HomeMy WebLinkAboutConsolidated contracts no 14 615 Sheridan Street
Port Townsend, WA 98368
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www.JeffersonCountyPublicHealth.org
Consent Agenda
Public Health
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, County Administrator
FROM: Apple Martine, JCPH Director
Veronica Shaw, JCPH Deputy Director
DATE: ���� '�`�� W2.3
SUBJECT: Agenda Item — Consolidated Contracts Amendment #14 with the Department
of Health; January 1 2022 — December 31, 2024; additional $1,758,658 for a
total of $6,166,503
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #14
between JCPH and State of Washington Department of Health (DOH); January 1, 2022 — December 31, 2024;
additional $1,758,658 for a total of $6,166,503.
ANALYSIS/STRATEGIC GOALS/PROS and CONS:
The purpose of this agreement is to provide public health services to the people of Washington State. This
Amendment adds and/or amends statements of work (SOW) and funding for the following programs:
• Foundational Public Health Services (core services which the governmental public health system is
responsible for providing in a consistent and uniform way in every community in Washington) — funding
to increase the availability of FPHS services statewide ($1,433,000)
• Infectious Disease Prevention Services — for syringe services program ($7,500)
• Office of Drinking Water— for conducting sanitary surveys and providing technical assistance to small
water systems
• Office of Immunization —to conduct activities to improve immunization coverage rates ($5,600)
• On-site Sewage System Local Management Plan — changes period of performance
• On-site Sewage System Local Management Plan (LMP) — funding implementation of LMP ($98,636)
• Recreational Shellfish Activities — provides funds for shellfish harvesting safety ($11,100)
• School-Based Health Centers Program (SBHC) — formalizes grant to JCPH for SBHC operations
($172,000)
• Sexual & Reproductive Health Program — revises SOW (removing one task) and reallocates and
increases funding (additional $30,822)
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
FISCAL IMPACT/COST BENEFIT ANALYSIS :
Total consideration for this Contract Amendment is an increase of $1,758,658 for a total of $6,166,503. The
Consolidated Contract is funded by DOH, and comprises both Federal and State funds.
RECOMMENDATION:
JCPH Management recommends BOCC approval of Consolidated Contract Amendment #14; January 1 2022 —
December 31, 2024; additional $1,758,658 for a total of $6,166,503.
REVIEWED BY:
AJuly 20, 2023
Mark McC_.&y, County A,. i istrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 Always working for a safer and healthier community (f) 360-379-4487
360-385-9401 (f)
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-22-002-A14
Contract For: Consolidated Contracts, Amendment 14 fertn: 1/1/2022 - 12/31/2024
COUNTY DEPARTMENT: Public Health
Contact Person: Veronica Shaw
Contact Phone: X 409
Contact email: veronica@co.jefferson.wa.us
AMOUNT: Additional$1,758,656 for a total of$6,166,503 PROCESS: Exempt from Bid Process
Revenue: $1,758,656 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 CO CE W a5.080 AND CHAPTER 42.23 RCW.
CERTIFIED: El N/A: July 17,2023
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEM DEBA ED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: El N/A: Eil July 17,2023
Signature Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 7/18/2023.
STEP 4: PROSECUTING ATTORNEY REVIEW(will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 7/18/2023.
State language - cannot change.
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
Page 1 of 41
JEFFERSON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLB31013 AMENDMENT NUMBER: 14
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as"DOH",and
JEFFERSON COUNTY PUBLIC HEALTH,a Local Health Jurisdiction, hereinafter referred to as"LHJ",pursuant to the
Modifications/Waivers clause,and to make necessary changes within the scope of this contract and any subsequent amendments
thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work,includes the following statements of work,which are incorporated by this reference and located on
the DOH Finance SharePoint site in the Upload Center at the following URL:
https://stateofwa.shareooint.com/sites/doh-ofsfundingresources/sitepapes/home as)x?=el•9a94688da2d94d3ea8Oac7fbc32e4d7c
® Adds Statements of Work for the following programs:
Foundational Public Health Services(FPHS)-Effective July I,2023
Infectious Disease Prevention Services-SSP-Effective July 1,2023
Office of Immunization-Promotion of Immunizations to Improve Vaccination Rates-Effective July I,2023
OSS LMP Implementation -Effective July I,2023
Recreational Shellfish Activities-Effective July I,2023
School-Based Health Centers Program—Effective July I,2023
® Amends Statements of Work for the following programs:
Office of Drinking Water Group A Program-Effective January 1,2022
OSS LMP Implementation-Effective January 1,2022
Sexual& Reproductive Health Program-Effective January 1,2022
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-14 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-I 3 Allocations as follows:
® Increase of$1,758,658 for a revised maximum consideration of$6,166,503.
❑ Decrease of —for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations are attached only for informational purposes.
Unless designated otherwise herein,the effective date of this amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force and effect.
IN WITNESS WHEREOF,the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
Greg Brotherton,Chair Date Date
APPROVED AS TO FORM ONLY: APPROVED AS TO FORM ONLY
Assistant Attorney General
O C
July 18, 2023
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
CC-22-002-Ai4 Page 1 of 1
EXHIBIT B-14
Jefferson Count Public Health Page 2 of 41
Y ALLOCATIONS Contract Number: C1,1131013
Contract Term:2022-2024 Date: June 1,2023
Indirect Rate January 1,2022 through December 31,2022:29.23%Public Health
Indirect Rate January 1,2023 through December 31,2023:35.85%Public Health DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY23 USDA BFPC Prog Mgmt 7WA700WAI Amd 10 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $28,238 $37,651 $81,040
FFY23 USDA BFPC Prog Mgmt 7WA700WAI Amd 8,10 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $9,413
FFY22 USDA BFPC Prog Mgmt 7WA700WAI Amd 1 10.557 333.10.55 01/01/22 09/30/22 10/01/21 09/30/22 $43,389 $43,389
FFY24 USDA WIC Client Svs Contracts NGA Not Received Amd 10 10.557 333.10.55 10/01/23 12/31/23 10/01/23 12/31/23 $25,238 $25,238 $232,295
FFY23 USDA WIC Client Svs Contracts 7WA700WA7 Amd 12 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $21,218 $120,681
FFY23 USDA WIC Client Svs Contracts 7WA700WA7 Amd 10 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $75,713
FFY23 USDA WIC Client Svs Contracts 7WA700WA7 Amd 1 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $23,750
FFY22 USDA WIC Client Svs Contracts 7WA700WA7 Amd 7 10.557 333.10.55 01/01/22 09/30/22 10/01/21 09/30/22 $5,600 $86,376
FFY22 USDA WIC Client Svs Contracts 7WA700WA7 Amd 5 10.557 333.10.55 01/01/22 09/30/22 10/01/21 09/30/22 $6,726
FFY22 USDA WIC Client Svs Contracts 7WA700WA7 Amd 1 10.557 333.10.55 01/01/22 09/30/22 10/01/21 09/30/22 $74,050
FFY23 USDA WIC Prog Mgmt CSS 7WA700WA7 Amd 10 10.557 333.10.57 01/01/23 09/30/23 10/01/22 09/30/23 $2,800 $2,800 $2,800
FFY22 USDA FMNP Prog Mgmt 7WA810WA7 Amd 4 10.572 333.10.57 05/01/22 09/30/22 10/01/21 09/30/22 $516 $516 $516
LHJ COVID-19 Gap Supplemental SLFRP0002 Amd 13 21.027 333.21.02 01/01/23 06/30/23 01/01/23 06/30/23 $35,651 $35,651 $35,651
PS SSI 1-5 OSS Task 4 OIJ18001 Amd 7 66.123 333.66.12 01/01/22 06/30/23 07/01/17 06/30/23 ($1,654) $233,844 $233,844
PS SSI 1-5 OSS Task 4 OIJ18001 Amd 2,5 66.123 333.66.12 01/01/22 06/30/23 07/01/17 06/30/23 $235,498
FFY23 Swimming Beach Act Grant lAR(ECY) OIJ74301 Amd11 66.472 333.66.47 03/01/23 10/31/23 03/01/23 10/31/23 $15,000 $15,000 $30,000
FFY22 Swimming Beach Act Grant IAR(ECY) OIJ74301 Amd 2 66.472 333.66.47 03/01/22 10/31/22 01/01/22 11/30/22 $15,000 $15,000
FFY22 PHEP BP4 LHJ Funding NU90TP922043 Amd 7 93.069 333.93.06 07/01/22 06/30/23 07/01/22 06/30/23' $34,384 $34,384 $48,138
FFY21 PHEP BP3 LIU Funding NU90TP922043 Amd 2 93.069 333.93.06 01/01/22 06/30/22 07/01/21 06/30/22 $13,754 $13,754
FFY22 Tide X Dire Needs FPHPA006495 Amd 2 93.217 333.93.21 01/14/22 03/31/22 01/14/22 03/31/22 $4,066 $4,066 $4,066
FFY23 Title X Family Planning NGA Not Received Amd la 93.217 333.93.21 04/O1/23 03/31/24 04/O1/23 03/31/24 $30,822 $30,822 $57,959
FFY22 Title X Family Planning FPBPA006560 Amd 5 93.217 333.93.21 04/O1/22 03/31/23 04/01/22 03/31/23 $27,137 $27,137
COVID19 Vaccines NH231P922619 Amd4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $278,114 $278,114 $278,114
COVID19 Vaccines R4 NH231P922619 Amd 4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803 $709,606 $709,606
COVID19 Vaccines R4 NH231P922619 Amd 1 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803
FFY24 CDC VFC Ops NGA Not Received Amd 14 93.268 333.93.26 07/O1/23 06/30/24 07/O1/23 06/30/24 $5,600 $5,600 $5,600
FFY23 VFC Ops NH231P922619 Amd 5 93.268 333.93.26 07/01/22 06/30/23 07/01/22 06/30/23 $5,600 $5,600 $11,200
FFY22 VFC Ops NH231P922619 Amd 3 93.268 333.93.26 01/01/22 06/30/22 07/01/21 06/30/22 $5,600 $5,600
Page I of 3
Jefferson County Public Health EXHIBIT B-14 Page 3 of 41
ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: June 1,2023
Indirect Rate January 1,2022 through December 31,2022:29.23%Public Health
Indirect Rate January 1,2023 through December 31,2023:35.85%Public Health DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY19 COVID CARES NU50CK000515 Amd 2 93.323 333.93.32 01/01/22 04/22/22 04/23/20 07/31/24 $14,664 $14,664 $14,664
FFY19 ELC COVID Ed LIU Allocation NU50CK000515 Amd? 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 ($2,281) $1,737 $1,737
FFY19 ELC COVID Ed LHJ Allocation NU50CK000515 Amd 4 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 ($78,694)
FFY19 ELC COVID Ed LHJ Allocation NU50CK000515 Amd 2 93.323 333.9332 01/01/22 10/18/22 05/19/20 10/18/22 $82,712
