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Public Health Consent Agenda
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Vicki Kirkpatrick, JCPH Director
Veronica Shaw, JCPH Deputy Director
DATE: 049 a-( Do d-'
SUBJECT: Consolidated Contract Amendment #21
STATEMENT OF ISSUE: Jefferson County Public Health requests Board approval of Consolidated Contract Amendment
#21; January 1, 2018- December 31, 2021.
ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S: This is a routine Consolidated Contract Amendment that comes to
local health jurisdictions every two months and includes both budgeted and new funding along with some tasks associated
with the funding.
FISCAL IMPACT/COST BENEFIT ANALYSIS: This amendment includes an increase of$53,870 for a revised maximum
of$3,921,519. These funds are included in the State 2019-2021 Biennial Budget and represent state fiscal year allocation.
Individual allocations are as follows:
• FFY20 USDA BFPC Prog Mgmt: $30,280 for 10/1/19-9/30/21
• FFY21 USDA WIC Client Svc: $7,454 for 10/1/20- 9/30/21
• FFY20 Swimming Bch Act Grant IAR(ECY) $15,000 for 3/1/21 - 10/31/21
• SFY21 Family Planning Cost Share $1,136 FOR 7/1/20-6/30/21
RECOMMENDATIONS: JCPH Management recommends BOCC approval and signature for Consolidated Contract
Amendment #21.
REVIEW Y:
t 9/2-
Mark McCauley, rim County Administrator 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
JEFFERSON COUNTY PUBLIC HEALTH
2018 — 2021 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH18247
AMENDMENT NUMBER: 21
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as
"DOH", and JEFFERSON COUNTY PUBLIC HEALTH, a Local Health Jurisdiction, hereinafter referred to as "LHJ",
pursuant to the Modifications/Waivers clause, and to make necessary changes within the scope of this contract and any
subsequent amendments thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of work, attached and incorporated by this reference, are amended as follows:
❑ Adds Statements of work for the following programs:
• BEACH Program - Effective March 1, 2021
X Amends Statements of work for the following programs:
• Family Planning - Effective December 1, 2019
• WIC Nutrition Program - Effective January 1, 2018
❑ Deletes Statements of work for the following programs:
2. Exhibit B-21 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-20 Allocations
as follows:
N Increase of $53,870 for a revised maximum consideration of $3 921 519.
n Decrease of for a revised maximum consideration of
El No change in the maximum consideration of
Exhibit B Allocations are attached only for informational purposes.
3. Exhibit C-21 Schedule of Federal Awards, attached and incorporated by this reference, amends and replaces
Exhibit C-20.
Unless designated otherwise herein, the effective date of this amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force
and effect.
IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY PUBLIC HEALTH
Date
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
APPROVED AS TO FORM ONLY
Assistant Attorney General
Date
Page 1 of 20
AMENDMENT #21
2018-2021 CONSOLIDATED CONTRACT
EXHIBIT A
STATEMENTS OF WORK
TABLE OF CONTENTS
DOH Program Name or Title: BEACH Program - Effective March 1, 2021.....................................................................
DOH Program Name or Title: Family Planning - Effective December 1, 2019................................................................
DOH Program Name or Title: WIC Nutrition Program - Effective January 1, 2018..........................................................
..........................................................................I.......... 3
..................................................................................... 5
................................................................................... 12
Exhibit A, Statements of Work Page 2 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Exhibit A
Statement of Work
Contract Term: 2018-2021
DOH Program Name or Title: BEACH Program - Effective March 1, 2021
SOW Type: Original Revision # (for this SOW)
Period of Performance: March 1, 2021 through October 31, 2021
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLHIS247
Funding Source Federal Compliance Type of Payment
N Federal Subrecipient (check if applicable) N Reimbursement
❑ State N FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The Beach Environmental Assessment, Communication, and Health (BEACH) Program monitors water at marine swimming beaches for bacteria
and provides public notification when levels are unsafe.
Revision Purpose: N/A
Chart of Accounts Program Name or Title
CFDA #
BARS
Master
Funding Period
Current
Change
Total
Revenue
Index
(LHJ Use Only)
Consideration
Consideration
Code
Code
Start Date End Date
Increase (+)
FFY20 Swimming Beach Grant IAR ECY
66.472
333.66.47
26505920
03/01/21 1 10/31/21
0
15,000
15,000
TOTALS
0
15,000
15,000
Task
Task/Activity/Description
*May Support PHAB `
Deliverables/Outcomes
Due Date/Time
Payment
Information and/or
Number
Standards/Measures-<
Frame
Amount
1
BEACH Program Administration and Annual
Summarize time spent on
Annual meeting held
Reimbursement for
Meeting: Time spent on administrative duties
administrative duties in annual
in March 2021.
actual costs up to
related to the BEACH Program and the 2021
report.
$15,000 for tasks 1-3.
Annual meeting.
Annual report due
Subrecipient may use
October 31, 2021.
its own discretion in
2
Bacteria Monitoring & Public Notification
1. Enter data into Department of
1. Enter data results
prioritizing which
• Collect samples and field observations in
Ecology's BEACH Program
into database by
task(s) to pay with
accordance with BEACH Program Quality
Database.
Friday each week of
this award.
Assurance Project Plan (QAPP). Notify BEACH
2. Email or mail copies of
sample collection.
Program Manager in advance if samples cannot be
laboratory analytical reports to
2. Email or mail
collected. Coordinate deviations from the QAPP
BEACH Program Data Manager.
copies of reports upon
and/or schedule with the BEACH Program
3. Include a list of swimming
receipt.
Manager.
advisories in annual report.
3. Annual report due
• Post and/or remove swimming advisory signs as
October 31, 2021.
needed. Provide public education about beach
water quality. Notify BEACH Program Manager of
swimming advisories as soon as possible.
Exhibit A, Statements of Work Page 3 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Task
Task/Activity/Description
*May Support PHAB
Deliverables/Outcomes
Due Date/Time
Payment
Information and/or
Number
Standards/Measures
Frame
Amount
3
Illness Pollution Investigations
1. Provide notification via
1. Within fourteen
Notify BEACH Program Manager of any illness
telephone to BEACH Program
(14) business days.
reports related to recreational swimming beaches.
Manager.
Conduct illness investigations as needed.
2. Summarize illness investigation
2. Annual report due
in annual report.
October 31, 2021.
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version- I.O.pdf
Program Specific Requirements/Narrative
The funds for this project are being provided by an Environmental Protection Agency grant, Agreement Number CU-01 J49701-1, Catalog of Federal Domestic Assistance Number 66.472
— Beach Monitoring and Notification Program Implementation Grants.
Special Requirements
Federal Funding Accountability and Transparency Act (FFATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the 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.
Program Manual, Handbook, Policy References
Quality Assurance Project Plan at: https://fortress.wa. o� v/ecy/publications/SummaryPages/1903119.html
DOH Program Contact
Laura Hermanson, BEACH Program, Office of Environmental Health and Safety, PO Box 47824, Olympia, WA 98504-7824, 360-480-4868, laura.hermansong_ecy.wa.gov
DOH Fiscal Contact
Taylor Warren, Budget Specialist, Office of Environmental Health and Safety, P.O. Box 47824, Olympia, WA 98504-7824, 360-236-3348, tUlor.warrengdoh.wa.gov
Exhibit A, Statements of Work Page 4 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Exhibit A
Statement of Work
Contract Term: 2018-2021
DOH Program Name or Title: Family Planning - Effective December 1, 2019
SOW Type: Revision Revision # (for this SOW) 4
Period of Performance: December 1, 2019 through June 30, 2021
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH18247
Funding Source Federal Compliance Type of Payment
❑ Federal <Select One> (check if applicable) ® Reimbursement
® State ❑ FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide family planning services to Washington State residents. These services will comply
with all state and DOH Famiy Planning Manual requirements. This statement of work replaces previous statements of work. It highlights specific requirements, but all must be
complied with.
Due dates after June 30, 2021 are for reporting only. LHJ may not bill under this statement of work for work done in July 2021.
Revision Purpose: The purpose of this revision is to add additional funding.
Chart of Accounts Program Name or Title
CFDA #
BARS
Revenue
Code
Master
Index
Code
Funding Period -
(LHJ Use Only)
Start Date End Date`
Current
Consideration
Change
Increase (+)
Total
Consideration
FAMILY PLANNING COST SHARE
N/A
334.04.91
78440100
12/01/19
06/30/20
53,449
0
53,449
FAMILY PLANNING COST SHARE
N/A
334.04.91
78440100
12/01/19
06/30/20
16,545
0
16,545
SFY21 FAMILY PLANNING COST SHARE
N/A
1 334.04.91
178440104
1 07/01/20
06/30/21
85,814
1,136
86,950
TOTALS
155,808
1 1,136
156,944
Task
Number
Task/Activity/Description
*May Support
PHAB
Standards/Measures
Deliverables/Outcomes
Due Date/Time
Frame
Payment Information and/or
Amount
1.
Family Planning Program Services —excluding
A19 invoice vouchers
No more than
Billing must be based on a
abortion and other surgical procedures related
submitted timely and
monthly and no
current cost methodology
to family planning
accompanied with an R&E
less than
approved by DOH (see
A. Comply with Washington State 2019 Family
showing revenue and
quarterly.
Reporting Requirements
Planning Program Manual, Family Planning
expenses for the month billed
table).
Program Network requirements and all state
and back up documentation
laws. Also see Program Manual, Handbook,
per DOH policy.
DOH reserves the right to
Policy References section below.
During the COVID19 crisis
withhold payment until:
B. Provide medical services, community
you may enter FTE related
• Compliance issues related
education and outreach, and staff training,
expenses for family planning
to this or a previous SOW
consistent with state requirements:
staff temporarily assigned to
are resolved in a way
other duties due to COVIDI9
accepted by DOH
or staff not working due to
Exhibit A, Statements of Work Page 5 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Task
Number
Task/Activity/Description
*May Support
PHA$
Standards/Measures
Deliverables/Outcomes
Due Date/Time
Frame
Payment Information and/or
Amount
1. LHJ is responsible for making sure all
COVIDI9, but still being paid
• Current data is submitted
staff have the knowledge to carry out the
by your organization as paid
to, and accepted by,
requirements of the SOW.
leave.
Ahlers.
2. Medical, laboratory, and other services
• All reports described in
As described in
• A19 back up
related to abortion are not covered by
Reporting Requirements table
Reporting
documentation required
this task.
below.
Requirements
by DOH has been
3. Community education services must be
table below.
submitted and approved.
based on the needs of the community.
• Other deliverables have
4. Outreach is to ensure all populations in
• Other data and documentation
As requested by
been met.
your community understands the
in format requested by DOH.
