HomeMy WebLinkAbout122120_ca06615 Sheridan Street
Port Townsend, WA 98368
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Consent Agenda
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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, 2020 — June 30, 2021; $18,500
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 and vapor product prevention
and intervention strategies; July 1, 2020 — June 30, 2021; $18,500.00 income generating.
ANALYSIS/STRATEGIC GOALS/PRO'S and COWS:
The purpose of this contract agreement is for Kitsap Public Health District to retain JCPH to develop and
implement coordinated tobacco and vapor product prevention and intervention strategies to prevent and
reduce tobacco and vapor use by youth in Jefferson County. JCPH agrees to conduct outreach Jefferson
Co. Board of Health and local schools, educate stakeholders and decision -makers, implement evidence -
based health communication interventions (including social media), monitor progress, etc. This
agreement, for $18,500.00, 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 and vapor product intervention strategies; July 1,
2020 — June 30, 2021; $18,500.00
REVIE7
WED BY:
Philip Morley, Co ty Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 (f) 360-379-4487
360-385-9401 (f) Always working for a safer and healthier community
KPHD 2097
Page 1 of 27
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:
t . Period of Performance: The period of performance of this Agreement shall begin July 1, 2020 and be
completed no later than June 30, 2021, 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 and vapor product, intervention strategies to prevent and reduce tobacco and vapor use by youth in
Jefferson County.
3. Qualifieations/Eligtbility: 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, attached hereto and incorporated herein. ATTACHMENT A contains the
Scope of Work and Budget concerning'tobacco and vaping prevention activities.
5. Compensation: This Agreement is funded by state and federal funds. The District agrees to pay
Subrecipient a total sum of $18,500 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
Scope of Work and Budget set forth respectively in ATTACHMENT A.
Subrecipient shall submit a Monthly Expenditure Report and Request for Reimbursement (Form A-19)
invoice voucher, hereto attached and herein incorporated as ATTACHMENT B, to the District for payment.
i. 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" Street, Suite 300
615 Sheridan Street
Bremerton, WA 98337
Port Townsend, WA 98368
KPHD 2097
Pege 2 of 27
(360) 728-2275 (360) 385-9408
Yolatida.1 ung�u ktsap uhiich<<ihh.prb vkfrl� rurick(ruru jell r ant w,i j s
7. Special Biiline Requirements: Billings to the District shall be submitted no more frequently than every 30
days and shall be quarterly at a minimum. Billing shall not exceed 5001* of contract budget before January 11,
2021. 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
Melissa Laird
345 611 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 20' of each month in order to receive reimbursement for the
previous month. If the District does not receive the A-19 by the 20' 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 timcly 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 fiords 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.
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.
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 2097
Page 3 of 27
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:
L 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
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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 insurer; 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 2097
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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 Procedure&Mocuments 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 HIPAA,
or any regulations enacted pursuant to its provisions. An excerpt of certifications and assurances is herein
attached as ATTACHMENT C.
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 D), certifies that it is not debarred, suspended, or proposed for debarment
by any federal agency.
KPHD 2097
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19. Federal Funding Restrictions and Limitations: Please see ATTACHMENTS A 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 2097
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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 Fundin : 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.
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IN WITNESS WHEREOF, the Parties have executed this Agreement as of the date set forth below.
KITiE:7
ICT
By:
Date:
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
By: _ -
L: imj f-�YL4hei,+on
Chair
Date:
Approved a7jz��
. (W.i 3o tv
Philip Hunsucker,
Chief Civil Deputy Prosecutor
Attest:
Clerk of the Board
Funding Source
Program: CH
Federal Contract/Grant: DOH Con Con CLH18248 (KPHD 1749)
KPHD 2097
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ATTACHMENT A -TOBACCO
Scope of Work and Budget
Jefferson County Public Health
July 1, 2020 — June 30, 2021
As a subrecipient of KPHD under the Washington Department of Health funded Commercial Tobacco
Prevention Program (CTPP), Jefferson County Public Health agrees to the following activities funded in
full or part by the associated budget.
ACMW
Planning Participate in statewide commercial tobacco prevention coalition meetings as
established.
2020-2021 DOH Regional Requirements:
1. In collaboration with priority population contractors, engage and educate
decision -makers and internal and external partners about: the value of local
control in preventing initiation, the value of a comprehensive commercial
tobacco prevention program to prevent initiation, and the impact of
flavored (including menthol) tobacco and vapor products on youth
initiation.
2. Disseminate prevention and Tobacco Use and Dependence Treatment
(TUDT)-informing materials for disparately affected communities that
address emerging tobacco/vapor products that are culturally &
linguistically appropriate, trauma -informed, & equity -based.
3. Build upon existing Tobacco and Vapor 21 implementation plan,
addressing diverse audiences and ensuring all communications materials
are culturally and linguistically appropriate.
