HomeMy WebLinkAboutState of Washington Department of Health Amendment 19 - 050624 Page 1 of 36
JEFFERSON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH31013 AMENDMENT NUMBER: 19
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:
httns://statcofwa.sharcnoint.com/sitcs/doh-ofsfundinaresourccs/sitcnagcs/homc.aspx?=c I:9a94688da2d94d3ca80ac7fbc32c4d7c
❑ Adds Statements of Work for the following programs:
• Amends Statements of Work for the following programs:
COVID-19 LHJ Gap Funding- Effective July 1, 2023
Office of Drinking Water Group A Program -Effective January 1, 2022
School-Based Health Centers Program —Effective July 1, 2023
Sexual& Reproductive Health Program - Effective January I, 2022
WIC Nutrition Program- Effective January 1, 2022
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-19 Allocations, attached and incorporated by this reference,amends and replaces Exhibit B-18 Allocations
as follows:
• Increase of$57,229 for a revised maximum consideration of$8,197,713.
❑ 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
c/ W1 y rll 44 05/07/2024
Kate Dean,Chair Date Date
APPROVED AS TO FORM ONLY APPROVED AS TO FORM ONLY
Assistant Attorney General
May 2, 2024
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney Page I of I
CC-22-002-A 19
EXHIBIT B-19 Page 2 of 36
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: April 1,2024
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
FFY24 USDA BFPC Prog Mgmt 7WA700WA1 Amd 15 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $37,651 $37,651 $118,691
FFY23 USDA BFPC Prog Mgmt 7WA700WA1 Amd 10,17 10.557 333.10.55 10/01/22 12/31/24 10/01/22 09/30/25 $28,238 $37,651
FFY23 USDA BFPC Prog Mgmt 7WA700WA1 Amd 8,10,17 10.557 333.10.55 10/01/22 12/31/24 10/01/22 09/30/25 $9,413
FFY22 USDA BFPC Prog Mgmt 7WA700WA1 Amd 1,17 10.557 333.10.55 01/01/22 09/30/24 10/01/21 09/30/24 $43,389 $43,389
FFY25 USDA WIC Client Svs Contracts NGA Not Received Amd 17 10.557 333.10.55 10/01/24 12/31/24 10/01/24 09/30/25 $26,268 $26,268 $399,993
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 18 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $48,183 $155,011
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 17 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $79,090
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 15 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $2,500
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 10,15 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $25,238
FFY23 USDA WIC Client Svs Contracts 7WA700WA7 Amd 15 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $11,657 $132,338
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
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 10.557 333.10.55 01/01/23 09/30/23 10/01/22 09/30/23 $2,800 $2,800 $2,800
FFY24 USDA FMNP Prog Mgmt 7WA810WA7 Amd 19 10.572 333.10.57 05/01/24 09/30/24 10/01/23 09/30/24 $496 $496 $1,508
FFY23 USDA FMNP Prog Mgmt 7WA810WA7 Amd 15 10.572 333.10.57 06/01/23 09/30/23 10/01/22 09/30/23 $496 $496
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
FY24 LHJ COVID-19 ARPA SLFRP0002 Amd 19 21.027 333.21.02 07/01/23 02/29/24 07/01/23 06/30/25 ($37,439) $9,301 $9,301
FY24 LHJ COVID-19 ARPA SLFRP0002 Amd 15,19 21.027 333.21.02 07/01/23 02/29/24 07/01/23 06/30/25 $46,740
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 01J18001 Amd 15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 $30,000 $263,844 $263,844
PS SSI 1-5 OSS Task 4 01J18001 Amd 7,15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 ($1,654)
PS SSI 1-5 OSS Task 4 01J18001 Amd 2,5,15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 $235,498
FFY24 Swimming Beach Act Grant IAR(ECY) NGA Not Received Amd 18 66.472 333.66.47 03/01/24 09/30/24 01/01/24 11/30/24 $15,000 $15,000 $45,000
FFY23 Swimming Beach Act Grant IAR(ECY) 01J74301 Amd 11 66.472 333.66.47 03/01/23 10/31/23 03/01/23 10/31/23 $15,000 $15,000
FFY22 Swimming Beach Act Grant IAR(ECY) 01J74301 Amd 2 66.472 333.66.47 03/01/22 10/31/22 01/01/22 11/30/22 $15,000 $15,000
FFY23 PREP BP5 LHJ Funding NU90TP922043 Amd 15 93.069 333.93.06 07/01/23 06/30/24 07/01/23 06/30/24 $34,384 $34,384 $82,522
FFY22 PREP 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
FFY21 PHEP BP3 LHJ 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
FFY23 OD2A OID CDC NU17CE010218 Amd 17 93.136 333.93.13 01/01/24 08/31/24 09/01/23 08/31/24 $98,000 $98,000 $98,000
Page 1 of 4
EXHIBIT B-19 Page 3 of 36
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: April 1,2024
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
FFY22 Title 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
FFY24 FPHPA Title X Family Plan NGA Not Received Amd 19 93.217 333.93.21 04/01/24 12/31/24 04/01/24 03/31/25 $17,733 $17,733 $17,733
FFY23 Title X Family Planning FPHPA006560 Amd 14 93.217 333.93.21 04/01/23 03/31/24 04/01/23 03/31/24 $30,822 $30,822 $57,959
FFY22 Title X Family Planning FPHPA006560 Amd 5 93.217 333.93.21 04/01/22 03/31/23 04/01/22 03/31/23 $27,137 $27,137
COV1D19 Vaccines NH23IP922619 Amd 4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $278,114 $278,114 $278,114
COV1D19 Vaccines R4 NH23IP922619 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 I
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 NH23IP922619 Amd 15 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $560 $6,160 $6,160
FFY24 CDC VFC Ops NH23IP922619 Amd 14 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $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
FFY19 COVID CARES NU5OCK000515 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 LHJ Allocation NU5OCK000515 Amd 7 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 NU5OCK000515 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 NU5OCK000515 Amd 2 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 $82,712
FFY20 ELC EDE LHJ Allocation NU5OCK000515 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 NU5OCK000515 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 NU5OCK000515 Amd 2,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 $439,039
FFY21 CDC COVID-19 PHWFD-LHJ NU90TP922181 Amd 16 93.354 333.93.35 07/01/23 06/30/24 07/01/23 06/30/24 $200,000 $200,000 $200,000
FFY22 NEHA Climate&Health Grant NU380T000300 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 NU380T000300 Amd 5 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 $11,000
FFY22 PH Infrastructure Comp Al-LHJ NE110E000053 Amd 17 93.967 333.93.96 01/01/24 12/31/24 12/01/22 06/30/25 $200,000 $200,000 $200,000
FFY24 HRSA MCHBG LHJ Contracts B04MC52960 Amd 15 93.994 333.93.99 10/01/23 09/30/24 10/01/23 09/30/24 $36,700 $36,700 $56,566
FFY23 HRSA MCHBG LHJ Contracts B04MC47453 Amd 15 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 ($16,834) $19,866
FFY23 HRSA 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
FFY22 HRSA MCHBG Special Proj B04MC45251 Amd 15 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 $16,834 $16,834 $16,834
FFY22 MCHBG LHJ Contracts B04MC45251 Amd 1 93.994 333.93.99 01/01/22 09/30/22 10/01/21 09/30/22 $27,525 $27,525 $27,525
Page 2 of 4
EXHIBIT B-19 Page 4 of 36
.lefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: April 1,2024
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
SFY25 SBHC Proviso Amd 19 N/A 334.04.90 07/01/24 12/31/24 07/01/24 06/30/25 $29,000 $91,000 $246,000
SFY25 SBHC Proviso Amd 14 N/A 334.04.90 07/01/24 12/31/24 07/01/24 06/30/25 $62,000
SFY24 SBHC Proviso Amd 19 N/A 334.04.90 07/01/23 06/30/24 07/01/23 06/30/24 S10,000 $155,000
SFY24 SBHC Proviso Amd 16 N/A 334.04.90 07/01/23 06/30/24 07/01/23 06/30/24 $35,000
SFY24 SBHC Proviso Amd 14 N/A 334.04.90 07/01/23 06/30/24 07/01/23 06/30/24 $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
SFY24 Sexual&Rep]-lath Cost Share Amd 18 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $1,800 $87,652 $211,761
SFY24 Sexual&Rep]-lath Cost Share Amd 17 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $42,926
SFY24 Sexual&Rep Hlth Cost Share Amd 15,17 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $42,926
SFY23 Sexual&Rep Hlth 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
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 07/0121 06/30/22 $5,880 $44,100
SFY22 Sexual&Rep Hlth Cost Share Amd 1 N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/22 $38,220
SFY25 Drug User Health Program Amd 17 N/A 334.04.91 07/01/24 12/31/24 07/01/24 06/30/25 $40,250 $40,250 $88,000
SFY24 Drug User Health Program Amd 17 N/A 334.04.91 01/0124 06/30/24 07/0123 06/30/24 $40,250 $40,250
SFY24 Drug User Health Program Amd 14 N/A 334.04.91 07/01/23 12/31/23 07/01/23 06/30/24 $7,500 $7,500
State Drug User Health Program Amd 5 N/A 334.04.91 07/01/22 06/30/23 07/0121 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
LHJ COVID-19 GFS Amd 19 N/A 334.04.92 07/01/23 06/30/24 07/01/23 06/30/24 $37,439 $37,439 $37,439
Rec Shellfish/Biotoxin Amd 14 N/A 334.04.93 07/01/23 12/31/24 07/0123 06/30/25 $11,100 $11,100 $28,600
Rec Shellfish/Biotoxin Amd 9 N/A 334.04.93 01/01/22 06/30/23 07/0121 06/3023 $7,000 $17,500
Rec Shellfish/Biotoxin Amd 1 N/A 334.04.93 01/01/22 06/30/23 07/01/21 06/30/23 $10,500 I
Small Onsite Management(ALEA) Amd 14 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 $33,333 $33,333 $104,166
Small Onsite Management(ALEA) Amd 14 N/A 334.04.93 07/01/23 06/30/24 07/01/23 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 06/3023 ($9,375) $13,125
Small Onsite Management(ALEA) Amd 1 N/A 334.04.93 01/01/22 06/30/22 07/01/21 06/30/23 $22,500
Small Onsite Management(GFS) Amd 16 N/A 334.04.93 07/01/24 12/31/24 07/01/23 07/01/25 ($31,970) $0 $0
Small Onsite Management(GFS) Amd 14 N/A 334.04.93 07/01/24 12/31/24 07/01/23 07/01/25 $31,970
SFY25 Wastewater Management-GFS Amd 16 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 $31,970 $31,970 $61,970
Wastewater Management-GFS Amd 1 N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $30,000 $30,000
Page 3 of 4
EXHIBIT B-19 Page 5 of 36
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: April 1,2024
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 Sub"1'otal Total
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
SFY24 FPHS-LHJ-Funds-GFS Amd 15 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $900,000 $2,333,000 $2,333,000
SFY24 FPHS-LHJ-Funds-GFS Amd 14 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $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(YRI) 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(YRI) Amd 4 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 ($137,500)
FPHS-LHJ-Proviso(YR1) Amd 1 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 $550,000
YR 26 SRF-Local Asst(15%)SS Amd 16 N/A 346.26.64 01/01/24 12/31/24 07/01/23 06/30/25 $1,800 $1,800 $5,400
YR 25 SRF-Local Asst(15%)SS Amd 11 N/A 346.26.64 01/01/23 12/31/23 01/01/23 12/31/23 $2,200 $2,200
YR24SRF-LocalAsst(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 SS-State Amd 16 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $1,800 $5,400 $5,400
Sanitary Survey Fees SS-State Amd 11,16 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $2,200
Sanitary Survey Fees SS-State Amd 1,11,16 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $1,400
YR 26 SRF-Local Asst(15%)TA Amd 19 N/A 346.26.66 01/01/24 12/31/24 01/01/23 06/30/25 $1,000 $1,000 $2,000
YR 25 SRF-Local Asst(15%)TA Amd 19 N/A 346.26.66 01/01/23 12/31/23 01/01/23 12/31/23 ($1,000) $0
YR 25 SRF-Local Asst(15%)TA Amd II N/A 346.26.66 01/01/23 12/31/23 01/01/23 12/31/23 $1,000
YR 24 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 58,197,713 $8,197,713
Total consideration: $8,140,484 GRAND TOTAL $8,197,713
$57,229
GRAND TOTAL $8,197,713 Total Fed $3,023,296
Total State $5,174,417
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 4 of 4
Page 6 of 36
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: COVID-19 LHJ Gap Funding- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2023
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
El Federal Subrecipient (check if applicable) IN Reimbursement
Period of Performance: July 1,2023 through June 30,2024 El State ®FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work is to support LHJ COVID-19 work utilizing American Rescue Plan Act(ARPA)funding and General Fund
State funding.