FFY20 ELC EDE LIUAllocation NU50CK000515 Amd 9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 ($6,375) $341,822 $341,822
FFY20 ELC EDE LHJ Allocation NU50CK000515 Amd 4,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 ($90,842)
FFY20 ELC EDE LHJ Allocation NU50CK000515 Amd 2,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 $439,039
FFY22 NEHA Climate&Health Grant NU38OT000300 Amd 9 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 $11,000 $22,000 $22,000
FFY22 NEHA Climate&Health Grant NU38OT000300 Amd 5 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 $11,000
FFY23 MCHBG LHJ Contracts B04MC47453 Amd 7 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 $36,700 $36,700 $64,225
FFY22MCHBGLHJContracts B04MC45251 Amd 1 93.994 333.93.99 01/01/22 09/30/22 10/01/21 09/30/22 $27,525 $27,525
SFY25 SBHC Proviso Amd 14 N/A 334.04.90 07/01/24 12/31/24 07/O1/24 06/3040 $62,000 $62,000 $172,000
SFY24 SBHC Proviso Amd 14 N/A 334.04.90 07/O1/23 06/30/24 07/O1/23 06/30/24 $110,000 $110,000
SFY23 School Based Health Centers Amd 5 N/A 334.04.90 07/01/22 06/30/23 07/01/22 06/30/23 $150,000 $150,000 $150,000
SFY23 Sexual&Rep Filth Cost Share Amd 10 N/A 334.04.91 07/01/22 06/30/23 07/01/22 06/30/23 $40,357 $80,009 $124,109
SFY23 Sexual&Rep Hlth Cost Share Amd 7,10 N/A 334.04.91 07/01/22 06/30/23 07/01/22 06/30/23 $39,652
SFY22 Sexual&Rep Hlth Cost Share Amd 5 N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/22 $5,880 $44,100
SFY22 Sexual&Rep Hith Cost Share Amd I N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/22 $38,220
SFY24 Drug User Health Program Amd 14 N/A 334.04.91 07/O1/23 12/31/23 07/O1/23 12/31/23 $7,500 57,500 $7,500
State Drug User Health Program Amd 5 N/A 334.04.91 07/01/22 06/30/23 07/01/21 06/30/23 $15,000 $15,000 $22,500
State Drug User Health Program Amd 1 N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/23 $7,500 $7,500
Rec Shellfish/Biotoxin Amd 14 N/A 334.04.93 07/O1/23 12/31/24 07/01/23 06/30/25 511.100 $11,100 $28,600
Rec ShellfishBiotoxin Amd 9 N/A 334.04.93 01/01/22 06/30/23 07/01/21 06/30/23 $7,000 $17,500
Rec ShellfishBiotoxin Amd 1 N/A 334.04.93 01/01/22 06/30/23 07/01/21 06/30/23 $10,500
Small Onsite Management(ALEA) Amd 14 N/A 334.04.93 07/O1/24 12/31/24 07/O1/23 06/30/25 $33,333 $33,333 $104,166
Small Onsite Management(ALEA) Amd 14 N/A 334.04.93 07/O1/23 06/30/24 07/O1/23 06/30/25 $33,333 $33,333
Small Onsite Management(ALEA) Amd 12 N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $9,375 $24,375
Small Onsite Management(ALEA) Amd 1 N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $15,000
Small Onsite Management(ALEA) Amd 12 N/A 334.04.93 01/01/22 06/30/22 07/01/21 06/30/23 ($9,375) $13,125
Small Onsite Management(ALEA) Amd 1 N/A 334.04.93 01/01/22 06/30/22 07/01/21 06/30/234 $22,500
Page 2 of 3
EXHEBff B-14
Page 4 of 41
Jefferson County Public Health ALLOCATIONS Contract Number. CLH31013
Contract Term:2022-2024 Date. June 1,2023
Indirect Rate January 1,2022 through December 31,2022:29.23%Public Health
Indirect Rate January 1,2023 through December 31,2023:35.85%Public Health DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
Small Onsite Management(GFS) Amd 14 N/A 334.04.93 07/01/24 12/31/24 07/O1/23 07/O1/25 $31,970 $31,970 $31,970
Wastewater Management-GFS Amd 1 N/A 334.04.93 07/O1/22 06/30/23 07/01/21 06/30/23 $30,000 $30,000 $30,000
SFY23 FPHS-LHJ-GFS Amd 6,9 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 $1,433,000 $1,433,000 $1,433,000
FPHS-LHJ-Proviso(YR2) Amd 7 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 ($550,000) $0 $445,181
FPHS-LHJ-Proviso(YR2) Amd 1 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 $550,000
FPHS-LHJ-PrOviso(YR I) Amd 10 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 $32,681 $445,181
FPHS-LHJ-Proviso(YR I) Amd4 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 ($137,500)
FPHS-LHJ-Proviso(YR 1) Amd 1 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 $550,000
FPHS-Local Health Jurisdiction Amd 14 N/A 336.04.25 07/01/23 06/30/24 07/O1/23 06/30/25 $1,433,000 $1,433,000 $1,433,000
YR 25 SRF-Local Asst(15%)(FO-SW)SS Amd 11 N/A 346.26.64 01/O1/23 12/31/23 01/01/23 12/31/23 $2,200 $2,200 $3,600
YR24 SRF-Local Asst(15%)(FO-SW)SS Amd 1 N/A 346.26.64 01/01/22 12/31/22 07/01/21 06/30/23 $1,400 $1,400
Sanitary Survey Fees(FO-SW)SS-State Amd 11 N/A 346.26.65 01/O1/22 12/31/23 07/01/21 12/31/23 $2,200 $3,600 $3,600
Sanitary Survey Fees(FO-SW)SS-State Amd 1,11 N/A 346.26.65 01/O1/22 12/31/23 07/01/21 12/31/23 $1,400
YR 25 SRF-Local Asst(15%)(FO-SW)TA Amd 11 N/A 346.26.66 01/01/23 12/31/23 01/01/23 12/31/23 $1,000 $1,000 $2,000
YR24 SRF-Local Asst(15%)(FO-SW)TA Amd 1 N/A 346.26.66 01/01/22 12/31/22 07/01/21 06/30/23 $1,000 $1,000
TOTAL $6,166,503 $6,166,503
Total consideration: $4,4079845 GRAND TOTAL $6,166,503
$1,758,658
GRAND TOTAL $6,166,503 Total Fed $2,175,277
Total State $3,991,226
*Catalog of Federal Domestic Assistance
"Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Page 5 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Foundational Public Health Services(FPHS)- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2023
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ❑ Reimbursement
® (Transparency ®
Period of Performance: July 1,2023 through June 30,2024 State FFATA Other ❑ ( p y Act)
Periodic Distribution
❑ Research&Development
Statement of Work Purpose: Per RCW 43.70.512,Foundational Public Health Services(FPHS)funds are for the governmental public health system: local health jurisdictions,
Department of Health,state Board of Health,sovereign tribal nations and Indian health programs. These funds are to build the system's capacity and increase the availability of
FPHS services statewide.
Revision Purpose: N/A
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FPHS-LOCAL HEALTH JURISDICTION 99200840 N/A 336.04.25 07/01/23 06/30/24 0 1,433,000 1,433,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 1,433,000 1,433,000
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
I FPHS funds to each LHJ—See below in Program Specific See below in Program Specific See below in Program Specific $520,000
Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
2 Assessment Reinforcing Capacity—See below in Pro ram Specific See below in Program Specific See below in Program Specific $60,000
Requirements—ActivitySpecial Instructions for details Requirements-Deliverables Requirements-Deliverables
3 Assessment—CHA/CHIP—See below in Program Specific See below in Program Specific See below in Program Specific $30,000
Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
4 Lifecourse—Infrastructure& Workforce Capacity—See below in See below in Program Specific See below in Program Specific $353,000
Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
Exhibit A,Statement of Work Page 1 of 6 Contract Number CLH31013-Amendment 14
Page 6 of 41
Payment
Task Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Assessment—Shared Regional Epidemiology—General See below in Program Specific See below in Program Specific
5 (Assessment/Surveillance,CHA/CHIP)—See below in Program $150,000
Specific Re uirements—ActivitySpecial Instructions for details Requirements-Deliverables Requirements-Deliverables
6 EPH Core Team—Safe and Healthy Communities—See below in See below in Program Specific See below in Program Specific $47,000
Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
7 EPH Core Team—Climate Change Response—See below in Program See below in Program Specific See below in Program Specific $80,000
Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
8 EPH Core Team—Water System Capacity—See below in Program See below in Program Specific See below in Program Specific $75,000
Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
EPH Core Team—System-Wide Data Management Improvement_— See below in Program Specific See below in Program Specific
9 See below in Pro ram Specific Requirements—Activity Special Requirements-Deliverables Requirements-Deliverables $63,000
Instructions for details
10 EPH Core Team—Homelessness Response—See below in Program See below in Program Specific See below in Program Specific $55,000
Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance c,doh.wa._oovv.
FPHS staff from DOH and the Washington State Association of Local Public Health Officials(WSALPHO)will coordinate and communicate together to build and assure common
systemwide approaches per FPHS Steering Committee direction and the FPHS framework intent.
• For LHJ questions about the use of funds:
o Chris Goodwin, FPHS Policy Advisor,WSALPHO—cgoodwing_wsac.org,564-200-3166
o Brianna Steere,FPHS Policy Advisor,WSALPHO—bsteere_,wsac.org,564-200-3171
The intent of FPHS funding is outlined in RCW 43.70.512.
Foundational Public Health Services Definitions and related information can be found here: www.doh.wa.gov/fphs.
Stable funding and an iterative decision-making process—The FPHS Steering Committee's roles and responsibilities are outlined in the FPHS Committee& Workgroup
Charter The Steering Committee is the decision making body for FPHS and operates under a consensus-based decision making model,outlined here.The Steering Committee use
an iterative approach to decision making meaning additional tasks and/or funds may be added to a local health jurisdiction's(LHJ)FPHS Statement of Work(SOW)as funding
decisions are made.
Spending of FPHS funds—FPHS funds do not require pre-approval or pre-authorization to spend. FPHS funds are to assure FPHS services are available in each jurisdiction based
on the FPHS Definitions(link)and as reflected in the SOW. Assurance includes providing FPHS as part of your jurisdiction's program operations,contracting with another
governmental public health system partner to provide the service,or receiving the service through a new service delivery model such as cross jurisdictional sharing or regional
staff. FPHS funds are eligible starting at the beginning of each state fiscal year(July 1)regardless of when funds are received by the LHJ,even if the expenditure
occurred before the LHJ's contract was signed.
