HomeMy WebLinkAbout012422ca04 615 Sheridan Street
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Ai/0aon www.JeffersonCountyPublicHealth.org
Consent Agenda
Public Healt
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, Interim County Administrator
FROM: Apple Martine, Director
Denise Banker, Community Health Director
DATE: J,Ititokafy
a tit a aa-0),
SUBJECT: Agenda Item — Amendment #1 to Professional Services Agreement with
Kitsap Public Health District; July 1, 2021 —June 30, 2022; additional
$27,380
STATEMENT OF ISSUE:
Jefferson County Public Health requests Board approval of Amendment No. 1 to the Professional Services
Agreement with Kitsap Public Health District to extend the period of the contract and increase funding; July1,
2021 —June 30, 2022; additional $27,380.00 income generating.
ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S:
This amendment is needed to extend the agreement expiration date from December 31, 2021 to June 30, 2022
and to increase funding by an additional $27,380 for a total compensation not to exceed $54,761. The purpose
of this contract agreement is for Kitsap Public Health District to retain JCPH to develop and implement
coordinated tobacco, vapor and marijuana product prevention and intervention strategies to prevent and
reduce tobacco and marijuana use by youth in Jefferson County. Allocated funding and period of performance
for this agreement has been extended by Washington Department of Health.
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.
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
N-21-027-A1
RECOMMENDATION:
JCPH management request approval of Amendment No. 1 to the Professional Services Agreement with Kitsap
Public Health District; July 1, 2021 -June 30, 2022; additional $27,380.00 income generating.
REVIEWED BY:
2-0
Mark McCauley, Inter ounty Administrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 (t) 360-379-4487
360-385-9401 (f) Always working for a safer and healthier community
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: Jefferson Healthcare(Public Hospital District No.2) Contract No: N-18-096-A3
Contract For: School-based health care Term: 9/2/18-8/31/22
COUNTY DEPARTMENT: Jefferson County Public Health
Contact Person: Denise Banker
Contact Phone: X438
Contact email: dbanker@co.jefferson.wa.us
AMOUNT: $67,536 PROCESS: �Exempt from Bid Process
Revenue: $67,536 Cooperative Purchase
Expenditure: — Competitive Sealed Bid
Matching Funds Required: Small Works Roster
Sources(s)of Matching Funds — Vendor List Bid
Fund# 127 _ RFP or RFQ
Munis Org/Obj 12756220 _Other:
APPROVAL STEPS:
STEP 1:DEPARTMENT CERTIFIES COM C CC 3.55.080 AND CHAPTER 42.23 RCW.
CERTIFIED: El N/A:0 1/13/22
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT B DEB D BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: E1 N/A: ® 1/13/22
Signature Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 1/13/2022.
STEP 4: PROSECUTING ATTORNEY REVIEW(will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 1/14/2022.
Contract amendment.
STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY(IF REQUIRED).
STEP 6: CONTRACTOR SIGNS
STEP 7: SUBMIT TO BOCC FOR APPROVAL
1
KPHD 2182
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PROFESSIONAL SERVICES AGREEMENT
Between
KITSAP PUBLIC HEALTH DISTRICT
And
JEFFERSON COUNTY PUBLIC HEALTH
This Professional Services Agreement("Agreement")is made and entered into between the Kitsap Public
Health District,a Health District organized pursuant to chapter 70.46 Revised Code of Washington and
Section 9.52 Kitsap County Code, hereinafter referred to as"District,"and Jefferson County Public Health,
hereinafter referred to as "Subrecipient." The parties mutually agree as follows:
1. Period of Performance: The period of performance of this Agreement shall begin July 1, 2021 and
be completed no later than December 31, 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,vapor product,and marijuana intervention strategies to prevent and reduce
commercial tobacco,vapor, and marijuana use by youth in Jefferson County.
3. Qualifications/Eligibility: Subrecipient shall have the qualifications necessary to successfully
complete the objectives of this Agreement. The Subrecipient hereby affirms that he/she is eligible to
work in the United States as set forth in the Immigration Reform and Control Act(IRCA).
4. Statement of Work and Budget: Subrecipient shall furnish the necessary personnel,equipment
material,and/or services and otherwise do all things necessary for or incidental to the performance
of the work set forth in ATTACHMENT A and ATTACHMENT B, attached hereto and
incorporated herein.ATTACHMENT A contains the Scope of Work and Budget concerning
commercial tobacco and vaping prevention activities.ATTACHMENT B contains the Scope of
Work and Budget for marijuana prevention activities.
5. Compensation: This Agreement is funded by state and federal funds. The District agrees to pay
Subrecipient a total sum of$27,381 in federal and state funds during the Agreement.The District
shall reimburse Subrecipient for travel as applicable at the federally approved rate.Compensation
will be based on invoices submitted by Subrecipient itemizing a detailed description of services
performed per the agreed upon Scopes of Work and Budgets set forth respectively in
ATTACHMENTS A and B.
Subrecipient shall submit a Monthly Expenditure Report and Request for Reimbursement(Form A-
19) invoice voucher,hereto attached and herein incorporated as ATTACHMENT C,to the District
for payment.
6. Performance Requirements and Notices: The assigned District staff shall monitor the
performance of this Agreement,approve billings submitted by Subrecipient,and determine the
acceptability of any reports provided by Subrecipient.District staff shall provide and facilitate
assistance and guidance to Subrecipient as necessary.
The District reserves the right to conduct periodic performance and billing reviews after the
execution of this Agreement in order to evaluate unspent/unclaimed funds.The District reserves for
itself the authority to reallocate funding pending the outcome of such a review.
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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 6th Street, Suite 300 615 Sheridan Street
Bremerton,WA 98337 Port Townsend, WA 98368
(360)728-2275 (360)385-9408
Yolanda.Fong@kitsappublichealth.org Vkirkpatrick(ico jefferson.wa.us
7. Special Billing Requirements:Billings to the District shall be submitted no more frequently than
every 30 days, and shall be quarterly at a minimum.Billings for services on a monthly fraction of
the budget will not beaccepted or approved.Billings shall be sent to:
Kitsap Public Health District
Melissa Laird
345 6th Street,Suite 300
Bremerton,WA 98337
(360)728-2283
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 20th of each month in order to receive
reimbursement for the previous month. If the District does not receive the A-19 by the 20th of the
month with the required deliverables,the District may withhold approval and payment at its
discretion.
The District will pay Subrecipient all allowable costs incurred as evidenced by proper invoice of
Subrecipient submitted to the District on a timely basis,insofar as those allowable and allocable
costs do not exceed the amount appropriated or otherwise available for such purposes as stated
herein or in subsequent amendments.
