicing Submit monthly invoices by the 20th of the month following the month in which costs were incurred,except for the Final Expenditure Report and Request for Reimbursement in each federal fiscal year(due July 1,2019). Invoices must include supporting documentation such as time cards for staff time and copies of invoices paid for goods and services. Budget July 1,2018—June 30,2019 Cost Description Staff Salary 8295.04 Staff salary Benefits 3078.62 Benefits Indirect 4582.34 32.33% Supplies 2250 Meeting supplies & Paid Advertising Poison Control 250 Truth Among the Vapors kit Travel 300 Regional meetings Total Jefferson $18,756 Funding Source Chart of Accounts Program CFDA# BARS Master 7/1/18- 10/1/18- Name or Title Code Index Code 6/30/19 6/30/19 Youth Tobacco&Vapor Products NA 334.04.93 77410880 $5,500 - FFY18 PHBG 93.758 333.93.75 TBD - $13,256 TOTAL to Jefferson $18,756 Subrecipient DUNS Number: 184826790 Subrecipient Indirect Rate: 32.33% MTDC Research and Development: No Federal Funding Accountability and Transparency Act(FFATA): The 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 to be eligible to perform the activities in this statement of work,the Local Health Jurisdiction(LHJ)must have a Data Universal Numbering System(DUNS)number. Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282. Federal Funding Restrictions and Limitations: a. Recipient may not use federal funds for lobbying. b. Recipient may not use funds for research. c. Recipient may not use funds for clinical care. d. Recipient may not use funds to supplant existing state funding or to supplant funds from federal or state sources. e. Recipient may use funds only for reasonable program purposes, including personnel,travel, supplies, and sources. f. Recipient are the direct and primary recipients in a cooperative agreement program and must perform a substantial role in carrying out project outcomes and not merely serve as a conduit for an award to another party or provider who is ineligible. g. Recipient are generally not allowed to use funds to purchase furniture or equipment. Any such proposed spending must be clearly identified in the budget. h. Recipient may not be reimbursed for pre-award costs. KPHD 1849 Page 11 of 29 i. Recipient may only use funds for evidence-based tobacco control interventions,strategies, and activities. j. Recipient may not use funds to provide direct cessation services or other direct services other than those through evidence-based quit line services. k. Recipient may not use funds to purchase nicotine replacement therapy or other products used for cessation. 1. Recipient may not use funds to purchase K-12 school curricula. m. Recipient may not use funds for construction. KPHD 1849 Page 12 of 29 ATTACHMENT B-MARIJUANA Scope of Work and Budget Jefferson County Public Health July 1,2018—June 30,2019 As a subrecipient of KPHD under the Washington State funded Youth Marijuana Prevention and Education Program (YMPEP), Jefferson County Public Health agrees to the following activities funded in full or part by the associated budget. Planning Participate in Regional Network; hold a position on the Strategic Planning Team. As a member of the Strategic Planning Team,help to: • Establish mission of YMPEP region. • Update and choose PSE activities to address risk and protective factors prioritized by the Regional Network. • Present new/additional strategies to the regional network members in your community and gather support. • Create Sustainability Plan. Education Participate in education and skill enhancement(training on cultural competency, programs sustainability,and other professional development needs identified during the needs assessment process.) Implementation 1. Develop and finalize the 2018-2019 Jefferson County YMPEP Work Action Plan. 2. Implement program strategies per the Jefferson County YMPEP Work Action Plan and the Olympic Regional YMPEP Work Action Plan. 3. Implement additional regional strategies as approved by the regional network and the Strategic Planning Team. Evaluation Participate in state process evaluation. Monitoring and Monitor progress for each activity as appropriate; submit monthly narrative and Reporting data reports as requested by KPHD on the 5th of every month. Calls/Meetings Participate in conference calls and webinars as scheduled; attend and participate in Regional Network and Planning Team meetings;review correspondences related to YMPEP;respond to activity assessments/surveys administered by KPHD as appropriate per scope of work. Midterm By January 15, 2019 report progress to YMPEP Regional Coordinator. If needed, Evaluation adjust activities to ensure spend down. Invoicing Submit monthly invoices by the 20th of the month following the month in which costs were incurred,except for the Final Expenditure Report and Request for Reimbursement in each