Exhibit A,Statement of Work Page 2 of 6 Contract Number CLH31013-Amendment 14
Page 7 of 41
These funds are not intended for fee-based services such as select environmental public health services.As state funding for FPHS increases,other funds sources(local revenue,
grants,federal block grants)should be directed to the implementation of additional important services and local/state priorities as determined by each agency/jurisdiction.
Annual Allocations—The legislature appropriates FPHS funding on an annual basis and the FPHS Steering Committee allocates funds annually through the FPHS Concurrence
Process for the State Fiscal Year(SFY):July-June.
The Legislature appropriates FPHS funding amounts for each fiscal year of the biennium. This means that funds must be spent within that fiscal year and cannot be carried
forward. Any funds not spent by June 30'each year must be returned to the State Treasury. Funding allocations reset and begin again at the start of the next fiscal year(July 1).
This Statement of Work is for the period of July 1,2023-June 30,2024 and may be included in multiple Consolidated Contracts(ConCons)which are based on the calendar year
and renewed every three years.
Disbursement of FPHS funds to LHJs—Unlike other ConCon grants,FPHS bill-back to DOH is NOT required. Half of the annual FPHS funds allocated by the Steering
Committee to each LHJ are disbursed each July and January. The July payments to LHJs and access to FPHS allocation for all other parts of the governmental public health
system occur upon completion of the FPHS Annual Assessment.
Deliverables—FPHS funds are to be used to assure FPHS services statewide. The FPHS accountability process measures how funds are spent,along with changes in system
capacity through the FPHS Annual Assessment,system performance indicators,and other data. DOH,SBOH and local health jurisdictions have agreed to complete:
1. Reporting of spending and spending projections. Process timelines and reporting template are provided by the FPHS Steering Committee via FPHS Support Staff.
2. FPHS Annual Assessment is due each July to report on the previous state fiscal year.Process and reporting template are provided by the FPHS Steering Committee via
FPHS Support Staff. System results are published in the annual FPHS Investment Report available at www.doh.wa.gov/fphs.
BARS Revenue Code:336.04.25
BARS Expenditure Coding—provided for your reference.
10 FPHS Epidemiology&Surveillance
11 FPHS Communi Health Assessment
12 FPHS Emergency Preparedness&Response
13 FPHS Communication
14 FPHS Polic Development
15 FPHS Community Partnership Development
16 FPHS Business Competencies
17 FPHS Technology
20 FPHS CD Data&Planning
21 FPHS Promote Immunizations
23 FPHS Disease Investigation—Tuberculosis TB
24 FPHS Disease Investigation—Hepatitis C
25 FPHS Disease Investigation—Syphilis,Gonorrhea&HIV
26 FPHS Disease Investigation—STD other
27 FPHS Disease Investigation—VPD
28 FPHS Disease Investigation—Enteric
29 FPHS Disease Investigation—General CD
Exhibit A,Statement of Work Page 3 of 6 Contract Number CLH31013-Amendment 14
40 FPHS EPH Data&Planning
Page 8 of 41
41 FPHS Food
42 FPHS Recreational Water
43 FPHS Drinking Water Quality
44 FPHS On-site Wastewater
45 FPHS Solid&Hazardous Waste
46 FPHS Schools
47 FPHS Temporary Worker Housing
48 FPHS Transient Accommodations
49 FPHS Smoking in Public Places
50 FPHS Other EPH Outbreak Investigations
51 FPHS Zoonotics includes vectors
52 FPHS Radiation
53 FPHS Land Use Planning
60 FPHS MCH Data&Planning
70 FPHS Chronic Disease,Injury&Violence Prevention Data&Planning
80 FPHS Access/Linkage with Medical,Oral and Behavioral Health Care Services Data&Planning
90 FPHS Vital Records
91 FPHS Laboratory—Centralized(PHSKC Only)
92 1 FPHS Laboratory
Special References(i.e.,RCWs,WACs,etc.):
FPHS Intent-RCW 43.70.512
FPHS Funding—RCW 43.70.515
FPHS Committee&Workgroup Charter
FPHS Steering Committee Consensus Decision Making Model
Activity Special Instructions:
Investments to Each LHJ:
1. FPHS Funds to Each LHJ
These funds are allocated to be used to provide any programs and services within all of the FPHS Definitions.Each LHJ is empowered to prioritize where and how to use
these funds to maximize equitable,effective and efficient delivery of FPHS to every community in Washington.
Use BARS expenditure codes from the list above that most closely align with expenditure made.
Tar¢eted Investments to Each LHJ:
2. Assessment Reinforcing Capacity(FPHS definition G.2)
Support LHJ assessment capacity with flexible funds to meet locally identified needs. BARS expenditure codes: 562.10 or 11
3. Assessment—CHA/CHIP(FPHS definitions G.3)
Support any CHA/CHIP activity or service(e.g.,data analysis, focus groups,report writing,process facilitation)and may be used to contract with other agencies for staff
time or services. Use BARS expenditure codes: 562.11
Exhibit A,Statement of Work Page 4 of 6 Contract Number CLH31013-Amendment 14
4. Lifecourse—Infrastructure&Workforce Capacity(FPHS definitions D,E,F) Page 9 of 41
Infrastructure and workforce investments to each LHJ to meet fundamental needs in three areas:Maternal/Child/Family Health; Access/Linkage with Medical,Oral and
Behavioral Health Services; and Chronic Disease,Injury and Violence Prevention. Use BARS expenditure codes: 562.60 or 70 or 80.
Targeted Investments to Select LHJs—Assurine FPHS Available for/in Multiple Jurisdictions:
5. Assessment—Shared Regional Epidemiology—General(Assessment/Surveillance,CHA/CHIP)(FPHS definitions G.1,2)
Increase assessment and epidemiology capacity via regional/shared epidemiologist model to meet locally identified needs. Use BARS expenditure codes:562.10 or 11
EPH--Core Teams(Applies to all EPH Core Team FPHS Investments)(FPHS definition B.1-7)
Each EPH Core Team investment is for LHJ staff to participate in a cross jurisdictional topic-specific Core Team.The Core Teams are each tasked with developing one or
more model program(s), intended to offer guidance for scalable environmental public health responses relating to their specific sub-topic area(s).Where it makes sense to
do so,the Core Teams may also work on implementation of these model programs.The content and output of these model programs will vary depending on the needs and
approaches specific to each sub-topic area.
Recipients of these Core Team FPHS funds are required to participate in the associated Core Team for each investment.Recipients may spend these funds towards
staffing time necessary to participate and on FPHS-qualifying activities for the specific sub-topic area(s)attached to its associated investment.Each Core Team FPHS
investment is distinctive from all other Core Team FPHS investments.
Core Teams exist outside the FPHS structure, in partnership between LHJs and WA DOH,with one co-lead from each.Model programs developed through Core Team
work will be made available to all Washington public health agencies.
There are currently six EPH Core Teams.They are listed below,with their sub-topic area(s),as applicable.
• System-Wide Data Management Improvement
• Climate-Change Response
• Lead Exposure
• Water System Capacity
• Homelessness Response
• Safe&Healthy Communities
Jefferson is receiving funds to participate in these EPH Core Teams:
6. EPH Core Team—Safe& Healthy Communities
This Core Team develops system capacity to advance EPH perspectives into planning processes such as State Environmental Policy Act(SEPA)work,Health Impact
Assessments,Comprehensive Plans,and related environmental review opportunities.The Core Team will develop one or more model program(s)to provide scalable
approaches to healthy community planning,which may include wastewater planning and treatment,seawater intrusion in drinking water,ventilation in public buildings,
PFAS contamination,climate change challenges,and other emerging topics identified by the Core Team.
• Use BARS expenditure code: 562.40
7. EPH Core Team—Climate-Chanee Response
This Core Team will address environmental health concerns related to climate and the effects of climate change.
• Model program development will start with Wildfire Smoke and Harmful Algal Blooms,and may include other priorities and topics.
Exhibit A,Statement of Work Page 5 of 6 Contract Number CLH31013-Amendment 14
8. EPH Core Team—Water System Capacity Page 10 of 41
The goal of this Core Team is to increase LHJ capacity for water resource management and planning.
• Use BARS expenditure code: 562.43 or 53.
9. EPH Core Team—System-Wide Data Manaeement Improvement
This Core Team will identify and employ a strategy for data sharing,storage and consistency across the state.
• Use BARS expenditure code: 562.40.
10. EPH Core Team—Homelessness Response
This Core Team will develop one or more model program(s)for a scalable response to homelessness-related public health concerns.
• Use BARS expenditure code: 562.40
Exhibit A,Statement of Work Page 6 of 6 Contract Number CLH31013-Amendment 14
Page 11 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Infectious Disease Prevention Services-SSP- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2023
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: July 1,2023 through December 31,2023 ® State El Other ❑ FFATA(Transparency Act)
❑ Fixed Price
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to provide a syringe services program(SSP)
Revision Purpose: N/A
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY24 DRUG USER HEALTH PROGRAM 12401140 N/A 334.04.91 07/01/23 12/31/23 0 7,500 7,500
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 7,500 7,500
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Syringe To provide comprehensive Syringe Service Program(SSP)to All data is entered into DOH provided Data is entered into $7,500—MI 12405100-
Service people who use drugs(PWUD). This plan of action is database for tracking SSP activities database by the 15th of the State Drug User Health
Program directed to distribute syringes to communities that use drugs monthly. following month. $7,500 for 7/1/23-
(SSP) to prevent transmission of infectious disease. SSP programs 12/31/23
will operate during scheduled hours to provide new harm
reduction supplies and syringes to prevent transmission of
disease. SSP will offer referrals to address social
determinants of health.
The contractor will enter all deliverable data into DOH
provided database for tracking SSP activities.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financegdoh.wa.g_ov.
Exhibit A,Statement of Work Page 1 of 2 Contract Number CLH31013-Amendment 14
Page 12 of 41
PROGRAM SPECIFIC REQUIREMENTS
1. Definitions
CONTRACTOR—For the purposes of this Statement of Work Only,the Entity receiving funds directly from Washington State Department of Health(DOH)for
client services to prevent or treat conditions named in the statement of work will be referred to as contractor.
2. Contract Management—
a. Fiscal Guidance
i) Funding—The CONTRACTOR shall submit all claims for payment for costs due and payable under this statement of work by January 31,2024
DOH will pay belated claims at its discretion,contingent upon the availability of funds.
ii) Submission of Invoice Vouchers—On a monthly basis,the CONTRACTOR shall submit correct A 19 invoice vouchers amounts billable to DOH
under this statement of work and Expense Summary backup form.All A 19 invoice vouchers must be submitted by the 25th of the following month.