DOH
services available. Focus your outreach
(Includes copies of program
Payment is limited to the
efforts on increasing equity.
and financial audits and
maximum funds available for
reviews including summaries
funding source.
Washington State Family Planning Network
conducted by other entities.)
priority populations are:
DOH will reimburse for:
• People under 20 years old
• To facilitate DOH desk
As requested by
• Actual allowable costs
• People with incomes at or below 250%
reviews —requested
DOH
according to your
FPL
documentation available to
approved cost
• People who are uninsured or
DOH in requested format.
methodology (see
underinsured
Reporting Requirements
• People who require an extra level of
• To facilitate DOH site-
table).
confidentiality
visits —appropriate staff and
or
• People with low English proficiency
documentation readily
• The amount remaining in
Extra efforts should be made to provide
available prior to and during
the SOW divided by the
information and services to people who intersect
review.
number of months
with multiple priority population categories.
remaining in the funding
DOH performs site visits at least
source, plus one,
Provide all services in accordance with:
annually. Follow-up site visits are
whichever is less.
• DOH Family Planning Manual
performed until identified issues
• Other state and federal requirements
are resolved.
Payment will be calculated by
• LHJ's Current Scope Report (defined
R&E provided by DOH (see
below)
Reporting Requirements
table).
C. Collect, maintain, and provide data about
CVR data submitted to DOH data
The last day of
each family planning clinic visit as defined in
contractor (Ahlers & Associates)
the next month.
All services through 06-30-21
the Family Planning Manual.
electronically in a format
y
Within thirty
must be billed b 07-31-21.
Y
1. Maintain a computer system that
compatible with Ahlers software.
(30) days of
includes normal safety precautions
receiving
error/rejection
against loss of information.
• Data for each month
2. Ensure data entry personnel protect
report or
request from
confidentiality of CVR data.
• Corrected CVR data
DOH family
Exhibit A, Statements of Work Page 6 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT 421
Task
Number
Task/Activity/Description
*May Support
PHAB '
Standards/Measures
Deliverables/Outcomes
Due Date/Time
Frame
Payment Information and/or
Amount
3. Have ability to retrieve all information
planning data
for auditing and monitoring by DOH or
manager.
its designee.
D. Notify DOH contract manager of all:
Email briefly describing change.
As needed to
• Key staff and organizational changes.
keep
• Proposed clinic site additions. New
information
clinic sites must be approved by DOH
current.
before offering services supported by
SOW funding.
• Expected clinic site closures. Note: DOH
may, at its sole discretion, recalculate
LHJ's funding allocation if it closes a
clinic site.
• Any other change that might affect
LHJ's ability to provide the family
planning services described in this SOW.
2.
Abortion and other surgical procedures
Surgical A19 accompanied by
No more than
DOH will only reimburse LHJ
related to family planning
Surgical Services Summary and
six (6) months
for these services if this SOW
A. LHJ may choose to use up to 3% of its total
Health Insurance Claim Forms
after date
includes surgical funds.
SOW funds for medical and surgical
form for each visit billed.
service was
abortions and other family planning related
provided.
DOH will pay for services at
surgical procedures.
DOH will provide Surgical
Health Care Authority (HCA)
B. LHJ must notify the DOH contract manager
Services Summary forms and
Medicaid reimbursement
prior to providing services with SOW funds.
surgical A19s as part of R&E
amounts.
DOH will move the appropriate amount to
workbook for all LHJ's who
• This will be considered
the appropriate funding source. This may or
receive surgical funds.
payment in full.
may not require an amendment.
. LHJ will not seek
C. Comply with Washington State 2019 Family
additional.payment from
Planning Manual, Family Planning Network
the client or any other
requirements and all state laws. Also see
person or organization.
Program Manual, Handbook, Policy
References section below.
D. Eligible clients are those with incomes at or
below 250% FPL.
E. If LHJ bills for services provided by someone
outside their organization the outside
provider must agree to accept DOH payment
as payment in full. LHJ is responsible for
ensuring that the outside provider does not
seek additional payment from the client or
Exhibit A, Statements of Work Page 7 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
*May Support
Task
Due Date/Time
Payment Information and/or
Number
Task/Activity/Description
PHAB
Deliverables/Outcomes
Frame
Amount
Standards/Measures
any other person or organization. (Also see
Payment column.)
Reporting Requirements:
Title and Purpose
Description
Due
1. Current Scope Report
This information must be reported using the template or format provided by DOH. All
01-31-20
signatures and forms must be completed by 01-31-20 It will include:
Information required at the beginning this SOW
-- - ----------------------------------------------------------------------------------------------------------------------------------------------------------
Information about your agency contacts and your organization's staffing
AND
period. This information ensures that DOH has
accurate information about LHJ's organization and
A. Head of Organization
As needed to maintain
the services it provides.
B. Head of Finance
accuracy of information.
C. Medical Director
In addition, elements of this report allow DOH to
D. The following (one person might fill more than one role)
ensure that Washington State Family Planning
a. Contract Coordinator
Network requirements regarding client fees,
b. Clinical representative
required services, requirements. It also provides
c. Billing contact
other information to assist DOH to manage this
d. Outreach and education contact
SOW and the Washington State Family Planning
e. Contact for CVR data
Network as a whole.
£ Contact for EHR information
---------------- --- - -- -— -------------------------------- - .._.... ------------ - - - ----- - -- -- ---------
Information regarding family planning related services offered at each clinic site:
A. Cost analysis: How LHJ determines what it costs to provide services. LHJ uses this
to help construct its fee schedule. A cost analysis must be performed by LHJ no
more than three years prior to the start date of this SOW.
B. Sliding fee schedule that includes all services required in the Family Planning
Submit 2021 sliding fee
Manual. Additional Task 1 family planning -related services may also be included on
scale to DOH by
LHJ's sliding fee schedule.
01-05-21
a. Sliding fee schedule must be based on cost analysis described above.
b. LHJ may use the last fee schedule approved prior to this SOW as long as it was
approved later than 04-01-19. LHJ must email the DOH contract manager
letting them know it is using a prior approved fee schedule.
c. LHJ must not implement a revised fee schedule until it has been approved in
writing by DOH.
C. Income conversion tables must be updated annually and approved by DOH
- - - --- - - - - - --- --- ------ --
-- --- --- ----------------- -------- --------------- ---
Information related to current Community Outreach Plan
LHFs community outreach plan follows a 5-year cycle. In the first year LHJ must assess,
document and disseminate community health needs, this process must include the following
steps:
A. Define the populations LHJ serves and identify opportunities to expand reach within
Exhibit A, Statements of Work
Page 8 of 20 Contract
Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
those populations and to unreached populations in each community it serves.
B. Identify organizations and people representing the broad interests of the community
and identify opportunities for partnership and collaboration.
C. Gather available data and current assessments (secondary data)
D. Seek community perspectives by gathering input from the various populations in
LHJ's community (collect primary data)
E. Aggregate secondary and primary data and analyze aggregated data
F. Prioritize health issues, define areas of unmet need, and incorporate both in plans for
outreach and education materials and activities
G. Document and disseminate the community health needs assessment to LHJ's FFP
consultant and appropriate stakeholders
Information related to current Washington State Family Planning Network work plan
Periodically, the Family Planning Network develops a statewide work plan. LHJ will be
involved in developing and finalizing this plan. Activities focus on improving the strength of
the Network and access to Network services for everyone who wants and needs them.
Describe plans to address portions of the Network work plan that LHJ is responsible for or
involved in. Include a description of the staff involved and timelines related to your activities.
------------------------------------------------------------------------------------------------------------------------------------------
Information related to billing and client fees
Cost methodology: How LHJ determines appropriate expenses for the purpose of billing
DOH.
If LHJ cost methodology was approved by DOH after 04-01-19, LHJ does not have to
resubmit unless changes were made. LHJ does need to email DOH contract manager
informing them that no changes were made.
2. Progress Summary Report
This information must be reported using the template or format provided by DOH. It
will include information about LHJ's work during the previous SOW:
Summary of activities from previous Family
Planning services SOW.
A. Progress on portions of the Network work plan LHJ was responsible for or
involved in.
It informs quality improvement of the
B. Community education and outreach strategies and activities and a discussion of
Washington State Family Planning Network.
their effectiveness.
C. Staff training.
3. Family Planning Annual Report (FPAR)
Organization -level data on clinical services emailed to DOH family planning data
01-31-21
manager
Information DOH is requesting to develop trend
data. All information is for calendar year 2020
Number of -
(January through December 2020).
A. Pap tests with an ASC or higher result
B. Pap tests with an HSIL or higher result
C. HIV Positive confidential tests
D. HIV Anonymous tests
E. FTE required to provide family planning services:
• Physicians
Exhibit A, Statements of Work Page 9 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
• Physician assistants + nurse practitioners + certified nurse midwives
• Registered nurses with expanded scope of practice who are trained and
permitted by state specific regulations to perform all aspects of the physical
assessment.
Financial data emailed to DOH Contract Manager
A. R&E showing Other Revenue through 12-31-20 as described in item 5, below.
4. Clinic Visit Reports (CVRs)
Clinic visit records must include all elements specified in the Clinic Visit Record (CVR)
Manual available at:
httUs://www.doh.wa.gov/Portals/1 /Documents/Pubs/930-139-C VRManual. pdi
CVR data must be submitted to DOH data contractor (Ahlers & Associates) electronically in
a format compatible with Ahlers software.
• Each month's CVR data
The last day of the next
month
• Corrected CVR data
Within thirty (30) days
of receiving error or
rejection report or
request from DOH
family planning data
manager.
5. Revenue and Expense Reports (R&E)
Completed R&E for time period that shows all revenue (including program income)
Submitted with each
that support Task 1 Family Planning Services and all expenses related to providing
invoice (A19). No more
those services. R&E workbook will be provided by DOH.
than monthly and no
A. Expenses must match General Ledger.
less than quarterly.
B. Other revenue/program income must reflect revenue actually received in the
R&E showing all
reporting month.
sources of revenue that
C. All entries on "Other" rows must be accompanied by a description of the revenue
support services for:
source or expense, including any calculations uses.
. January -December
2019 due 01-31-20
• January -December
2020 due 01-31-21
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
http://www. phaboard. org/wl2-content/uploads/PHAB-Standards-and-Measures-Version-1.O.pdf
Exhibit A, Statements of Work Page 10 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Program Manual, Handbook, Policy References
LHJ must comply with all state and DOH Family Planning requirements, policies, and regulations and with their DOH approved Current Scope Report.