Backup documentation will be provided to the District with invoice.Backup documentation can
include,but is not limited to:receipts,invoices,billing records,work orders,positive time and
attendance records(timesheets),travel vouchers and accounting expense reports.
Failure to provide the required information may result in nonpayment of invoices or termination of
this Agreement.
This is a subrecipient contract.All expenditures incurred,and reimbursements made for
performance under this Agreement 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 Agreement Unexpended funds in each fiscal year may not be carried
forward into the new budget period unless otherwise approved by the District.
For information in determining allowable costs,indirect rates and pass through agency requirements,
such as fiscal monitoring of Subrecipients,please reference the document titled"Uniform
Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards:" (2
Code of Federal Regulation CFR 200).
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Email submission of invoices,electronic reports,and deliverables is encouraged.However, original
hardcopy of the A-19 is required and shall be mailed to the District.
Upon expiration of the Agreement,any claim for payment not already made shall be submitted to the
District within 20 days after the expiration date.
8. Independent Capacity: Subrecipient and its employees or agents who are engaged in the
performance of this Agreement shall continue to be employees or agents of Subrecipient and shall
not be considered to be employees or agents of the District for any purpose.
9. Rights in Data: Unless otherwise provided,data which originates from this Agreement shall be
"works for hire"as defined by the U.S. Copyright act of 1976 and shall be owned by the District.
Data shall include,but not limited to, reports,documents,pamphlets,advertisements,books,
magazines,surveys,studies,computer programs,films,tapes,and/or sound reproductions.
Ownership includes the right to copyright,patent,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.However, that in the case of negligence of both the District and the
Subrecipient,any damages allowed shall be levied in proportion to the percentage of negligence
attributable to each party. 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
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Subrecipient's Commercial General Liability insurance policy with respect to the work
performed for the District.
3. Workers'Compensation coverage as required by the Industrial Insurance laws of the state of
Washington.
4. Professional Liability insurance appropriate to the Subrecipient's profession.Subrecipient
shall provide the District with proof of liability insurance or professional errors and
omissions coverage as appropriate.
B. Minimum Amounts of Insurance
Subrecipient shall maintain the following insurance limits:
1. Automobile Liability insurance with a minimum combined single limit for bodily injury and
property damage of$1,000,000 per accident
2. Commercial General Liability insurance shall be written with limits no less than$1,000,000
each occurrence,$2,000,000 general aggregate.
3. Professional Liability insurance shall be written with limits no less than $1,000,000 per claim
and$1,000,000 policy aggregate limit.
C. Other Insurance Provisions
The insurance policies are to contain,or be endorsed to contain,the following provisions for
Automobile Liability,Professional Liability and Commercial General Liability insurance:
1. Subrecipient's insurance coverage shall be primary insurance as respect the District.Any
insurance,self-insurance,or insurance pool coverage maintained by the District shall be
excess of Subrecipient's insurance and shall not contribute with it.
2. Subrecipient's insurance shall be endorsed to state that coverage shall not be cancelled by
either party,except after thirty(30)days prior written notice by certified mail,return receipt
requested,has been given to the District.
D. Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M. Best rating of not less than A:VII.
E. Verification of Coverage
Subrecipient shall furnish the District with original certificates and a copy of the amendatory
endorsements, including but not necessarily limited to the additional insured endorsement,
evidencing the insurance requirements of Subrecipient before commencement of the work.
12. Safeguarding of Information and Privacy: The use or disclosure by any party of any information
concerning a client obtained in providing service under this Agreement shall be subject to Chapter
42.56 RCW and Chapter 70.02 RCW, as well as 45 CFR Parts 160 and 164 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
KPHD 2182
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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)728-2232. 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.
Records and other documents,in any medium,furnished by one party to this Agreement to the other
party,will remain the property of the furnishing party,unless otherwise agreed. The receiving party
will not disclose or make available this material to any third parties without first giving notice to the
furnishing party and giving that party a reasonable opportunity to respond. Each party will utilize
reasonable security procedures and protections to assure that records and documents provided by the
other party are not erroneously disclosed to third parties.
14. Written Policies and Procedures/Documents on File: Written policies and procedures,consistent
with federal and state regulations,as applicable,will be kept on file in the office of the Subrecipient
and available for review at the request of District staff. Such policies and procedures will include,
but not be limited to,as appropriate:
• Job Descriptions
• Confidentiality Policy
• Community Needs Assessment
• 5-Year Regional Strategic Plan (includes biennial work plan)
Special Instructions:
a. Subrecipient must conduct criminal background checks for those staff,volunteer,contractor,
or subcontractor working directly with youth(ages 0-17).
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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 Agreement. 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 D.
18. Certification Regarding Suspension and Debarment: Subrecipient,by completing and returning
to the District the"Debarment, Suspension,Ineligibility or Voluntary Exclusion Certification
Form,"and completing,signing and returning to the District the"Certification Regarding
Debarment, Suspension,Ineligibility or Voluntary Exclusion for Lower Tier Covered Transactions"
form,(to be supplied to lower tier participants;see ATTACHMENT E), certifies that it is not
debarred,suspended,or proposed for debarment by any federal agency.
19. Federal Funding Restrictions and Limitations:Please see ATTACHMENTS A and B for
restrictions and limitations.
20. Suspension of Performance and Resumption of Performance: In the event contract funding from
state,federal,or other sources is withdrawn,reduced,or limited in any way after the effective date of
this Agreement and prior to normal completion,the District may give notice to Subrecipient to
suspend performance as an alternative to termination. The District may elect to give written notice
to Subrecipient to suspend performance when the District determines that there is a reasonable
likelihood that the funding insufficiency may be resolved in a timeframe that would allow
performance to be resumed prior to the end date of this Agreement. Notice may occur by facsimile
or email to Subrecipient's representative. Subrecipient shall suspend performance on the date stated
in the written notice to suspend. During the period of suspension of performance,each party may
KPHD 2182
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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 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.
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27. Termination for Funding: If funding for the Agreement or matter is withdrawn, reduced or limited
in any way after the Agreement is signed or becomes effective,the Parties may summarily terminate
the Agreement notwithstanding any other termination provision in the Agreement. Termination
under his provision will be effective upon the date specified in the written notice of termination.No
costs incurred after the effective date of the termination will be paid.
28. Choice of Law: This Agreement is entered into pursuant to and under the authority granted by the
laws of the State of Washington and applicable federal laws, both as to its interpretation and
performance.The provisions of this Agreement shall be construed to conform to those laws.Any
action at 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.
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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.