• The CONTRACTOR must provide all backup documentation as required based on the assigned risk level. DOH may ask for additional backup
information to pay invoices based on the needs of the funding sources supporting the work.
iii) Advance Payments Prohibited—DOH funds are"cost reimbursement"funds. DOH will not make payment in advance or in anticipation of services
or supplies provided.This includes payments of"one-twelfth"of the current fiscal year's funding.
iv) Payment of Cash or Checks to Clients Not Allowed—Where direct provision of service is not possible or effective,vouchers or similar programs,
which may only be exchanged for a specific service(e.g.,transportation),shall be used to meet the need for such services. CONTRACTOR shall
administer voucher programs to assure that recipients cannot readily convert vouchers into cash.
v) Small and Attractive items—Each agency shall perform a risk assessment(both financial and operational)on the agency's assets to identify those
assets that are particularly at risk or vulnerable to loss. Operational risks include risks associated with data security on mobile or portable computing
devices that store or have access to state data.Assets so identified that fall below the state's capitalization policy are considered small and attractive
assets.Agency shall develop written internal policies for managing small and attractive assets.Internal policies should take into consideration the
Office of the Chief Information Officer(OCIO)IT Security Standard 141 Section 5.8 Mobile Computing and Section 8.3 Media Handling and
Disposal at httus://ocio.wa.eov/policies.
The agency shall implement specific measures to control small and attractive assets in order to minimize identified risks.Periodically,the agency should perform a
follow up risk assessment to determine if the additional controls implemented are effective in managing the identified risks.
Agency must include,at a minimum,the following assets with unit costs of$300 or more:
1)Laptops and Notebook Computers
2)Tablets and Smart Phones
Agencies must also include the following assets with unit costs of$1,000 or more:
1)Optical Devices,Binoculars,Telescopes,Infrared Viewers,and Rangefinders
2)Cameras and Photographic Projection Equipment
3)Desktop Computers(PCs)
4)Television Sets,DVD Players,Blu-ray Players,and Video Cameras(home type)
b. Contract Modifications
Notice of Change in Services—The CONTRACTOR shall notify DOH program staff,within 45 days,if any situations arise that may impede implementation of the
services contained in the statement of work.DOH and the CONTRACTOR will agree to strategies for resolving any shortfalls.DOH retains the right to withhold
funds in the event of substantial noncompliance.
Exhibit A,Statement of Work Page 2 of 2 Contract Number CLH31013-Amendment 14
Page 13 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Drinking Water Group A Pro ram - Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1.2022.
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
® Federal Contractor (check if applicable) ❑ Reimbursement
® Trans FFATA(Transparency Period of Performance: January, 1,2022 through December 31.2023 State Other ® ( p y Act)
®Fixed Price
ElResearch&Development
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non-community Group A water systems
Revision Purpose: The purpose of this revision is to identify Data Sharing Information.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None Allocation
SANITARY SURVEY FEES FO-SW SS-STATE 24232522 N/A 346.26.65 01/01/22 12/31/23 3,600 0 3,600
YR 24 SRF-LOCAL ASST 15%)(FO-SW)SS 24239224 N/A 346.26.64 01/01/22 12/31/22 1,400 0 1,400
YR 24 SRF-LOCAL ASST 15%)(FO-SW)TA 24239224 N/A 346.26.66 01/01/22 12/31/22 1,000 0 1,000
YR 25 SRF-LOCAL ASST 15%)(FO-SW)SS 24239225 N/A 346.26.64 01/01/23 12/31/23 2,200 0 2,200
YR 25 SRF-LOCAL ASST 15%)(FO-SW)TA 24239225 N/A 346.26.66 01/01/23 12/31/23 1,000 0 1,000
0 0 0
TOTALS 9,200 0 9,200
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
1 Trained LHJ staff will conduct sanitary Provide Final*Sanitary Survey Reports Final Sanitary Survey Upon ODW acceptance of the Final Sanitary
surveys of small community and non- to ODW Regional Office.Complete Reports must be received Survey Report,the LHJ shall be paid$400 for
community Group A water systems identified Sanitary Survey Reports shall include: by the ODW Regional each sanitary survey of a non-community
by the DOH Office of Drinking Water 1. Cover letter identifying significant Office within 30 system with three or fewer connections.
(ODW)Regional Office. deficiencies, significant findings, calendar days of
observations,recommendations,and conducting the sanitary Upon ODW acceptance of the Final Sanitary
See Special Instructions for task activity. referrals for further ODW follow-up. survey. Survey Report,the LHJ shall be paid$800 for
2. Completed Small Water System each sanitary survey of a non-community
The purpose of this statement of work is to checklist. system with four or more connections and each
provide funding to the LHJ for conducting 3. Updated Water Facilities Inventory community system.
sanitary surveys and providing technical (WFI).
assistance to small community and non- 4. Photos of water system with text Payment is inclusive of all associated costs
community Group A waters stems. identifying features I such as travel,lodging,per diem.
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH31013-Amendment 14
Page 14 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
5. Any other supporting documents.
Payment is authorized upon receipt and
*Final Reports reviewed and accepted by acceptance of the Final Sanitary Survey Report
the ODW Regional Office. within the 30-day deadline.
Late or incomplete reports may not be accepted
for payment.
2 Trained LHJ staff will conduct Special Provide completed SPI Report and any Completed SPI Reports Upon acceptance of the completed SPI Report,
Purpose Investigations(SPI)of small supporting documents and photos to must be received by the the LHJ shall be paid$800 for each SPI.
community and non-community Group A ODW Regional Office. ODW Regional Office
water systems identified by the ODW within 2 working days Payment is inclusive of all associated costs
Regional Office. of the service request. such as travel, lodging,per diem.
See Special Instructions for task activity. Payment is authorized upon receipt and
acceptance of completed SPI Report within the
2-working day deadline.
Late or incomplete reports may not be accepted
for a ment.
3 Trained LHJ staff will provide direct Provide completed TA Report and any Completed TA Report Upon acceptance of the completed TA Report,
technical assistance(TA)to small community supporting documents and photos to must be received by the the LHJ shall be paid for each technical
and non-community Group A water systems ODW Regional Office. ODW Regional Office assistance activity as follows:
identified by the ODW Regional Office. within 30 calendar days . Up to 3 hours of work: $250
of providing technical • 3-6 hours of work:$500
See Special Instructions for task activity. assistance. • More than 6 hours of work: $750
Payment is inclusive of all associated costs
such as consulting fee,travel,lodging,per
diem.
Payment is authorized upon receipt and
acceptance of completed TA Report within the
30-day deadline.
Late or incomplete reports may not be accepted
for a ment.
4 LHJ staff performing the activities under For training attended in person,prior to Annually For training attended in person.LHJ shall be
tasks 1,2 and 3 attend periodic required attending the training,submit an paid mileage,per diem,lodging,and
survey training as directed by DOH. "Authorization for Travel(Non- registration costs as approved on the pre-
Employee)"DOH Form 710-013 to the authorization form in accordance with the
See Special Instructions for task activity. ODW Program Contact for approval(to current rates listed on the OFM Website
ensure enough funds are available). htt ://www.ofm.wa.,ov/resources/travel.as
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH31013-Amendment 14
Page 15 of 41
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance a,doh.wa.g_o_v.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpendinggou by DOH as required by P.L. 109-282.
Program Specific Requirements
Data Sharing
The Office of Drinking Water will share water system information and files with the local health jurisdiction to support the work identified in this statement of work. To request
water system data please contact the regional office with the name of the water system, water system ID#, specific information being requested and any timeline requirements. If
allowable,please give administrative staff 3 to 5 business days to provide records.
Program Manual,Handbook,Policy References: Field Guide(DOH Publication 331-486).
Special References:
Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work,ODW contracts with the LHJ to conduct sanitary surveys(and SPIs and
provide technical assistance)for small community and non-community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys(and
SPIs and provide technical assistance)for small community and non-community water systems with surface water sources,large water systems,and systems with complex
treatment.
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4,below.
Special Billing Requirements
The LHJ shall submit quarterly invoices within 30 days following the end of the quarter in which work was completed,noting on the invoice the quarter and year being billed for.
Payment cannot exceed a maximum accumulative fee of$7,200 for Task 1,and$2,000 for Task 2,Task 3 and Task 4 combined during the contracting period,to be paid at the
rates specified in the Payment Method/Amount section above. When invoicing for sanitary surveys bill half to BARS Revenue Code 346 26 64 and half to BARS Revenue Code
346.26.65.
When invoicing for Task 1,submit the list of WS Name,ID#,Amount Billed,Survey Date and Letter Date for which you are requesting payment.
When invoicing for Task 2-3,submit the list of WS Name,ID#,TA Date and description of TA work performed,and Amount Billed.
When invoicing for Task 4,submit receipts and the signed pre-authorization form for non-employee travel to the ODW Program Contact below and a signed A19-IA Invoice
Voucher to DOH Grants Management,billing to BARS Revenue Code 346.26.66 under Technical Assistance(TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW.Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance(Field Guide).The sanitary survey will include an
evaluation of the following eight elements:source;treatment;distribution system; finished water storage;pumps,pump facilities and controls;monitoring,reporting and data
verification;system management and operation;and certified operator compliance. If a system is more complex than anticipated or other significant issues arise,the LHJ may
request ODW assistance.
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH31013-Amendment 14
Page 16 of 41
• No more than I surveys of non-community systems with three or fewer connections be completed between January 1,2022 and December 31,2022.
• No more than 3 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2022 and
December 31,2022.
• No more than 3 surveys of non-community systems with three or fewer connections be completed between January 1,2023 and December 31,2023.
• No more than 4 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2023 and
December 31,2023.
The process for assignment of surveys to the LHJ,notification of the water system,and ODW follow-up with unresponsive water systems;and other roles and responsibilities of
the LHJ are described in the Field Guide.
Task 2
Trained LHJ staff will perform Special Purpose Investigations(SPIs)as assigned by ODW. SPIs are inspections to determine the cause of positive coliform samples or the cause of
other emergency conditions.SPIs may also include sanitary surveys of newly discovered Group A water systems.Additional detail about conducting SPIs is described in the Field
Guide. The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staff will conduct Technical Assistance as assigned by ODW.Technical Assistance includes assisting water system personnel in completing work or verifying work
has been addressed as required,requested,or advised by the ODW to meet applicable drinking water regulations. Examples of technical assistance activities are described in the
Field Guide.The ODW Regional Office must authorize in advance any technical assistance provided by the LHJ to a water system.