Reference documents include:
• DOH Family Planning Manual (DOH publication 930-122, available at https://www.doh.wa.gov/portals/l/Documents/Pubs/930-122-FPRHManualComplete.pdf). Some
provisions of this manual are highlighted in this SOW, but all provisions of the manual must be complied with.
• Clinic Visit Record Manual (https://www.doh.wa.gov/Portals/l/Documents/Pubs/930-139-CVRManual.pdf)
• Current Washington State Family Planning Network work plan
• LHJ's approved Current Scope Report
Special Billing Requirements
See Payment column of Tasks and Deliverables table and R&E report description in Reporting Requirements table
Special Instructions
Accessibility of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to target populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible, services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal, State, and local governments, including local fire, building, and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis. Acceptance of family planning services must not be a prerequisite to eligibility for, or receipt of, services in any
non -family planning programs of the LHJ.
Availability of Emergency Services
The LHJ must have written plans and procedures for the management of on -site medical emergencies, including emergencies that require transport and after-hours management of
contraceptive emergencies. (See DOH Family Planning Manual)
DOH Program Contact
Carol Oakes
PO Box 47880
Olympia, WA 98504-7880
Carol.Oakeskdoh.wa. go_v
(360)236-3588
Exhibit A, Statements of Work Page 11 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Exhibit A
Statement of Work
Contract Term: 2018-2021
DOH Program Name or Title: WIC Nutrition Program - Effective January 1, 2018
SOW Type: Revision Revision # (for this SOW) 14
Period of Performance: January 1, 2018 through December 31, 2021
Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH18247
Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) N Reimbursement
❑ State N FFATA (Transparency Act) ❑ Fixed Price
❑ Other ❑ Research & Development
Statement of Work Purpose: The purpose is to provide Women, Infants, and Children (WIC) Nutrition Program services by following WIC federal regulations, WIC state office
policies and procedures, WIC directives, and other rules. Refer to the Program Specific Requirements section of this document.
Revision Purpose: The purpose of this revision is to add FFY21 USDA WIC Client SVS Contracts funds, add FFY20 USDA BFPC Program Management funds and include
language for initiating the BFPC program.
Chart of Accounts Program Name or Title
CFDA #
BARS
Revenue
Code
Master
Index
Code
Funding Period
(LHJ Use Only)
Start Date End Date
Current
Consideration
Change
Increase (+)
Total
Consideration
FFY18 CSS USDA WIC PROGRAM MGNT
10.557
333.10.55
76211280
01/01/18
09/30/18
74,490
0
74,490
FFY19 CSS USDA WIC PROGRAM MGNT
10.557
333.10.55
76211290
10/01/18
09/30/19
106,856
0
106,856
FFY20 USDA WIC PROGRAM MGNT
10.557
333.10.55
76101202
10/01/19
09/30/20
0
0
0
FFY21 CSS USDA WIC PROGRAM MGNT
10.557
333.10.55
76101212
10/01/20
09/30/21
2,450
0
2,450
FFY18 CSS USDA FMNP PROGRAM MGNT
10.572
333.10.57
76211284
01/01/18
09/30/18
500
0
500
FFY16 CASCADES USDA WIC PROGRAM MGNT-MIS
10.578
333.10.57
76411261
10/01/18
09/30/19
845
0
845
FFY19 CSS USDA FMNP PROGRAM MGNT
10.572
333.10.57
76211294
01/01/19
09/30/19
502
0
502
FFY19 MIS TECH GRANT
10.578
333.10.57
76411291
10/01/19
09/30/20
790
0
790
FFY20 USDA WIC CLIENT SVS CONTRACTS
10.557
333.10.55
76101204
10/01/19
09/30/20
104,932
0
104,932
FFY21 USDA WIC CLIENT SVS CONTRACTS
10.557
333.10.55
76101214
10/01/20
09/30/21
103,275
7,454
110,729
FFY20 USDA FMNP PROGRAM MGMT
10.572
333.10.57
76540201
10/01/19
09/30/20
481
0
481
FFY20 USDA WIC NUTRITION ED
10.557
333.10.55
76101206
10/01/19
09/30/20
1,295
0
1,295
FFY22 USDA WIC CLIENT SVS CONTRACTS
10.557
333.10.55
TBD
10/01/21
12/31/21
26,275
0
26,275
FFY20 USDA BFPC PROGRAM MGMT
10.557
333.10.55
76214220
10/01/19
09/30/21
0
30,280
30,280
TOTALS
422,691
37,734
460,425
Task
*May'; Support PHAB
Due Date/Time
Payment
Number
Task/Activity/Description
Standards/Measures
Deliverables/Outcomes
Frame
Information and/or
Amount
See "Special Billing
1
WIC Nutrition Program
Requirements" below.
Exhibit A, Statements of Work Page 12 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Task
Task/Activity/Description
*May Support PHAB
Deliverables/Outcomes
Due Date/Time
Payment
Information and/or
Number
Standards/Measures
Frame
Amount
1.1
Maintain authorized participating caseload at 100%
7.2
Outcomes based on monthly
based on quarterly average as determined from
participation data from state WIC
monthly caseload management reports generated at
caseload management reports.
the state WIC office.
The Department of Health (DOH) State WIC
Nutrition Program has the option of reducing
authorized participating caseload and
corresponding funding when:
1. Unanticipated funding situations occur.
2. Reallocations are necessary to redistribute
caseload statewide.
Authorized participating caseload for January
2018 through December 2020 = 320
Authorized participating caseload for January
2019 through December 2020 = 310
Revised participating caseload for January 2021
through December 2021= 300
1.2
Submit the annual Nutrition Services Plan for each
9.2 `
Nutrition Services Plan
First year due
Payment withheld if
year of the Contract.
11/30/18
not received by due
Second year due
date.
11/30/19
Third year due
11/30/20
Extension year due
09/30/21
1.3
Submit the annual Nutrition Services Expenditure
11.2
Nutrition Services Expenditure
First year due
Payment withheld if
Report for each year of the Contract.
Report
11/30/18
not received by due
Second year due
date.
11/30/19
Third year due
11/30/20
Extension year due
11/30/21
1.4
Tell participants about other health services in the
3.1
Documentation must be available
Biennial WIC monitor
agency. If needed, develop written agreements
for review by WIC monitor staff.
with other health care agencies and refer
participants to these services.
Exhibit A, Statements of Work Page 13 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Task
Task/Activity/Description
*May Support PHAB
Deliverables/Outcomes
Due Date/Time
Payment
Information and/or
Number
Standards/Measures
Frame
Amount
1.5
Provide nutrition education services to participants
3.1
Documentation must be available
Biennial WIC monitor
and caregivers in accordance with federal and state
for review by WIC monitor staff.
requirements.
1.6
Issue WIC benefits while assuring adequate card
11.2
Documentation must be available
Biennial WIC monitor
security and reconciliation.
for review by WIC monitor staff.
1.7
Collect data, maintain records, and submit reports
7.1
Documentation must be available
Biennial WIC monitor
to effectively enforce the non-discrimination laws
for review by WIC monitor staff.
Refer to Civil Rights Assurances below).
1.8a
Submit entire WIC and Breastfeeding Peer
11.2
Budget Workbook
First year due
Counseling Budget Workbook for each year of the
10/31/18
contract.
Second year due
09/30/19
Third year due
09/30/20
Extension year due
09/30/21
1.8b
Submit Rev-Exp Report spreadsheet from the WIC
11.2
Revenue and Expense Report and
Mid -year revision due
Budget Workbook monthly -with A19
A19 Invoice Voucher.
04/30/19
Mid -year revision due
04/30/20
Extension year due
monthly through
12/31/21
See "Special Billing
2
Breastfeeding Promotion
Requirements" below
2.1
Provide breastfeeding promotion activities in
3.1
Status report of chosen activities in
First year due
accordance with federal and state requirements
Nutrition Services Plan.
11/30/18
Second year due
11/30/19
Third year due
11/30/20
Extension year due
Documentation must be available
11/30/21
for review by WIC monitor staff.
Biennial WIC monitor
2.2
Optional for FFY21: Work with community
4.2 '
Optional status report of chosen
First year due
partners to improve practices that affect
activities in Nutrition Services
11/30/18
breastfeeding. Choose one or more of the
Plan.
Second year due
following projects:
11/30/19
Third year due
11/30/20
Exhibit A, Statements of Work Page 14 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Task
Task/Activity/Description
*May Support PHAB
Deliverables/Outcomes
Due Date/Time
Payment
Information and/or
Number
Standards/Measures
Frame
Amount
■ Change worksite policies of employers who
Extension year due
likely employ low income women
11/30/21
■ Provide breastfeeding education to health care
Documentation must be available
providers who serve low income pregnant and
for review by WIC monitor staff.
Biennial WIC monitor
breastfeeding women
■ Work with birthing hospitals to improve
maternity care practices that affect WIC client
breastfeeding rates
■ Provide participants access to lactation
consultants
■ Provide staff and community partners
breastfeeding training
Other projects will need pre -approval from the
State WIC Office.
3
Breasfeeding Peer Counseling Program
See "Special Billing
Requirements" below
3.1
Provide breas feeding peer counseling program
3.1
Breastfeeding Peer Counseling
Extension year due
activities in accordance with federal and state
Annual Report and expenditures
12131121
requirements. The WIC Breastfeeding Peer
from the previous federal fiscal
Counseling Program is meant to enhance, not
year.
replace, WIC Breas feeding Promotion and
support activities.
Documentation must be available
Biennial WIC monitor
or review by WIC monitor staff.
3.2
Track Breastfeeding Peer Counseling Program
3.1
Documentation must be available
Biennial WIC monitor
expenditures and bill separately from the WIC
for review by WIC monitor staff.
ant.
34
Farmers Market Nutrition Program (FMNP)
See "Special Billing
Requirements" below
4.1
Distribute all Farmers Market Nutrition Program
Send completed readable copy of
Weekly June -Sept.
checks to eligible WIC participants between June
FMNP check registers to State
2018
and September 30 of current year.
WIC office on a weekly basis
Weekly June -Sept.
following FMNP procedures.
2019
Weekly June -Sept.
2020
Weekly June -Sept.
2021
All sent by Oct. 1,
2018; Oct. 1, 2019,
Exhibit A, Statements of Work Page 15 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Task
*May Support PHAB `
Due Date/Time
Payment
Number
Task/Activity/Description
Standards/Measures
Deliverables/Outcomes
Frame
Information and/or
Amount
Oct. 1, 2020, and by
Oct. 1, 2021
Documentation must be available
for review by WIC monitor staff.
Biennial WIC Monitor
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:
http://www.12haboard. org/wp-content/uploads/PHAB-Standards-and-Measures-Version- I.O.pdf
Program Specific Requirements/Narrative
Federal Fundine Accountability and Transparency Act (FFATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work, the 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.sov by DOH as required by P.L. 109-282.