KITSAP P LIC H LTH DISTRICT JEFFERSON COUNTY
BOARD OFOUNTY COMMISSIONERS
By: By: r✓'
LA
Keit Grellner,Administrator Kate D an,BOCC Chair
Date: /77/20 Date: 6, Z
Approved as to Form:
t
' July 19, 2021
Philip Hunsucker,Chief Civil Deputy
Prosecutor
ATTEST:
Cam( 6 l v✓C i
Carolyn' allaway,Clerk4f the Board
Funding Source
•
Program: CH
Contract/Grant: DOH Con Con CLH18248 (KPHD 1749)
KPHD 2182
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ATTACHMENT A—COMMERCIAL TOBACCO PREVENTION PROGRAM
Scope of Work and Budget
Jefferson County Public Health
July 1,2021 —December 31,2021
As a subrecipient of KPHD under the Washington Department of Health funded Youth Cannabis &
Commercial Tobacco Prevention Program (YCCTPP), Jefferson County agrees to the following activities
for Commercial Tobacco Prevention funded in full or part by the associated budget.
Activity
Planning Participate in statewide commercial tobacco prevention coalition meetings as
established.
2021-2022 DOH Regional Requirements:
1. In collaboration with priority population contractors,engage and educate
internal and external decision makers,stakeholders,and community leaders
about:
a. The value of local control in preventing initiation and continued
use of commercial tobacco products that lead to tobacco-related
health issues and health disparities.
b. The value of a comprehensive tobacco prevention program to
prevent the initiation of commercial tobacco product use among
youth and young adults.
c. Evidence-based and promising policy options to address the appeal
of commercial tobacco products to youth and young adults,
including the impact of commercial tobacco product flavors
(including menthol)on youth initiation and use.
Implementation 2. Build or enhance partnerships with youth-serving organizations and local
champions(including identifying youth champions)to collaborate on youth
access and industry marketing interventions.
3. Plan and conduct a minimum of one meeting with the prevention-
intervention lead at your region's Educational Service District to establish a
connection,build relationships,and share resources.
4. Promote the Washington State Quitline and self-help options for TUDT
(Tobacco Use,Dependence,Treatment),including 2Morrow Health app
(doh.wa.gov/quit)and This is Quitting(doh.wa.gov/vapefreewa),to people
who use commercial tobacco.
5. In collaboration with CTPP, incorporate 2022-2022 Centers for Disease
Control and Prevention(CDC)(e.g.,Tips®campaign)materials into
agency communications,and report efforts in a template provided by the
CTPP as part of the monthly reporting requirement.
6. Disseminate TUDT resources provided by CTPP and/or developed locally
to community-based organizations,centers,and networks supporting
disparately affected communities that address emerging tobacco/e-
KPHD 2182
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cigarettes and are culturally&linguistically appropriate,trauma-informed,
&equity-based.
7. 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; technical
assistance requests to colleges/universities on the adoption and
implementation of tobacco-and vape-free campuses;and to technical
assistance to multi-unit housing organizations,landlords,and residents on
smoke-and/or vape-free policies.
8. 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.
Specific Jefferson County activities are described in the 2021-2022 CTPP
workplan. Workplans are subject to change.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 5th of every month.
Midterm By February 1,2022 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
Health;respond to activity assessments/surveys administered by KPHD as
appropriate per scope of work.
Submit monthly invoices by the 20th of the month following the month in which
costs were incurred,except for the Final Expenditure Report and Request for
Invoicing Reimbursement in each federal fiscal year(due July 1, 2022). Invoices must include
supporting documentation such as timecards for staff time and copies of invoices
paid for goods and services.
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Budget July 1,2021 —December 31,2021
Cost J)w? Jtion, .,
Staff Salary 3645.36
Benefits 1383.56
Indirect 1230.08
Goods & Services
Mileage
Travel/Training
Total Jefferson 6259.00
Funding Source
Chart of Accounts Program Name or
CFDA# BARS Code
Tithe7/1121 1 31121
FFY21 Tobacco-Vape Prey Comp 1 (CDC) 93.387 333.93.38 $6,259
Total to Jefferson $6,259
Subrecipient DUNS Number: 184826790
Subrecipient Indirect Rate: 24.26% of salary
Research and Development: No
Federal Funding Accountability and Transparency Act(FFATA): The Statement of Work is
supported by federal funds that require compliance with the Federal Funding Accountability and
Transparency Act(FFATA) or the Transparency Act. The purpose of the Transparency Act is to make
information available online so the public can see how the federal funds are spent.To comply with this
act and to be eligible to perform the activities in this statement of work, the Local Health Jurisdiction
(LHJ)must have a Data Universal Numbering System(DUNS) number.Information about the LHJ and
this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-
282.
Federal Funding Restrictions and Limitations:
a. Recipient may not use federal funds for lobbying.
b. Recipient may not use funds for research.
c. Recipient may not use funds for clinical care.
d. Recipient may not use funds to supplant existing state funding or to supplant funds from
federal or state sources.
e. Recipient may use funds only for reasonable program purposes,including personnel,travel,
supplies,and sources.
f. Recipient are the direct and primary recipients in a cooperative agreement program and must
perform a substantial role in carrying out project outcomes and not merely serve as a conduit
for an award to another party or provider who is ineligible.
g. Recipient are generally not allowed to use funds to purchase furniture or equipment.Any
such proposed spending must be clearly identified in the budget.
h. Recipient may not be reimbursed for pre-award costs.
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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.
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ATTACHMENT B—YOUTH MARIJUANA PREVENTION
Scope of Work and Budget
Jefferson County Public Health
July 1,2021 —December 31,2021
As a subrecipient of KPHD under the Washington State funded Youth Cannabis& Commercial Tobacco
Prevention Program (YCCTPP), Jefferson County agrees to the following Youth Marijuana Prevention
activities funded in full or part by the associated budget.
Activity
Planning Participate in Regional Network,hold a position on the Strategic Planning Team.
As a member of the Strategic Planning Team,help to:
1. Update the 2022-2023 Olympic Region YMPEP Needs Assessment,
including the Community Readiness Assessment.
2. Update the 2022-2023 Olympic Region YMPEP Strategic Plan,per DOH
guidance.
Education Participate in a minimum of one skill enhancement opportunity per month.
Implementation 1. 2021-2022 DOH Approved Regional Strategies:
• PSE Priority 1: Local Laws &Ordinances
• PSE Priority 2: Community Norms
• PSE Priority 3: Retailer Consumer Education
• PSE Priority 4: Health Care Policy &Procedures
2. Specific Jefferson County activities are described in the 2021-2022
YMPEP workplan. Work plans are subject to change.Any changes will
be approved by both parties.