Implementation 4. Build or enhance partnerships with youth -serving organizations and local
champions (including identifying youth champions) to collaborate on youth
access and industry marketing.
5. Inform providers about TUDT resources and referral processes, including
those for the Washington State Tobacco Quitline (WAQL), 2Morrow
Health application, and WA -Branded Truth Initiative's "This is Quitting"
promotional materials.
6. In collaboration with CTPP, incorporate 2020-2021 Centers for Disease
Control and Prevention (CDC) (e.g., Tips® campaign) materials into
agency social media content.
7. Conduct education and outreach within respective ACH region addressing
local smoking and vaping in public places ordinances.
8. Respond to technical assistance requests and needs from local agencies and
organizations interested in adopting and/or that have adopted voluntary
smoke -free and vape-free campus and/or organizational policies; to
colleges/universities on the adoption and implementation of tobacco- and
vape-free campuses; and to multi -unit housing organizations, landlords, and
residents on smoke- and/or vane -free policies.
KPHD 2097
Page 10 of 27
9. Plan and implement public relations/earned media efforts (i.e. press
releases, social media) utilizing national media campaigns to prevent youth
initiation and support cessation.
10. Conduct education and outreach activities to prevent the initiation and use
of vapor products as delivery devices for nicotine and marijuana and that
focuses on the potential health risks of vapor product use, regardless of the
substance it contains.
Specific Jefferson County activities are described in the 2020-2021 CTPP
workplan. Work plans are subject to change. The most recent version of the work
plan will be shared. Any changes will be approved by both parties.
Monitoring and
Monitor progress for each activity as appropriate; submit monthly narrative and
Reporting
data reports as requested by KPHD on the 5' of every month.
Midterm
By January 15, 2021 report progress to CTPP Regional Coordinator. If needed,
Evaluation
adjust activities to ensure spend down. Conduct a mid -year workplan reevaluation.
Participate in monthly conference call with KPHD and attend webinars as
Calls/Meetings—
scheduled; respond to correspondences related to CTPP from the Department of
Heaith; respond to activity assessmen�turveys administered by KPHD as
appropriate sco c of work.
Submit monthly invoices by the 201 of the month following the month in which
costs were incurred, except for the Final Expenditure Report and Request for
Invoicing
Reimbursement in each federal fiscal year (due July 1, 2021). Invoices must include
supporting documentation such as timecards for staff time and copies of invoices
id for goods and services.
Budget July 1, 2020 — June 30, 2021
EStaffalary
Coot
9,900
Staff Salary
Benefits
3,626
Benefits
Supplies
354
Signage for new SVIPP ordinance
Travel
0
Annual and regional meetings
Indirect 33.28%
4,620
Indirect
Total
$18,500
Funding Source
Chart of Accounts Pry Nam or
Twe
CFDA#
BARS
Code
W
61MI
7/1t29-
12MAO
liR29- hi-
3/31/21
Youth Tobacco Vapor Products
NA
334.04.93
$6.259
-
-
FFY20 Tobacco-y2pq Prev Comp 1 CDC
TBD
TBD
-
$6,121
$6,120
Total to Jefferson
$18,500
Subrecipient DUNS Number: 1848267"
Subrecipient Indirect Rate: 33.28% MTDC
KPHD 2097
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Research and Development: No
Federal Fundine 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 Fundine 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 fimds 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.
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 2097
Page 12 of 27
FORM STATE OF WASHINGTON
INVOICE VOUCHER
A 19-1Ais
(Rev.1/91)
AGENCY NAME
Kitsap Public Health District
Attn: Melissa Laird
345 6th St, Suite 300
Bremerton, WA 98337-1866
VENDOR OR CLAIMANT (Warrant is to be payable to)
Page A-11
I - AGENCY NO. LOCATIONCODE P.R.ORAUTHNO
INSTRUCTION TO VENDOR OR CLAIMANT. Submit this
form to claim payment for materials, merchandise or services.
Show complete decal for each item.
VENDOR'S CERTIFICATE. I hereby certify under penalty
of perjury that the Items and totals listed herein are proper
charges for materlah, merchandise or services furnished
to the State of Washington, and that all goods furnished
and/or services rendered have been provided without
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
DATE
DESCRIPTION
QUANTITY
UNIT
UNIT
PRICE
AMOUNT
FOR AGENCY
USE
Services provided In performance of contract
Billing period! to
Total Tobacco Expenses
YTVPP, State Funding
$
PHBG Tobacco
$ -
Tobacco Prevention
$
TOTAL DUE:
$ _
PREPARED BY
TELEPHONE NUMBER
DATE
AGENCY APPROVAL
DATE
DOC. DATE
PMT DUE DATE
CURRENT DOC. NO.
REF. DOC. NO.