Program Manual, Handbook, Policy References:
The LHJ shall be responsible for providing services according to rules, regulations and other information contained in the following:
• WIC Federal Regulations, USDA, FNS 7CFR Part 246, 3016, 3017 and 3018
• Washington State WIC Nutrition Program Policy and Procedure Manual
• Farmers Market Nutrition Program Federal Regulations, USDA, FNS 7CFR Part 248
• Other directives issued during the term of the Contract
Staffing Requirements:
The LHJ must:
Use Competent Professional Authority staff, as defined by WIC policy, to determine client eligibility, prescribe an appropriate food package and offer nutrition education
based on the participants' needs.
Use a Registered Dietitian (RD) or other qualified nutritionist to provide nutrition services to high risk participants, to include development of a high risk care plan. The RD
is also responsible for quality assurance of WIC nutrition services. See WIC Policy for qualifications for a Registered Dietitian and other qualified nutritionist.
Assign a qualified person to be the Breastfeeding Coordinator to organize and direct local agency efforts to meet federal and state policies regarding breastfeeding promotion
and support. The Breastfeeding Coordinator must be an International Board Certified Lactation Consultant or attend an intensive lactation management course, or other state
approved training.
Restrictions on Funds:
The LHJ shall follow the instructions found in the Policy and Procedure Manual under WIC Allowable Costs.
Exhibit A, Statements of Work Page 16 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
Monitoring Visits:
Program and fiscal monitoring are done on a Biennial (every two years) basis, and are conducted onsite.
The LHJ must maintain on file and have available for review, audit and evaluation:
1) All criteria used for certification, including information on income, nutrition risk eligibility and referrals
2) Program requirements
3) Nutrition education
4) All financial records
Definitions:
What is the WIC program?
(1) The WIC program in the state of Washington is administered by DOH.
(2) The WIC program is a federally funded program established in 1972 by an amendment to the Child Nutrition Act of 1966. The purpose of the program is to provide nutrition
and health assessment; nutrition education; nutritious food; breastfeeding counseling; and referral services to pregnant, breastfeeding, and postpartum women, infants, and young
children in specific risk categories.
(3) Federal regulations governing the WIC program (7 CFR Part 246) require implementation of standards and procedures to guide the state's administration of the WIC program.
These regulations define the rights, responsibilities, and legal procedures of WIC employees, participants, persons acting on behalf of a client, and retailers. They are designed to
promote:
(a) High quality nutrition services;
(b) Consistent application of policies and procedures for eligibility determination;
(c) Consistent application of policies and procedures for food benefit issuance and delivery; and
(d) WIC program compliance.
(4) The WIC program implements policies and procedures stated in program manuals, handbooks, contracts, forms, and other program documents approved by the USDA Food
and Nutrition Service.
(5) The WIC program may impose sanctions against WIC participants for not following WIC program rules stated on the WIC rights and responsibilities.
(6) The WIC program may impose monetary penalties against persons who misuse WIC checks or WIC food but who are not WIC participants.
Assurances/Certifications:
1. Computer Equipment Loaned by the DOH WIC Nutrition Program
In order to perform WIC program activities, DOH requires computers and printers to be in local WIC clinics or to be transported to mobile clinics. This equipment ("Loaned
Equipment") is owned by DOH and loaned to the local agency (LHJ). The Loaned Equipment is supported by DOH. This equipment shall be used for WIC business only or
according to WIC Policy and Procedures.
An inventory of Loaned Equipment is kept by DOH. Each time Loaned Equipment is changed, the parties shall complete the Equipment Transfer Form and DOH updates the
inventory. A copy of the Transfer Form will be provided to the LHJ. Copies of the updated inventory list may be requested at any time.
The LHJ agrees to:
a. Defend, protect and hold harmless DOH or any of its employees from any claims, suits or actions arising from the use of this Loaned Equipment.
b. Assume responsibility for any loss or damage from abnormal wear or use, or from inappropriate storage or transportation.
Exhibit A, Statements of Work Page 17 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
DOH may enforce this by:
1) Requiring reimbursement from the LHJ of the value of the Loaned Equipment at the time of the loss or damage.
2) Requiring the LHJ to replace the Loaned Equipment with equipment of the same type, manufacturer, and capabilities (as pre -approved by DOH), or
3) Assertion of a lien against the LHJ's property.
c. Notify DOH immediately of any damage to Loaned Equipment.
d. Notify DOH prior to moving or replacing any Loaned Equipment.
The Department recommends LHJs carry insurance against possible loss or theft.
2. Civil Rights Assurance
The LHJ shall perform all services and duties necessary to comply with federal law in accordance with the following Civil Rights Assurance:
a. "The LHJ hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Title IX of the Education Amendments of 1972 (20
U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.); all provisions required by
the implementing regulations of the Department of Agriculture; Department of Justice Enforcement Guidelines, 28 CFR 50.3 and 42; and INS directives and guidelines,
to the effect that, no person shall, on the ground of race, color, national origin, sex, age or handicap, be excluded from participation in, be denied benefits of, or otherwise
be subject to discrimination under any program or activity for which the LHJ receives Federal financial assistance from FNS; and hereby gives assurance that it will
immediately take measures necessary to effectuate this Contract.
b. `By accepting this assurance, the LHJ agrees to compile data, maintain records and submit reports as required, to permit effective enforcement of the nondiscrimination
laws and permit authorized USDA personnel during normal working hours to review such records, books and accounts as needed to ascertain compliance with the
nondiscrimination laws. If there are any violations of this assurance, the Department of Agriculture, Food and Nutrition Service, shall have the right to seek judicial
enforcement of this assurance. This assurance is binding on the LHJ, its successors, transferees, and assignees, as long as it receives assistance or retains possession of any
assistance from DOH. The person or persons whose signatures appear on the contract are authorized to sign this assurance on behalf of the LHJ."
3. 7CFR Parts 3016, 3017, 3018
The LHJ shall comply with all the fiscal and operations requirements prescribed by the state agency as directed by Federal WIC Regulations (7CFR part 246.6), 7CFR part
3016, the debarment and suspension requirements of 7CFR part 3017, if applicable, the lobbying restrictions of 7CFR part 3018, and INS guidelines and instructions and shall
provide on a timely basis to the state agency all required information regarding fiscal and program information.
Special Billing Requirements:
1. Definitions
Contract Period: January 1, 2018-December 31, 2021
Contract Budget Period: The time period for which the funding is budgeted.
• There are four federal budget periods (Adding two more for the one-year FFY21 extension)
January 1, 2018 through September 30, 2018;
October 1, 2018 through September 30, 2019;
October 1, 2019 through September 30, 2020;
October 1, 2020 through December 31, 2020;
January 1, 2021 through September 30, 2021;
October 1, 2021 through December 31, 2021.
Exhibit A, Statements of Work Page 18 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
2. Billing Information
a. Billings are submitted on an A19-lA form, which is coded and provided by DOH prior to each federal fiscal budget period. Submit summary level financial data to
support each individual program billing.
b. A19-IA forms are submitted monthly following the close of each calendar month or upon completion of services, before the end of the federal contract budget period.
c. Funds are allocated by budget categories (refer to Chart of Accounts Program names) and by state and federal budget periods (refer to the allocation sheet).
d. Expenses are incurred only during the budget period; no carry forward from previous time periods, or borrowing from future time periods is allowed. Advance payments
are not allowed.
e. Payments for a budget period are limited to the amounts allocated for the budget period for each budget category.
f. Billings are based on actual costs, with back up documentation retained by the LHJ and available for inspection by DOH or other appropriate authorities.
g. Payments will be made only for WIC approved expenditures. Refer to the Washington State WIC Nutrition Program Policy and Procedure Manual Volume 2, Chapter 4 —
Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards.
Special Instructions:
The LHJ shall:
1) Maintain complete, accurate, and current accounting of all local, state, and federal program funds received and expended.
2) Provide, as necessary, a single audit in accordance with the provisions of 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards. This circular requires the LHJ to have a single audit performed should LHJ spend $750,000 or more of federal grants or awards from all sources. The LHJ
is a subrecipient of federal funds.
3) Staff must use Breastfeeding Peer Counseling (BFPC) Program funds only to support the peer counseling program. Once the program is established and peer counselors are
trained, the majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs see Volume 2, Chapter 4 —
Allowable Costs. The priority use of BFPC funds is to hire and train peer counselors to provide breastfeeding peer counseling services to WIC participants.
Special Requirements:
Contract Funding Period
Time Period Special Requirement
Funds Available
Amount
Description of Special Requirement
January 2018- September 2018
January 2018- September 2018
$4,700
Added in the USDA/WIC Program Management "Other" category to fund
training and travel expenses for WIC staff to attend WIC -related trainings.
This doesn't include out of state trainings.
October 2018 - September 2019
October 2018- September 2019
$4,530
Added in the USDA/WIC Program Management "Other" category to fund
training and travel expenses for WIC staff to attend WIC -related trainings.
This doesn't include out of state trainings.
January 2019 — September 2019
January 2019 — September 2019
$6,401
Added in WIC/USDA CSS Other category to fund training and travel expenses
for WIC staff to attend WIC -related trainings. This does not include out of
state trainings.
October 2018 - September 2019
October 2018 - September 2019
$845
Added in the FFY16 Cascades USDA WIC Program Management -MIS
category to fund training and travel expenses for WIC staff to attend Cascades
trainings.
Exhibit A, Statements of Work Page 19 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
AMENDMENT #21
October 2019 — September 2020
October 2019 — December 2019
$2,381
Added in WIC/USDA CSS Other category to fund staff salaries, training and
travel expenses for WIC staff to attend WIC — related trainings. This does not
include out of state trainings.
October 2018 - September 2019
January 2019 - September 2019
$6,400
Added in the CSS Program Management Other category to fund part-time staff
salaries and benefits to support staff completing Cascades training.
October 2019 — September 2020
October 2019 - September 2020
$2,381
Added in the USDA/WIC CSS Program Management Other category to fund
training and travel expenses for all WIC staff to attend WIC- related trainings.
This doesn't include out of state trainings.
October 2019 — September 2020
October 2019 - September 2020
$790
Added in the MIS tech grant category to fund training and travel expenses for
WIC staff to attend Cascades trainings.
October 2018 - September 2019
October 2018 - September 2019
$750
Added in the CSS USDA Program Management category to purchase a
scanner.
October 2018 - September 2019
October 2018 - September 2019
$30
Added in the CSS USDA Program Management category to fund staff time for
Cascades training and rollout activities.
