HomeMy WebLinkAbout062722ca02 615 Sheridan Street
Port Townsend, WA 98368
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Public He� Consent Agenda
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, County Administrator
FROM: Apple Martine, Public Health Director
Denise Banker, Community Health Director
DATE:
SUBJECT: Agenda item — Professional Services Agreement with Kitsap Public Health
District; July 1, 2022 — June 30, 2023; $54,761
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH), Community Health Division, requests Board approval of the Professional
Services Agreement with Kitsap Public Health District (the District) to develop and implement coordinated
tobacco, vapor and marijuana product prevention and intervention strategies; July 1, 2022 —June 30, 2023;
$54,761.00 income generating.
ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S:
The purpose of this contract agreement is for the 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. JCPH agrees to conduct outreach and planning for the
Olympic Prevention Partnership. This agreement, for $54,761.00, is to pay for direct labor, direct material, and
other direct costs.
FISCAL IMPACT/COST BENEFIT ANALYSIS:
This contract agreement is fully funded by the District through a regional funding received from the
Washington State Department of Health.
RECOMMENDATION:
JCPH management requests approval of the Professional Services Agreement with Kitsap Public Health District
to develop and implement coordinated tobacco, vapor and marijuana product intervention strategies; July 1,
2022 —June 30, 2023; $54,761.00
REVIEWED BY:
,e/j.5,A
Mark McCaule ounty Administrator Date
Community Health
Developmental Disabilities Environmental Public Health
360-385-9400 360-385-9444
360-385-9401 (f) (f) 360-379-4487
Always working for a safer and healthier community
N-22-028
KPHD 2262
Page 1 of 16 N-22-028
PROFESSIONAL SERVICES AGREEMENT
Between
KITSAP PUBLIC HEALTH DISTRICT
And
JEFFERSON COUNTY PUBLIC HEALTH
This Professional Services Agreement("Agreement") is made and entered into between the Kitsap Public
Health District, a Health District organized pursuant to chapter 70.46 Revised Code of Washington and
Section 9.52 Kitsap County Code, hereinafter referred to as "District," and Jefferson County Public Health,
hereinafter referred to as "Subcontractor." The parties mutually agree as follows:
1. Period of Performance: The period of performance of this Agreement shall begin July 1, 2022 and
be completed no later than June 30, 2023, unless terminated sooner or extended as provided for
herein.
2. Purpose: The District requires the expertise of this Subcontractor 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: Subcontractor shall have the qualifications necessary to successfully
complete the objectives of this Agreement. The Subcontractor 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: Subcontractor shall furnish the necessary personnel, equipment
material, and/or services and otherwise do all things necessary for or incidental to the performance
of the work set forth in ATTACHMENT A, attached hereto and incorporated herein.
ATTACHMENT A contains the Scope of Work and Budget.
5. Compensation: This Agreement is funded by state funds. The District agrees to pay Subcontractor
a total sum of$54,761 in state funds during this Agreement. The District shall reimburse
Subcontractor for travel as applicable at the federally approved rate. Compensation will be based on
invoices submitted by Subcontractor itemizing a detailed description of services performed per the
agreed upon Scopes of Work and Budgets set forth respectively in ATTACHMENTS A.
Subcontractor shall submit a Monthly Expenditure Report and Request for Reimbursement (Form
A-19) invoice voucher, hereto attached and herein incorporated as ATTACHMENT B, to the
District for payment.
6. Performance Requirements and Notices: The assigned District staff shall monitor the
performance of this Agreement, approve billings submitted by Subcontractor, and determine
the acceptability of any reports provided by Subcontractor. District staff shall provide and
facilitate assistance and guidance to Subcontractor 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.
KPHD 2262
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Subcontractor 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 Subcontractor:
Kitsap Public Health District Jefferson County Public Health
Attn: Yolanda Fong Attn: Denise Banker
345 6th Street, Suite 300 615 Sheridan Street
Bremerton, WA 98337 Port Townsend, WA 98368
(360) 728-2275 (360)385-9400
Yolanda.Fongnkitsappublichealth.org dbankernco.j efferson.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 be accepted 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 Subcontractor all allowable costs incurred as evidenced by proper invoice
of Subcontractor 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 subcontractor 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.
KPHD 2262
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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 this Agreement, any claim for payment not already made shall be submitted to
the District within 20 days after the expiration date.