federal fiscal year(due July 1,2019). Invoices must include supporting documentation such as time cards for staff time and copies of invoices paid for goods and services. KPHD 1849 Page 13 of 29 Budget July 1,2018—June 30,2019 Cost Description Staff Salary $22,304 Benefits $8,450 Indirect $10,320 32.33% Goods&Services $200 Meeting supplies Training/Travel $970 Four Regional meetings,One All provider's Workshop in Yakima Total Jefferson $42,244 Funding Source Chart of Accounts Program Name or Title CFDA# BARS Code Master Index Code SFY19 Marijuana Tobacco Edu n/a 334.04.93 77420890 Community Resources: Subrecipient shall make a reasonable and ongoing effort,throughout the period of performance,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 shall be kept current and on file in the office of the Subcontractor and be available for review upon request by District staff. Funding Restrictions and Limitations: a. Recipient may not use funds for research. b. Recipient may not use funds for clinical care. c. Recipient may only expend funds for reasonable program purposes, including personnel,travel, supplies, and services,such as contractual. d. Recipient may not generally use 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 and approved by the District. e. Recipient may not use funding for construction. f. Recipient must comply with District guidance on food, incentives and use of District or DOH logo outlined in YMPEP Regional Implementation Guide and should not exceed federal per diem rates. g. Reimbursement of pre-award costs is not allowed. KPHD 1849 ATTACHMENT C Page 14 of 29 REQUEST FOR REIMBURSEMENT FORM A-19 FORM "" STATE OF WASHINGTON EXHIBIT C Page A-11 A 19-1A U = INVOICE VOUCHER (Rev.1/91) '""" AGENCY NO. LOCATION CODE P.R.OR AUTH NO. AGENCY NAME INSTRUCTION TO VENDOR OR CLAIMANT:Submit this form to claim payment for materials,merchandise or services. Kitsap Public Health District Show complete detail for each item. Attn:Yolanda Fong 345 6th St,Suite 300 VENDOR'S CERTIFICATE.I hereby certify under penalty Bremerton,WA 98337-1866 of perjury that the items and totals listed herein are proper charges for materials,merchandise or services furnished to the State of Washington,and that all goods furnished and/or services rendered have been provided without VENDOR OR CLAIMANT(Warrant is to be payable to) discrimination on the grounds of race,creed,color, national origin,sex,or age. BY (DATE) FEDERAL I.D.NO.OR SOCIAL SECURITY NO. RECEIVED BY DATE RECEIVED UNIT FOR AGENCY DATE DESCRIPTION QUANTITY UNIT PRICE AMOUNT USE Services provided in performance of contract Billing period: to Total Tobacco Expenses YTVPP,State Funding $ - PHBG Tobacco $ - Tobacco Prevention $ - YMPEP Expenses TOTAL DUE: $ PREPARED BY TELEPHONE NUMBER DATE AGENCY APPROVAL DATE DOC DATE PMT DUE DATE CURRENT DOC.NO. REF.DOC.NO. VENDOR NUMBER VENDOR MESSAGE I USE TAX UBI NUMBER REF M MASTER INDEX SUB WKCLAS`.COUNT` CITY I AMOUNT INVOICE NUMBER DOC TRANS 0 FUND APPN PROGRAM SUB SUB ORG BDGT SUB PROJ SUF CODE D INDEX INDEX OBJ INDEX ALLOC UNIT MOS PRJT PROJ PHAS ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NO. KPHD 1849 Page 15 of 29 ATTACHMENT D HIPAA BUSINESS ASSOCIATE AGREEMENT This Agreement("Agreement") is entered into by and between the Kitsap Public Health District ("Covered Entity") and Jefferson County Public Health ("Business Associate"). Section I: Purpose Performance of the Underlying Agreement may require Business Associate to use or disclose protected health information that is subject to provisions of the Health Insurance Portability and Accountability Act of 1996, set forth in 45 C.F.R. Parts 160 and 164 (commonly known as the "HIPAA Rules"). The purpose of this Agreement is to set forth the obligations of the Parties with regard to the way in which protected health information is created, used, disclosed, maintained, provided or received on behalf of Covered entity by the Business Associate. Section II. Definitions The following terms used in this Agreement shall have the same meaning as those terms in the HIPAA Rules: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary,Notice of Privacy Practices, Protected Health Information, Required by Law, Secretary, Security Incident, Subcontractor, Unsecured Health Information, and Use. Specific Definitions: 1. Business Associate. "Business Associate"shall generally have the same meaning as the term "business associate" at 45 CFR 160.103, and in reference to this Agreement shall mean Jefferson County Public Health. 2. Covered Entity. "Covered Entity" shall generally have the same meaning as the term "covered entity" in 45 CFR 160.103, and in reference to the party in this Agreement shall mean the Kitsap Public Health District. 