Revision Purpose: The purpose of this revision is to clear the ARPA LHJ COVID 19 balance and add coding for General Fund State for the remaining balance.
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
FY24 LHJ COVID-19 ARPA 926CO240 21.027 333.21.02 07/01/23 02/29/24 46,740 -37,439 9,301
LHJ COVID-19 GFS 926C0140 N/A 334.04.92 07/01/23 06/30/24 0 37,439 37,439
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 46,740 0 46,740
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Task 1,2,and 3 Activities Supported by LHJ COVID-19 Gap Supplemental July 1,2023—June 30,2024 Reimbursement for actual
costs incurred,not to exceed
total funding allocation.
Due date: Every 60 days as
specified in the ConCon
billing instructions.
1. Provide vaccination services to increase COVID-19 vaccine Vaccine availability to the
availability in the community. Vaccination services are community and prioritized in your
defined as those outside the usual healthcare delivery jurisdiction's community.
method,such as pop-up clinics,mobile clinics,non-clinical
facilities and may be conducted during non-traditional
Exhibit A, Statement of Work Page 1 of 8 Contract Number CLH310 1 3-Amendment 19
Page 7 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
hours such as evenings and weekends. Activities may
include vaccine strike teams,mobile vaccine clinics,
satellite clinics,temporary or off-site clinics to travel and
provide vaccination services in non-traditional settings,
community outreach/messaging or to supplement the work
of other community partners in underserved communities
and may include administration costs for COVID-19
vaccine.
1 A. Vaccination data—will be maintained according to current Submission of vaccine use into Within two(2) days of vaccine use
state and federal requirements. WA IIS database within 48 hours
of use.
Vaccine Registration Systems—If a local jurisdiction or
region does not have a registration system(s)then include Jurisdiction/Regions will ensure a
internet based,phone option and other methods to ensure fair and equitable process for
equitable registration.The state PrepMod system and tools registration of eligible
will be available for use. Washingtonians across all
available modalities.
1 B. Specific itemized breakdown of activities and costs from Final written report including Report due within 30 days of the
our partners for vaccine efforts and keeping Washington activities completed and how LHJ end of each quarter listed below:
safe. addressed equitable distribution of Year 1 Quarter 1
the vaccine,community outreach
and messaging. July 1,2023-September 30,2023
Year 1 Quarter 2
October 1,2023-December 31,
2023
Year 1 Quarter 3
January 1,2024-March 31,2024
Year 1 Quarter 4
April 1,2024-June 30,2024
1C. COVID-19 vaccine purchase See Special Requirements Below See reporting requirements in IA
and 1 B
2. Participate in public health emergency preparedness and See Special Requirements below. See Special Requirements below.
response activities for COVID-19.This may include
surveillance,epidemiology,laboratory capacity,infection
control,mitigation,communications and or other
preparedness and response activities for COVID-19.
Examples of key activities include:
• Incident management for the response
Exhibit A, Statement of Work Page 2 of 8 Contract Number CLH31013-Amendment 19
Page 8 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
• Testing
• Case Investigation/Contact Tracing
• Sustainable isolation and quarantine
• Care coordination
• Surge management
• Data reporting
NOTE:The purpose of this agreement is to supplement
existing funds for local health jurisdictions to carry out
surveillance,epidemiology,case investigations and contact
tracing, laboratory capacity,infection control,mitigation,
communications,community engagement,and other public
health preparedness and response activities for COVID-19.
3. 1) LHJ Active monitoring activities. In partnership with Data collected and reported into Enter performance metrics daily
WA DOH and neighboring Tribes,the LHJ must ensure DOH systems daily. into DOH identified systems
adequate culturally and linguistically responsive testing,
investigation and contact tracing resources to limit the
spread disease.LHJs must conduct the following Quarterly performance reporting
activities in accordance with the guidance to be updates
provided by DOH.
a. Allocate enough funding to ensure the following
Contact Tracing and Case Investigation Support:
Hire a minimum of 1.0 data entry FTE to assure
system requirements for task 2.1.a.
i. Contact tracing Enter all contact tracing data in
1. Strive to maintain the capacity to conduct CREST following guidance from
targeted investigations as appropriate. DOH.
2. Have staff that reflect the demographic
makeup of the jurisdiction and who can
provide culturally and linguistically
competent and responsive services. In
addition,or alternatively,enter into an
agreement(s)with Tribal,community-
based and/or culturally-specific
organizations to provide such services.
DOH centralized investigations will count
towards this minimum.
3. Ensure all contact tracing staff are trained
in accordance with DOH investigative
guidelines and data entry protocols.
Exhibit A, Statement of Work Page 3 of 8 Contract Number CLH3 10 13-Amendment 19
Page 9 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
4. Coordinate with Tribal partners in
conducting contact tracing for Tribal
members.
5. Ensure contact tracing and case
investigations activities meet DOH case
and Contact Tracing Metrics. (Metrics to
be determined collaboratively by DOH,
LHJs and Tribes.)Work with DOH to
develop a corrective action plan if unable
to meet metrics.
ii. Case investigation
1. Strive to maintain the capacity to conduct
targeted investigations as appropriate.
2. Enter all case investigation and outbreak
data in WDRS following DOH guidance. Enter all case investigation data in
a) Strive to enter all case investigation WDRS-following guidance from
and outbreak data into CREST as DOH.
directed by DOH.
b) Ensure all staff designated to utilize
WDRS have access and are trained in
the system.
c) Include if new positive cases are tied
to a known existing positive case or
indicate community spread.
d) Conduct targeted case investigation
and monitor outbreaks.
e) Coordinate with Tribal partners in
conducting case investigations for
tribal members.
3. Ensure contact tracing and case
investigation activities meet DOH Case
and Contact Tracing Metrics.(Metrics to
be determined collaboratively by DOH,
LHJs,and Tribes.)Work with DOH to
develop a corrective action plan if unable
to meet metrics.
b. Testing
i. Work with partners and Tribes to ensure
testing is available to every person within the
jurisdiction meeting current DOH criteria for
testing and other local testing needs.
Exhibit A, Statement of Work Page 4 of 8 Contract Number CLH3 1013-Amendment 19
Page 10 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
ii. Work with partners and Tribes to ensure
testing is provided in a culturally and
linguistically responsive manner with an
emphasis on making testing available to
disproportionately impacted communities and
as a part of the jurisdiction's contact tracing
strategy. Maintain a current list of entities
iii. Maintain a current list of entities providing providing COVID-19 testing and
COVID-19 testing and at what volume. at what volume.Provide reports to
Provide reports to DOH on testing locations DOH Contract manager on testing
and volume as requested. locations and volume as requested.
c. Surveillance FTE support at a minimum of.5 FTE
Epidemiologist to support daily reporting needs
below. Ensure all COVID positive test
i. Ensure all COVID positive lab test results from results are entered into WDRS
LHJ are entered in to WDRS by 1)entering data within 2 days of receipt
directly in to WDRS,2)sending test results to
DOH to enter,or 3)working with DOH and
entities conducting tests to implement an
electronic method for test result submission.
ii. Maintain records of all COVID negative lab test
results from the LHJ and enter into WDRS
when resources permit or send test results to
DOH.
iii. Collaborate with Tribes to ensure Tribal entities
with appropriate public health authority have
read/write access to WDRS and CREST to
ensure that all COVID lab results from their
jurisdictions are entered in WDRS or shared
with the LHJ or DOH for entry.
Quarterly performance updates
d. Tribal Support. Ensure alignment of contact related to culturally and linguistic
tracing and support for patients and family by competency and responsiveness,
coordinating with local tribes if a patient identified tribal support,infection prevention
as American Indian/Alaska Native and/or a and control for high-risk
member of a WA tribe. populations,community education
and regional active monitoring
e. Support Infection Prevention and control for high- activities. Performance update
risk populations should include status of all projects
i. Migrant and seasonal farmworker support. listed.
Partner with fanners,agriculture sector and
Exhibit A, Statement of Work Page 5 of 8 Contract Number CLH31013-Amendment 19
Page 11 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
farmworker service organizations to develop
and execute plans for testing,quarantine and
isolation,and social service needs for migrant
and seasonal farmworkers.
ii. Congregate care facilities: In collaboration
with the state licensing agency(DSHS),
support infection prevention assessments,
testing. Infection control and isolation and
quarantine protocols in congregate care
facilities.
iii. High risk businesses or community-based
operations. In collaboration with state
licensing agencies and Labor and Industries,
partner with food processing and
manufacturing businesses to ensure adequate
practices to prevent COVID-19 exposure,
conduct testing and respond to outbreaks.
iv. Healthcare: Support infection prevention and
control assessments,testing,cohorting,and
isolation procedures. Provide educational
resources to a variety of healthcare setting
types(e.g.,nursing homes,hospitals,dental,
dialysis).
v. Non-healthcare settings that house vulnerable
populations: In collaboration with state
corrections agency(DOC)and other state
partners,support testing,infection control,
isolation and quarantine and social services
and wraparound supports for individuals
living or temporarily residing in congregate
living settings,including detention centers,
prisons,jails,transition housing,homeless
shelters,and other vulnerable populations.
vi. Schools: In collaboration with OSPI and local
health jurisdictions, support infection
prevention and control and outbreak response
in K-12 and university school settings.
f. Ensure adequate resources are directed towards
H2A housing facilities within communities,fishing
industries and long-term care facilities to prevent
and control disease transmission. Funds can be
Exhibit A, Statement of Work Page 6 of 8 Contract Number CLH3 1013-Amendment 19
Page 12 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
used to hire support staff,provide incentives or
facility-based funding for onsite infection
prevention efforts,etc.
g. Community education. Work with Tribes and
partners to provide culturally and linguistically
responsive community outreach and education
related to COVID-19.
h. Establish sustainable isolation and quarantine
(I&Q)measures in accordance with WAC 246-
100-045(Conditions and principles for isolation or
quarantine).
i. Have at least one(1)location for conducting Quarterly performance updates to
I&Q operations identified and confirmed.This include name,address and capacity
location should be sufficient for supporting of identified location that can
I&Q services that are adequate for the support isolation and quarantine,
population for your jurisdiction and have an and confirmation of appropriate
ability to expand if needed.This can be planning and coordination as
through contract/formal agreement; required.
alternatively,the jurisdiction may establish
with an adjacent jurisdiction a formal
agreement to provide the isolation and
quarantine capacity adequate to the population
for your jurisdiction with the ability to
expand.
ii. Maintain ongoing census data for isolation Report census numbers to include
and quarantine for your population. historic total by month and
iii. Planning must incorporate transfer or receipt monthly total for current quarter to
of people requiring I&Q support to and from date
adjacent jurisdictions or state facilities in the
event of localized increased need.
Planning must incorporate indicators for activating and
surging to meet demand and describe the process for
coordinating requests for state I&Q support,either through
mobile teams or the state facility.