8. Independent Capacity: Subcontractor and its employees or agents who are engaged in the
performance of this Agreement shall continue to be employees or agents of Subcontractor and
r be employees or a agents of the District for anypurpose.
shall not be considered tog p p
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: Subcontractor shall defend, indemnify and hold the District, its officers, officials,
employees and volunteers harmless from any and all claims, injuries, damages, losses or suits
including attorney fees, arising out of or resulting from the acts, errors or omissions of the
Subcontractor 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
Subcontractor, any damages allowed shall be levied in proportion to the percentage of negligence
attributable to each party. Solely for the purposes of this provision, Subcontractor waives its
immunity under Title 51 (Industrial Insurance) of the Revised Code of Washington and
acknowledges that this waiver was mutually negotiated by the parties. This provision will survive
the expiration or termination of this Agreement.
11. Insurance: Subcontractor shall procure and maintain for the duration of this Agreement, coverage
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 Subcontractor, its agents, representatives, or
employees.
No Limitation. Subcontractor's maintenance of coverage as required by this Agreement shall not be
construed to limit the liability of Subcontractor to the coverage provided by such coverage, or otherwise
limit the District's recourse to any remedy available at law or in equity.
A. Minimum Scope of Coverage
Subcontractor shall obtain coverage of the types described below:
1. Automobile Liability coverage covering all owned, non-owned, hired and leased vehicles.
If necessary, the policy shall be endorsed to provide contractual liability coverage.
2. Commercial General Liability coverage shall cover liability arising from premises,
operations, independent contractors and personal injury and advertising injury. The District
shall be named as an additional insured under
KPHD 2262
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Subcontractor's Commercial General Liability coverage 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 coverage appropriate to the Subcontractor's profession.
Subcontractor shall provide the District with proof of liability coverage or professional
errors and omissions coverage as appropriate.
B. Minimum Amounts of Coverage
Subcontractor shall maintain the following coverage limits:
1. Automobile Liability coverage with a minimum combined single limit for bodily injury and
property damage of$1,000,000 per accident
2. Commercial General Liability coverage shall be written with limits no less than$1,000,000
each occurrence, $2,000,000 general aggregate.
3. Professional Liability coverage shall be written with limits no less than$1,000,000 per claim
and $1,000,000 policy aggregate limit.
C. Other Coverage Provisions
The coverages are to contain, or be endorsed to contain,the following provisions for Automobile
Liability, Professional Liability and Commercial General Liability coverage:
1. Subcontractor's coverage shall be primary coverage as respect the District. Any
coverage maintained by the District shall be excess of Subcontractor's coverage and
shall not contribute with it.
2. Subcontractor's coverage 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 Coverage
Subcontractor has a memorandum of liability coverage with the Washington Counties Risk Pool,
which the District agrees is acceptable.
E. Verification of Coverage
Subcontractor shall furnish the District with original certificates and a copy of the amendatory
endorsements, including but not necessarily limited to the additional coverage endorsement,
evidencing the coverage requirements of Subcontractor 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.
Subcontractor agrees not to release, divulge, publish, transfer, sell or otherwise make known to
KPHD 2262
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unauthorized persons personal information without the express written consent of the agency or as
provided by law.
Subcontractor agrees to implement physical, electronic, and managerial safeguards to prevent
unauthorized access to personal information. Any unauthorized access or use of confidential
information must be reported to the District 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 Subcontractor through this Agreement. The monitoring, auditing, or
investigating may include but is not limited to "salting" by the District. Salting is the act of placing
a record containing unique but false information in a database that can be used later to identify
inappropriate disclosure of data contained in the database.
Subcontractor shall certify the return or destruction of all personal information upon expiration of
this 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
Subcontractor 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. Subcontractor must conduct criminal background checks for those staff, volunteer,
contractor, or subcontractor working directly with youth(ages 0-17).
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b. Subcontractor 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, Subcontractor will keep on file and make available for review by District staff
documents consistent with federal and state regulations that will include but are not limited to the
latest agency audit and Subcontractor agreements. Subcontractor will include these requirements in
all approved subcontracts.
15. Required Reports: Subcontractor will submit required reports using required forms according
to procedures issued by the District.
Subcontractor will be obligated to submit required reports after the close of the contract period,
during the transfer of obligations to another contractor, or upon termination of the contract for any
reason.
Subcontractor will include all requirements listed above in all approved subcontracts.
Due dates outside the Budget Period are for reporting only. Subcontractor may not bill for work done
outside the Budget Period.