Task 4
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work.
If required trainings,workshops or meetings are not available,not scheduled,or if the LHJ staff person is unable to attend these activities prior to conducting assigned tasks,the
LHJ staff person may,with ODW approval,substitute other training activities to be determined by ODW. Such substitute activities may include one-on-one training with ODW
staff,co-surveys with ODW staff,or other activities as arranged and pre-approved by ODW.LHJ staff may not perform the activities under tasks 1,2,and 3 without completing
the training that has been arranged and approved by ODW.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH31013-Amendment 14
Page 17 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Immunization-Promotion of Immunizations to Local Health Jurisdiction Name: Jefferson County Public Health
Improve Vaccination Rates-Effective July 1 2023
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance T pe of Payment
® Federal Subrecipient (check if applicable) Reimbursement
Period of Performance: July 1,2023 through June 30,2024 ❑ State ® FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to contract with local health to conduct activities to improve immunization coverage rates
Revision Purpose: N/A
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY24 CDC VFC O s 74310241 93.268 333.93.26 07/01/23 06/30/24 0 5,600 5,600
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 5,600 5,600
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Develop a proposal to improve immunization coverage rates for Written proposal summarizing project plan August 1,2023 Reimbursement for actual
a target population by increasing promotion activities and and method of assessing/observing change costs incurred,not to
collaborating with community partners(can use pre and post in target population. exceed total funding
qualitative or quantitative collection methods consideration amount.
Examples of qualitative&quantitative methods/measures: (Template will be provided)
■ Surveys,Questionnaires, Interviews
• Immunization coverage rates expressed in percentages
• Observations(i.e.,feedback from surveys/interviews,
social media posts comments)
■ Analytic tools(i.e.,google analytics measuring
website traffic,page views etc.)
Exhibit A,Statement of Work Page ] of 2 Contract Number CLH31013-Amendment 14
Page 18 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
2 Upon approval of proposal,implement the plan to increase Written report describing the progress November 30,2023 Reimbursement for actual
immunization coverage rates with the target population made on reaching milestones for activities costs incurred,not to
identified. identified in the plan(template will be March 31,2024 exceed total funding
provided) consideration amount.
3 Develop final report to include comparison of change or Final written report including measured June 15,2024 Reimbursement for actual
improvement of targeted outcome from start of the and/or observed outcomes[what was costs incurred,not to
project/intervention[This can be short-term or intermediate achieved as a result of the exceed total funding
outcomes with overall goal to increase immunization rates] activity/intervention?]. consideration amount.
Examples:
■ Increased partner knowledge on immunization (Template will be provided)
guidelines
■ Change in attitudes about childhood vaccines
■ Increase in school district immunization coverage
rates
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance a,doh.wa.gov.
Federal Fundine Accountability and Transaarency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
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.
Exhibit A,Statement of Work Page 2 of 2 Contract Number CLH31013-Amendment 14
Page 19 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: OSS LMP Implementation-Effective January 1 2022 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: January 1,2022 through June 30,2023 ® State ❑ FFATA(Transparency Act) ❑ Fixed Price
❑Other Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to fund implementation of the on-site sewage system(OSS)local management plam(LMP).
Revision Purpose: The purpose of this revision is to change the period of performance from December 31,2023 to June 30,2023 to close out this concon for the end of the 21-23
biennium.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None Allocation
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 01/01/22 06/30/22 13,125 0 13,125
WASTEWATER MANAGEMENT-GFS 26701100 N/A 334.04.93 07/01/22 06/30/23 30,000 0 30,000
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 07/01/22 06/30/23 24,375 0 24,375
0 0 0
0 0 0
0 0 0
TOTALS 67,500 0 67,500
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Program/Local Management Plan Implementation Electronic copy of progress report and Report Due Date: $6,750
• Enforcement for system deficiencies found during mapping data to include: June 15,2022
Operations,Maintenance and Monitoring(O&M) • Number of systems with known January 15,2023
inspections system type. June 15,2023
• O&M program administration • Number of septic systems with December 31,2023
• Onsite Sewage System(OSS)complaint response current inspections.
• O&M data reports about deficiencies • Number of septic failures. Task is ongoing throughout
the project period.
2 Investigation • Number of Pollution Identification and Report Due Date: $8,387
Identification of"unknown"systems to"known"status: There Correction(PIC)surveys completed June 15,2022
are approximately 3,250 properties that may be developed for • Number of systems going from January 15,2023
which the LHJ does not have records. Focus is in the Hood Unknown to Known status June 15,2023
Canal Watershed which is a part of the marine recovery area December 31,2023
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH31013-Amendment 14
Page 20 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
(MRA). The goal is to clarify/determine the status of twenty- . Number of operations and maintenance
five(25). (O&M)inspections received on Task is ongoing throughout
previously unknown systems the project period.
• Number of pumpers' reports on
systems not previously
documented/known
3 Follow-up on Operating and Maintenance(O&M) • Report Summary of activities and Report Due Date: $4,725
Inspections and Pumper Reports evaluation of reports where corrective June 15,2022
Awareness/Warning and compliance letters sent to owners actions were required January 15,2023
where deficiencies were identified during an O&M inspection. • Number of Failures identified,and June 15,2023
Audit inspection will be conducted to verify corrections for corrective action taken December 31,2023
major issues. • Report number of Notice of Non-
compliance filed due to lack of
Utilize recording of Notice of Non-compliance for OSS where completion of corrective actions
corrective actions were required and not completed. The required Task is ongoing throughout
notices will be placed for items that indicate system failure the project period.
including leaking septic tanks and surfacing sewage. Per
county procedure/policy our standard methods of enforcement
will be conducted prior to filing a notice to property.
4 Data Management • Assure that the required information Report Due Date: $11,863
Coordinate management of the permitting and O&M database for mapping is incorporated into the June 15,2022
with the improvements and changes in the County GIS system Permitting and O&M database from the January 15,2023
that is being upgraded over the next two years and the Assessor database. June 15,2023
Assessors database that was new in 2014. • Continue to `clean-up'the existing data December 31,2023
to reflect information obtained through
monitoring inspections,pumping
reports and sanitary surveys. Task is ongoing throughout
• Improve documentation of corrections the project period
of deficient items identified during
monitoring inspections.
• Develop Application Program Interface
(API)between database and Online-
RME.
5 On-site Sewage Systems(OSS)Professional Training • Meeting agenda and attendance Report Due Date: $5,750
Conduct OSS professional industry meetings. Meetings will tracking June 15,2022
focus on current OSS issues, inspection standardization and • Retain consistency in reporting January 15,2023
consistency in reporting. June 15,2023
December 31,2023
Task is ongoing throughout
the r ject period.
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH31013-Amendment 14
Page 21 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
6 Public Outreach • Document postings on website and Report Due Date: $3,025
Communicate via website,mailings,public presentations the information provided via newsletters June 15,2022
requirements and benefits of regular system monitoring. and public presentations January 15,2023
• Track attendance at public June 15,2023
presentations and `hits'on the December 31,2023
Resources for Homeowners webpage at
the Jefferson County Public Health
(JCPH)website Task is ongoing throughout
• Improve compliance with OSS the project period.
monitoring inspection requirements
• Improve completion of deficiencies
identified during OSS monitoring
inspections.
• Continue to provide information on
funding to repair and upgrade existing
OSS.
7 Monitoring Inspection Incentives/Rebates • Provide rebates for monitoring Report Due Date: $27,000
Priority will be given to sites that have never had a monitoring inspections and access risers to grade. June 15,2022
inspection and others in the MRA.Rebates issued will be up to Target is thirty(30)incentives each January 15,2023
$150 for monitoring inspections and$100 for risers. (60 total). June 15,2023
December 31,2023
Task is ongoing throughout
the project period.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Data Universal Numbering System(DUNS®)number.
Information about the LHJ and this statement of work will be made available on USASpendinggov by DOH as required by P.L. 109-282.
Pro-aram Specific Requirements
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
These funds can NOT be used for local match to federal grants.
Special References(i.e.,RCWs,WACs,etc.):
WAC 246-272A and RCW 70A.110
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH31013-Amendment 14
Page 22 of 41
State funds from the Aquatic Lands Enhancement Account must be used to implement elements and activities of the local on-site sewage management plans that do not conflict
with and are consistent with the goals,strategies,objectives,and actions of the Puget Sound Action Agenda.
Definitions:
Failure: A condition of an on-site sewage system or component that threatens the public health by inadequately treating sewage or by creating a potential for direct or indirect
contact between sewage and the public.Examples of failure include: (a)Sewage on the surface of the ground;(b)Sewage backing up into a structure caused by slow soil
absorption of septic tank effluent;(c)Sewage leaking from a sewage tank or collection system;(d)Cesspools or seepage pits where evidence of ground water or surface water
quality degradation exists;(e)Inadequately treated effluent contaminating ground water or surface water;or(f)Noncompliance with standards stipulated on the permit.
Maintenance and Monitoring: The actions necessary to keep the on-site sewage system components functioning as designed.Periodic or continuous checking of an on-site sewage
system,which is performed by observations and measurements,to determine if the system is functioning as intended and if system maintenance is needed. Monitoring also
includes maintaining accurate records that document monitoring activities.
Billing Requirements:
1. Billings are submitted on an A19-IA form,which is provided by DOH.
2. A19-IA forms maybe submitted monthly and must be submitted bi-monthly at minimum.
Special Instructions:
Semi-annual progress reports, including marine recovery area(MRA)mapping data,are due to DOH via email to Roger.Parker &doh.wa.gov and taylor.warren(&doh.wa.gov.
Progress Report Due Dates: January 15,2022,June 15,2022, December 31,2022 June 15,2023 and December 31,2023.
The report format will be provided by DOH and may be modified throughout the contract period via email announcement.
Exhibit A,Statement of Work Page 4 of 4 Contract Number CLH31013-Amendment 14
Page 23 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: OSS LMP Implementation-Effective July 1 2023 Local Health Jurisdiction Name: Jefferson Countv Public Health
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) 0 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ®Reimbursement
Tr Period of Performance: July 1,2023 through December 31,2024 ® State ❑ FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to fund implemation of the on-site sewage system(OSS)local management plan(LMP).
Note: Statements of work with GFS funds must exhaust those funds before billing ALEA funds. GFS funds in the 07/01/23-06/30/24 funding period cannot roll over into the next
funding period. This funding allocation is for the 2023-2025 state biennium.New statements of work with a period of performance of January 1,2025 to June 30,2025 will be
issued in the next consolidated contract term.