October 2019 — September 2020
October 2019 - September 2020
$640
Added in the CSS USDA Program Management category to fund staff time for
Cascades training and rollout activities.
October 2019 - September 2020
January 2020 - September 2020
$2,270
Added in the USDA WIC Client Services Contracts category to fund training
and travel expenses for all WIC staff to participate in WIC -related trainings.
With this amendment, these training funds may be used to purchase items to
support COVID-19 Remote Access needs. All COVID-19 Remote Access
purchases must be approved by the Local Program Operations supervisor or
designee prior to purchase.
October 2019 - September 2020
January 2020 - September 2020
$260
Added in the WIC/USDA Client Services Contracts category to purchase items
to support COVID-19 Remote Access needs. All COVID-19 Remote Access
purchases must be approved by the Local Program Operations supervisor or
desi nee rior to purchase.
October 2019 - September 2020
January 2020 - September 2020
$1,295
Added in the USDA WIC Nutrition Education category to fund WIC staff to
attend the fall 2020 NWA Nutrition Education and Breastfeeding Conference
or another state approved training.
January 2021 - September 2021
January 2021 - September 2021
$2,450
Added in the USDA WIC Program Management CSS category to fund training
and travel expenses for all WIC staff to participate in WIC -related trainin s.
.January 2021 - September 2021
January 2021 - September 2021
$30,280
Added in the FFY20 USDA Breastfeeding Peer Counseling category to
complete the requirements of operating a USDA Loving Support Breastfeeding
Peer Counseling program.
Other
Any program requirements that are not followed may be subject to corrective action, and may result in monetary fines, repayment of funds, or withholding of Contract payment.
DOH Program Contact DOH Fiscal Contact
Michael Schweizer HSC Chris Keesee, FA
WIC Nutrition Program WIC Nutrition Program
PO Box 47886, Olympia, WA 98504-7886 PO Box 47886, Olympia, WA 98504-7886
mike.schweizer@doh.wa.gov christopher.keesee?_doh.wa.gov
360-236-3714 360-236-3631 or 1-800-841-1410 x 3631
Exhibit A, Statements of Work Page 20 of 20 Contract Number CLH18247-21
Revised as of March 15, 2021
Jefferson County Public Health
Indirect Rate as of January 2018: 32.33%
Indirect Rate as of January 2019: 33.85% Public Health
Indirect Rate as of January 2020: 33.28% Public Health
Indirect Rate as of January 2021: 24.46% Public Health
Federal Award
Chart of Accounts Program Title Identification #
EXHIBIT B-21
ALLOCATIONS
Contract Term: 2018-2021
BARS Statement of Work
Revenue Funding Period
Amend # CFDA* Codex* Start Date End Date
Contract Number:
CLH18247
Date:
March 15, 2021
Funding
Chart of
Period
Accounts
Amount Sub Total
Total
FFY20 USDA BFPC Prog Mgmt
207WAWAIW5003
Amd 21
10.557
333.10.55
10/01/19
09/30/21
10/01/19
09/30/21
$30,280
$30,280
$30,280
FFY21 USDA WIC Program Mgnt CSS
217WAWA7W 1003
Amd 19
10.557
333.10.55
10/01/20
09/30/21
10/01/20
09/30/21
$2,450
$2,450
$183,796
FFY21 USDA WIC Program Mgnt CSS
217WAWA7W1003
Amd 15
10.557
333.10.55
10/01/20
12/31/20
10/01/20
12/31/20
($24,250)
$0
FFY21 USDA WIC Program Mgnt CSS
217WAWA7W1003
Amd 6
10.557
333.10.55
10/01/20
12/31/20
10/01/20
12/31/20
$4,820
FFY21 USDA WIC Program Mgnt CSS
217WAWA7W1003
N/A
10.557
333.10.55
10/01/20
12/31/20
10/01120
12/31/20 '
$19,430
FFY20 USDA WIC Program Mgnt CSS
207WAWA7W1003
Amd 15
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09/30/20
($102,402)
$0
FFY20 USDA WIC Program Mgnt CSS
207WAWA7W1003
Amd 10
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09/30/20
$640
FFY20 USDA WIC Program Mgnt CSS
207WAWA7W 1003
Amd. 8
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09/30/20
$2,381
FFY20 USDA WIC Program Mgnt CSS
207WAWA7W 1003
Amd 6
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09/30/20 '
$21,661
FFY20 USDA WIC Program Mgnt CSS
207WAWA7W 1003
N/A
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09130/20
$77,720
FFY19 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd 10
10.557
333.10.55
10/01/18
09/30/19
10/01/18
09/30/19
$780
$106,856
FFY19 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd 9
10.557
333.10.55
10/01/18
09/30/19
10/01/18
09/30/19 +
$200
FFY19 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd 8
10.557
333.10.55
10/01/18
09/30/19
10/01/18
09/30/19 '
$6,515
FFY19 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd 6
10.557
333.10.55
10/01/18
09/30/19
10/01/18
09/30/19
$17,111
FFY19 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd 5
10.557
333.10.55
10/01/18
09/30/19
10/01/18
09/30/19
$4,530
FFY19 CSS USDA WIC Program Mgnt
187WAWA7W1003
N/A
10.557
333.10.55
10/01/18
09/30/19
10/01/18
09/30/19
$77,720
FFY18 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd 3
10.557
333.10.55
01/01/18
09/30/18
10/01/17
09/30/18 '
$2,800
$74,490
FFY18 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd 2
10.557
333.10.55
01/01/18
09/30/18
10/01/17
09/30/18 I
$4,700
FFY18 CSS USDA WIC Program Mgnt
187WAWA7W1003
Amd. 1
10.557
333.10.55
01/01/18
09/30/18
10/01/17
09/30/18
$8,700
FFY18 CSS USDA WIC Program Mgnt
187WAWA7W1003
N/A
10.557
333.10.55
01/01/18
09/30/18
10/01/17
09/30/18 '
$58,290
FFY22 USDA WIC Client Svs Contracts
NGA Not Received
Amd 19
10.557
333.10.55
10/01/21
12/31/21
10/01/21
12/31/21 '
$26,275
$26,275
$241,936
FFY21 USDA WIC Client Svs Contracts
217WAWA7WI003
Amd 21
10.557
333.10.55
10/01/20
09/30/21
10/01/20
09/30/21
$7,454
$110,729
FFY21 USDA WIC Client Svs Contracts
217WAWA7W1003
Amd 19
10.557
333.10.55
10/01/20
09/30/21
10/01120
09/30/21
$79,025
FFY21 USDA WIC Client Svs Contracts
217WAWA7W1003
Amd 15,19
10.557
333.10.55
10/01/20
09/30/21
10/01/20
09/30/21
$24,250
FFY20 USDA WIC Client Svs Contracts
207WAWA7W1003
Amd 16
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09/30/20 :
$260
$104,932
FFY20 USDA WIC Client Svs Contracts
207WAWA7W 1003
Amd 15
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09/30/20
$102,402
FFY20 USDA WIC Client Svs Contracts
207WAWA7W1003
Amd 12
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09/30/20
$2,270
FFY20 USDA WIC Nutrition Ed
207WAWA7W1003
Amd 17
10.557
333.10.55
10/01/19
09/30/20
10/01/19
09130/20
$1,295
$1,295
$1,295
FFY20 USDA FMNP Prog Mgmt
207WAWA7Y8604
Amd 16
10.572
333.10.57
10/01/19
09/30/20
10/01/19
09/30/20
$481
$481
$1,483
FFY19 CSS USDA FMNP Prog Mgnt
197WAWA7Y8604
Amd 8
10.572
333.10.57
01/01/19
09/30/19
10/01/18
09/30/19
$502
$502
FFY18 CSS USDA FMNP Prog Mgnt
187WAWA7Y8604
Amd 2
10.572
333.10.57
01/01/18
09/30/18
10/01/17
09/30/18 ';
$500
$500
FFY16 Cascades USDA WIC Prog Mgnt-MIS 16157WAWA6W522 Amd. 6, 8 10.578 333,10.57 10/01/18 09/30/19 03/11/16 09/30/19 $845 $845 $845
FFY19 MIS Tech Grant 197WAWAIG5212 Amd 8 10.578 333.10.57 10/01/19 09/30/20 10/01/18 09/30/20 $790 $790 $790
Page 1 of 6
Jefferson County Public Health
Indirect Rate as of January 2018: 32.33%
Indirect Rate as of January 2019: 33.85% Public Health
Indirect Rate as of January 2020: 33.28% Public Health
Indirect Rate as of January 2021: 24.46% Public Health
Federal Award
Chart of Accounts Program Title Identification #
BITV-COVID Ed LHJ Allocation -CARES
BITV-COVID Ed LHJ Allocation -CARES
COVID LHJ OFM Allocation -CARES
PS SSI 1-5 BEACH Task 4
PS SSI 1-5 BEACH Task 4
PS SSI 1-5 BEACH Task 4
PS SSI 1-5 BEACH Task 4
PS SSI 1-5 OSS Task 4
PS SSI 1-5 OSS Task 4
PS SSI 1-5 Subaward Process Task 4
PS SSI 1-5 Subaward Process Task 4
FFY20 Swim Beach Act Grant IAR (ECY-NEP)
FFY20 Swimming Beach Act Grant IAR (ECY)
FFY19 Swimming Beach Act Grant IAR (ECY)
FFY18 Swimming Beach Act Grant IAR (ECY)
FFY17 EPR PHEP BPI LHJ Funding
FFY 17 EPR PHEP BPI LHJ Funding
FFY18 EPR PHEP BPI Supp LHJ Funding
FFY18 EPR PHEP BPI Supp LHJ Funding
FFY20 PHEP BP2 LHJ Funding
FFY20 PHEP BP2 LHJ Funding
FFY19 PHEP BPI LHJ Funding
FFY19 Family Planning Title X
FFY18 Family Planning Title X
FFY17 Family Planning Title X
FFY17 Family Planning Title X
FFY17 317 Ops
FFY17 AFIX
EXHIBIT B-21
ALLOCATIONS
Contract Term: 2018-2021
BARS Statement of Work
Revenue Funding Period
Amend # CFDA* Code** Start Date End Date
Contract Number:
CLH18247
Date:
March 15, 2021
Funding
Chart of
Period
Accounts
Amount Sub Total
Total
NGA Not Received
Amd19
21.019
33321.01
07/01/20
12/30/21
07/01/20
12/30/2111
$129,483
$172,644
$172,644
NGA Not Received
Amd 17,19
21.019
333.21.01
07/01/20
12/30/21
07/01/20
12/30/21 '