16. Statutory and Regulatory Compliance: Subcontractor 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: Subcontractor shall not use
protected health information created or shared under this Agreement in any manner that would
constitute a violation of RCW 70.02, RCW 42.56, the Health Information Portability and
Accountability Act, commonly known as HIPAA, or any regulations enacted pursuant to its
provisions. An excerpt of certifications and assurances is herein attached as ATTACHMENT
C.
18. Suspension of Performance and Resumption of Performance: In the event contract funding from
state, federal, or other sources is withdrawn, reduced, or limited in any way after the effective date of
this Agreement and prior to normal completion, the District may give notice to Subcontractor to
suspend performance as an alternative to termination. The District may elect to give written notice
to Subcontractor to suspend performance when the District determines that there is a reasonable
likelihood that the funding insufficiency may be resolved in a timeframe that would allow
performance to be resumed prior to the end date of this Agreement. Notice may occur by facsimile
or email to Subcontractor's representative. Subcontractor shall suspend performance on the date
stated in the written notice to suspend. During the period of suspension of performance, each party
may inform the other party of any conditions that may reasonably affect the potential for resumption of
performance.
KPHD 2262
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When the District determines that the funding insufficiency is resolved, the District may give
Subcontractor written notice to resume performance and a proposed date to resume performance.
Upon receipt of written notice to resume performance, Subcontractor will give written notice to the
District as to whether it can resume performance, and if so, the date upon which it agrees to resume
performance. If Subcontractor gives notice to the District that it cannot resume performance, the
parties agree that this Agreement will be terminated retroactive to the original date of termination. If
the date Subcontractor gives notice it can resume performance is not acceptable to the District, the
parties agree to discuss an alternative acceptable date. If an alternative date is not acceptable to the
District, the parties agree that this Agreement will be terminated retroactive to the original date of
termination.
19. Non-Discrimination: Subcontractor shall not discriminate against any employee or applicant for
employment because of race, color, sex, religion, national origin, creed, marital status, age, Vietnam
era or disabled veteran status, sexual preference, or the presence of any sensory mental or physical
handicap.
20. 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.
21. 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.
22. 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 Subcontractor in the performance for any work required
under this Agreement, Subcontractor will make all necessary corrections without additional
compensation. All work submitted by Subcontractor will be certified by Subcontractor and checked
by Subcontractor for errors and omissions. Subcontractor will continue to be responsible for the
accuracy of work even after the work is accepted by the District.
23. 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.
24. 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.
KPHD 2262
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25. Termination for Funding: If funding for this Agreement or matter is withdrawn, reduced or
limited in any way after this Agreement is signed or becomes effective, the Parties may summarily
terminate this Agreement notwithstanding any other termination provision in this 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.
26. 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.
27. Dispute Resolution: In the event that a dispute or conflict arises under this 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.
28. 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.
29. Survival: Those provisions of this Agreement that by their sense and purpose should survive
expiration or termination of this 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.
30. Subcontracting: Subcontractor 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 Subcontractor to the Department for any
breach in the performance of Subcontractor's duties. This clause does not include contracts of
employment between Subcontractor and personnel assigned to work under this Agreement.
Subcontractor is responsible for ensuring that all terms, conditions, assurances and certifications set
forth in this Agreement are carried forward to any subcontracts. Subcontractor agrees not to release,
divulge, publish, transfer, sell or otherwise make known to unauthorized persons personal
information without the express written consent of the District or as provided by law.
If at any time during the progress of the work, the District determines in its sole judgment that any
contractor is incompetent, the District shall notify Subcontractor, and Subcontractor shall take
immediate steps to terminate its Subcontractor's involvement in the work. The rejection or approval
by the District of any Subcontractor or the termination of a Subcontractor shall not relieve
Subcontractor of any of its responsibilities under this Agreement, nor be the basis for additional
charges to the District.
KPHD 2262 N-22-028
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31. 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 PUBLIC HEALTH DISTRICT BOARD OF COUNTY COMMISSIONERS
JEFFERSON COUNTY, WASHINGTON
•
ith Grellner Date Heidi Eisenhour, Chair Date
Administrator
ATTEST:
Carolyn Gallaway,Clerk of the Board
APPROVED AS TO FORM:
C
June 21, 2022
Philip C.Hunsucker Date
Chief Civil Deputy Prosecuting Attorney
Funding Source
Program: CH
Contract/Grant: DOH Con Con CLH31014(KPHD 2203)
KPHD 2262
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ATTACHMENT A—SCOPE OF WORK AND BUDGET
Jefferson County Public Health
July 1,2022—June 30,2023
As a subcontractor of KPHD under the Washington Department of Health funded Youth Cannabis & Commercial Tobacco
Prevention Program (YCCTPP), Jefferson County Public Health agrees to the following activities funded in full or part by
the associated budget.