3. HIPAA Rules."HIPAA Rules" shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and 164. Section III. Obligations and Activities of Business Associate Business Associate agrees to: 1. Not use or disclose protected health information other than as permitted or required by the Agreement or as required by law. 1 KPHD 1849 Page 16 of 29 2. Use appropriate safeguards, and comply with Subpart C of 45 CFR, Part 164 with respect to protected electronic health information and to prevent use or disclosure of protected health information other than as provided for by this Agreement. 3. Report to Covered Entity any use or disclosure of protected health information not provided for by this Agreement of which it becomes aware, including breaches of unsecured protected health information as required by 45 CFR 164.410, and any security incident of which it becomes aware. Business Associate agrees to promptly notify covered entity following the discovery of a Breach of unsecured PHI. A Breach is considered "discovered" as of the first day on which the Breach is known, or reasonably should have been known, to Business Associate or any employee, officer or agent of Business Associate, other than the individual committing the Breach. Any notice of a Security Incident or Breach of Unsecured PHI shall include the identification of each Individual whose PHI has been, or is reasonably believed by Business Associate to have been, accessed, acquired, or disclosed during such Security Incident or Breach as well as any other relevant information regarding the Security Incident or Breach. 4. In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any subcontractors that create, receive, maintain, or transmit protected health information on behalf of the Business Associate agree to the same restrictions, conditions, and requirements that apply to the Business Associate with respect to such information. 5. Business Associate agrees to mitigate, to the extent possible, any harmful resulting from use or disclosure of PHI by Business Associate or its agents or subcontractors, in violation of the requirements of this Agreement. 6. Maintain and make available protected health information in a designated record set to the Covered Entity as necessary to satisfy Covered Entity's obligations under 45 CFR 164.524. If an Individual makes a request for access to the protected health information directly to Business Associate, business associate shall notify covered entity within three (3) business days of such request and shall cooperate with the Covered Entity to send the response to the Individual. 7. Make any amendment(s) to protected health information in a designated record set as directed or agreed to by the Covered Entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy Covered Entity's obligations under 45 CFR 164.526. If an Individual makes a request for amendment to the protected health information directly to Business Associate, Business Associate shall notify Covered Entity within three(3) business days of such request and shall cooperate with the Covered Entity to send the response to the Individual. 2 KPHD 1849 Page 17 of 29 8. Maintain and make available the information required to provide to provide an accounting of disclosures to the Covered Entity as necessary to satisfy Covered Entity's obligations under 45 CFR 164.528. If an Individual makes a request for accounting of disclosures directly to Business Associate, Business Associate shall notify Covered Entity within three(3) business days of such request and shall cooperate with the Covered Entity to send the response to the Individual. 9. To the extent the Business Associate is to carry out one or more of Covered Entity's obligations(s) under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to the Covered Entity in the performance of such obligation(s); and 10. Make its internal practices, books, and records available to the Secretary for purposes of determining compliance with the HIPAA Rules. Section IV. Permitted Uses and Disclosures by Business Associate I. Business Associate may only use or disclose protected health information as necessary to perform the services as outlined in the underlying agreement. 2. Business Associate is not authorized to use protected health information to de-identify the information in accordance with 45 CFR 164.514(a)-(c). 3. Business Associate may use or disclose protected health information as required by law. 4. Business Associate agrees to make uses and disclosures and requests for protected health information consistent with Covered Entity's minimum necessary policies and procedures. Business Associate may not use or disclose protected health information in a manner that would violate Subpart E of 45 CFR Part 164 if done by Covered Entity except for the specific used and disclosures set forth below: a) Business Associate may disclose protected health information for the proper management and administration of Business Associate or to carry out the legal responsibilities of the Business Associate, provided the disclosures are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached. b) Business Associate may provide data aggregation services relating to the health care operations of the Covered Entity. 