Revision Purpose: N/A
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 07/01/23 06/30/24 0 33,333 33,333
SMALL ONSITE MANAGEMENT(ALEA) 26705100 N/A 334.04.93 07/01/24 12/31/24 0 33,333 33,333
SMALL ONSITE MANAGEMENT GFS 26701100 N/A 334.04.93 07/01/24 12/31/24 0 31,970 31,970
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 98,636 98,636
GOALS& MEASURABLE OBJECTIVES
This table summarizes starting and target metrics achieved by implementing the tasks below. This data is reported on an ongoing basis in the semiannual progress reports.
(e.g., OSS compliance")Description " " Units Starting g
P pliance
(e.g."systems") Amount Targets
OSS compliant with inspections in Marine Recovery Areas(MRAs) Number of OSS 486 550
OSS compliant with inspections countywide Number of OSS 1693 1900
Number of OSS failures identified/ 9/2
OSS failures identified/corrected in MRA number of OSS failures with completed 12/6
repairs
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH31013-Amendment 14
age 24 of 41
Number of OSS failure identified/ 25/8
OSS failures identified/corrected countywide number of OSS failures with completed 32/16
repairs
Task Due Date/Time Payment
# Task/Activity/Description Deliverables/Outcomes Information and/or
Frame Amount
Task 1.Grant Administration
This task is to fund the required financial and reporting activities necessary to meet state DOH and Auditor requirements including administration of LHJ local management
plan and OSS LMP grant program.
1.1 Bi-monthly Invoicing and Progress Reports Bimonthly/Monthly invoices Bimonthly/monthly Reimbursement up to
DOH Consolidated Contracts(ConCon)requires billing within for duration of $4,104 based on
60 days of completing work.LHJ will submit invoices through contract period. actual costs.
the ConCon process and will send progress reports and
deliverables to the LMP Contract Manager.Invoices must be
submitted at least bi-monthly(per ConCon requirements)but no
more frequently than monthly.Invoices will be reviewed for
consistency with progress.The LMP Contract Manager may
require monthly invoices.
1.2 Semi-Annual Progress Reports Data about the following: Due July 15 and
Reporting periods are semi-annually from January 1 —June 30 • Qualitative: December 31 for
and July 1 —December 31.Progress reports include data o Summary of work. the duration of the
described in the outcome column. o Barriers to LMP Implementation. contract period.
• Quantitative:
o OSS inventory metrics.
o Enforcement actions.
o Outreach and Education efforts.
Task 2. Local Management Plan Implementation
This task includes all work done to implement the county's LMP excluding grant management tasks and inspection rebates/incentives.
2.1 Database Maintenance and Quality Assurance/Quality a. Provide narrative of data clean-up tasks a-d. Report in Reimbursement up to
Control(QA/QC) completed and in-progress. semi-annual $58,394 based on
Database maintenance and QA/QC is ongoing to ensure accurate progress report in actual costs.
tracking methods for all OSS in the county. Specific tasks b. Provide narrative of progress on configuring Subtask 1.2.
include: Energov database for SOM workflows,reports,
• Continue to `clean-up'the existing data post data automation tasks.
conversion in Energov permitting database
• Configure Energov database for SOM workflows,reports, c. Provide narrative of API development tasks
automation tasks. completed and in-progress.
• Develop Application Program Interface(API)between
database and Online-RME. d. Provide narrative of Homeowner Inspector
• Develop replacement Homeowner Inspector Authorization Authorization website tasks completed and in-
website progress.
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH31013-Amendment 14
Page 25 of 41
Task Due Date/Time Payment
# Task/Activity/Description Deliverables/Outcomes Information and/or
Frame Amount
2.2 Operations and Maintenance(O&M)Program a. Enforcement Protocol. a. September 1,
Administration b. Data on the following: 2023.
• Mail inspection reminders to homeowners as needed. • Number of OSS with current inspections
• Inspection Compliance tracking/mapping. • Number of OSS failures and calculated risk b. Report in semi-
• Failure and repair tracking/mapping. using DOH-provided risk assessment. annual progress
• Compliance enforcement. • Number of repairs. report in Subtask
• Complaint response. 1.2.
• O&M data reports about inventory and deficiencies.
2.3 Education and Outreach a. Track number of social media posts and mailings a-c.Report in semi-
Education and outreach is conducted for OSS owners,realtors, annual progress
etc. Specific tasks include: b. Track attendance of in-person homeowner septic report in Subtask
• Communicate via social media,website,and mailings inspector classes 1.2.
• Provide in-person homeowner septic inspector classes for
property owners c. Track number of homeowner inspectors trained
• Provide online homeowner inspector training and and authorized online
authorization for property owners
2.4 Professional Development and Coordination a.Attendance and contribution at four(4)meetings a-b.Report
• The LHJ will participate in LMP and West Side per year. attendance semi-
Coordinators Meetings and will network between counties. annually,as
• The LHJ will support professional development through: b.Conference and Training participation as scheduled in Task
o Attending DOH OSS Program trainings. available. 1.2.
o Environmental Heath Conferences
■ Annual Education Conference(AEC)-Two(2)
Staff members.
■ Washington On-Site Sewage Association
WOSSA Conference-Two 2 Staff members.
Task 3.Homeowner Inspection Rebates/Incentives Program
Provide low-income rebates to homeowners.Provide inspection compliance incentives to homeowners in priority areas.
3.1 Low-Income Homeowner Inspection Rebates a.Provide draft and final process/policy documents a.Prior to issuing Reimbursement up to
The LHJ will provide rebates to homeowners for pumping, to DOH. any rebates. $36,138 based on
inspection and minor repairs.Rebates issued will be up to$350. actual costs.
b.Report number of rebates provided for pumping, b.By grant
monitoring inspections and access risers. closeout.
3.2 Homeowner Inspection Incentives a.Provide draft and final process/policy documents a.Prior to issuing
Promote pumping, inspection and minor repairs with rebates to to DOH. any incentives.
homeowners in priority areas. Rebates issued will be up to$350.
b. Report number of rebates for pumping, b. By grant
monitoring inspections and access risers to grade closeout.
provided to priority-area homeowners.
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH31013-Amendment 14
Page 26 of 41
Budget
Category Amount
Personnel/Salaries $28,775
Fringe Benefits $16 625
Travel $3,500
Supplies
Contracts
Other 8
,49
• Registration Fees $$2$2,498
• Rebates/Incentives
Total Direct Charges $87,536
Indirect Charges(federally approved rate) $11,100
TOTAL—Not to Exceed $98,636
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financekdoh.wa.gov.
Exhibit A,Statement of Work Page 4 of 4 Contract Number CLH31013-Amendment 14
Page 27 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Recreational Shellfish Activities- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2023
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ®Reimbursement
Period of Performance: July 1,2023 through December 31,2024 ® State ❑ FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide funds for shellfish harvesting safety
Revision Purpose: N/A
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
REC. SHELLFISH BIOTOXIN 26402600 N/A 334.04.93 07/01/23 12/31/24 0 11,100 11,100
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 11,100 11,100
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Biotoxin Monitoring Submit annual report on DOH approved Email Report to DOH by $10,600
• Collect monitoring samples on schedule according to format of activities for the year,including February 15,2024
Department of Health(DOH)Biotoxin Monitoring Plan, the number of sites monitored and samples
coordinate deviations from the schedule with DOH,notify collected,and number and names of (See Special Instructions
DOH in advance if samples cannot be collected. beaches posted with signs. below.)
• Conduct emergency biotoxin sampling when needed.
• Post/remove recreational shellfish warning and/or
classification signs on beaches and restock cages as needed.
• Issue biotoxin news releases during biotoxin closures in
Jefferson County.
• This task may also include recruiting,training,and
coordination of volunteers,and fuel reimbursement funds for
volunteer biotoxin monitoring.
Exhibit A, Statement of Work Page 1 of 2 Contract Number CLH31013-Amendment 14
Page 28 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
2 Outreach Submit annual report including the Email Report to DOH by $500
• Staff educational booths at local events. number of events staffed and amount of February 15,2024
• Distribute safe shellfish harvesting information. educational materials distributed.
(See Special Instructions
below.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance n,doh.wa.gov.
Program Specific Requirements
Program Manual,Handbook,Policy References:
Department of Health's Biotoxin Monitoring Plan
Special References(i.e.,RCWs,WACs,etc.):
Chapter 246-280 WAC
https://doh.wa.gov/community-and-environment/sheIIfish/recreational-shellfish
https:Hdoh.wa.gov/about-us/programs-and-services/environmental-public-health/environmental-health-and-safety/about-shellfish-program/about biotoxins and illness prevention
rp ogram
Special Instructions:
Report for work performed in 2023 must be submitted via email to Liz Maier(liz.maier@doh.wa._og_v)by February 15,2024.
The report format will be provided by DOH and may be modified throughout the period of performance via email announcement.
Exhibit A,Statement of Work Page 2 of 2 Contract Number CLH31013-Amendment 14
Page 29 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: School-Based Health Centers Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2023
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ®Reimbursement
Period of Performance: July 1,2023 through December 31,2024 ® State ❑ FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to fulfill the legislative mandate,RCW 43.70.825,and formalize a grant award to Jefferson
County Public Health for a School-Based Health Centers(SBHC)operations/expansion/improvement grant.A school-based health center is defined in the law as"a student-
focused health center located in or adjacent to a school that provides integrated medical,behavioral health,and other health care services such as dental care."
Jefferson County Public Health will complete infrastructure and capacity building tasks and activities outlined in the contract to operate,expand,and/or improve a school-based
health center at Quilcene,Chimacum,and Port Townsend School Districts.Activities include participation in trainings,technical assistance,and contract meetings;expanding,
sustaining,and/or improving SBHC services;engaging the community about the SBHC;and reporting on performance.
Revision Purpose: N/A
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY24 SBHC PROVISO 78310840 N/A 334.04.90 07/01/23 06/30/24 0 110,000 110,000
SFY25 SBHC PROVISO TBD N/A 334.04.90 07/01/24 12/31/24 0 62,000 62,000
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 172,000 172,000
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
la Implement sustainability plan.Create workplan that outlines SBHC Operations project workplan September 30,2023 $25,000
tasks and activities for the project,including: Updated sustainability plan
• Exploration of expansion of Port Townsend SBHC
services to Blue Heron Middle School
• Securing funding for permanent Student
Engagement/Equity Coordinator position
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH31013-Amendment 14
Page 30 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Workplan will identify the due date,staff that will work on
each task,and staff s role for each task
1 b Review and update sustainability workplan for 2024-2025 SBHC Operations project workplan and September 30,2024 $25,000
school year.Continue previous project/focus area or identify a sustainability plan updates
new focus. Update tasks,activities,roles,and due dates.