$43,161
NGA Not Received
Amd 17,19
21.019
333.21.01
03/01/20
06/30/21
03/01/20
06130/21 '
$638,000
$638,000
$638,000
OIJ18001
Amd 13
66.123
333.66.12
03/01/20
10/31/20
07/01/17
06/30/23
$10,000
$10,000
$32,400
OIJ18001
Amd 9
66.123
333.66.12
03/01/19
10/31/19
07/01/17
06/30/23 ",
$2,000
$12,200
01J18001
Amd 7
66.123
333.66.12
03/01/19
10/31/19
07/01/17
06/30/23
$10,200
OIJ18001
Amd 1
66.123
333.66.12
03/01/18
10/31/18
07/01/17
06/30/23
$10,200
$10,200
OIJ18001
Amd. 19
66.123
333.66.12
05/01/19
12/31/21
07/01/16
08/31/23
$14,800
$314,800
$314,800
OIJ18001
Amd 12,19
66.123
333.66.12
05/01/19
12/31/21
07/01/16
08/31/23
$300,000
OIJ18001
Amd 12
66.123
333.66.12
05/01/19
12/31/20
07/01/16
08/31/23
($300,000)
$0
$0
OIJ18001
Amd 9
66.123
333.66.12
05/01/19
12/31/20
07/01/16
08/31/23
$300,000
CE-OIJ65401
Amd 15
66.456
333.66.45
03/01/20
10/31/20
12/15/19
12/14/20
$2,315
$2,315
$2,315
CU-01J49701-1
Amd 21
66.472
333.66.47
03/01/21
10/31/21
12/15/19
10/31/21 "
$15,000
$15,000
$19,000
OIJ49701
Amd 7
66.472
333.66.47
03/01/19
10/31/19
12/15/18
10/31/19
$2,000
$2,000
OOJ75501
Amd 1
66.472
333.66.47
03/01/18
10/31/18
12/15/17
12/14/18
$2,000
$2,000
NU90TP921889-01
Amd 2
93.069
333.93.06
01/01/18
06/30/18
07/01/17
07/02/18 ±
$1,145
$15,024
$15,024
NU90TP921889-01
N/A
93.069
333.93.06
01/01/18
06/30/18
07101/17
07/02/18
$13,879
NU90TP921889-01
Amd 5
93.069
333.93.06
07/01/18
06/30/19
07/01/18
06/30/19 `
$619
$34,384
$34,384
NU90TP921889-01
Amd 4
93.069
333.93.06
07/01/18
06/30/19
07/01/18
06/30/19
$33,765
NU90TP922043
Amd 18
93.069
333.93.06
07/01/20
06/30/21
07/01/20
06/30/21 '
$13,754
$34,384
$68,768
NU90TP922043
Amd 17,18
93.069
333.93.06
07/01/20
06/30/21
07/01/20
06/30/21
$20,630
NU90TP922043
Amd 10
93.069
333.93.06
07/01/19
06/30/20
07/01/19
0613OY20
$34,384
$34,384
FPHPA006462
Amd 8,12
93.217
333.93.21
04/01/19
06/30/19
04/01/19
03/31/20
$26,467
$26,467
$65,099
FPHPA006359
Amd4
93.217
333.93.21
09/01/18
03/31/19
09/01/18
08/31/19
$19,048
$19,048
FPHPA106286
Amd 3
93217
333.93.21
01/01/18
08/31/18
04/01/17
08/31/18
$13,603
$19,584
FPHPA106286
N/A, Amd 3
93.217
333.93.21
01/01/18
08/31/18
04/01/17
03/31/18 '
$5,981
5NH23IP000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/18 04/01/17 06/30/18 $333 $333 $333
5NH23IP000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/18 04/01/17 06/30/18 ' $1,113 $1,113 $1,113
Page 2 of 6
Jefferson County Public Health
Indirect Rate as of January 2018: 32.33%
Indirect Rate as of January 2019: 33.85% Public Health
Indirect Rate as of January 2020: 33.28% Public Health
Indirect Rate as of January 2021: 24.46% Public Health
Federal Award
Chart of Accounts Proeram Title Identification #
FFY21 COVIDI9 Vaccine Services -CARES
FFY21 COVIDI9 Vaccine Services -CARES
FFY17 Increasing Immunization Rates
FFY20 PPHF Ops
FFY20 PPHF Ops
FFY17 PPHF Ops
FFY21 VFC Ops
FFY21 VFC Ops
FFY20 VFC Ops
FFY17 VFC Ops
FFY19 COVID CARES
FFY19 ELC COVID Ed LHJ Allocation
FFY20 ELC EDE LHJ Allocation
FFY20 CDC COVID-19 Crisis Resp LHJ-Tribe
FFY21 MCHBG LHJ Contracts
FFY20 MCHBG LHJ Contracts
FFY19 MCHBG LHJ Contracts
FFY18 MCHBG LHJ Contracts
FEMA-75 COVID LHJ Allocation
FEMA-75 COVID LHJ Allocation
SFY21 Family Planning Cost Share
SFY21 Family Planning Cost Share
SFY21 Family Planning Cost Share
SFY20 Family Planning Cost Share
SFY20 Family Planning Cost Share
SFY20 Family Planning Cost Share
SFY20 Family Planning Cost Share
SFY20 Family Planning Cost Share
EXHIBIT B-21
ALLOCATIONS
Contract Term: 2018-2021
BARS Statement of Work
Revenue Funding Period
Amend # CFDA* Code** Start Date End Date
NH23IP922619
Amd 20
93.268
333.93.26
07/01/20
12/31/21
NH23IP922619
Amd 19,20
93.268
333.93.26
07/01/20
12/31/21
NH23IP000762
Amd 3, 4
93.268
333.93.26
07/01/18
06/30/19
NH23IP922619
Amd 15
93.268
333.93.26
07/01/19
06/30/20
NH23IP922619
Amd 9
93.268
333.93.26
07/01/19
06/30/20
NH23IP000762
Amd 3, 4
93.268
333.93.26
07/01/18
06/30/19
NH23IP922619
Amd 18
93.268
333.93.26
07/01/20
06/30/21
NH23IP922619
Amd 16, 18
93.268
333.93.26
07/01/20
06/30/21
NH23IP922619
Amd 9
93.268
333.93.26
07/01/19
06/30/20
5NH23IP000762-05-00
N/A
93.268
333.93.26
01/01/18
06/30/18
NU50CK000515
Amd 16,19
93.323
333.93.32
06/01/20
12/31/21
NGA Not Received
Amd 20
93.323
333.93.32
01/01/21
12/31/21
NGA Not Received
Amd 20
93.323
333.93.32
01/15/21
12/31/21
NU90TP922069
Amd 14, 19, 20
93.354
333.93.35
01/20/20
12/31/21
B0440169
Amd 18
93.994
333.93.99
10/01/20
09/30/21
B04MC32578
Amd 10
93.994
333.93.99
10/01/19
09/30/20
B04MC32578
Amd 4
93.994
333.93.99
10/01/18
09/30/19
B04MC31524
N/A
93.994
333.93.99
01/01/18
09/30/18
NGA Not Received
Amd 19
97.036
333.97.03
07/01/20
12/30/20
NGA Not Received
Amd 17
97.036
333.97.03
07/01/20
12/30/20
Amd 21
N/A
334.04.91
07/01/20
06/30/21
Amd 19
N/A
334.04.91
07/01/20
06/30/21
Amd 17,19
N/A
334.04.91
07/01/20
06/30/21
Amd 17
N/A
334.04.91
12/01/19
06/30/20
Amd 12,17
N/A
334.04.91
12/01/19
06/30/20
Amd 16
N/A
334.04.91
12/01/19
06/30/20
Amd 8, 12
N/A
334.04.91
07/01/19
11/30/19
Amd 4, 12
N/A
334.04.91
07/01/19
11/30/19
Page 3 of 6
Contract Number:
CLH18247
Date:
March 15, 2021
Funding
Chart of
Period
Accounts
Amount Sub Total
Total
$354,803
$14,582
$5,600
($500)
$500
$500
$2,800
$2,800
$5,600
$557
$57,656
$168,448
$376,690
$78,522
$36,700
$36,700
$36,700
$27,525
($129,483)
$129,483
$1,136
$40,000
$45,814
($45,814)
$99,263
$16,545
$36,250
$9.761
$369,385
$5,600
$0
$500
$5,600
$5,600
$557
$57,656
$168,448
$376,690
$78,522
$36,700
$36,700
$36,700
$27,525
$0
$86,950
$53,449
$16,545
$46,011
$369,385
$5,600
$500
$11,757
$57,656
$168,448
$376,690
$78,522
$137,625
$0
$348,045
EXHIBIT B-21
Jefferson County Public Health
ALLOCATIONS
Contract
Number:
CLH18247
Contract Term: 2018-2021
Date:
March 15, 2021
Indirect Rate as of January 2018: 32.33%
Indirect Rate as of January 2019: 33.85% Public Health
Indirect Rate as of January 2020: 33.28% Public Health
DOH Use Only
Indirect Rate as of January 2021: 24.46% Public Health
BARS
Statement
of Work
Chart of Accounts
Funding
Chart of
Federal Award
Revenue
Funding Period
Funding Period
Period
Accounts
Chart of Accounts Program Title Identification #
Amend #
CFDA*
Code**
Start Date End Date Start Date End Date
Amount
Sub Total
Total
SFY19 Family Planning Cost Share
Amd 7
N/A
334.04.91
09/01/18
03/31/19
07/01/18
06/30/19
$5,589
$5,589
SFY19 Family Planning Cost Share
Amd. 8
N/A
334.04.91
09/01/18
06/30/19
07/01/18
06/30/19
$1,393
$50,196
SFY19 Family Planning Cost Share
Amd 4
N/A
334.04.91
09/01/18
06/30/19
07/01/18
06/30/19
$48,803
SFY19 Family Planning Cost Share
Amd 3
N/A
334.04.91
07/01/18
08/31/18
07/01/18
06/30/19
$16,311
$16,311
SFY18 Family Planning Cost Share
Amd 1
N/A
334.04.91
01/01/18
06/30/18
07/01/17
06/30/18
$56,987
$72,994
SFY18 Family Planning Cost Share
N/A, Amd 1
N/A
334.04.91
01/01/18
06/30/18
07/01/-17
06/30/18 i
$16,007
Zoonotics-GFS
Amd 9
N/A
334.04.91
07/01/19
06/30/20
07/01/19
06130/21
$4,029
$4,029
$5,000
Zoonotics-GFS
Amd 9
N/A
334.04.91
06/01/19
06/30/19
07/01/17
06/30/19
$971
$971
State Drug User Health Program
Amd 18
N/A
334.04.91
07/01/20
06/30/21
07/01/19
06/30/21
$7,500
$15,000
$30,000
State Drug User Health Program
Amd 16, 18
N/A
334.04.91
07/01/20
06/30/21
07/01/19
06/30/21
$7,500
State Drug User Health Program
Amd 9
N/A
334.04.91
07/01/19
06/30/20
07/01/19
06/30/21
$15,000
$15,000
FY20/21 COVID-19 Disaster Response Acet
Amd 14,19
N/A
334.04.92
01/20/20
06/30/21
01/01/20
06/30/21
$71,478
$71,478
$71,478
FFY21 COVID GFS LHJ Regional
Amd 20
N/A
334.04.92
12/31/20
06/30/21
12/31/20
06130/21
($85,250)
$0
$0
FFY21 COVID GFS LHJ Regional
Amd 19
N/A
334.04.92
12/31/20
06/30/21
12/31/20
06/30/21
$85,250
SFY1 Lead Environments of Children
Amd 1
N/A
334.04.93
01/01/18
06/30/18
07/01/17
06/30/18
$2,000
$2,000
$2,000
Rec Shellfish/Biotoxin
Amd 19
N/A
334.04.93
07/01/19
06/30/21
07/01/19
06/30/21
$3,500
$13,500
$23,250
Rec Shellfish/Biotoxin
Amd 16,19
N/A
334.04.93
07/01/19
06/30/21
07/01/19
06/30/21
$3,500
Rec Shellfish/Biotoxin
Amd 9, 16, 19
N/A
334.04.93
07/01/19
06/30/21
07/01/19
06/30/21
$6,500
Rec Shellfish/Biotoxin
N/A
N/A
334.04.93
01/01/18
06/30/19
07/01/17
06/30/19 1
$9,750
$9,750
Small Onsite Management (ALEA)
Amd 19
N/A
334.04.93
01/01/21
06/30/21
07/01/19
06130/21
$10,151
$10,151
$90,099
Small Onsite Management (ALEA)
Amd 9
N/A
334.04.93
07/01/19
06/30/20
07/01/19
06/30/21
$45,000
$45,000
Small Onsite Management (ALEA)
Amd 9
N/A
334.04.93
07/01/18
06/30/19
07/01/17
06/30/19 !