3. Participate in statewide collaboration on the strategies listed above. More
detail for how to participate is listed within work plan.
Monitoring and Monitor progress for each activity as appropriate; submit monthly narrative and
Reporting data reports as requested by KPHD on the 5th of every month.
Calls/Meetings Participate in monthly check-in call with regional lead. Attend and participate in
Regional Network and Planning Team meetings;review correspondences related
to YMPEP; respond to activity assessments/surveys administered by KPHD as
appropriate per scope of work. Attend at least one statewide All-Providers
Meeting or Practice Collaborative Meeting.
Mid-Year By February 1,2022 report progress to YMPEP Regional Coordinator.If needed,
Evaluation adjust activities to ensure spend down.Conduct a work plan reevaluation.
Invoicing Submit monthly invoices by the 20th of the month following the month in which
costs were incurred,except for the Final Expenditure Report and Request for
Reimbursement in each federal fiscal year(due July 1,2022). Invoices must
include supporting documentation such as timecards for staff time and copies of
invoices paid for goods and services.
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Budget July 1,2021 —December 31,2021
Cost Description
Staff Salary $7,039
Benefits $3,139
Goods & Services $7,664 Materials to implement Peer-2-Peer program;
informational material for targeted Jefferson County
residents to address low readiness ratings
Training/Travel $750 Travel to the 4 school districts for meetings;travel for
quarterly regional meetings
Indirect $2,530
Total Jefferson $21,122
Funding Source
Chart of Accounts Program Name or Title CFDA# BARS 7/1/21-12/31/21
Code
SFY22 Marijuana Tobacco Edu n/a 334.04.93 $21,122
Community Resources: Subrecipient shall make a reasonable and ongoing effort,throughout the period
of performance,to secure and/or leverage resources from private and public entities to supplement the
administrative,operational,and implementation costs under this program. Documentation of any
collaborative efforts and securing of resources that benefit this project shall be kept current and on file in
the office of the Subcontractor and be available for review upon request by District staff.
Funding Restrictions and Limitations:
a. Recipient may not use funds for research.
b. Recipient may not use funds for clinical care.
c. Recipient may only expend funds for reasonable program purposes, including personnel,
travel,supplies,and services, such as contractual.
d. Recipient may not generally use funding for the purchase of furniture or equipment.
However, if equipment purchase is integral to a selected strategy,it will be considered. Any
such proposed spending must be identified in the budget and approved by the District.
e. Recipient may not use funding for construction.
f. Recipient must comply with District guidance on food,incentives and use of District or DOH
logo outlined in YMPEP Regional Implementation Guide and should not exceed federal per
diem rates.
g. Reimbursement of pre-award costs is not allowed.
FORM STATE OF WASHINGTON EXHIBIT C Page A-11
A 19 lA ? INVOICE VOUCHER
(Rev. 1/91) _ AGENCY NO. LOCATION CODE P.R.ORAUTHNO.
AGENCY NAME
INSTRUCTION TO VENDOR OR CLAIMANT:Submit this
form to claim payment for materials,merchandiseorservices.
Kitsap Public Health District Show complete detail for each item.
Attn:Melissa Laird
345 6th St,Suite 300 VENDOR'S CERTIFICATE.I hereby certify under penalty
Bremerton, WA 98337-1866 of perjury that the items and totals listed herein are proper
charges for materials,merchandise or services furnished
to the State of Washington,and that all goods furnished
and/or services rendered have been provided without
VENDOR OR CLAIMANT (Warrant is to be payable to) discrimination on the grounds of race,creed,color,
national origin,sex,or age.
BY
(DATE)
FEDERAL I.D.NO.OR SOCIAL SECURITY NO. RECEIVED BY DATE RECEIVED
UNIT FOR AGENCY
DATE DESCRIPTION QUANTITY UNIT PRICE AMOUNT USE
Services provided in performance of contract
Billing period: to
Total Tobacco Expenses
YMPEP Expenses
TOTAL DUE: $ -
PREPARED BY TELEPHONE NUMBER DATE AGENCY APPROVAL DATE
DOC.DATE PMT DUE DATE CURRENT DOC.NO. REF.DOC.NO. VENDOR NUMBER VENDOR MESSAGEIUSETAX U8I NUMBER
REF M MASTER INDEX SUB WKCLAS COUNT CITY I AMOUNT INVOICE NUMBER
DOC TRAN! 0 FUNC APPN PROGRAM SUB SUB ORG BDGT SUB PROJ
SUF CODE D INDEX INDEX OBJ INDEX ALLOC UNIT MOS PRJT PROJ PHAS
ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NO.
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ATTACHMENT D
HIPAA BUSINESS ASSOCIATE AGREEMENT
This Agreement("Agreement")is entered into by and between the Kitsap Public Health District
("Covered Entity")and Jefferson County Public Health("Business Associate").
Section I: Purpose
Performance of the Underlying Agreement may require Business Associate to use or disclose
protected health information that is subject to provisions of the Health Insurance Portability and
Accountability Act of 1996, set forth in 45 C.F.R. Parts 160 and 164 (commonly known as the
"HIPAA Rules").
The purpose of this Agreement is to set forth the obligations of the Parties with regard to the way
in which protected health information is created,used, disclosed,maintained,provided or
received on behalf of Covered entity by the Business Associate.
Section II.Definitions
The following terms used in this Agreement shall have the same meaning as those terms in the
HIPAA Rules:Breach, Data Aggregation,Designated Record Set,Disclosure,Health Care
Operations,Individual,Minimum Necessary,Notice of Privacy Practices,Protected Health
Information,Required by Law, Secretary,Security Incident, Subcontractor,Unsecured Health
Information,and Use.
Specific Definitions:
1. Business Associate."Business Associate"shall generally have the same meaning as the
term"business associate"at 45 CFR 160.103, and in reference to this Agreement shall
mean Clallam County Health&Human Services.
2. Covered Entity."Covered Entity"shall generally have the same meaning as the term
"covered entity"in 45 CFR 160.103, and in reference to the party in this Agreement shall
mean the Kitsap Public Health District.
3. HIPAA Rules. "HIPAA Rules"shall mean the Privacy, Security,Breach Notification,
and Enforcement Rules at 45 CFR Part 160 and 164.
Section III.Obligations and Activities of Business Associate
Business Associate agrees to:
1. Not use or disclose protected health information other than as permitted or required by
the Agreement or as required by law.
1
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2. Use appropriate safeguards,and comply with Subpart C of 45 CFR, Part 164 with respect
to protected electronic health information and to prevent use or disclosure of protected
health information other than as provided for by this Agreement.