Activity
Coordinate and maintain the Olympic Prevention Partnership steering committee
and network.
Planning& • Invite new community partners to join the Olympic Prevention Partnership
Coordination of Steering Committee.
Regional • Attend nine monthly steering committee meetings(Sept 2022—June 2023)
Network • Each subcontractor will be responsible for planning one of the above
meetings. Refer to the workplan for schedule.
2022-2023 Strategies for Youth Cannabis& Commercial Tobacco Prevention:
• Social Norms: Media&Health Communications
• Youth Empowerment&Engagement
Implementation • Decision-maker Engagement
• Policy,System,Environmental Changes
Specific Jefferson County activities are described in the 2022-2023 YCCTPP
workplan. Please refer to the workplan for guidance on which activities fall under
each funding source. 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 1,2023,report progress to CTPP Regional Coordinator. If needed,
Evaluation adjust activities to ensure spend down. Conduct a mid-year workplan re-evaluation.
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 1,2023).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 1,2022—June 30,2023
Cannabis Cost Description
Staff Salary $23,580 15 hours per week
Benefits $4,820
Indirect $8,301
Goods& Services $2,500 Materials necessary and approved for programing
Mileage $1,522 Any travel to and from implementation sites
Travel/Training $1,521 Any training approved and applicable
Total Jefferson $42,244
Tobacco Cost Description
Staff Salary $7,860 5 hours per week
Benefits $1,770
Indirect $2,815
Goods& Services $0 Materials as necessary to implement program
Mileage $72 Any travel to and from implementation sites
Travel/Training $0 Any training approved and applicable
Total Jefferson $12,517
Funding Source
Chart of Accounts Program Name or CFDA# BARS Code 7/1/22—6/30/23
Title
SFY23 Dedicated Cannabis Account NA 334.04.93 $42,244
SFY23 Youth Tobacco Vapor Products NA 334.04.93 $12,517
Total to Jefferson $54,761
Subcontractor DUNS Number: 184826790
Subcontractor Indirect Rate: 29.23%of salary
Research and Development: No
KPHD 2262
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FORM STATE OF WASHINGTON Attachment B Page A-11
A 19-1A (;) INVOICE VOUCHER
(Rev.1/91) AGENCY 0 A EN Y N . LOCATION CODE P.R.OR AUTH NO.
AGENCY NAME
INSTRUCTION TO VENDOR OR CLAIMANT:Submit this
form to claim payment for materials,merchandise or services.
Kitsap Public Health District Show complete detail for each item.
Attn: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 MESSAGE'USE TAX UBI NUMBER
REF M MASTER INDEX SUB WKCLAS COUNT CITY AMOUNT INVOICE NUMBER
DOC TRANS 0 FUND APPN PROGRAM SUB SUB ORG BDGT SUB PRO.
SUF CODE D INDEX INDEX OBJ INDEX ALLOC UNIT MOS PRJT PROJ PHA5
ACCOUNTING APPROVAL FOR PAYMENT DATE WARRANT TOTAL WARRANT NO.
KPHD 2262
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ATTACHMENT C
HIPAA BUSINESS ASSOCIATE AGREEMENT
This Agreement("Agreement") is entered into by and between the Kitsap Public Health District
("Covered Entity") and Jefferson County Public Health("Business Associate").
Section I: Purpose
Performance of the Underlying Agreement may require Business Associate to use or disclose
protected health information that is subject to provisions of the Health Insurance Portability and
Accountability Act of 1996, set forth in 45 C.F.R. Parts 160 and 164 (commonly known as the
"HIPAA Rules").
The purpose of this Agreement is to set forth the obligations of the Parties with regard to the way
in which protected health information is created, used, disclosed, maintained, provided or
received on behalf of Covered entity by the Business Associate.
Section 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
this 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.
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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.
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Section V. Termination
1. Term. This Agreement shall terminate on June 30, 2023 or on the date Covered
Entity terminates for cause, whichever is sooner.
2. Termination for Cause. Business Associate authorizes termination of this Agreement if
Covered Entity determines Business Associate has violated a material term of this
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.
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