$4,948
$13,616
Small Onsite Management (ALEA)
Amd 5
N/A
334.04.93
07/01/18
06/30/19
07/01/17
06/30/19
$8,668
Small Onsite Management (ALEA)
Amd 5
N/A
334.04.93
01/01/18
06/30/18
07/01/17
06/30/19 `
($8,668)
$21,332
Small Onsite Management (ALEA)
N/A, Amd 5
N/A
334.04.93
01/01/18
06/30/18
07/01/17
06/30/19
$30,000
Wastewater Management-GFS
Amd 19
N/A
334.04.93
01/01/21
06/30/21
07/01/19
06/30/21
$4,849
$4,849
$59,901
Wastewater Management-GFS
Amd 9,19
N/A
334.04.93
07/01/20
06/30/21
07/01/19
06/30/21
$30,000
$30,000
Wastewater Management-GFS
Amd 9
N/A
334.04.93
07/01/18
06/30/19
07/01/17
06/30/19
($4,948)
$25,052
Wastewater Management-GFS
N/A
N/A
334.04.93
07/01/18
06/30/19
07/01/17
06/30/19 !
$30,000
FFY20 Swim Beach Act Grant IAR (ECY-ALEA)
Amd 15
N/A
334.04.96
03/01/20
10/31/20
12/15/19
12/14/20 -
$1,685
$1,685
$1,685
Page 4 of 6
Jefferson County Public Health
Indirect Rate as of January 2018: 32.33%
Indirect Rate as of January 2019: 33.85% Public Health
Indirect Rate as of January 2020: 33.28% Public Health
Indirect Rate as of January 2021: 24.46% Public Health
Federal Award
Chart of Accounts Program Title Identification #
EXHIBIT B-21
ALLOCATIONS
Contract Term: 2018-2021
BARS Statement of Work
Revenue Funding Period
# CFDA* Code** Start Date End Date
Contract Number:
CLH18247
Date:
March 15, 2021
Funding
Chart of
Period
Accounts
Amount Sub Total
Total
FPHS Funding for LHJs
Amd 17,19
N/A
336.04.25
07/01/20
06/30/21
07/01/19
06/30/21 '
$58,000
$100,000
$242,000
FPHS Funding for LHJs
Amd 11, 19
N/A
336.04.25
07/01/20
06/30/21
07101/19
06/30/21
($4,238)
FPHS Funding for LHJs
Amd 10, 19
N/A
336.04.25
07/01/20
06/30/21
07/01/19
06/30/21
$46,238
FPHS Funding for LHJs
Amd 17
N/A
336.04.25
07/01/19
06/30/20
07/01/19
06/30/21 ;
$58,000
$100,000
FPHS Funding for LHJs
Amd. 11
N/A
336.04.25
07/01/19
06/30/20
07/01/19
06/30/21
($4,238)
FPHS Funding for LHJs
Amd 10
N/A
336.04.25
07/01/19
06/30/20
07/01/19
06/30/21
$46,238
FPHS Funding for LHJs Dir
Amd 3
N/A
336.04.25
07/01/18
06/30/19
07/01/17
06/30/19
$42,000
$42,000
YR 20 SRF - Local Asst (15%)(FS) - SS
Amd 1
N/A
346.26.64
01/01/18
12/31/18
07/01/17
12/31/18
($2,200)
$0
$0
YR 20 SRF - Local Asst (15%)(FS) - SS
N/A
N/A
346.26.64
01/01/18
12/31/18
07/01/17
12/31/18
$2,200
YR 21 SRF - Local Asst (15%) (FS) SS
Amd 10
N/A
346.26.64
01/01/18
06/30/19
07/01/17
06/30/19 "
($2,000)
$0
$0
YR 21' SRF - Local Asst (15%) (FS) SS
Amd 6, 10
N/A
346.26.64
01/01/19
06/30/19
07/01/17
06/30/19
$2,000
YR 22 SRF - Local Asst (15%) (FO-SW) SS
Amd 12
N/A
346.26.64
01/01/19
12/31/20
01/01/10
06/30/21 +
$3,000
$4,800
$4,800
YR 22 SRF - Local Asst (15%) (FO-SW) SS
Amd 10, 12
N/A
346.26.64
01/01/19
12/31/20
01/01/19
06/30/21
$1,800
YR 23 SRF - Local Asst (15%) (FO-SW) SS
Amd 20
N/A
346.26.64
01/01/21
12/31/21
09/01/20
12/31/21
$3,600
$3,600
$3,600
Sanitary Survey Fees (FO-SW) SS State
Amd 12
N/A
346.26.65
01/01/18
12/31/20
07/01/17
06/30/21
$3,000
$4,800
$4,800
Sanitary Survey Fees (FO-SW) SS State
Amd 10, 12
N/A
346.26.65
01/01/19
12/31/20
07/01/17
06/30/21
($200)
Sanitary Survey Fees (FO-SW) SS State
Amd 6,12
N/A
346.26.65
01/01/19
12/31/20
07/01/17
06/30/21
$2,000
Sanitary Survey Fees (FO-SW) SS -State
Amd 1
N/A
346.26.65
01/01/18
12/31/18
07/01/17
12/31/18
($2,200)
$0
Sanitary Survey Fees (FO-SW) SS -State
N/A
N/A
346.26.65
01/01/18
12/31/18
07/01/17
12/31/18
$2,200
YR 20 SRF - Local Asst (15%) (FS) TA
Amd 3
N/A
346.26.66
01/01/18
12/31/18
07101117
12/31/18
($2,000)
$0
$0
YR 20 SRF - Local Asst (15%) (FS) - TA
N/A
N/A
346.26.66
01/01/18
12/31/18
07/01/17
12/31/18
$2,000
YR 21 SRF - Local Asst (15%) (FS) TA
Amd 10
N/A
346.26.66
01/01/18
06/30/19
07/01/17
06/30/19 '
($3,627)
$373
$373
YR 21 SRF - Local Asst (15%) (FS) TA
Amd 6, 10
N/A
346.26.66
01/01/18
06/30/19
0710i/17
06/30/19
$2,000
YR 21 SRF - Local Asst (15%) (FS) TA
Amd 3, 6, 10
N/A
346.26.66
01/01/18
06/30/19
07/01/17
06/30/19
$2,000
YR 22 SRF - Local Asst (15%) (FO-SW) TA
Amd 15
N/A
346.26.66
01/01/19
12/31/20
01/01/19
06/30/21 ?
($1,000)
$3,000
$3,000
YR 22 SRF - Local Asst (15%) (FO-SW) TA
Amd 12
N/A
346.26.66
01/01/19
12/31/20
01/01/19
06/30/21 '
$2,000
YR 22 SRF - Local Asst (15%) (FO-SW) TA
Amd 10, 12
N/A
346.26.66
01/01/19
12/31/20
01/01/19
06/30/21
$2,000
YR 23 SRF - Local Asst (15%) (FO-SW) TA
Amd. 20
N/A
346.26.66
01/01/21
12/31/21
09/01120
12/31/21
$1,000
$1,000
$1,000
Page 5 of 6
EXHIBIT B-21
Jefferson County Public Health ALLOCATIONS Contract Number: CLH18247
Contract Term: 2018-2021 Date: March 15, 2021
Indirect Rate as of January 2018: 32.33%
Indirect Rate as of January 2019: 33.85% Public Health
Indirect Rate as of January 2020: 33.28% Public Health
Indirect Rate as of January 2021: 24.46% Public Health
Federal Award
Chart of Accounts Program Title Identification #
TOTAL
Total consideration: $3,867,649
$53,870
GRAND TOTAL $3,921,519
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with "333". State revenue codes begin with "334".