3. Report to Covered Entity any use or disclosure of protected health information not
provided for by this Agreement of which it becomes aware,including breaches of
unsecured protected health information as required by 45 CFR 164.410, and any security
incident of which it becomes aware.
Business Associate agrees to promptly notify covered entity following the discovery of a
Breach of unsecured PHI. A Breach is considered"discovered"as of the first day on
which the Breach is known, or reasonably should have been known,to Business
Associate or any employee,officer or agent of Business Associate,other than the
individual committing the Breach.Any notice of a Security Incident or Breach of
Unsecured PHI shall include the identification of each Individual whose PHI has been, or
is reasonably believed by Business Associate to have been,accessed,acquired,or
disclosed during such Security Incident or Breach as well as any other relevant
information regarding the Security Incident or Breach.
4. In accordance with 45 CFR 164.502(e)(1)(ii)and 164.308(b)(2),if applicable,ensure that
any subcontractors that create,receive, maintain,or transmit protected health information
on behalf of the Business Associate agree to the same restrictions,conditions,and
requirements that apply to the Business Associate with respect to such information.
5. Business Associate agrees to mitigate,to the extent possible,any harmful resulting from
use or disclosure of PHI by Business Associate or its agents or subcontractors,in
violation of the requirements of this Agreement.
6. Maintain and make available protected health information in a designated record set to
the Covered Entity as necessary to satisfy Covered Entity's obligations under 45 CFR
164.524.
If an Individual makes a request for access to the protected health information directly to
Business Associate,business associate shall notify covered entity within three(3)
business days of such request and shall cooperate with the Covered Entity to send the
response to the Individual.
7. Make any amendment(s)to protected health information in a designated record set as
directed or agreed to by the Covered Entity pursuant to 45 CFR 164.526, or take other
measures as necessary to satisfy Covered Entity's obligations under 45 CFR 164.526.
If an Individual makes a request for amendment to the protected health information
directly to Business Associate,Business Associate shall notify Covered Entity within
three(3)business days of such request and shall cooperate with the Covered Entity to
send the response to the Individual.
2
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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.
3
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Section V. Termination
1. Term.The Agreement shall terminate on June 30, 2022 or on the date Covered Entity
terminates for cause,whichever is sooner.
2. Termination for Cause. Business Associate authorizes termination of the Agreement if
Covered Entity determines Business Associate has violated a material term of the
Agreement and has not cured the breach or ended the violation within the time specified
by Covered Entity.
3. Obligations of Business Associate Upon Termination.Upon termination of this
Agreement for any reason Business Associate shall return or destroy all protected health
information received from Covered Entity,or created or received by Business Associate
on behalf of Covered entity.This provision shall apply to protected health information
that is in the possession of subcontractors or agents of Business Associate.Business
Associate shall retain no copies of the protected health information.
In the event that Business Associate determines that returning or destroying the protected
health information is infeasible,Business Associate shall provide to Covered Entity
notification of the conditions that make return or destruction infeasible.Upon mutual
agreement of the Parties that return or destruction of protected health information is
infeasible,Business Associate shall extend the protections of this Agreement to such
protected health information and limit further uses and disclosures of such protected
health information to those purposes that make the return or destruction infeasible,for so
long as Business Associate maintains such protected health information.
4. The obligations of Business Associate under this section shall survive the termination of
this Agreement.
Section VI. Miscellaneous
1. A reference in this agreement to a section in the HIPAA Rules means the section as in
effect or amended.
2. The Parties agree to take such action as is necessary to amend this Agreement from time
to time as is necessary for compliance with the HIPAA Rules and any other applicable
law.
3. Any ambiguity in this Agreement shall be resolved to permit compliance with the HIPAA
Rules.
4
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FEDERAL COMPLIANCE
AND STANDARD FEDERAL CERTIFICATIONS AND ASSURANCES
In the event federal funds are included in this agreement, added by futureamendment(s),
or redistributed between fund sources resulting in the provision of federal funds, the
following sections apply: I.Federal Compliance and II.Standard Federal Assurances and
Certifications. In the instance of inclusion of federal funds as a result of an amendment,
the Contractor may be designated as a subrecipient and the effective date of the
amendment shall also be the date at which these requirements go
I. FEDERAL COMPLIANCE - The use of federal funds requires additional compliance and control
mechanisms to be in place. The following represents the majority of compliance elements that
may apply to any federal funds provided under this contract. (Refer to Catalog of Domestic
Assistance number(s) cited in the "Payment" section of this contract for requirements specific to
that fund source.) For clarification regarding any of these elements or details specific to the federal
funds in this contract, contact:
Compliance and Internal Control Officer
Office of Financial Services
Department of Health
Post Office Box 47901
Olympia, Washington 98504-7901
1. UNIFORM ADMINISTRATIVE GUIDANCE —The Uniform Administrative Guidance (Supercircular)
became effective December 26, 2014 and combines numerous OMB Circulars into one document.
This document establishes requirements which govern expenditure of federal funds. These
requirements apply to the Department of Health, as the primary recipient of federal funds, and then
follow the funds to the subrecipient. The Uniform Administrative Guidance provides the applicable
administrative requirements, cost principles and audit requirements are identified by subrecipient
organization type.
COMPLIANCE MATRIX
OMB CIRCULAR
ENTITY TYPE ADMINISTRATIVE COST AUDIT
REQUIREMENTS PRINCIPLES REQUIREMENTS
State. Local and Indian Tribal 2 CFR 200 2 CFR 200 2 CFR 200
Governments &Governmental Subpart D Subpart E Subpart F
Hospitals
Non-Profit Organizations 2 CFR 200 2 CFR 200 2 CFR 200
Subpart D Subpart E Subpart F
Hospitals 2 CFR 200 45 CFR 74 2 CFR 200
Subpart D Appendix E Subpart F
Colleges or Universities &Affiliated 2 CFR 200 2 CFR 200 2 CFR 200
Hospitals Subpart D Subpart E Subpart F
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2. CITIZENSHIP/ALIEN VERIFICATION/DETERMINATION - The Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA) of 1996 (PL 104-193) states that federal public benefits
should be made available only to U.S. citizens and qualified aliens. Entities that offer a service
defined as a "federal public benefit" must make a citizenship/qualified alien determination/
verification of applicants at the time of application as part of the eligibility criteria. Non-US citizens
and unqualified aliens are not eligible to receive the services. PL 104-193 also includes specific
reporting requirements. Exemptions from the determination/verification requirement is afforded the
following programs offered by the Department of Health: Family Planning, Breast &Cervical Health
Program (BCHP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC),
WIC Farmers Market Program, Immunization Programs, and Ryan White CARE Act programs and
other communicable disease treatment and diagnostic programs.