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 Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
Exhibit A, Statement of Work Page 7 of 8 Contract Number CLH3 10 13-Amendment 19
Page 13 of 36
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
Special Requirements:
A report on the specific areas the LHJ partners have spent the ARPA vaccine dollars if the legislature requests this information.
The funds from the American Rescue Plan Act are not available for the purchase of vaccines when the federal government is already making COVID-19 vaccines available to
certain populations. The Department of Health Office of Immunization, is using a combination of federal and state funds to supply COVID-19 vaccines for the following groups:
• All children less than 19 years of age.
• Adults 19 years of age and older who are:
o Uninsured.
o Underinsured—lacks cost-free coverage for COVID-19 vaccines.
To access these vaccines, healthcare providers must be enrolled in the Childhood Vaccine Program and/or the Adult Vaccine Program.
In order for LHJs to utilize the American Rescue Plan Act(FY24 LHJ COVID-19 ARPA)funding as listed on the LHJ con-con to purchase COVID-19 vaccines beyond what is
currently available as stated above for administration in their jurisdiction, the LHJ must follow the guidance provided. In this guidance, it specifically asks that this funding is
targeted to disproportionately impacted, underserved populations and communities having COVID-19 impacts that are documented and the response must be tailored to benefit
this impacted class.
DOH has received the following guidance:to(1)identify and respond to other pandemic impacts and(2)serve other populations that experienced pandemic impacts, beyond the
enumerated uses and presumed eligible populations. Recipients can also identify groups or 'classes'of beneficiaries that experienced pandemic impacts and provide services to
those classes. You should refer to pages 32 and 33 of the Overview of the Final Rule for(1)identifying impacts to a specific household or class of households and(2)
tailoring the response to benefit this impacted class.
If LHJs identify a disproportionately impacted underserved population in their LHJ COVID-19 vaccination plan that would benefit from expanded access to COVID-19 vaccines
and is not already served by another state program, they may use this funding to purchase COVID-19 vaccines in support of a documented mission.
Exhibit A, Statement of Work Page 8 of 8 Contract Number CLH3 10 13-Amendment 19
Page 14 of 36
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Drinking Water Group A Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2022
Contract Number: CLH31013
SOW Type: Revision Revision #(for this SOW) 4 Funding Source Federal Compliance Type of Payment
® Federal Contractor (check if applicable) Reimbursement
Period of Performance: January 1,2022 through December 31,2024 ® State Z FFATA(Transparency Act) ® Fixed Price
❑Other Research&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 finalize activity completed 1/1/2022 through 12/31/2023 for Sanitary Survey, Sanitary Survey State and Technical
Assistance and to update funding provided for Sanitary Survey, Sanitiary Survey State and Technical Assistance activity assigned 1/1/2024 through 12/31/2024..
Master Assistance BARS Allocation
LHJ Funding Period e Chan
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None Allocation
SANITARY SURVEY FEES SS-STATE 24112522 N/A 346.26.65 01/01/22 12/31/24 5,400 0 5,400
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%)SS 24119226 N/A 346.26.64 01/01/23 12/31/23 2,200 0 2,200
YR 25 SRF-LOCAL ASST(15%)TA 24119226 N/A 346.26.66 01/01/23 12/31/23 1,000 -1,000 0
YR 26 SRF-LOCAL ASST(15%)SS 24119226 N/A 346.26.64 01/01/24 12/31/24 1,800 0 1,800 1
YR 26 SRF-LOCAL ASST(15%)TA 24119226 N/A 346.26.66 01/01/24 12/31/24 0 1,000 1,000
0 0 0
TOTALS 12,800 0 12,800
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 community system.
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH31013-Amendment 19
Page 15 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
sanitary surveys and providing technical 3. Updated Water Facilities Inventory
assistance to small community and non- (WFI). Payment is inclusive of all associated costs
community Group A water systems. 4. Photos of water system with text such as travel,lodging,per diem.
identifying features
5. Any other supporting documents. Payment is authorized upon receipt and
acceptance of the Final Sanitary Survey Report
*Final Reports reviewed and accepted by within the 30-day deadline.
the ODW Regional Office.
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 payment.
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 supporting documents and photos to must be received by the the LHJ shall be paid for each technical
community and non-community Group A ODW Regional Office. ODW Regional Office assistance activity as follows:
water systems identified by the ODW within 30 calendar days • Up to 3 hours of work: $250
Regional Office. of providing technical • 3-6 hours of work:$500
assistance. • More than 6 hours of work: $750
See Special Instructions for task activity.
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 payment.
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
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH31013-Amendment 19
Page 16 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
See Special Instructions for task activity. ODW Program Contact for approval(to current rates listed on the OFM Website
ensure enough funds are available). http://www.ofm.wa.gov/resources/travel.asp
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
fmance-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 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
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$10,800 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 A 19-1 A Invoice
Voucher to DOH Grants Management,billing to BARS Revenue Code 346.26.66 under Technical Assistance(TA).
Exhibit A, Statement of Work Page 3 of 4 Contract Number CLH31013-Amendment 19
Page 17 of 36
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.
• No more than 1 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.
• No more than 1 survey of non-community systems with three or fewer connections be completed between January 1,2024 and December 31,2024.
• No more than 4 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2024 and
December 31,2024.
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 CLH3 1013-Amendment 19
Page 18 of 36
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: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
El Federal<Select One> (check if applicable) F 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: The purpose of this revision is to add$10,000 in funds for FY24 to support professional development for SBHC staff. This amendment also adds$29,000 in
the FY25 budget for the current contract,increasing the grant award to the previous award level(year one award of$150,000).
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g 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 06/30/24 145,000 10,000 155,000
SFY25 SBHC PROVISO 78310850 N/A 334.04.90 07/01/24 12/31/24 62,000 29,000 91,000
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 207,000 39,000 246,000
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 19
Page 19 of 36
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 staffs role for each task
lb Review and update sustainability workplan for 2024-2025 SBHC Operations project workplan and September 30,2024 $25,000$32,000
school year.Continue previous project/focus area or identify a sustainability plan updates
new focus.Update tasks,activities,roles,and due dates.
1 c 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, staffmg model,and services provided) April 15
• Include milestones, successes,challenges,and barriers July 15
2a 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.
2b Participate in professional development opportunities for Professional development plan June 30, 2024 $10,000
SBHC staff such as conferences, trainings, or continuing
education opportunities.
3a Update health equity plan each for 2023-2024 school year. Updated health equity plan September 30,2023 $20,000
September 30,2024 ($10,000--eaeh)
ih Update health equity plan for 2024-2025 school year. Updated health equity plan September 30, 2024 $32,000
313 3c 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 December 31,2023 $30,000
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
Exhibit A, Statement of Work Page 2 of 4 Contract Number CLH3 I013-Amendment 19
Page 20 of 36
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
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
4d Write plan that outlines steps,barriers,and resources needed Draft data reporting plan March 30,2024 June 30, $26,000
for participation in SBHC statewide data platform. 2024
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.
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 A 19-1 A 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.
Exhibit A, Statement of Work Page 3 of 4 Contract Number CLH31013-Amendment 19
Page 21 of 36
• 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:$48,500
o Year 1,Q2 deliverables(October-December)due by January 15,2024: $43,500
o Year 1,Q3 deliverables(January-March)due by April 15,2024:$39380$13,500
o Year 1,Q4 deliverables(April-June)due by July 15,2024:$43,500$49,500
o Year 2,Q1 deliverables(July-September)due by October 15,2024:$48,500$77,500
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 fmal 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 CLH3 1013-Amendment 19
Page 22 of 36
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) 9 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) Reimbursement
Period of Performance: January 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 Years 1-3 of the contract,which runs January 1,2022—March 31,2025.
For state funding, due dates after June 30,2024 are for reporting only. LHJs may not bill state funds under this contract for work done after June 30,2024.
For federal funding,due dates after December 31,2024 are for reporting only.LHJs may not bill federal funds under this contract for work done after December 31,2024.
Revision Purpose: The purpose of this revision is to add$17,733 to FFY24 FPHPA Title X Family Plan Funds for the period of 04/01/2024- 12/31/2024,and update SOW
language.
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g 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 30,822 0 30,822
SFY24 Sexual&Rep Hlth Cost Share 78430140 N/A 334.04.91 07/01/23 06/30/24 87,652 0 87,652
FFY24 FPHPA Title X Family Plan 78430240 93.217 333.93.21 04/01/24 12/31/24 0 17,733 17,733
0 0 0
TOTALS 273,786 17,733 291,519
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
# Frame and/or Amount
I. Sexual and Reproductive Health Program • A 19 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. analysis approved by
SRHP• required back up documentation per DOH policy.
Exhibit A, Statement of Work Page 1 of 8 Contract Number CLH31013-Amendment 19
Page 23 of 36
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
# Frame and/or Amount
A. Comply with Washington State SRHP Manual, • All reports described in Reporting Requirements table As described in DOH(see Reporting
federal Title X requirements and all state and below. Reporting Requirements table).
federal laws.Also see Program Manual, Requirements table
Handbook,Policy References under Reporting • Other data and documentation in format requested by below. DOH reserves the right
Requirements below. DOH.(Includes copies of program and fmancial to withhold payment
audits and reviews including summaries conducted by As requested by DOH until:
B. Complete required Agency Information other entities.) • Compliance issues
Request including Title or a previous SOW
X Assurance of Compliance and National • To facilitate DOH/TX desk reviews—requested invoice are
Provider Identifier(NPI)billing numbers. documentation available to DOH in requested format. resolved in a way
accepted by DOH
1. • To facilitate DOH/TX site-visits—appropriate staff • Current data is
and documentation readily available prior to and submitted to,and
during review. accepted by,
Ahlers.
• Site review directed by • A 19 back up
Enhanced-rate. DOH SRHP. Follow-up site visits wed as documentation
needed until identified issues are resolved. As requested by DOH required by DOH
C. Provide medical services,community education has been submitted
and outreach,and staff training,consistent with • Submit documentation to DOH SRHP as requested for and approved.
state requirements: a desk review prior to site visit. • Other deliverables
1. LHJ is responsible for making sure all staff have been met.
have the knowledge to carry out the • Appropriate staff and documentation readily available
requirements of the SOW. to DOH SRHP prior to and during site visit. Payment is limited to
2. Medical, laboratory,and other services the maximum funds
related to abortion are not covered by this available for funding
task.
source.
3. Community education services must be
based on the needs of the community.LHJ DOH will reimburse
must have an Information&Education for:
(I&E)committee with no rowers five • Actual allowable
(5)or more members-ate-up-te-m-many costs according to
members as the L HJ deterines;be that is
broadly representative of the population or yourapproved cost
analysis
community for which materials are Reporting
intended. The committee must review all
Requirements
a batch of table).
patient facing materials annually(at least
or
15 products or 15%of your total number of • The amount
materials, whichever is smaller);meet at remaining in the
least annually and establish a written record
SOW
of its determination.(42 CFR 59[59.6]) by the
R&E divided
number of
months remaining
Exhibit A, Statement of Work Page 2 of 8 Contract Number CLH31013-Amendment 19
Page 24 of 36
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
# Frame and/or Amount
4. Outreach is to ensure all populations in in the funding
your community understands the services source,plus one,
available.Focus your outreach efforts on whichever is less.
increasing equity.
The Payment will be
Washington State Sexual and Reproductive Health next-month. 15`"of the calculated by R&E
Network priority populations are: following month. provided by DOH(see
• Teens CVR data submitted to DOH data contractor(Ahlers& Within thirty(30)days Reporting
• People who are uninsured or underinsured, Associates)electronically in a format compatible with of receiving Requirements table).
and/or low-income(at or below 250%of the Ahlers software. error/rejection report
federal poverty line) or request from DOH All services through the
• Rural communities • Data for each month Sexual and
• Hispanic Reproductive Health period must be billed
• Black, Indigenous,People of Color • Corrected CVR data data manager. within 60 days of the
Extra efforts should be made to provide information budget period, with the
and services to people who intersect with multiple exception of the
priority population categories. December billing that is
As needed to keep due within 45 days to
Provide all services in accordance with: Email briefly describing change. information current. meet federal reporting
• DOH SRHP&Title X Manual
requirements.