BARS Statement of Work
Revenue Funding Period
Amend # CFDA* Code** Start Date End Date
Page 6 of 6
Funding
Period
Amount Sub Total
Chart of
Accounts
Total
$3,921,519 $3,921,519
GRAND TOTAL
$3,921,519
Total Fed
$3,030,488
Total State
$8919031
Exhibit C-21 Schedule of Federal Awards
AMENDMENT #21
Date: March 15, 2021
JEFFERSON COUNTY PUBLIC HEALTH-SWV0002430.07
CONTRACT CLH18247-Jefferson County Public
Health
CONTRACT PERIOD: 01/01/2018-12131/2021
DOH
Total Amt Allocation Period
Chart of Accounts Program Title
BARS
Federal
Federal Start
End
Contract
CFDA
CFDA Program Title
Federal Agency Name
Federal Award
Federal Grant Award Name
Award Date
Award Date
Date
Amt
Identification Number
NGA Not
NGA Not
Special Supplemental Nutrition
Department of Agriculture Food
FFY22 USDA WIC CLIENT SVS CONTRACTS
333.10.55
Received
Received 10/01/21
12/31/21
$26,275
10.557
Program for Women, Infants, and
and Nutrition Service
NGA Not Received
NGA Not Received
Children
Special Supplemental Nutrition
Department of Agriculture Food
WOMEN, INFANTS AND CHILDREN (2
FFY21 USDA WIC PROGRAM MGMT CSS
333.10.55
10/01/20
$11,664,919 10/01/20
09/30/21
$2,450
10.557
Program for Women, Infants, and
and Nutrition Service
217WAWA7W1003
YR)
Children
Special Supplemental Nutrition
Department of Agriculture Food
WOMEN, INFANTS AND CHILDREN (2
FFY21 USDA WIC CLIENT SVS CONTRACTS
333.10.55
10/01/20
$11,664,919 10/01/20
09/30/21
$110,729
10.557
Program for Women, Infants, and
and Nutrition Service
217WAWA7W1003
YR)
Children
Special Supplemental Nutrition
Department of Agriculture Food
FFY20 USDA WIC PROGRAM MGMT CSS
333.10.55
10/01/19
$6,161,312 10/01/19
09/30/20
$104,932
10.557
Program for Women, Infants, and
and Nutrition Service
207WAWA7W1003
WOMEN, INFANTS AND CHILDREN
Children
Special Supplemental Nutrition
Department of Agriculture Food
FFY20 USDA WIC NUTRITION ED
333.10.55
10/01/19
$6,161,312 10/01/19
09/30/20
$1,295
10.557
Program for Women, Infants, and
and Nutrition Service
207WAWA7W1003
WOMEN, INFANTS AND CHILDREN
Children
Special Supplemental Nutrition
Department of Agriculture Food
WIC BREASTFEEDING PEER
FFY20 USDA BFPC FROG MGMT
333.10.55
02/18/20
$1,861,572 10/01/19
09/30/21
$30,280
10,557
Program for Women, Infants, and
and Nutrition Service
207WAWA1W5003
COUNSELING
Children
Special Supplemental Nutrition
Department of Agriculture Food
FFY19 CSS USDA WIC PROGRAM MGMT
333.10.55
10/01/17
$40,101,357 10/01/18
09/30/19
$106,856
10.557
Program for Women, Infants, and
and Nutrition Service
187WAWA7W1003
WOMEN, INFANTS AND CHILDREN
Children
Special Supplemental Nutrition
Department of Agriculture Food
FFY18 CSS USDA WIC PROGRAM MGMT
333.10.55
10/02/17
$27,576,710 01/01/18
09/30/18
$74,490
10.557
Program for Women, Infants, and
and Nutrition Service
187WAWA7W1003
USDA -WIC ADMIN
Children
FFY20 USDA FMNP PROG MGMT
333.10.57
10/01/19
$129,791 10/01/19
09/30/20
$481
10,572
WIC Fanners' Market Nutrition
Department of Agriculture -Food
207WAWA7Y8604
COMMODITY ASSISTANCE PROGRAM
Program (FMNP)
and Nutrition Service
FFY19 CSS USDA FMNP FROG MGNT
333.10.57
10/01/18
$130,973 01/01/19
09/30/19
$502
10.572
WIC Farmers' Market Nutrition
Department of Agriculture -Food
197WAWA7Y8604
COMMODITY ASSISTANCE PROGRAM
Program (FMNP)
and Nutrition Service
FFY18 CSS USDA FMNP FROG MGNT
333.10.57
10/01/17
$86,117 01/01/18
09/30/18
$500
10.572
WIC Farmers' Market Nutrition
Department of Agriculture Food
187WAWA7Y8604
COMMODITY ASSISTANCE PROGRAM
Program (FMNP)
and Nutrition Service
FFY19 MIS TECH GRANT
333.10.57
01/28/19
$2,209,026 10/01/19
09/30/20
$790
10.578
WIC Grants to States (WGS)
Department of Agriculture Food
and Nutrition Service
197WAWA1G5212
WIC CONTINGECY
Department of Agriculture Food
WOMEN, INFANTS AND CHILDREN
FFY16 CASCADES USDA WIC FROG MGNT-MIS
333.10.57
03/11/16
$2,224,476 10/01/18
09/30/19
$845
10.578
WIC Grants to States (WGS)
and Nutrition Service
16157WAWA6W522
WIC SAM PROJECTS
COVID LHJ OFM ALLOCATION -CARES
333.21.01
NGA Not
NGA Not 03/01/20
06/30/21
$638,000
21.019
Coronavirus Relief Fund
Department of the Treasury
NGA Not Received
NGA Not Received
Received
Received
Page 1 of 4
Exhibit C-21 Schedule of Federal Awards
AMENDMENT #21
Date: March 15, 2021
JEFFERSON COUNTY PUBLIC HEALTH-SWV0002430.07
CONTRACT CLH18247-Jefferson County Public Health
CONTRACT PERIOD: 01101/2018-1213112021
DOH
Total Amt Allocation Period
Chart of Accounts Program Title
BARS
Federal
Federal Start
End
Contract
CFDA
CFDA Program Title
Federal Agency Name
Federal Award
Federal Grant Award Name
Award Date
Award Date
Date
Amt
Identification Number
BIN-COVID ED LHJ ALLOCATION -CARES
333.21.01
NGA Not
NGA Not 07/01/20
12/30/21
$172,644
21.019
Coronavirus Relief Fund
Department of the Treasury
NGA Not Received
NGA Not Received
Received
Received
....
...
.......
_..
...
_.
_.
Puget Sound Action Agenda
_... _... _.
....
...
PS SSI 1-5 OSS TASK 4
333.66.12
08/02/16
$5,000,000 05/01/19
12/31/21
$314,800
66.123
Technical Investigations and
Environmental Protection Agency
01J18001
PUGET SOUND SHELLFISH
Implementation Assistance
Region 10
STRATEGIC INITIATIVE LEAD
,....._
_. _.....
Program
_ _.. _.
...
.... _ ......,.
... _.....
_.. _.. _.
Puget Sound Action Agenda
Technical Investigations and
Environmental Protection Agency
PUGET SOUND SHELLFISH
PS SSI 1-5 BEACH TASK 4
333.66.12
08/02/16
$9,200,000 03/01/18
10/31/20
$32,400
66.123
Implementation Assistance
Region 10
01J18001
STRATEGIC INITIATIVE LEAD
Program
MARINE SWIMMING BEACH
FFY20 SWIMMING BEACH ACT GRANT IAR (ECY)
333.66.47
09/26/19
$237,000 03/01/21
10/30/21
$15,000
66.472
Beach Monitoring and Notificaiton
Environmental Protection Agency
CU-01J49701-1
MONITORING AND PUBLIC
Program Implementation Grants
Office of Water
NOTIFICATION
FFY20 SWIM BEACH ACT GRANT IAR (ECY-NEP)
333.66.47
01/31/20
$49,000 03/01/20
10/31/20
$2,315
66.472
Beach Monitoring and Notificaiton
Environmental Protection Agency
CE-01J65401
PUGET SOUND PARTNERSHIP
Program Implementation Grants
Office of Water
NATIONAL ESTUARY PROGRAM
MARINE SWIMMING BEACH
FFY19 SWIMMING BEACH ACT GRANT IAR (ECY)
333.66.47
12/01/18
$91,991 03/01/19
10/31/19
$2,000
66.472
Beach Monitoring and Notificaiton
Environmental Protection Agency
OIJ49701
MONITORING AND PUBLIC
program Implementation Grants
Office of Water
NOTIFICATION
MARINE SWIMMING BEACH
FFY18 SWIMMING BEACH ACT GRANT IAR (ECY)
333.66.47
12/15/17
$91,990 03/01/18
10/31/18
$2,000
66.472
Beach Monitoring and Notificaiton
Environmental Protection Agency
o0J75501
MONITORING AND PUBLIC
program Implementation Grants
Office of Water
NOTIFICATION
Department of Health and Human
PUBLIC HEALTH EMERGENCY
FFY20 PHEP BP2 LHJ FUNDING
333.93.06
06/12/20
$11,365,797 07/01/20
06/30/21
$34,384
93.069
Public Health Emergency
Services Centers for Disease
NU90TP922043
PREPAREDNESS (PHEP)
preparedness
Control and Prevention
COOPERATIVE AGREEMENT
Department of Health and Human
PUBLIC HEALTH EMERGENCY
FFY19 PHEP BPI LHJ FUNDING
333.93.06
06/29/19
$11,307,904 07/01/19
06/30/20
$34,384
93.069
Public Health Emergency
Services Centers for Disease
NU90TP922043
PREPAREDNESS (PHEP)
preparedness
Control and Prevention
COOPERATIVE AGREEMENT
.
_...
.:HOSPITAL PREPAREDNESS
Public Health Emergency
Department of Health and Human
PROGRAM AND PUBLIC HEALTH
FFY18 EPR PHEP BPI SUPP LHJ FUNDING
333.93.06
08/01/18
$11,062,782 07/01/18
06/30/19
$34,384
93.069
Preparedness
Services Centers for Disease
NU90TP921889-01
EMERGENCY PREPAREDNESS
Control and Prevention
COOPERATIVE AGREEMENT
Public Health Emergency
Department of Health and Human
HPP AND PHEP COOPERATIVE
FFY17 EPR PHEP BPI LHJ FUNDING
333.93.06
07/18/17
$11,062,782 01/01/18
06/30/18
$15,024
93.069
preparedness
Services Centers for Disease
NU90TP921889-01
AGREEMENT
Control and Prevention
Department of Health and Human
FFY19 FAMILY PLANNING TITLE X
333.93.21
03/26/19
$4,100,000 04/01/19
06/30/19
$26,467
93.217
Family Planning Services
Services Office of Population
FPHPA006462
TITLE X FAMILY PLANNING SERVICES
Affairs
Department of Health and Human
FFY18 FAMILY PLANNING TITLE X
333.93.21
09/12/18
$2,783,000 09/01/18
03/31/19
$19,048
93.217
Family Planning_Services
Services Office of Population
FPHPA006359
TITLE X FAMILY PLANNING SERVICES
Affairs
Department of Health and Human
TITLE X FAMILY PLANNING SERVICES
FFY17 FAMILY PLANNING TITLE X
333.93.21
03/30/17
$1,940,000 01/01/18
08/31/18
$19,584
93.217
Family Planning_Services
Services Office of Population
FPHPA106286
GRANT
Affairs
Page 2 of 4