I Provide updates to DOH on progress of SBHC operations, Quarterly report Quarterly, $24,000($4,000 per
project,and workplan completion. October 15 report)
• Include status report of SBHC operations(hours of January 15
operation,staffing model,and services provided) April 15
• Include milestones,successes,challenges,and barriers July 15
2 Attend bi-monthly contract meetings,starting by August 31, Quarterly report that includes: Quarterly, $12,000($2,000 per
2023,with DOH to discuss progress, support needs, • List of contract meetings attended October 15 report)
barriers/challenges. during the reporting period January 15
• List of trainings and TA meetings April 15
Participate in at least one key training,support,and/or technical attended during the reporting period July 15
assistance activity per quarter,as recommended by DOH or • List of any additional resources or
WA School-Based Health Alliance(SBHA). training needed
Identify additional resources or training needed;collaborate
with DOH to participate in and/or get access to resources,if
needed.
3a Update health equity plan each school year. Updated health equity plan September 30,2023 $20,000
September 30,2024 ($10,000 each)
3b Implement health equity plan and provide progress updates: Quarterly report Quarterly, $15,000($2,500 per
• Can include pictures,products,stories,and/or October 15 report)
testimonials January 15
• Include successes,challenges,and any barriers to April 15
completing this activity July 15
4a In collaboration with DOH SBHC epidemiologist,draft SBHC Evaluation plan September 30,2023 $11,000
evaluation plan for SBHC operations and identified project.
Include reporting mechanism for identified evaluation
measures.
4b Provide updates on implementation of evaluation plan;review Quarterly report Quarterly, $12,000($2,000 per
and update evaluation plan,as needed. Include successes, October 15 report)
challenges,and any barriers to completing this activity. January 15
April 15
July 15
4c Collect and report on required performance measures,using Quarterly performance measure report Quarterly, $18,000($3,000 per
provided DOH performance measure spreadsheet. October 15 report)
January 15
April 15
July 15
Exhibit A, Statement of Work Page 2 of 4 Contract Number CLH31013-Amendment 14
Page 31 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
4d Write plan that outlines steps,barriers,and resources needed Draft data reporting plan March 30,2024 $10,000
for participation in SBHC statewide data platform.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance n doh.wa.eov.
Program Specific Requirements
Special Requirements:Quarterly progress reports will be submitted to the Department contract manager via email on a quarterly basis,using a provided template.
• Reports should include progress on deliverables to date, successes,barriers/challenges,and support needs and include:
o General updates on the progress on other deliverables
o Challenges/barriers to completing deliverables
o Support needs from DOH
o Specific deliverables/products requested
• Specific/separate reports should be submitted separately and on the specified due date.
Special References(i.e.,RCWs,WACs,etc.):In accordance with RCW 43.70.825:Concerning School Based Health Centers(2021),the Washington State Department of Health
(DOH)contemplates awarding a contract to Jefferson County Public Health Department(LHJ)to operate,expand,and/or improve their School-Based Health Centers.
Definitions: A school-based health center is defined in the law as"a student-focused health center located in or adjacent to a school that provides integrated medical,behavioral
health,and other health care services such as dental care."Upon execution of the contract,the SBHC must meet the minimum requirements outlined below:
• Be open during regular school hours
• Provide on-site primary care services by a nurse practitioner,physician's assistant,medical doctor,and/or doctor of osteopathy,at least once a week
• Coordinate clinic services
• Provide behavioral health care services by a behavior health provider that is on-site,through telehealth,and/or through mobile units.If a behavioral health provider is not
licensed,they must be supervised by a licensed behavioral health provider.
Billing Requirements:
• The LHJ will invoice no more than monthly and no less than quarterly.
• Due dates and deliverables can be negotiated on and changed,as needed,with prior approval from the contract manager.
• Invoices will be submitted on the DOH A19-1A Invoice Voucher form with a copy of the general ledger(or grant budget and spending documentation)and agreed upon
back-up documentation. Invoices must reference this contract number and provide detailed information as requested.
• All invoices must be approved by DOH prior to payment;approval will not be unreasonably withheld. DOH will authorize payment only upon satisfactory completion
and acceptance of deliverables and for allowable costs as outlined in the statement of work and/or budget.DOH will issue payment within 30 days of receiving a correct
and complete invoice and approving the deliverable(s).
• DOH will return all incorrect or incomplete invoices and will not pay for services that occur outside the period of performance.
• The LHJ will not invoice for services if they are entitled to payment,have been,or will be paid by any other source for that service.
• The LHJ may bill incrementally for progress on objectives, but the entire product will be delivered for the amount specified regardless of time spent on the tasks for each
objective.
• Quarterly report deadlines and invoice amounts are as follows(invoice amount listed below is an estimate and is flexible based on deliverables completed):
o Year 1,Q1 deliverables(July-September)due by October 15,2023: $59,500
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH31013-Amendment 14
o Year 1,Q2 deliverables(October-December)due by January 15,2024: $13,500 Page 32 of 41
o Year 1,Q3 deliverables(January-March)due by April 15,2024:$23,500
o Year 1,Q4 deliverables(April-June)due by July 15,2024:$13,500
o Year 2,Ql deliverables(July-September)due by October 15,2024: $48,500
o Year 2,Q2 deliverables(October-December)due by January 15,2025: $13,500
• DOH must receive correct and complete invoices within 60 days of the contract expiration date. Late invoices will be paid at the discretion of DOH and are contingent
upon the availability of funds.
o Submit all final billings within 45 days of the end of the contract
o Submit all required program reports and deliverables within 60 days
Exhibit A,Statement of Work Page 4 of 4 Contract Number CLH31013-Amendment 14
Page 33 of 41
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Sexual&Reproductive Health Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2022
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 5 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: JanuM 1,2022 through December 31,2024 ® State ® FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide sexual and reproductive health services(SRH)to Washington State residents.These
services will comply with all state,federal,and DOH SRHP Manual requirements. It highlights specific requirements,but all must be complied with. Budgets are based on an
approved allocation formula with funds available.
This Statement of Work spans Year 1 and Year 2 of the contract,which runs January 1,2022—March 31,2024
For state funding,due dates after June 30,2023 are for reporting only. LHJs may not bill under this contract for work done after June 30,2023.
Revision Purpose: The purpose of this revision is to add$30,822 in Federal Title X Family Planning Funds for the period of 04/01/2023 -03/31/2024,remove Task 2 and revise
task activities.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY22 Sexual&Rep Hlth Cost Share 78430120 N/A 334.04.91 01/01/22 06/30/22 44,100 0 44,100
FFY22 Title X Dire Needs 78430222 93.217 333.93.21 01/14/22 03/31/22 4,066 0 4,066
FFY22 Title X Family Planning 78430225 93.217 333.93.21 04/01/22 03/31/23 27,137 0 27,137
SFY23 Sexual&Rep Hlth Cost Share 78430130 N/A 334.04.91 07/01/22 06/30/23 80,009 0 80,009
FFY23 Title X Family Planning 78430241 93.217 333.93.21 04/01/23 03/31/24 0 30,822 30,822
0 0 0
TOTALS 155,312 30,822 186,134
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
1. Sexual and Reproductive Health Program • A19 invoice vouchers submitted in a timely manner No more than monthly Billing must be based
(SRHP)&Title X(TX)Services—excluding accompanied by an R&E workbook showing revenue and no less than on a current cost
abortion and other surgical procedures related to and expenses for the month billed and any other quarterly. methodology analysis
SRHP. required back up documentation per DOH policy. approved by DOH(see
A. Comply with Washington State 2422 SRHP Reporting Requirements
Manual, federal Title X requirements and all table).
state and federal laws.Also see Program
Exhibit A,Statement of Work Page 1 of 9 Contract Number CLH31013-Amendment 14
Page 34 of 41
Task Payment Information
# Activity Deliverables/Outcomes Due Date/Time Frame and/or Amount
Manual, Handbook,Policy References under 3. DOH reserves the right
Reporting Requirements below. to withhold payment
until:
B. Complete required Agency Information • Compliance issues
Dashboard that includes Title X Assurance of Fe'a. 4his or a
Compliance previous SOW are
resolved in a way
1. Compile all National Provider accepted by DOH
Identifier(NPI)billing numbers for • Current data is
SRHP services and submit to DOH. submitted to,and
DOH will compile and send to Health accepted by,
Care Authority(HCA)in order for Ahlers.
LHJ to qualify for the Medicaid • A 19 back up
Enhanced rate. documentation
required by DOH
C. Provide medical services,community education • All reports described in Reporting Requirements table As described in has been submitted
and outreach,and staff training,consistent with below. Reporting and approved.
state requirements: Requirements table Other deliverables
1. LHJ is responsible for making sure all staff below. have been met.
have the knowledge to carry out the
requirements of the SOW. • Other data and documentation in format requested by As requested by DOH Payment is limited to
2. Medical,laboratory,and other services DOH.(Includes copies of program and financial the maximum funds
related to abortion are not covered by this audits and reviews including summaries conducted by available for funding
task. other entities.) source.
3. Community education services must be
based on the needs of the community.LHJ • To facilitate DOH/TX desk reviews—requested DOH will reimburse
must have an Information&Education documentation available to DOH in requested format. for:
(I&E)committee with no fewer than five • Actual allowable
(5)members and up to as many members • To facilitate DOH/TX site-visits—appropriate staff costs according to
as the LHJ determines;be broadly and documentation readily available prior to and your approved cost
representative of the population or during review. methedelegy
community for which materials are ana/vsis(see
intended; review all educational materials DOH performs site visits.Follow-up site visits are As requested by DON Reporting
for clients;meet at least annually and performed until identified issues are resolved. Requirements
establish a written record of its table).
determination.(42 CFR 59[59.6]) or
4. Outreach is to ensure all populations in • The amount
your community understands the services
available.Focus your outreach efforts on remaining in the
SOW divided by
increasing equity. the number of
Washington State Sexual and Reproductive Health months remaining
in the funding
Network priority populations are:
Exhibit A,Statement of Work Page 2 of 9 Contract Number CLH31013-Amendment 14
Page 35 of 41
Task Payment Information
# Activity Deliverables/Outcomes Due Date/'Time Frame
and/or Amount
• Teens source,plus one,
• People who are uninsured or underinsured, whichever is less.
and/or low-income(at or below 250%of
the federal poverty line) Payment will be
• Rural communities calculated by R&E
• Hispanic provided by DOH(see
• Black,Indigenous,People of Color Reporting Requirements
Extra efforts should be made to provide information table).
and services to people who intersect with multiple
priority population categories. All services through
06 30 23 must be billed
Provide all services in accordance with: by 07 30 23 the end of
• DOH SRHP&Title X Manual this contract period
• Other state and federal requirements must be billed within 60
• LHJ's Current Scope Report(defined under days.