• Other state and federal requirements
• '
3-Reporting Requirements(see below)
D. Collect,maintain,and provide data about each
family planning clinic visit as defined in the
SRH CVR Manual.
1. Maintain a computer system that includes
gal safety precautions against loss of
information.
2. Ensure data entry personnel protect
confidentiality of CVR data.
3. Have ability to retrieve all information for
auditing and monitoring by DOH or its
designee.
E. Notify DOH contract manager of all:
• Key staff and organizational changes.
• Proposed clinic site additions.New clinic
sites must be approved by DOH before
offering services supported by SW
SRHP/Title X funding.
Exhibit A, Statement of Work Page 3 of 8 Contract Number CLH3 1013-Amendment 19
Page 25 of 36
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
# Frame and/or Amount
• 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
reproductive services described in this
SOW.
Reporting Requirements
1. Agency Information Dashboard-Request This information must be reported using the template April 30th during each
or format provided by DOH.All signatures and forms year of this contract.
DOH SRHP requires updated information must be completed by April 30"'during each year of
this contract. If Requested information will include: AND
from all members of the SRHP Network to This
in€or-mation ensure that-DOH-has accurate Information about your agency contacts and your As needed or
records of LHJ's organization organization's staffing requested to maintain
and the services it provides. A. Head of Organization accuracy of
B. Head of Finance information.
In addition,elements of this report allow DOH C. Medical Director
to ensure that SRHP&Title X requirements D. NPI numbers used to bill Medicaid
regarding including client fees and required E. The following(one person might fill more than one
services requirements are met. It also-provides role)
The updated information a. Contract Coordinator
also assists DOH to manage this SOW and the
Sexual&Reproductive Health Network as a b. Clinical representative
whole. 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 within three years prior to the start
date of this SOW.If contractor cost analysis was
approved by DOH at the beginning of the contract
period, LHJ does not have to resubmit unless changes
are made. LHJ must email DOH contract manager
informing them that no changes were made.
Exhibit A, Statement of Work Page 4 of 8 Contract Number CLH31013-Amendment 19
Page 26 of 36
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
Frame and/or Amount
B. Sliding fee schedule that includes all services required
in the SRH Manual.Additional Task 1 SRH-related
services as outlined in Task I may also be included on Submit an updated
LHJ's sliding fee schedule. income conversion
a. Sliding fee schedule must be based on cost table by March 15 of
analysis described above. each year of the
b. Fee schedule must be resubmitted for reapproval contract.
anytime there are any significant changes,which
may include 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-a
the first year T Ili must a document andl dlisseminate
This process must
include the following steps:
A. Utilize the state level priority populations, county
level domographic data, and agency profile to
identifi,unmet need in the community served
B. Determine objectives and activities to expand sexual
and reproductive health to reach populations in need
of services in the community served.
C. Measure completion of the objectives and activities
F. Ga�tther a ailable data and c nt a ents
(
\V__vta)
(co"eet-pcimafy
z. Prioritize heelt i a define a of unmet need]
Exhibit A, Statement of Work Page 5 of 8 Contract Number CLH31013-Amendment 19
Page 27 of 36
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
# Frame and/or Amount
education ate el.. nd cti ,itie
J. D„eume„t anal.disseminate♦he a nit.,health
needs-agsessment-te-L-14-J1s-SR14-eonsultant-and
Information related to billing an,d client fees
If d Hd cost analysis. .e.d by DOH] at the
beginning of the contract p od eL HJ.does not have to
resubmit unless changes were made. dud .deer need to
changes ade
2. ProgressReport Updates This information must be reported using the template During quarterly
or format provided by DOH. It will include information check ins and as
Summary of ongoing activities related to the about contractor's work during the-previous current requested by DOH
SRH Program and past SOWs:
SOW.
A. Community education and outreach strategies and
It informs quality improvement of the activities and a discussion of their effectiveness.
Washington 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 grant
data. All information is for the calendar year Number of: (2027).
202-3(January through December 2823).The A. Pap tests with an ASC or higher result
subsequent agreements sent to the agency will B. Pap tests with an HSIL or higher result
request that these data be collected and reported C. HIV Positive confidential tests
on within the statement of work period of D. HIV Anonymous tests
performance. 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 03 31 24 the end of
the grant as described below.
Exhibit A, Statement of Work Page 6 of 8 Contract Number CLH3 10 13-Amendment 19
Page 28 of 36
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
Frame and/or Amount
Subsequent agreements will request that data be collected
and reported on during the appropriate contract period of
performance.(FPAR due 01-31 annually through 2027)
4. Clinic Visit Reports(CVRs) Clinic visit records must include all elements specified Theme
in the Clinic Visit Record(CVR)Manual available at: nextonth 15t of the
https://www.doh.wa.zov/Portals/l/Documents/Pubs/930- following month.
139-CVRManual.pdf. Within thirty(30)days
of receiving error or
CVR data must be submitted to DOH data contractor rejection report or
(Ahlers&Associates)electronically in a format compatible request from DOH
with Ahlers software. SRH data manager.
- 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(A19).No
Services and all expenses related to providing those more than monthly
services.R&E workbook will be provided by DOH. and no less than
A. Expenses must match General Ledger. quarterly.
B. Other revenue/program income must reflect revenue R&E showing all
actually received in the reporting month.
All entries on"Other"rows must be accompanied by a sources of revenue that
sicedescription of the revenue source or expense,including any upport bes billed wwith n must
in 45
calculations uses. days of the budget
period December
billings must be
submitted by February
10'". for
April 2023 March
2024 due through-the
end-of-this contract
60 day.
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)
Exhibit A, Statement of Work Page 7 of 8 Contract Number CLH3 1013-Amendment 19
Page 29 of 36
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,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.gov/Portals/I/Documents/Pubs/930-139-CVRManual.pdf)
• LHJ's approved Agency Information Dashboard Request.
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 priority 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.
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 8 of 8 Contract Number CLH31013-Amendment 19
Page 30 of 36
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: WIC Nutrition Program-Effective January 1,2022 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 10 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: January 1,2022 through December 31,2024 ❑ State ®FFATA(Transparency Act) El Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose is to provide Women, Infants,and Children(WIC)Nutrition Program services by following WIC federal regulations, WIC state office
policies and procedures,WIC directives, and other rules. Refer to the Program Specific Requirements section of this document.
Revision Purpose: To add FFY24 USDA FMNP MGMT funds.
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY22 USDA WIC CLIENT SVS CONTRACTS 76101234 10.557 333.10.55 07/01/22 09/30/22 86,376 0 86,376
FFY23 USDA WIC CLIENT SVS CONTRACTS 76101244 10.557 333.10.55 10/01/22 09/30/23 132,338 0 132,338
FFY22 USDA BFPC PROG MGMT 76214231 10.557 333.10.55 01/01/22 09/30/24 43,389 0 43,389
FFY22 USDA FMNP PROG MGMT 76540237 10.572 333.10.57 05/01/22 09/30/22 516 0 516
FFY23 USDA BFPC PROG MGMT 76214241 10.557 333.10.55 10/01/22 12/31/24 37,651 0 37,651
FFY23 USDA WIC PROG MGMT CSS 76101242 10.557 333.10.55 01/01/23 09/30/23 2,800 0 2,800
FFY24 USDA WIC CLIENT SVS CONTRACTS 7610124B 10.557 333.10.55 10/01/23 09/30/24 155,011 0 155,011
FFY23 USDA FMNP MGMT 76540248 10.572 333.10.57 06/01/23 09/30/23 496 0 496
FFY24 USDA BFPC PROG MGMT 7621424A 10.557 333.10.55 10/01/23 09/30/24 37,651 0 37,651
FFY25 USDA WIC CLIENT SVS CONTRACTS 76101251 10.557 333.10.55 10/01/24 12/31/24 26,268 0 26,268
FFY24 USDA FMNP MGMT 76540241 10.572 333.10.57 05/01/24 09/30/24 0 496 496
0 0 0
TOTALS 522,496 496 522,992
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
See"Billing
1 WIC Nutrition Program Requirements"
below.
1.1 Outcomes based on monthly participation Authorized participating
Maintain authorized participating caseload at 100%based on data from state WIC caseload management caseload for January 2022
quarterly average as determined from monthly caseload reports. through December 2024=
management reports generated at state WIC office. 250
Exhibit A, Statement of Work Page 1 of 7 Contract Number CLH3 1013-Amendment 19
Page 31 of 36
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
The Department of Health(Department)State WIC Nutrition Revised authorized
Program has the option of reducing authorized participating participating caseload for
caseload and corresponding funding when: January 2023 through
1. Unanticipated funding situations occur. December 2024=265
2. Reallocations are necessary to redistribute caseload
statewide. Revised authorized
3. Caseload declines. caseload for January 2024
through December 2024=
270
1.2 Submit the annual Nutrition Services Plan for each year of the Nutrition Services Plan First year due 9/30/22 Payment withheld if
contract. Second year due 9/30/23 not received by due
Third year due 9/30/24 date.
1.3 Submit the annual Nutrition Services Expenditure Report for each Nutrition Services Expenditure Report 11/30/22 Payment withheld if
year of the contract. 11/30/23 not received by due
11/30/24 date.
Tell participants about other health services in the agency. If Documentation must be available for review
1.4 needed,develop written agreements with other health care agencies by WIC monitor staff Biennial WIC Monitor
and refer participants to these services.
Provide nutrition education services to participants and caregivers Documentation must be available for review
1.5 in accordance with federal and state requirements. by WIC monitor staff Biennial WIC Monitor
Issue WIC benefits while assuring adequate WIC card security and Documentation must be available for review
1.6 reconciliation. by WIC monitor staff Biennial WIC Monitor
Collect data,maintain records,and submit reports to effectively Documentation must be available for review
1.7 enforce the non-discrimination laws(Refer to Civil Rights by WIC monitor staff. Biennial WIC Monitor
Assurances below).
Submit entire WIC and Breastfeeding Peer Counseling Budget Budget Workbook First year due 9/30/22
1.8a Workbook for each year of the contract Second year due 9/30/23
Third year due 9/30/24
Submit Rev-Exp Report spreadsheet from the WIC Budget Revenue and Expense Report and A-19 First year due monthly
Workbook monthly with A-19 through December 31,2022
1.8b Second year due monthly
through December 31,2023
Third year due monthly
through December 31,2024
See"Billing
2 Breastfeeding Promotion Requirements"
below.
Provide breastfeeding promotion activities in accordance with Status report of chosen activities in First year due 11/30/22
federal and state requirements. Nutrition Services Plan. Second year due 11/30/23
2.1 Third year due 11/30/24
Documentation must be available for review
by WIC monitor staff.
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH31013-Amendment 19
Page 32 of 36
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Biennial WIC Monitor
Work with community partners to improve practices that affect Status report of chosen activities in First year due 8/30/22
breastfeeding. Choose one or more of the following projects: Nutrition Services Plan. Second year due 8/30/23
• Provide staff,health care providers and community partners Third year due 11/30/24
virtual breastfeeding training resources. Documentation must be available for review
2.2 •
Work with employers who likely employ low-income people by WIC monitor staff. Biennial WIC Monitor
to create worksite environments that support breastfeeding.
• Work with birthing hospitals to improve maternity care
practices that affect WIC participant breastfeeding rates.
• Provide participants access to lactation consultants.
Other projects will need pre-approval from the State WIC Office
See"Billing
3 Breastfeeding Peer Counseling Program(BFPC) Requirements"
below.