3 KPHD 1849 Page 18 of 29 Section V. Termination I. Term. The Agreement shall terminate on June 30, 2019 or on the date Covered Entity terminates for cause, whichever is sooner. 2. Termination for Cause. Business Associate authorizes termination of the Agreement if Covered Entity determines Business Associate has violated a material term of the Agreement and has not cured the breach or ended the violation within the time specified by Covered Entity. 3. Obligations of Business Associate Upon Termination. Upon termination of this Agreement for any reason Business Associate shall return or destroy all protected health information received from Covered Entity, or created or received by Business Associate on behalf of Covered entity. This provision shall apply to protected health information that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the protected health information. In the event that Business Associate determines that returning or destroying the protected health information is infeasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction infeasible. Upon mutual agreement of the Parties that return or destruction of protected health information is infeasible, Business Associate shall extend the protections of this Agreement to such protected health information and limit further uses and disclosures of such protected health information to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such protected health information. 4. The obligations of Business Associate under this section shall survive the termination of this Agreement. Section VI. Miscellaneous 1. A reference in this agreement to a section in the HIPAA Rules means the section as in effect or amended. 2. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for compliance with the HIPAA Rules and any other applicable law. 3. Any ambiguity in this Agreement shall be resolved to permit compliance with the HIPAA Rules. 4 KPHD 1849 Page 19 of 29 ATTACHMENT E 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 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 1849 Page 20 of 29 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 1849 Page 21 of 29 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 i. 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 1849 Page 22 of 29 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— i. Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; G. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (A), (B), (C), (D), (E), and (F). For purposes of paragraph (e) regarding agency notification of criminal drug convictions, DOH has designated the following central point for receipt of such notices: Compliance and Internal Control Officer Office of Grants Management WA State Department of Health PO Box 47905 Olympia, WA 98504-7905 KPHD 1849 Page 23 of 29 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 1849 Page 24 of 29 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 1849 Page 25 of 29 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 1849 Page 26 of 29 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; 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 TITLE Please also print or type name: ORGANIZATION NAME: (if applicable) DATE KPHD 1849 Page 27 of 29 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. 1-4728- 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 1849 Page 28 of 29 Education Amendments of 1972, as amended (20 U.S.C. [1111681-1683, 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. [1794), 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) n❑ 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. n fl 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. 11 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 (j)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. n171501-1508 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. C1276a to 276a-7), the Copeland Act (40 U.S.C. 11276c and 18 U.S.C. 1111874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. F1❑ 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. 11111451 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. 11117401 et seq.); (g) protection of underground sources of drinking water under the KPHD 1849 Page 29 of 29 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. (lI-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. -P469a-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. nn2131 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. [1 I74801 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 Please also print or type name: ORGANIZATION NAME: (if applicable) DATE