3. Reporting Requirements below)
D. Collect,maintain,and provide data about each CVR data submitted to DOH data contractor(Ahlers& The last day of the next
family planning clinic visit as defined in the Associates)electronically in a format compatible with month.
SRH CVR Manual. Ahlers software. Within thirty(30)days
1. Maintain a computer system that includes of receiving
normal safety precautions against loss of • Data for each month error/rejection report or
information.
2. Ensure data entry personnel protect request from DOH
confidentiality of CVR data. • Corrected CVR data Sexual and
3. Have ability to retrieve all information for Reproductive Health
auditing and monitoring by DOH or its data manager.
designee.
E. Notify DOH contract manager of all:
• Key staff and organizational changes. Email briefly describing change. As needed to keep
information current.
• Proposed clinic site additions.New clinic
sites must be approved by DOH before
offering services supported by SOW
funding.
• Expected clinic site closures.Note:DOH
may,at its sole discretion,recalculate
LHJ's funding allocation if it closes a clinic
site.
• Any other change that might affect LHJ's
ability to provide the sexual and
Exhibit A, Statement of Work Page 3 of 9 Contract Number CLH31013-Amendment 14
Page 36 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
reproductive services described in this
SOW.
to 8R11P and Health insuranee Glaim FeFms form feF eaeh visit menths after-d e
reimburse LuJ FOF these
A. Ll4j may eheese to use tip te 3%of its total billed. ),Aded. seFY*ees if this SOW
SOW swe funds for medieal and sur-gieal +neludes state surg+sc3l
suFgieal�� -t F D AC kbeek F all I l4 t ti Titlz-rr[e��t-
.+•b•..... �RI[p[1cOGG np1KVVVlc'[V[-RiT'i.-i7�,7�Piip �'..pay..
' 'V'
at Heald.Care
sement
e«tn n rid all state In A Isee �s.
PregFam Manual,Handbook,Pelie),Referenees This will
seetien below. ee ed payment
s.
L1. Eligible elients aFe these ' „ems at [ eM
belew 250 CUI
. I ul will net
ayne�t.
if L:4J bills F«n f;evideal by n e addifienal payment
f em the el; nt er any
6theF person e
affee to aeeept D014 payment as payment in full. 0Fgafli,8atieH.
Client eF any etheF per-soft t'on.(A I
se see
Payment eelum"
3. Reporting Requirements
1. Agency Information Dashboard This information must be reported using the template 0^�3 Apri130`"
or format provided by DOH.All signatures and forms during each year of this
Information required at the beginning of this must be completed by°A3-23 April 30 during each contract.
SOW period.This information ensures that year of this contract. It will include:
DOH has accurate information about LHJ's AND
organization and the services it provides. Information about your agency contacts and your
organization's staffing As needed or requested
In addition,elements of this report allow DOH A. Head of Organization to maintain accuracy of
to ensure that SRHP&Title X requirements information.
C. Medical regarding client fees,required services, B. Head l Finance
requirements are met.It also provides other C. Director
information to assist DOH to manage this SOW D. NPI numbers used to bill Medicaid
E. The following(one person might fill more than one
role
Exhibit A,Statement of Work Page 4 of 9 Contract Number CLH31013-Amendment 14
Page 37 of 41
Task Payment Information
# Activity Deliverables/Outcomes Due Date/Time Frame
and/or Amount
and the Sexual&Reproductive Health Network a. Contract Coordinator
as a whole. b. Clinical representative
c. Billing contact
d. Outreach and education contact
e. Contact for CVR data
f. Contact for EHR information
Information regarding sexual and reproductive health
related services offered at each clinic site:
A. Cost analysis: How LHJ determines what it costs to
provide services. LHJ uses this to help construct its
fee schedule.A cost analysis must be performed by
LHJ no more than three years prior to the start date of
this SOW.
B. Sliding fee schedule that includes all services required
in the SRH Manual.Additional Task I SRH-related
services may also be included on LHJ's sliding fee
schedule.
a. Sliding fee schedule must be based on cost
analysis described above.
b. LHj may use the last fee sehedule approved pfie Submit 2023 in
to this SOW as leng it was approved lateF!haft
nn 01 17 r Hj must ail the 00H_ _ _aet
E9HV2rsiAft�)3@�b}`
03 15 23 Submit an
manager.eQ wo,..�e therA knew ..�:�� �� updated income
ap ffev d= .Fee schedule must be conversion table by
resubmitted for reapproval anytime there are March 15 of each year
any significant changes, which may include of the contract.
changing of services,fees, etc.
c. LHJ must not implement a revised fee schedule
until it has been approved in writing by DOH.
d. Income conversion tables must be updated
annually and approved by DOH
Information related to current Community Outreach Plan:
LHJ's community outreach plan follows a 5-year cycle.In
the first year LHJ must assess,document and disseminate
community health needs assessment,this process must
include the following steps:
A. Define the populations LHJ serves and identify
opportunities to expand reach within those
populations and to unreached populations in each
community it serves.
Exhibit A,Statement of Work Page 5 of 9 Contract Number CLH31013-Amendment 14
Page 38 of 41
Task Payment Information
# Activity Deliverables/Outcomes Due Date/Time Frame and/or Amount
B. Identify organizations and people representing the
broad interests of the community and identify
opportunities for partnership and collaboration.
C. Gather available data and current assessments
(secondary data)
D. Seek community perspectives by gathering input
from the various populations in LHJ's community
(collect primary data)
E. Aggregate secondary and primary data and analyze
aggregated data
F. Prioritize health issues,define areas of unmet need,
and incorporate both in plans for outreach and
education materials and activities
G. Document and disseminate the community health
needs assessment to LHJ's SRH consultant and
appropriate stakeholders
Information related to billing and client fees
Cost methodology analysis:How LHJ determines
appropriate expenses for the purpose of billing DOH.
If LHJ cost niethedelegy analysis was approved by DOH
after.^ =-at the beginning of the contract period, LHJ
does not have to resubmit unless changes were made. LHJ
does need to email DOH contract manager informing them
that no changes were made.
2. Progress Summary Report This information must be reported using the template or As requested by DOH
format provided by DOH. It will include information
Summary of activities from previous SRHP about contractor's work during the previous SOW.•
services SOW.
A. Community education and outreach strategies and
It informs quality improvement of the activities and a discussion of their effectiveness.
ft ashin ton State.SRH Network. B. Staff training.
3. Family Planning Annual Report(FPAR) Organization-level data on clinical services emailed to Data to be collected
DOH SRH data manager annually through the
Information DOH is requesting to develop trend end of the eentraet
data. All information is for calendar year 242-2 Number o£ period.grant(2027).
2023(January through December 2022 2023). A. Pap tests with an ASC or higher result
The subsequent agreements sent to the agency B. Pap tests with an HSIL or higher result
will request that these data be collected and C. HIV Positive confidential tests
reported on within the statement of work period D. HIV Anonymous tests
of performance.
Exhibit A,Statement of Work Page 6 of 9 Contract Number CLH31013-Amendment 14
Page 39 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
E. FTE required to provide sexual and reproductive
health services:
• Physicians
• Physician assistants+nurse practitioners+
certified nurse midwives
• Registered nurses with expanded scope of practice
who are trained and permitted by state specific
regulations to perform all aspects of the physical
assessment.
Financial data emailed to DOH Contract Manager
R&E showing Other Revenue through "r�3 03-31-4
as described below.
Subsequent agreements will request that data be collected
and reported on during the appropriate contract period of
performance.(FPAR due 0 1-3 1 annually through 2027)
4. Clinic Visit Reports(CVRs) Clinic visit records must include all elements specified The last day of the next
in the Clinic Visit Record(CVR)Manual available at: month
httas://www.doh.wa.i!ov/Portals/1/Documents/Pubs/930- Within thirty(30)days
139-CVRManual.ydf. of receiving error or
rejection report or
CVR data must be submitted to DOH data contractor request from DOH
(Ahlers&Associates)electronically in a format compatible SRH data manager.
with Ahlers software.
- Each month's CVR data
- Corrected CVR data
Data elements will be changed in 2024. CVRs submitted
start 01-01-24 must be done so based on the new
reporting requirements.
5. Revenue and Expense Reports(R&E) Completed R&E for time period that shows all revenue Submitted with each
(including program income)that support Task 1 SRH invoice(A 19).No
Services and all expenses related to providing those more than monthly and
services. R&E workbook will be provided by DOH. no less than quarterly.
A. Expenses must match General Ledger. R&E showing all
B. Other revenue/program income must reflect revenue sources of revenue that
actually received in the reporting month. support services for:
All entries on"Other"rows must be accompanied by a januavy Apri12023-
description of the revenue source or expense,including any june 23 March 2024
calculations uses. due within 30 days
f4eF 06 30 n due
through the end of this
Exhibit A, Statement of Work Page 7 of 9 Contract Number CLH31013-Amendment 14
Page 40 of 41
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
contract period must be
billed within 60 days.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance 2cdoh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual,Handbook,Policy References:
LHJ must comply with all state,federal,a*d DOH SRHP,and Title X requirements,policies,and regulations and with their DOH approved Agency
Information Dashboard.
Reference documents include:
• DOH SRHP Manual(DOH publication 930-122,available at 930-122-FPRHManualComplete.pdf(wa.gov)
Some provisions of this manual are highlighted in this SOW,but all provisions of the manual must be complied with.
• Clinic Visit Record Manual(https://www.doh.wa.pov/Portals/I/Documents/Pubs/930-139-CVRManual pdf)
• LHJ's approved CHFreHt Seepe Repei4 Agency Information Dashboard.
Billing Requirements:
See Payment column of Tasks and Deliverables table and R&E report description in Reporting Requirements table
Special Instructions:
Accessibility of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to target populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible,services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal, State,and local governments,including local fire,building,and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis.Acceptance of SRH services must not be a prerequisite to eligibility for,or receipt of,services in any non-SRH
programs of the LHJ.
Exhibit A,Statement of Work Page 8 of 9 Contract Number CLH31013-Amendment 14
Page 41 of 41
Availability of Emergency Services
The LHJ must have written plans and procedures for the management of on-site medical emergencies, including emergencies that require transport and after-hours management of
contraceptive emergencies.(See DOH SRH Manual)
If LHJ or DOH discontinues this contract:
See SRHP Manual for close out requirements and resources.
Exhibit A,Statement of Work Page 9 of 9 Contract Number CLH31013-Amendment 14