Provide Breastfeeding Peer Counseling Program activities in Breastfeeding Peer Counseling Annual First year due 12/31/22
accordance with federal and state requirements.The WIC Report and expenditures from the previous Second year due 12/31/23
3.1 Breastfeeding Peer Counseling Program is meant to enhance,not federal fiscal year. Third year due 12/31/24
replace,WIC Breastfeeding promotion and support activities.
Documentation must be available for review Biennial WIC Monitor
by WIC monitor staff.
Track Breastfeeding Peer Counseling Program expenditures and Documentation must be available for review Biennial WIC Monitor
3.2 bill separately from the WIC grant. by WIC monitor staff.
See"Billing
4 Farmers Market Nutrition Program(FMNP) Requirements"
below.
Distribute all Farmers Market Nutrition Program checks to eligible Send completed readable copy of FMNP Weekly June-Sept.2022 and
WIC participants between June and September 30 of current year. check registers to State WIC office on a June-Sept.2023
weekly basis following FMNP procedures.
4.1 All sent by Oct. 1,2022,
Documentation must be available for review Oct. 1,2023,and Oct 1,
by WIC monitor staff. 2024
Biennial WIC Monitor
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 financeAdoh.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.
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH31013-Amendment 19
Page 33 of 36
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:
The LHJ shall be responsible for providing services according to rules,regulations and other information contained in the following:
• WIC Federal Regulations,USDA,and FNS 7CFR Part 246.
• Washington State WIC Nutrition Program Policy and Procedure Manual
• Office of Management and Budget, Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards,2 CFR 200
• Farmers Market Nutrition Program Federal Regulations,USDA,FNS 7CFR Part 248
• Other directives issued during the term of the contract
Staffing Requirements:
The LHJ shall:
• Use Competent Professional Authority staff,as defined by WIC policy,to determine participant eligibility,prescribe an appropriate food package and offer nutrition
education based on the participants' needs.
• Use a Registered Dietitian(RD)or other qualified nutritionist to provide nutrition services to high risk participants,to include development of a high-risk care plan. The
RD is also responsible for quality assurance of WIC nutrition services. See WIC Policy for qualifications for a Registered Dietitian and other qualified nutritionist.
• Assign a qualified person to be the Breastfeeding Coordinator to organize and direct local agency efforts to meet federal and state policies regarding breastfeeding
promotion and support. The Breastfeeding Coordinator must be an International Board-Certified Lactation Consultant or attend an intensive lactation management
course,or other state approved training.
Restrictions on Funds:
The LHJ shall follow the instructions found in the Policy and Procedure Manual under WIC Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements, Cost
Principles,and Audit Requirements for Federal Awards.
Special References:
What is the WIC program?
1. The WIC program in the state of Washington is administered by the Department of Health.
2. The WIC program is a federally funded program established in 1972 by an amendment to the Child Nutrition Act of 1966.The purpose of the program is to provide nutrition
and health assessment;nutrition education;nutritious food;breastfeeding counseling;and referral services to pregnant,breastfeeding,and postpartum women, infants,and
young children in specific risk categories.
3. Federal regulations governing the WIC program(7 CFR Part 246)require implementation of standards and procedures to guide the state's administration of the WIC program.
These regulations define the rights,responsibilities,and legal procedures of WIC employees,participants,persons acting on behalf of a participant,and retailers.They are
designed to promote:
a. High quality nutrition services;
b. Consistent application of policies and procedures for eligibility determination;
c. Consistent application of policies and procedures for food benefit issuance and delivery;and
d. WIC program compliance.
4. The WIC program implements policies and procedures stated in program manuals,handbooks,contracts,forms,and other program documents approved by the USDA Food
and Nutrition Service.
5. The WIC program may impose sanctions against WIC participants for not following WIC program rules stated on the WIC rights and responsibilities.
6. The WIC program may impose monetary penalties against persons who misuse WIC benefits or WIC food but who are not WIC participants.
Exhibit A, Statement of Work Page 4 of 7 Contract Number CLH31013-Amendment 19
Page 34 of 36
Monitoring Visits:
Program and fiscal monitoring are done on a biennial(every two years)basis and are conducted onsite.
The LHJ must maintain on file and have available for review,audit and evaluation:
• All criteria used for certification, including information on income,nutrition risk eligibility and referrals
• Program requirements
• Nutrition education
• All financial records
Assurances/Certifications:
1. Computer Equipment Loaned by the Department of Health WIC Nutrition Program
In order to perform WIC program activities,the Department requires computer equipment,such as computers, signature pads,document scanners,card readers and printers to
be in local WIC clinics or to be transported to mobile clinics. This equipment("Loaned Equipment")is owned by the Department and loaned to the local agency(Contractor).
The Loaned Equipment is supported by the Department. This equipment shall be used for WIC business only or according to WIC Policy and Procedures.
An inventory of Loaned Equipment is kept by the Department. Each time Loaned Equipment is changed,the parties shall complete the Equipment Transfer Form and the
Department updates the inventory. A copy of the Transfer Form will be provided to the contractor. Copies of the updated inventory list may be requested at any time.
The LHJ agrees to:
a. Defend,protect and hold harmless the Department or any of its employees from any claims,suits or actions arising from the use of this Loaned Equipment.
b. Assume responsibility for any loss or damage from abnormal wear or use,or from inappropriate storage or transportation. The Department may enforce this by:
1) Requiring reimbursement from the LHJ of the value of the Loaned Equipment at the time of the loss or damage.
2) Requiring the LHJ to replace the Loaned Equipment with equipment of the same type,manufacturer,and capabilities(as pre-approved by the Department),or
3) Assertion of a lien against the Contractor's property.
c. Notify the Department immediately of any damage to Loaned Equipment.
d. Notify the Department prior to moving or replacing any Loaned Equipment.
The Department recommends Contractors carry insurance against possible loss or theft.
2. Civil Rights Assurance
a. The LHJ shall perform all services and duties necessary to comply with federal law in accordance with the following Civil Rights Assurance.
b. "The Program applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964(42 U.S.C.2000d et seq.),Title IX of the Education Amendments
of 1972(20 U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973(29 U.S.C.794),Age Discrimination Act of 1975(42 U.S.C.6101 et seq.);all provisions
required by the implementing regulations of the Department of Agriculture;Department of Justice Enforcement Guidelines,28 CFR 50.3 and 42;and FNS directives and
guidelines,to the effect that,no person shall,on the ground of race,color,national origin, sex,age or handicap,be excluded from participation in,be denied benefits of,or
otherwise be subject to discrimination under any program or activity for which the Program applicant receives Federal financial assistance from FNS;and hereby gives
assurance that it will immediately take measures necessary to effectuate this agreement.
c. "By accepting this assurance,the Program applicant agrees to compile data,maintain records and submit reports as required,to permit effective enforcement of the
nondiscrimination laws and permit authorized USDA personnel during normal working hours to review such records,books and accounts as needed to ascertain
compliance with the nondiscrimination laws. If there are any violations of this assurance,the Department of Agriculture,Food and Nutrition Service,shall have the right
to seek judicial enforcement of this assurance.This assurance is binding on the Program applicant, its successors,transferees,and assignees,as long as it receives
assistance or retains possession of any assistance from the Department.The person or persons whose signatures appear on the contract are authorized to sign this
assurance on behalf of the Program applicant."
3. 2CFR 200
The LHJ shall comply with all the fiscal and operations requirements prescribed by the state agency as directed by Federal WIC Regulations(7CFR part 246.6),2CFR part
200,the debarment and suspension requirements of 2CFR part 200.213, if applicable,the lobbying restrictions of 2CFR part 200.245,and FNS guidelines and instructions and
shall provide on a timely basis to the state agency all required information regarding fiscal and program information.
Exhibit A, Statement of Work Page 5 of 7 Contract Number CLH3 10 I 3-Amendment 19
Page 35 of 36
Billing Requirements:
1. Definitions
Contract Period: January 1,2022-December 31,2024
Contract Budget Period: The time period for which the funding is budgeted.
• There are four federal budget periods
January 1,2022 through September 30,2022;
October 1,2022 through September 30,2023;
October 1,2023 through September 30,2024;
October 1,2024 through December 31,2024.
2. Billing Information:
a. Billings are submitted on an A-19-1A invoice. These invoices are provided by the Department in the WIC Budget Workbook and include accounting codes for different
budget categories.
b. A-19s are submitted monthly and must be received by the Department within 30 days following the close of each calendar month.Additional A-19s may be submitted at
any time,but must be received within 60 days of the close of the federal budget period.
c. Funds are allocated by budget categories and by federal budget periods(refer to the budget spreadsheet).
d. Funds are encumbered or spent only during the budget period;no carry forward from previous time periods or borrowing from future time periods is allowed.
e. Payments are limited to the amounts allocated for the budget period for each budget category.
f. Billings are based on actual costs for completed activities. Advance payments are not allowed. Back up documentation must be retained by the LHJ and available for
inspection by the Department or other appropriate authorities.
g. Payments will be made only for WIC approved expenditures.Refer to the Washington State WIC Nutrition Program Policy and Procedure Manual Volume 2, Chapter 4—
Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards.
h. If billing for indirect costs,a Cost Allocation Plan or Federal Indirect Cost Agreement must be submitted prior to payment.
Special Instructions:
The LHJ shall:
1. Maintain complete,accurate,and current accounting of all local,state,and federal program funds received and expended.
2. Provide,as necessary,a single audit in accordance with the provisions of 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for
Federal Awards. This circular requires all recipients and sub-recipients of federal funds to have a single audit performed should they spend$750,000 or more of federal grants
or awards from all sources. Contractors spending less than$750,000 in federal grants or awards may also be subject to audit.
3. Use Breastfeeding Peer Counseling(BFPC)Program funds only to support the peer counseling program. Once the program is established and peer counselors are trained,the
majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs see Volume 2,Chapter 4—Allowable
Costs. The priority use of BFPC funds is to hire and train peer counselors to provide breastfeeding peer counseling services to WIC participants.
SPECIAL REQUIREMENTS
Contract Time Period special Amount Special Requirement Description
Funding Period requirement funds are
available
January 2022 to January 2022 to September $2,800 Added in the USDA WIC Client Services Contracts category to cover training and travel expenses for all local
September 2024 2022 WIC staff to participate in WIC-related trainings.
January 2023- January 2023 -September $2,800 This funding is for all WIC staff to participate in WIC-related training.Added in the USDA WIC Client Services
September 2023 2023 Contracts category to cover training registrations,travel expenses, staff time to participate in training
(salary/benefits or contractor),and other approved WIC training expenses.
Exhibit A, Statement of Work Page 6 of 7 Contract Number CLH31013-Amendment 19
Page 36 of 36
October 2023 - October 2023 -September $2,500 This funding is for all WIC staff to participate in WIC-related training. Added in the USDA WIC Client Services
September 2024 2024 Contracts category to cover training registrations,travel expenses, staff time to participate in training
(salary/benefits for part-time or contractors),and other approved WIC training expenses.
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
Exhibit A, Statement of Work Page 7 of 7 Contract Number CLH31013-Amendment 19
615 Sheridan Street
Port Townsend, WA 98368
�e rson www.JeffersonCountyPublicHealth.org
Consent Agenda
Public Healt
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:
SUBJECT: Agenda Item — Consolidated Contracts Amendment #19 with the Department
of Health; January 1 2022 — December 31, 2024; additional $57,229 for a
total of $8,197,713
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #19
between JCPH and State of Washington Department of Health (DOH); January 1, 2022 — December 31, 2024;
additional $57,229 for a total of $8,197,713.
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:
• COVID-19 LHJ Gap Funding; revision clears funding and adds coding for General Fund State for
remaining balance
• Office of Drinking Water Group A Program; finalizes activity completed 1/1/22 — 12/31/23 for Sanitary
Survey, and updates funding provided for activity assigned 1/1/24 — 12/31/24.