3. CIVIL RIGHTS AND NONDISCRIMINATION - During the performance of this agreement, the
Contractor shall comply with all current and future federal statutes relating to nondiscrimination.
These include but are not limited to: Title VI of the Civil Rights Act of 1964 (PL 88-352), Title IX of
the Education Amendments of 1972 (20 U.S.C. §§ 1681-1683 and 1685-1686), section 504 of the
Rehabilitation Act of 1973 (29 U.S.C. §794), the Age Discrimination Act of 1975 (42 U.S.C. §§ 6101-
6107), the Drug Abuse Office and Treatment Act of 1972 (PL 92-255), the Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616),
§§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290dd-3 and 290ee-3), Title
VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), and the Americans with Disability Act
(42 U.S.C., Section 12101 et seq.).
4. SINGLE AUDIT ACT - A subrecipient (including private, for-profit hospitals and non-profit
institutions) shall adhere to the federal Uniform Administrative Guidance (subpart F) as well as all
applicable federal and state statutes and regulations. A subrecipient who expends $750,000 or more
in federal awards during a given fiscal year shall have a single or program-specific audit for that year
in accordance with the provisions of 2 CFR 200 Subpart F
II. STANDARD FEDERAL CERTIFICATIONS AND ASSURANCES - Following are the Assurances,
Certifications, and Special Conditions that apply to all federally funded (in whole or in part)
agreements administered by the Washington State Department of Health.
CERTIFICATIONS
1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
The undersigned (authorized official signing for the contracting organization) certifies to the best of his or
her knowledge and belief, that the contractor, defined as the primary participant in accordance with 45
CFR Part 76, and its principals:
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A. are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal Department or agency;
B. have not within a 3-year period preceding this contract been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public(Federal, State, or local) transaction or contract under
a public transaction; violation of Federal or State antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. are not presently indicted or otherwise criminally or civilly charged by a governmental entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph (b) of
this certification; and
D. have not within a 3-year period preceding this contract had one or more public transactions
(Federal, State, or local) terminated for cause or default.
Should the contractor not be able to provide this certification, an explanation as to why should be
placed after the assurances page in the contract.
The contractor agrees by signing this contract that it will include,without modification, the clause titled
Certification Regarding Debarment, Suspension, In eligibility, and Voluntary Exclusion--Lower Tier
Covered Transactions in all lower tier covered transactions (i.e., transactions with sub- grantees
and/or contractors) and in all solicitations for lower tier covered transactions in accordance with 45
CFR Part 76.
2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
The undersigned (authorized official signing for the contracting organization) certifies that the
contractor will, or will continue to, provide a drug-free workplace in accordance with 45 CFR Part 76
by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the grantee's workplace
and specifying the actions that will be taken against employees for violation of such prohibition;
B. Establishing an ongoing drug-free awareness program to inform employees about
i. The dangers of drug abuse in the workplace;
ii. The contractor's policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
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iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
C. Making it a requirement that each employee to be engaged in the performance of the contract
be given a copy of the statement required by paragraph (a) above;
D. Notifying the employee in the statement required by paragraph (a), above, that, as a condition of
employment under the contract, the employee Will—
i. Abide by the terms of the statement; and
ii. Notify the employer in writing of his or her conviction for a violation of a criminal drug statute
occurring in the workplace no later than five calendar days after such conviction;
E. Notifying the agency in writing within ten calendar days after receiving notice under paragraph
(d) (2) from an employee or otherwise receiving actual notice of such conviction. Employers of
convicted employees must provide notice, including position title, to every contract officer or other
designee on whose contract activity the convicted employee was working, unless the Federal
agency has designated a central point for the receipt of such notices. Notice shall include the
identification number(s) of each affected grant;
F. Taking one of the following actions, within 30 calendar days of receiving notice under paragraph
(d) (ii), with respect to any employee who is so convicted—
i. Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended;
or
ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency;
G. Making a good faith effort to continue to maintain a drug-free workplace through implementation
of paragraphs (A), (B), (C), (D), (E), and (F).
For purposes of paragraph (e) regarding agency notification of criminal drug convictions, DOH
has designated the following central point for receipt of such notices:
Compliance and Internal Control Officer
Office of Grants Management
WA State Department of Health
PO Box 47905
Olympia, WA 98504-7905
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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, aMember
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 isawarded.
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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 2182
Page 27 of 31
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 lowertier 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 2182
Page 28 of 31
7. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
A. The prospective contractor certifies to the best of its knowledge and belief, that it and its
principals:
i. Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any Federal department or
agency;
ii. Have not within a three-year period preceding this contract been convicted of or had
a civil judgment rendered against them for commission of fraud or a criminal offense
in connection with obtaining, attempting to obtain, or performing a public (Federal,
State or local) transaction or contract under a public transaction; violation of Federal
or State antitrust statutes or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, or receiving stolen
property;
iii. Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State or local) with commission of any of the offenses
enumerated in paragraph (1)(b) of this certification; and
iv. Have not within a three-year period preceding this contract had one or more public
transactions (Federal, State or local) terminated for cause or default.
B. Where the prospective contractor is unable to certify to any of the statements in this certification,
such prospective contractor shall attach an explanation to this contract.
CONTRACTOR'S SIGNATURE IS REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
Please also print or type name:
ORGANIZATION NAME:(if applicable) DATE
KPHD 2182
Page 29 of 31
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. :74728-
4763) relating to prescribed standards for merit systems for programs funded underone
of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit
System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondiscrimination. These include but
are not limited to: (a)Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits
discrimination on the basis of race, color or national origin; (b) Title IX of the
KPHD 2182
Page 30 of 31
Education Amendments of 1972, as amended (20 U.S.G. 1681 -1683, and 1685-
1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C. 1794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. "' 6101-6107), which prohibits discrimination on the basis of
age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-
616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) -1-1 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.
[1 7 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug
abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. ❑ 3601 et
seq.), as amended, relating to nondiscrimination in the sale, rental or financing of
housing; (i) any other nondiscrimination provisions in the specific statute(s) under which
application for Federal assistance is being made; and (j) the requirements of anyother
nondiscrimination statute(s) which may apply to the application.
7. Will comply, or has already complied, with the requirements of Titles II and III of the
uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L.
91-646) which provide for fair and equitable treatment of persons displaced or whose
property is acquired as a result of Federal or federally assisted programs. These
requirements apply to all interests in real property acquired for project purposes
regardless of Federal participation in purchases.