VENDOR NUMBER
VENDOR MESSAGEI USE TAX
UBI NUMBER
REF
DOC
SUF
TRAM
CODE
M
O
D
FUN
MASTER INDEX
SUB
Del
SUB
SUB
ORG
INDEX
WKCLAS COUNT CITY
PW
SUB
PROD
AMOUNT
PR01
PHAS
INVOICE NUMBER
APPN
INDEX
PROGRAM
INDEX
ALLOC
BDGT
UNIT
MOS
ACCOUNTING APPROVAL FOR PAYMENT
DATE
WARRANTTOTAL
WARRANT NO.
KPHD 2097
Page 13 of 27
ATTACHMENT C
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 U. 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 Dcfinitions:
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. EIIPAA 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.
KPHD 2097
Page 14 of 27
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.
KPHD 2097
Page 15 of 27
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
1. 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.
KPHD 2097
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Section V. Termination
1. Term. The Agreement shall terminate on June 30, 2021 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.
KPHD 2097
Page 17 of 27
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 subreciplent and the
effective date of the amendment shall also be the date at which these requirements go
1. 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 subrecipfent
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 2087
Page 18 of 27
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 S 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
Vill of the Civil Rights Act of 1968 (42 U.S.C. §§3601 at seq.), and the Americans with Disability
Act (42 U.S.C., Section 12101 at 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 2097
Page 18 of 27
A. are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal Department or agency;
B. have not within a 3-year period preceding this contract been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or
contract under a public transaction; violation of Federal or State antitrust statutes or commission
of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. are not presently indicted or otherwise criminally or civilly charged by a governmental entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph (b) of
this certification; and
D. have not within a 3-year period preceding this contract had one or more public transactions
(Federal, State, or local) terminated for cause or default.
Should the contractor not be able to provide this certification, an explanation as to why should be
placed after the assurances page in the contract.
The contractor agrees by signing this contract that it will include, without modification, the clause
titled Certification Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion —Lower
Tier Covered Transactions in all lower tier covered transactions (i.e., transactions with sub -
grantees and/or contractors) and in all solicitations for lower tier covered transactions in accordance
with 45 CFR Part 76.
2. CERTIFICATION REGARDING DRUG -FREE WORKPLACE REQUIREMENTS
The undersigned (authorized official signing for the contracting organization) certifies that the
contractor will, or will continue to, provide a drug -free workplace in accordance with 45 CFR Part 76
by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the grantee's workplace
and specifying the actions that will be taken against employees for violation of such prohibition;
B. Establishing an ongoing drug -free awareness program to inform employees about
The dangers of drug abuse in the workplace;
ii. The contractor's policy of maintaining a drug -free workplace;
III. Any available drug counseling, rehabilitation, and employee assistance programs; and
KPHD 2097
Page 20 of 27
iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
C. Making it a requirement that each employee to be engaged in the performance of the contract
be given a copy of the statement required by paragraph (a) above;
D. Notifying the employee in the statement required by paragraph (a), above, that, as a condition of
employment under the contract, the employee will —
Abide by the terms of the statement; and
ii. Notify the employer in writing of his or her conviction for a violation of a criminal drug statute
occurring in the workplace no later than five calendar days after such conviction;
E. Notifying the agency in writing within ten calendar days after receiving notice under paragraph
(d) (2) from an employee or otherwise receiving actual notice of such conviction. Employers of
convicted employees must provide notice, including position title, to every contract officer or
other designee on whose contract activity the convicted employee was working, unless the --
Federal agency has designated a central point for the receipt of such notices. Notice shall
include the identification numbers) 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
it. 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 2097
Page 21 of 27
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 2097
Page 22 of 27
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 2097
Page 23 of 27
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 2097
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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
KPHD 2097
Page 25 of 27
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. 9r14728-
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
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Education Amendments of 1972, as amended (20 U.S.C. nn1681-1683, 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. n794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. nn 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) Fin 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.
n n 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. n 3601 at
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. nn1501-1508
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.
nn276a to 276a-7), the Copeland Act (40 U.S.C. F-276c and 18 U.S.C. nn874) and
the Contract Work Hours and Safety Standards Act (40 U.S.C. nn 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; (a) assurance of project consistency with the approved State management
program developed under the Coastal Zone Management Act of 1972 (16 U.S.C.
n r 1451 at 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.
nr7401 et seq.); (g) protection of underground sources of drinking water under the
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Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of
endangered species under the Endangered Species Act of 1973, as amended, (P.L.
93-205).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. nr1721 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. r1470), EO 11593
(identification and protection of historic properties), and the Archaeological and Historic
Preservation Act of 1974 (16 U.S.C. ❑o469a-1 at 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. n n2131 at 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. ❑n4801 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
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Please also print or type name:
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ORGANIZATION NAME: (if a plicable) DATE