• School-Based Health Centers Program; adds funds for FY24 to support professional development for
SBHC staff, and adds funds for FY25 budget (additional 39,000).
• Sexual & Reproductive Health Program; adds funds to FFY24 FPHPA Title X Family Plan Funds, and
updates SOW language (additional $17,733)
• WIC Nutritional Program; provides additional funds (additional $496)
FISCAL IMPACT/COST BENEFIT ANALYSIS :
Total consideration for this Contract Amendment is an increase of $57,229 for a total of $8,197,713. The
Consolidated Contract is funded by DOH, and comprises both Federal and State funds.
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
CC-22-002-A 18
RECOMMENDATION:
JCPH Management recommends BOCC approval of Consolidated Contract Amendment #18; January 1 2022 —
December 31, 2024; additional $57,229 for a total of $8,197,713.
REVIEWED BY:
/ Z
Mark McCau ey;Eoufl° y Administrator 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 I Clear Form I
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-22-002-A19
Contract For: Consolidated Contracts, Amendment 19 Term: 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$57,229 fora total of$8,197,713 PROCESS: st Exempt from Bid Process
Revenue: $57,229 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 COMP J ' E WI '1 5.080 AND CHAPTER 42.23 RCW.
CERTIFIED: fl N/A: May 1, 2024
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BE N DEBA ED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY. /
CERTIFIED: ri N/A: /, May 1,2024
Signature Date •
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 5/2/2024.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 5/2/2024.
State contract -- 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 22
JEFFERSON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
2ONTRACT NUMBER: CLH31013 AMENDMENT NUMBER: 18
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.sharepoint.com/sites/doh-ofsfundint resources/sitepages/hnme.aspx?-,e1:9a94(88da2d94d3ea80ac7tbe32e4d7c
® Adds Statements of Work for the following programs:
BEACH Program-Effective March 1,2024
• Amends Statements of Work for the following programs:
Sexual&Reproductive Health Program -Effective January 1, 2022
WIC Nutrition Program -Effective January 1, 2022
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-18 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-17 Allocations
as follows:
® Increase of$64,983 for a revised maximum consideration of$8,140,484.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of .
Exhibit B Allocations arc 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
(1)..\1\,
Al 4410114017 03/20/2024
Kate Dean,Chair Date Date
APPROVED,AS TO FORM ONLYAPPROVED AS TO FORM ONLY
Assistant Attorney General
`
'" March 13.2024
Philip C. l Iunsucker, Date
Chief Civil Deputy Prosecuting Attorney
CC-22-002-A i s Page 1 of 1
:HIBIT B-18 Page 2
Jefferson County Public Health r+LLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: February 1,2024
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
FFY24 USDA BFPC Prog Mgmt 7WA700WA1 Amd 15 10.557 333.10.55 I0/01/23 09/30/24 10/01/23 09/30/24 $37,651 $37,651 $118,691
FFY23 USDA BFPC Prog Mgmt 7WA700WA1 Amd 10,17 10.557 333.10.55 10/01/22 12/31/24 10/01/22 09/30/25 $28,238 $37,651
FFY23 USDA BFPC Prog Mgmt 7WA700WA1 Amd 8,10,17 10.557 333.10.55 10/01/22 12/31/24 10/01/22 09/30/25 $9,413
FFY22 USDA BFPC Prog Mgmt 7WA700WA1 Amd 1,17 10.557 333.10.55 01/01/22 09/30/24 10/01/21 09/30/24 $43,389 $43,389
FFY25 USDA WIC Client Svs Contracts NGA Not Received Amd 17 10.557 333.10.55 10/01/24 12/31/24 10/01/24 09/30/25 $26,268 $26,268 $399,993
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 18 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $48,183 $155,011
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 17 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $79,090
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 15 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $2,500
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 10,15 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $25,238
FFY23 USDA WIC Client Svs Contracts 7WA700WA7 Amd 15 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $11,657 $132,338
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
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 10.557 333.10.55 01/01/23 09/30/23 10/01/22 09/30/23 $2,800 $2,800 $2,800
FFY23 USDA FMNP Prog Mgmt 7WA810WA7 Amd 15 10.572 333.10.57 06/01/23 09/30/23 10/01/22 09/30/23 $496 $496 $1,012
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
FY24 LHJ COVID-19 ARPA SLFRP0002 Amd 15 21.027 333.21.02 07/01/23 06/30/24 07/01/23 06/30/25 $46,740 $46,740 $46,740
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 01J18001 Amd 15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 $30,000 $263,844 $263,844
PS SSI 1-5 OSS Task 01J18001 Amd 7,15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 ($1,654)
PS SSI 1-5 OSS Task 4 01J18001 Amd 2,5,15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 $235,498
FFY24 Swimming Beach Act Grant IAR(ECY) NGA Not Received Amd 18 66.472 333.66.47 03/01/24 09/30/24 01/01/24 11/30/24 $15,000 $15,000 $45,000
FFY23 Swimming Beach Act Grant lAR(ECY) 01J74301 Amd 11 66.472 333.66.47 03/01/23 10/31/23 03/01/23 10/31/23 $15,000 $15,000
FFY22 Swimming Beach Act Grant JAR(ECY) 01J74301 Amd 2 66.472 333.66.47 03/01/22 10/31/22 01/01/22 11/30/22 $15,000 $15,000
FFY23 PHEP BPS LHJ Funding NU90TP922043 Amd 15 93.069 333.93.06 07/01/23 06/30/24 07/01/23 06/30/24 $34,384 $34,384 $82,522
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
FFY21 PHEP BP3 LHJ 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
FFY23 OD2A OD CDC NU17CE010218 Amd 17 93.136 333.93.13 01/01/24 08/31/24 09/01/23 08/31/24 $98,000 $98,000 $98,000
FFY22 Title 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
Page 1 of 4
:HIBIT B-18 Page 3
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: February 1,2024
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 Title X Family Planning FPHPA006560 Amd 14 93.217 333.93.21 04/01/23 03/31/24 04/01/23 03/31/24 $30,822 $30,822 $57,959
FFY22 Title X Family Planning FPHPA006560 Amd 5 93.217 333.93.21 04/01/22 03/31/23 04/01/22 03/31/23 $27,137 $27,137
COVID19 Vaccines NH23IP922619 Amd 4 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 NH237922619 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 NH237922619 Amd 15 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $560 $6,160 $6,160
FFY24 CDC VFC Ops NH231P922619 Amd 14 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $5,600
FFY23 VFC Ops NH237922619 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
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 LHJ Allocation NU5OCK000515 Amd 7 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 NU5OCK000515 Amd 2 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 $82,712
FFY20 ELC EDE LHJ Allocation 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 NU5OCK000515 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
FFY21 CDC COVID-19 PHWFD-LHJ NU90TP922181 Amd 16 93.354 333.93.35 07/01/23 06/30/24 07/01/23 06/30/24 $200,000 $200,000 $200,000
FFY22 NEHA Climate&Health Grant NU380T000300 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 NU380T000300 Amd 5 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 $11,000
FFY22 PH Infrastructure Comp Al-LW NE110E000053 Amd 17 93.967 333.93.96 01/01/24 12/31/24 12/01/22 06/30/25 $200,000 $200,000 $200,000
FFY24 HRSA MCHBG LHJ Contracts B04MC52960 Amd 15 93.994 333.93.99 10/01/23 09/30/24 10/01/23 09/30/24 $36,700 $36,700 $56,566
FFY23 HRSA MCHBG LHJ Contracts B04MC47453 Amd 15 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 ($16,834) $19,866
FFY23 HRSA 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
FFY22 HRSA MCHBG Special Proj B04MC45251 Amd 15 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 $16,834 $16,834 $16,834
FFY22 MCHBG LHJ Contracts 804MC45251 Amd 1 93.994 333.93.99 01/01/22 09/30/22 10/01/21 09/30/22 $27,525 $27,525 $27,525
SFY25 SBHC Proviso Amd 14 N/A 334.04.90 07/01/24 12/31/24 07/01/24 06/30/25 $62,000 $62,000 $207,000
SFY24 SBHC Proviso Amd 16 N/A 334.04.90 07/01/23 06/30/24 07/01/23 06/30/24 $35,000 $145,000
SFY24 SBHC Proviso Amd 14 N/A 334.04.90 07/01/23 06/30/24 07/01/23 06/30/24 $110,000
Page 2 of 4
HIBIT B-18 Page 4.
Jefferson County Public Health AALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: February 1,2024
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
SFY23 School Based Health Centers Aind 5 N/A 334.04.90 07/01/22 06/30/23 07/01/22 06/30/23 $150,000 $150,000 $150,000
SFY24 Sexual&Rep Hlth Cost Share Amd 18 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $1,800 $87,652 $211,761
SFY24 Sexual&Rep Hlth Cost Share Amd 17 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $42,926
SFY24 Sexual&Rep Hlth Cost Share •Amd 15,17 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $42,926
SFY23 Sexual&Rep 111th 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
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 Hlth Cost Share Amd 1 N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/22 $38,220
SFY25 Drug User Health Program Amd 17 N/A 334.04.91 07/01/24 12/31/24 07/01/24 06/30/25 $40,250 $40,250 $88,000
SFY24 Drug User Health Program Amd 17 N/A 334.04.91 01/01/24 06/30/24 07/01/23 06/30/24 $40,250 $40,250
SFY24 Drug User Health Program Amd 14 N/A 334.04.91 07/01/23 12/31/23 07/01/23 06/30/24 $7,500 $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 07/01/23 12/31/24 07/01/23 06/30/25 $11,100 $11,100 $28,600
Rec Shellfish/Biotoxin Amd 9 N/A 334.04.93 01/01/22 06/30/23 07/01/21 06/30/23 $7,000 $17,500
Rec Shellfish/Biotoxin 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 07/01/24 12/31/24 07/01/23 06/30/25 $33,333 $33,333 $104,166
Small Onsite Management(ALEA) Amd 14 N/A 334.04.93 07/01/23 06/30/24 07/01/23 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 06/30/23 $22,500
Small Onsite Management(GFS) Amd 16 N/A 334.04.93 07/01/24 12/31/24 07/01/23 07/01/25 ($31,970) $0 $0
Small Onsite Management(GFS) Amd 14 N/A 334.04.93 07/01/24 12/31/24 07/01/23 07/01/25 $31,970
SFY25 Wastewater Management-GFS Amd 16 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 $31,970 $31,970 $61,970
Wastewater Management-GFS Amd 1 N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $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
SFY24 FPHS-LHJ-Funds-GFS Amd 15 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $900,000 $2,333,000 $2,333,000
SFY24 FPHS-LHJ-Funds-GFS Amd 14 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $1,433,000
Page 3 of 4
:HIBIT B-18 Page 5 1
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: February 1,2024
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
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(YR1) 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(YR1) Amd 4 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 ($137,500)
FPHS-LHJ-Proviso(YR1) Amd 1 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 $550,000
YR 25 SRF-Local Asst(15%)SS Amd 16 N/A 346.26.64 01/01/24 12/31/24 07/01/23 06/30/25 $1,800 $1,800 $5,400
YR 25 SRF-Local Asst(15%)SS Amd 11 N/A 346.26.64 01/01/23 12/31/23 01/01/23 12/31/23 $2,200 $2,200
YR 24 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 SS-State Amd 16 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $1,800 $5,400 $5,400
Sanitary Survey Fees SS-State Amd 11,16 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $2,200
Sanitary Survey Fees SS-State Amd 1,11,16 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $1,400
YR 25 SRF-Local Asst(15%)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
YR 24 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 $8,140,484 $8,140,484
Total consideration: $8,075,501 GRAND TOTAL $8,140,484
$64,983
GRAND TOTAL $8,140,484 Total Fed $3,042,506
Total State $5,097,978
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 4 of 4
Page 6,
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: BEACH Program-Effective March 1,2024 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: March 1,2024 through September 30,2024 El State ®FFATA(Transparency Act) Li Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The Beach Environmental Assessment,Communication,and Health(BEACH)Program works with LHJ to monitor water at marine swimming
beaches for bacteria and provide public notification when levels are unsafe.