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. "'1501-1508
and 7324-7328) which limit the political activities of employees whose principal
employment activities are funded in whole or in part with Federal funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C.
rr 276a to 276a-7), the Copeland Act (40 U.S.C. i-276c and 18 U.S.C. -,r1874) and
the Contract Work Hours and Safety Standards Act (40 U.S.C. r 327-333), regarding
labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a)
of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a
special flood hazard area to participate in the program and to purchase flood insurance
if the total cost of insurable construction and acquisition is $10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the
following: (a) institution of environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b)
notification of violating facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with
EO 11988; (e) assurance of project consistency with the approved State management
program developed under the Coastal Zone Management Act of 1972 (16 U.S.C.
"'1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation
Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C.
-7401 et seq.); (g) protection of underground sources of drinking water under the
KPHD 2182
Page 31 of 31
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. 1H1721 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. i 1470), EO 11593
(identification and protection of historic properties), and the Archaeological and Historic
Preservation Act of 1974 (16 U.S.C. [1469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in
research, development, and related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended,
7 U.S.C. - 2131 et seq.) pertaining to the care, handling, and treatment of warm
blooded animals held for research, teaching, or other activities supported by this award
of assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention Act(42 U.S.C. ^ 4801 et
seq.) which prohibits the use of lead- based paint in construction or rehabilitation of
residence structures.
17. Will cause to be performed the required financial and compliance audits in accordance
with the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, Audits of
States, Local Governments, and Non-Profit Organizations.
18. Will comply with all applicable requirements of all other Federal laws, executive orders,
regulations and policies governing this program.
CONTRACTOR'S SIGNATURE IS REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
Please also print or type name:
ORGANIZATION NAME:(if applicable) DATE
KPHD 2182 Amendment 1 (2222)
AMENDMENT TO AGREEMENT 2182
This Amendment(`Amendment")to Kitsap Public Health District Contract 2182 for
Youth Cannabis&Commercial Tobacco Prevention Program(the "Contract"), is entered into
between Jefferson County Public Health("Contractor")and the Kitsap Public Health District
("District").
RECITALS
WHEREAS,the Parties entered into the Contract effective July, 1, 2021; and
WHEREAS,Allocated Funding and period of performance for this agreement has been
extended by Washington Department of Health; and therefore the parties have agreed it is
desirable to increase the amount of eligible funding and extend the Contract term, and
In consideration of mutual benefits and covenants contained herein,the parties agree that
the Contract is amended as follows:
I. Section 1,Period of Performance. Section 1 is amended to extend the Contract
termination date to June 30, 2022.
II. Section 5,Compensation. Section 5 is amended to add an additional $27,380 in
funding for the period of July 1,2021 -June 30,2022, for a total compensation
not to exceed$54,761.
III. Attachment A,CTPP Scope of Work and Budget. Attachment A is amended
and replaced in its entirety with the revised Attachment A-1 which is attached
hereto and incorporated in full by reference.
IV. Attachment B,YMP Scope of Work and Budget.Attachment B is amended
and replaced in its entirety with the revised Attachment B-1 which is attached
hereto and incorporated in full by reference.
V. Other Provisions Unchanged. The other provisions of the Contract,remain
unchanged.
VI. Effective Date. The effective date of this Amendment is the date last executed by
all parties.
VII. Authorization. Each party signing below warrants to the other party that they
have the full power and authority to execute this Amendment on behalf of the
party for whom they sign.
IN WITNESS WHEREOF,the Parties have subscribed their names hereto.
[Signatures on next page]
KPHD Amendment Standard Form.docx
N-21-027-AI
Dated thisICA-c-lay o ^',2022. Dated this day of ,2022.
KITS PUB JEFFERSON COUNTY
H A CT
Keith Grellner Heidi Eisenhour
Administrator Chair,Board of County Commissioners
Approved as to Form Only:
January 14,2022
Philip C.Hunsucker Date
Chief Civil Deputy Prosecuting Attorney
2
4)
Dated this (V day o - ,2022. Dated this day of ,2022.
KITS PUB JEFFERSON COUNTY PUBLIC HEALTH
CT
Keith Grellner
Administrator
2
KPHD 2182
ATTACHMENT A—COMMERCIAL TOBACCO PREVENTION PROGRAM
Scope of Work and Budget
Jefferson County Public Health
July 1,2021—June 30,2022
As a subrecipient of KPHD under the Washington Department of Health funded Youth Cannabis&
Commercial Tobacco Prevention Program(YCCTPP), Jefferson County agrees to the following activities
for Commercial Tobacco Prevention funded in full or part by the associated budget.
Activity
Planning Participate in statewide commercial tobacco prevention coalition meetings as
established.
2021-2022 DOH Regional Requirements:
1. In collaboration with priority population contractors,engage and educate
internal and external decision makers,stakeholders,and community leaders
about:
a. The value of local control in preventing initiation and continued
use of commercial tobacco products that lead to tobacco-related
health issues and health disparities.
b. The value of a comprehensive tobacco prevention program to
prevent the initiation of commercial tobacco product use among
youth and young adults.
c. Evidence-based and promising policy options to address the appeal
of commercial tobacco products to youth and young adults,
including the impact of commercial tobacco product flavors
(including menthol)on youth initiation and use.
Implementation 2. Build or enhance partnerships with youth-serving organizations and local
champions(including identifying youth champions)to collaborate on youth
access and industry marketing interventions.
3. Plan and conduct a minimum of one meeting with the prevention-
intervention lead at your region's Educational Service District to establish a
connection,build relationships,and share resources.
4. Promote the Washington State Quitline and self-help options for TUDT
(Tobacco Use,Dependence,Treatment), including 2Morrow Health app
(doh.wa.gov/quit)and This is Quitting(doh.wa.gov/vapefreewa),to people
who use commercial tobacco.
5. In collaboration with CTPP,incorporate 2022-2022 Centers for Disease
Control and Prevention(CDC)(e.g.,Tips®campaign)materials into
agency communications,and report efforts in a template provided by the
CTPP as part of the monthly reporting requirement.
6. Disseminate TUDT resources provided by CTPP and/or developed locally
to community-based organizations,centers,and networks supporting
disparately affected communities that address emerging tobacco/e-
KPHD 2182
cigarettes and are culturally&linguistically appropriate,trauma-informed,
&equity-based.
7. 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;technical
assistance requests to colleges/universities on the adoption and
implementation of tobacco-and vape-free campuses;and to technical
assistance to multi-unit housing organizations, landlords,and residents on
smoke-and/or vape-free policies.
8. 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.
Specific Jefferson County activities are described in the 2021-2022 CTPP
workplan.Workplans are subject to change.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 5th of every month.