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 SWIMMING BEACH GRANT IAR(ECY) 26505924 66.472 333.66.47 03/01/24 09/30/24 0 15,000 15,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 15,000 15,000
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 BEACH Program Administration and Annual Meeting:Time Summarize time spent on administrative Annual meeting held in Reimbursement for actual
spent on administrative duties related to the BEACH Program duties in annual report. March 2024.Annual report costs up to$15,000 for
and the 2024 Annual meeting. due September 30,2024. tasks 1-3. Subrecipient
2 Bacteria Monitoring&Public Notification 1. Enter data into Department of 1.Enter data results into may use their discretion in
• Collect samples and field observations in accordance Ecology's BEACH Program Database. database by Friday each prioritizing which task(s)
with BEACH Program Quality Assurance Project Plan week of sample collection. to pay with this award.
(QAPP).Notify BEACH Program Coordinator in
advance if samples cannot be collected.Coordinate 2.Email copies of laboratory analytical 2.Email copies of reports
deviations from the QAPP and/or schedule with the reports to BEACH Program Coordinator. upon receipt.
BEACH Program Coordinator.
• Post and/or remove swimming advisory signs as 3. Include a list of swimming advisories in 3.Annual report due
needed.Provide public education about beach water annual report. September 30,2024.
quality.Notify BEACH Program Coordinator of .
swimming advisories as soon as possible.
Exhibit A,Statement of Work Page 1 of 2 Contract Number CLH31013-Amendment 18
Page 7 _
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
3 Illness Pollution Investigations 1.Provide notification via telephone to 1.Within fourteen(14)
Notify BEACH Program Coordinator of any illness reports BEACH Program Coordinator. business days.
related to recreational swimming beaches.Conduct illness •
investigations as needed. 2. Summarize illness investigation in 2.Annual report due
annual report. September 30,2024.
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 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
The funds for this project are being provided by an Environmental Protection Agency grant,Agreement Number CU-01J74301-3,Catalog of Federal Domestic Assistance Number
66.472—Beach Monitoring and Notification Program Implementation Grants.
Program Manual,Handbook,Policy References:
Quality Assurance Project Plan https://apps.ecology.wa.gov/publications/SummaryPages/1903119.html
Exhibit A,Statement of Work Page 2 of 2 Contract Number CLH31013-Amendment 18
Page 8,.
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) 8 Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2022 through December 31,2024 ® State ®FFATA(Transparency Act) ❑ Fixed Price
0 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 Years 1-3 of the contract,which runs January 1,2022—March 31,2025.
For state funding,due dates after June 30,2024 are for reporting only.LHJs may not bill under this contract for work done after June 30,2024.
Revision Purpose: The purpose of this revision is to add$1,800 to SFY24 Sexual&Rep Hlth Cost Share for the period of 07/01/23-06/30/24.These additional funds are to be
used for EHR costs as a result of the federal requirement to move to FPAR 2.0 reporting. No changes were made to the language in this revision.
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g 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 30,822 0 30,822
SFY24 Sexual&Rep Hlth Cost Share 78430140 N/A 334.04.91 07/01/23 06/30/24 85,852 1,800 87,652
0 0 0
0 0 0
TOTALS 271,986 1,800 273,786
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. analysis approved by
SRHP. required back up documentation per DOH policy. DOH(see Reporting
A. Comply with Washington State SRHP Manual, Requirements table).
federal Title X requirements and all state and
Exhibit A,Statement of Work Page 1 of 8 Contract Number CLH31013-Amendment 18
_ Page 9, _
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
federal laws.Also see Program Manual, DOH reserves the right
Handbook,Policy References under Reporting to withhold payment
Requirements below. until:
• Compliance issues
B. Complete required Agency Information or a previous SOW
Dashboard that includes Title X Assurance of are resolved in a
Compliance way accepted by
DOH
1. Compile all National Provider • Current data is
Identifier(NPI)billing numbers for submitted to,and
SRHP services and submit to DOH. accepted by,
DOH will compile and send to Health Ahlers.
Care Authority(HCA)in order for • Al9 back up
LHJ to qualify for the Medicaid documentation
Enhanced rate. required by DOH
has been submitted
C. Provide medical services,community education • All reports described in Reporting Requirements table As described in and approved.
and outreach,and staff training,consistent with below. Reporting • Other deliverables
state requirements: Requirements table have been met.
1. LHJ is responsible for making sure all staff below.
have the knowledge to carry out the Payment is limited to
requirements of the SOW. • Other data and documentation in format requested by As requested by DOH the maximum funds
2. Medical,laboratory,and other services DOH.(Includes copies of program and financial available for funding
related to abortion are not covered by this audits and reviews including summaries conducted by source.
task. other entities.)
3. Community education services must be DOH will reimburse
based on the needs of the community.LHJ • To facilitate DOH/TX desk reviews—requested for:
must have an Information&Education documentation available to DOH in requested format. • Actual allowable
(I&E)committee with no fewer than five costs according to
(5)members and up to as many members • To facilitate DOH/TX site-visits—appropriate staff your approved cost
as the LHJ determines;be broadly and documentation readily available prior to and analysis(see
representative of the population or during review. Reporting
community for which materials are Requirements
intended;review all educational.materials DOH performs site visits.Follow-up site visits are As requested by DOH table).
for clients;meet at least annually and performed until identified issues are resolved. or -
establish a written record of its • The amount
determination.(42 CFR 59[59.6]) remaining in the
4. Outreach is to ensure all populations in SOW divided by
your community understands the services the number of
available.Focus your outreach efforts on months remaining
increasing equity. in the funding
source,plus one,
whichever is less.
Exhibit A,Statement of Work Page 2 of 8 Contract Number CLH31013-Amendment 18
Page 10 _
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Washington State Sexual and Reproductive Health
Network priority populations are: Payment will be
• Teens calculated by R&E
• People who are uninsured or underinsured, provided by DOH(see
and/or low-income(at or below 250%of Reporting Requirements
the federal poverty line) table).
• Rural communities
• Hispanic All services through
• Black,Indigenous,People of Color
the end of this contract
Extra efforts should be made to provide information period must be billed
and services to people who intersect with multiple within 60 days.
priority population categories.
Provide all services in accordance with:
• DOH SRHP&Title X Manual
• Other state and federal requirements
• LHJ's Current Scope Report(defined under
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. request from DOH
2. Ensure data entry personnel protect • Corrected CVR data Sexual and
confidentiality of CVR data. Reproductive Health
3. Have ability to retrieve all information for data manager.
auditing and monitoring by DOH or its
designee.
E. Notify DOH contract manager of all: Email briefly describing change. As needed to keep
information current.
• Key staff and organizational changes.
• 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.
Exhibit A,Statement of Work Page 3 of 8 Contract Number CLH31013-Amendment 18
Page 11 .
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Any other change that might affect LHJ's
ability to provide the sexual and
reproductive services described in this
SOW.
Reporting Requirements
1. Agency Information Dashboard This information must be reported using the template April 30th during each
or format provided by DOH.All signatures and forms year of this contract.
Information required at the beginning of this must be completed by April 3011'during each year of
SOW period.This information ensures that this contract. It will include: AND
DOH has accurate information about LHJ's
organization and the services it provides. Information about your agency contacts and your As needed or requested
organization's staffing to maintain accuracy of
In addition,elements of this report allow DOH A. Head of Organization information.
to ensure that SRHP&Title X requirements B. Head of Finance
regarding client fees,required services, C. Medical Director
requirements are met.It also provides other
information to assist DOH to manage this SOW D. NPI numbers used to bill Medicaid
and the Sexual&Reproductive Health Network E. The following(one person might fill more than one
as a whole. role)
a. Contract Coordinator
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 1 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.
Submit an updated
income conversion
Exhibit A,Statement of Work Page 4 of 8 Contract Number CLH31013-Amendment 18
Page 12. _
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
b. Fee schedule must be resubmitted for reapproval table by March 15 of
anytime there are any significant changes,which each year of the
may include changing of services,fees,etc. contract.
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.
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 analysis:How LHJ determines appropriate expenses
for the purpose of billing DOH.
If LHJ cost analysis was approved by DOH at the
beginning of the contract period,LHJ does not have to
resubmit unless changes were made. LHJ does need to
Exhibit A, Statement of Work Page 5 of 8 Contract Number CLH31013-Amendment 18
Page 13
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
email DOH contract manager informing them that no
changes were made.
2. Progress Summary Report This information must be reported using the template As requested by DOH
or 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.
Washington 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 grant(2027).
data. All information is for calendar year 2023 Number of:
(January through December 2023).The A. Pap tests with an ASC or higher result
subsequent agreements sent to the agency will B. Pap tests with an HSIL or higher result
request that these data be collected and reported C. HIV Positive confidential tests
on within the statement of work period of D. HIV Anonymous tests
performance. 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 03-31-24 as
described below.
Subsequent agreements will request that data be collected
and reported on during the appropriate contract period of
performance.(FPAR due 01-31 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
https://www.doh.wa.aov/Portals/1/Documents/Pubs/930- Within thirty(30)days
139-CVRManual.pdf. 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
Exhibit A,Statement of Work Page 6 of 8 Contract Number CLH31013-Amendment 18
Page 14 _
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
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(A19).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.
All entries on"Other"rows must be accompanied by a support services for:
Apdescription of the revenue source or expense,including any 2024 du20 through3-March
calculations uses. 2024 due the
end of this 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 financed doh.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,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.gov/Portals/1/Documents/Pubs/930-139-CVRManual.pdf)
• LHJ's approved Agency Information Dashboard.
Exhibit A,Statement of Work Page 7 of 8 Contract Number CLH31013-Amendment 18
Page 15
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.
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 8 of 8 Contract Number CLH3 1013-Amendment 18
Page 16. 2
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: WIC Nutrition Program-Effective January 1,2022 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 9 Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: January 1,2022 through December 31,2024 ❑State /1 FFATA(Transparency Act) ❑Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose is to provide Women,Infants,and Children(WIC)Nutrition Program services by following WIC federal regulations,WIC state office
policies and procedures,WIC directives,and other rules.Refer to the Program Specific Requirements section of this document.
Revision Purpose: To add FFY24 USDA WIC CLIENT SVS CONTRACTS funds,add deliverable due dates,and update Billing Requirements.
Master Assistance BARS Allocation
LHJ Funding Period Change Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY22 USDA WIC CLIENT SVS CONTRACTS 76101234 10.557 333.10.55 07/01/22 09/30/22 86,376 0 86,376
FFY23 USDA WIC CLIENT SVS CONTRACTS 76101244 10.557 333.10.55 10/01/22 09/30/23 132,338 0 132,338
FFY22 USDA BFPC PROG MGMT 76214231 10.557 333.10.55 01/01/22 09/30/24 43,389 0 43,389
FFY22 USDA FMNP PROG MGMT 76540237 10.572 333.10.57 05/01/22 09/30/22 516 0 516
FFY23 USDA BFPC PROG MGMT 76214241 10.557 333.10.55 10/01/22 12/31/24 37,651 0 37,651
FFY23 USDA WIC PROG MGMT CSS 76101242 10.557 333.10.55 01/01/23 09/30/23 2,800 0 2,800
FFY24 USDA WIC CLIENT SVS CONTRACTS 7610124B 10.557 333.10.55 10/01/23 09/30/24 106,828 48,183 155,011
FFY23 USDA FMNP MGMT 76540248 10.572 333.10.57 06/01/23 09/30/23 496 0 496
FFY24 USDA BFPC PROG MGMT 7621424A 10.557 333.10.55 10/01/23 09/30/24 37,651 0 37,651
FFY25 USDA WIC CLIENT SVS CONTRACTS 76101251 10.557 333.10.55 10/01/24 12/31/24 26,268 0 26,268
0 0 0
TOTALS 474,313 48,183 522,496
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
See"Billing
1 WIC Nutrition Program Requirements"
below.