Midterm By February 1,2022 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
Health;respond to activity assessments/surveys administered by KPHD as
appropriate per scope of work.
Submit monthly invoices by the 20th of the month following the month in which
costs were incurred,except for the Final Expenditure Report and Request for
Invoicing Reimbursement in each federal fiscal year(due July 1,2022).Invoices must include
supporting documentation such as timecards for staff time and copies of invoices
paid for goods and services.
KPHD 2182
Budget July 1,2021—June 30,2022
Cost Description
Staff Salary 7,290
Benefits 2,767
Indirect 2,460
Goods&Services
Mileage
Travel/Training
Total Jefferson 12,517
Funding Source
Chart of Accounts Program CFDA# BARS Code FAIN/Award Date 7/1/21-6/30/22
Name orTitle
FFY21 Tobacco-Vape Prey Comp 1 93.387 333.93.38 NU58DP006808 $8,000
(CDC) 04/29/21
SFY22 Youth Tobacco Vapor 334.04.93 $4,517
Products
Total to Jefferson $12,517
Subrecipient DUNS Number: 184826790
Subrecipient Indirect Rate: 24.26%tai 9;t1a
Research and Development: No
Federal Funding Accountability and Transparency Act(FFATA):The Statement of Work is
supported by federal funds that require compliance with the Federal Funding Accountability and
Transparency Act(FFATA)or the Transparency Act.The purpose of the Transparency Act is to make
information available online so the public can see how the federal funds are spent.To comply with this
act and to be eligible to perform the activities in this statement of work,the Local Health Jurisdiction
(LHJ)must have a Data Universal Numbering System(DUNS)number.Information about the LHJ and
this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-
282.
Federal Funding Restrictions and Limitations:
a. Recipient may not use federal funds for lobbying.
b. Recipient may not use funds for research.
c. Recipient may not use funds for clinical care.
d. Recipient may not use funds to supplant existing state funding or to supplant funds from
federal or state sources.
e. Recipient may use funds only for reasonable program purposes,including personnel,travel,
supplies,and sources.
f. Recipient are the direct and primary recipients in a cooperative agreement program and must
perform a substantial role in carrying out project outcomes and not merely serve as a conduit
for an award to another party or provider who is ineligible.
g. Recipient are generally not allowed to use funds to purchase furniture or equipment.Any
such proposed spending must be clearly identified in the budget.
h. Recipient may not be reimbursed for pre-award costs.
KPHD 2182
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.
I. Recipient may not use funds to purchase K-12 school curricula.
m. Recipient may not use funds for construction.
KPI ID 2182
ATTACHMENT B—YOUTH MARIJUANA PREVENTION
Scope of Work and Budget
Jefferson County Public Health
July 1,2021—June 30,2022
As a subrecipient of KPHD under the Washington State funded Youth Cannabis&Commercial Tobacco
Prevention Program(YCCTPP), Jefferson County agrees to the following Youth Marijuana Prevention
activities funded in full or part by the associated budget.
Activity
Planning Participate in Regional Network,hold a position on the Strategic Planning Team.
As a member of the Strategic Planning Team,help to:
1. Update the 2022-2023 Olympic Region YMPEP Needs Assessment,
including the Community Readiness Assessment.
2. Update the 2022-2023 Olympic Region YMPEP Strategic Plan,per DOH
guidance.
Education Participate in a minimum of one skill enhancement opportunity per month.
Implementation 1. 2021-2022 DOH Approved Regional Strategies:
• PSE Priority 1:Local Laws&Ordinances
• PSE Priority 2:Community Norms
• PSE Priority 3:Retailer Consumer Education
• PSE Priority 4:Health Care Policy&Procedures
2. Specific Jefferson County activities are described in the 2021-2022
YMPEP workplan.Work plans are subject to change.Any changes will
be approved by both parties.
3. Participate in statewide collaboration on the strategies listed above.More
detail for how to participate is listed within work plan.
Monitoring and Monitor progress for each activity as appropriate;submit monthly narrative and
Reporting data reports as requested by KPHD on the 5th of every month.
Calls/Meetings Participate in monthly check-in call with regional lead.Attend and participate in
Regional Network and Planning Team meetings;review correspondences related
to YMPEP;respond to activity assessments/surveys administered by KPHD as
appropriate per scope of work.Attend at least one statewide All-Providers
Meeting or Practice Collaborative Meeting.
Mid-Year By February 1,2022 report progress to YMPEP Regional Coordinator.If needed,
Evaluation adjust activities to ensure spend down.Conduct a work plan reevaluation.
Invoicing Submit monthly invoices by the 20th of the month following the month in which
costs were incurred,except for the Final Expenditure Report and Request for
Reimbursement in each federal fiscal year(due July 1,2022). Invoices must
include supporting documentation such as timecards for staff time and copies of
invoices paid for goods and services.
KPIID 2182
Budget July 1,2021—June 30,2022
Cost Description
Staff Salary S18,739
Benefits $8,356
Goods&Services $7,664 Materials to implement Peer-2-Peer program;
informational material for targeted Jefferson County
residents to address low readiness ratings
Training/Travel $750 Travel to the 4 school districts for meetings;travel for
quarterly regional meetings
Indirect $6,735
Total Jefferson S42,244
Funding Source
Chart of Accounts ProgramName or Title CFDA# BARS 7/1/21-6/30/22
Code
SFY22 Marijuana Tobacco Edu n/a 334.04.93 $42,244
Subrecipient DUNS Number: 184826790
Subrecipient Indirect Rate: 24.226% ;f a(try
Research and Development: No
Community Resources: Subrecipient shall make a reasonable and ongoing effort,throughout the period
of performance,to secure and/or leverage resources from private and public entities to supplement the
administrative,operational,and implementation costs under this program.Documentation of any
collaborative efforts and securing of resources that benefit this project shall be kept current and on file in
the office of the Subcontractor and be available for review upon request by District staff.
Funding Restrictions and Limitations:
a. Recipient may not use funds for research.
b. Recipient may not use funds for clinical care.
c. Recipient may only expend funds for reasonable program purposes,including personnel,
travel,supplies,and services,such as contractual.
d. Recipient may not generally use funding for the purchase of furniture or equipment.
However,if equipment purchase is integral to a selected strategy,it will be considered. Any
such proposed spending must be identified in the budget and approved by the District.
e. Recipient may not use funding for construction.
f. Recipient must comply with District guidance on food,incentives and use of District or DOH
logo outlined in YMPEP Regional Implementation Guide and should not exceed federal per
diem rates.
g. Reimbursement of pre-award costs is not allowed.