1.1 Maintain authorized participating caseload at 100%based on Outcomes based on monthly participation Authorized participating
quarterly average as determined from monthly caseload data from state WIC caseload management caseload for January 2022
management reports generated at state WIC office. reports. through December 2024=
The Department of Health(Department)State WIC Nutrition 250
Program has the option of reducing authorized participating
caseload and corresponding funding when:
Exhibit A,Statement of Work Page 1 of 7 Contract Number CLH31013-Amendment 18
Page 17
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
1. Unanticipated funding situations occur. Revised authorized
2. Reallocations are necessary to redistribute caseload participating caseload for
statewide. January 2023 through
3. Caseload declines. December 2024=265
Revised authorized
caseload for January 2024
through December 2024=
270
1.2 Submit the annual Nutrition Services Plan for each year of the Nutrition Services Plan First year due 9/30/22 Payment withheld if
contract. Second year due 9/30/23 not received by due
Third year due 9/30/2024 date.
1.3 Submit the annual Nutrition Services Expenditure Report for each Nutrition Services Expenditure Report 11/30/22 Payment withheld if
year of the contract. 11/30/23 not received by due
11/30/2024 date.
Tell participants about other health services in the agency. If Documentation must be available for review
1.4 needed,develop written agreements with other health care agencies by WIC monitor staff. Biennial WIC Monitor
and refer participants to these services.
Provide nutrition education services to participants and caregivers Documentation must be available for review
1.5 in accordance with federal and state requirements. by WIC monitor staff. Biennial WIC Monitor
Issue WIC benefits while assuring adequate WIC card security and Documentation must be available for review
1.6 reconciliation. by WIC monitor staff. Biennial WIC Monitor
Collect data,maintain records,and submit reports to effectively Documentation must be available for review
1.7 enforce the non-discrimination laws(Refer to Civil Rights by WIC monitor staff. Biennial WIC Monitor
Assurances below).
Submit entire WIC and Breastfeeding Peer Counseling Budget Budget Workbook First year due 9/30/22
1.8a Workbook for each year of the contract Second year due 9/30/23
Third year due 9/30/24
Submit Rev-Exp Report spreadsheet from the WIC Budget Revenue and Expense Report and A-19 First year due monthly
Workbook monthly with A-19 through December 31,2022
1.8b Second year due monthly
through December 31,2023
Third year due monthly
through December 31, 2024
See"Billing
2 Breastfeeding Promotion Requirements"
below.
Provide breastfeeding promotion activities in accordance with Status report of chosen activities in First year due 11/30/22
federal and state requirements. Nutrition Services Plan. Second year due 11/30/23
2.1 Third year due 11/30/2024
Documentation must be available for review
by WIC monitor staff.
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH31013-Amendment 18
Page 18,
Task Payment
Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Biennial WIC Monitor
Work with community partners to improve practices that affect Status report of chosen activities in First year due 8/30/22
breastfeeding. Choose one or more of the following projects: Nutrition Services Plan. Second year due 8/30/23
■ Provide staff,health care providers and community partners Third year due 11/30/2024
virtual breastfeeding training resources. Documentation must be available for review
2.2 • Work with employers who likely employ low-income people by WIC monitor staff. Biennial WIC Monitor
to create worksite environments that support breastfeeding.
• Work with birthing hospitals to improve maternity care
practices that affect WIC participant breastfeeding rates.
• Provide participants access to lactation consultants.
Other projects will need pre-approval from the State WIC Office
See"Billing
3 Breastfeeding Peer Counseling Program(BFPC) Requirements"
below.
Provide Breastfeeding Peer Counseling Program activities in Breastfeeding Peer Counseling Annual First year due 12/31/22
accordance with federal and state requirements.The WIC Report and expenditures from the previous Second year due 12/31/23
3.1 Breastfeeding Peer Counseling Program is meant to enhance,not federal fiscal year. Third year due 12/31/24
replace,WIC Breastfeeding promotion and support activities.
Documentation must be available for review Biennial WIC Monitor
by WIC monitor staff.
Track Breastfeeding Peer Counseling Program expenditures and Documentation must be available for review Biennial WIC Monitor
3.2 bill separately from the WIC grant. by WIC monitor staff.
See"Billing
4 Farmers Market Nutrition Program(FMNP) Requirements"
below.
Distribute all Farmers Market Nutrition Program checks to eligible Send completed readable copy of FMNP Weekly June-Sept. 2022 and
WIC participants between June and September 30 of current year. check registers to State WIC office on a June-Sept.2023
weekly basis following FMNP procedures.
4.1 All sent by Oct. 1,2022,
Documentation must be available for review Oct. 1,2023, and Oct 1,
by WIC monitor staff 2024
Biennial WIC Monitor
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 financeAdoh.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.
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH31013-Amendment 18
Page 19
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:
The LHJ shall be responsible for providing services according to rules,regulations and other information contained in the following:
• WIC Federal Regulations,USDA,and FNS 7CFR Part 246.
• Washington State WIC Nutrition Program Policy and Procedure Manual
• Office of Management and Budget,Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards,2 CFR 200
• Farmers Market Nutrition Program Federal Regulations,USDA,FNS 7CFR Part 248
• Other directives issued during the term of the contract
Staffing Requirements:
The LHJ shall:
• Use Competent Professional Authority staff,as defined by WIC policy,to determine participant eligibility,prescribe an appropriate food package and offer nutrition
education based on the participants'needs.
• Use a Registered Dietitian(RD)or other qualified nutritionist to provide nutrition services to high risk participants,to include development of a high-risk care plan. The
RD is also responsible for quality assurance of WIC nutrition services. See WIC Policy for qualifications for a Registered Dietitian and other qualified nutritionist.
• Assign a qualified person to be the Breastfeeding Coordinator to organize and direct local agency efforts to meet federal and state policies regarding breastfeeding
promotion and support. The Breastfeeding Coordinator must be an International Board-Certified Lactation Consultant or attend an intensive lactation management
course,or other state approved training.
Restrictions on Funds:
The LHJ shall follow the instructions found in the Policy and Procedure Manual under WIC Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,Cost
Principles,and Audit Requirements for Federal Awards.
Special References:
What is the WIC program?
1. The WIC program in the state of Washington is administered by the Department of Health.
2. The WIC program is a federally funded program established in 1972 by an amendment to the Child Nutrition Act of 1966.The purpose of the program is to provide nutrition
and health assessment;nutrition education;nutritious food;breastfeeding counseling;and referral services to pregnant,breastfeeding,and postpartum women,infants,and
young children in specific risk categories.
3. Federal regulations governing the WIC program(7 CFR Part 246)require implementation of standards and procedures to guide the state's administration of the WIC program.
These regulations define the rights,responsibilities,and legal procedures of WIC employees,participants,persons acting on behalf of a participant,and retailers.They are
designed to promote:
a. High quality nutrition services;
b. Consistent application of policies and procedures for eligibility determination;
c. Consistent application of policies and procedures for food benefit issuance and delivery;and
d. WIC program compliance.
4. The WIC program implements policies and procedures stated in program manuals,handbooks,contracts,forms,and other program documents approved by the USDA Food
and Nutrition Service.
5. The WIC program may impose sanctions against WIC participants for not following WIC program rules stated on the WIC rights and responsibilities.
6. The WIC program may impose monetary penalties against persons who misuse WIC benefits or WIC food but who are not WIC participants.
Exhibit A,Statement of Work Page 4 of 7 Contract Number CLH31013-Amendment 18
Page 20.
Monitoring Visits:
Program and fiscal monitoring are done on a biennial(every two years)basis and are conducted onsite.
The LHJ must maintain on file and have available for review,audit and evaluation:
• All criteria used for certification,including information on income,nutrition risk eligibility and referrals
• Program requirements
• Nutrition education
• All fmancial records
Assurances/Certifications:
1. Computer Equipment Loaned by the Department of Health WIC Nutrition Program
In order to perform WIC program activities,the Department requires computer equipment,such as computers,signature pads,document scanners,card readers and printers to
be in local WIC clinics or to be transported to mobile clinics. This equipment("Loaned Equipment")is owned by the Department and loaned to the local agency(Contractor).
The Loaned Equipment is supported by the Department. This equipment shall be used for WIC business only or according to WIC Policy and Procedures.
An inventory of Loaned Equipment is kept by the Department. Each time Loaned Equipment is changed,the parties shall complete the Equipment Transfer Form and the
Department updates the inventory. A copy of the Transfer Form will be provided to the contractor. Copies of the updated inventory list may be requested at any time.
The LHJ agrees to:
a. Defend,protect and hold harmless the Department or any of its employees from any claims,suits or actions arising from the use of this Loaned Equipment.
b. Assume responsibility for any loss or damage from abnormal wear or use,or from inappropriate storage or transportation. The Department may enforce this by:
1) Requiring reimbursement from the LHJ of the value of the Loaned Equipment at the time of the loss or damage.
2) Requiring the LHJ to replace the Loaned Equipment with equipment of the same type,manufacturer,and capabilities(as pre-approved by the Department),or
3) Assertion of a lien against the Contractor's property.
c. Notify the Department immediately of any damage to Loaned Equipment.
d. Notify the Department prior to moving or replacing any Loaned Equipment.
The Department recommends Contractors carry insurance against possible loss or theft.
2. Civil Rights Assurance
a. The LHJ shall perform all services and duties necessary to comply with federal law in accordance with the following Civil Rights Assurance.
b. "The Program applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964(42 U.S.C.2000d et seq.),Title IX of the Education Amendments
of 1972(20 U.S.C. 1681 et seq.),Section 504 of the Rehabilitation Act of 1973(29 U.S.C.794),Age Discrimination Act of 1975(42 U.S.C.6101 et seq.);all provisions
required by the implementing regulations of the Department of Agriculture;Department of Justice Enforcement Guidelines,28 CFR 50.3 and 42;and FNS directives and
guidelines,to the effect that,no person shall,on the ground of race,color,national origin,sex,age or handicap,be excluded from participation in,be denied benefits of,or
otherwise be subject to discrimination under any program or activity for which the Program applicant receives Federal financial assistance from FNS;and hereby gives
assurance that it will immediately take measures necessary to effectuate this agreement.
c. "By accepting this assurance,the Program applicant agrees to compile data,maintain records and submit reports as required,to permit effective enforcement of the
nondiscrimination laws and permit authorized USDA personnel during normal working hours to review such records,books and accounts as needed to ascertain
compliance with the nondiscrimination laws.If there are any violations of this assurance,the Department of Agriculture,Food and Nutrition Service,shall have the right
to seek judicial enforcement of this assurance.This assurance is binding on the Program applicant,its successors,transferees,and assignees,as long as it receives
assistance or retains possession of any assistance from the Department.The person or persons whose signatures appear on the contract are authorized to sign this
assurance on behalf of the Program applicant."
3. 2CFR 200
The LHJ shall comply with all the fiscal and operations requirements prescribed by the state agency as directed by Federal WIC Regulations(7CFR part 246.6),2CFR part
200,the debarment and suspension requirements of 2CFR part 200.213,if applicable,the lobbying restrictions of 2CFR part 200.245,and FNS guidelines and instructions and
shall provide on a timely basis to the state agency all required information regarding fiscal and program information.
Exhibit A,Statement of Work Page 5 of 7 Contract Number CLH31013-Amendment 18
Page 21
Billing Requirements:
1. Definitions
Contract Period: January 1,2022-December 31,2024
Contract Budget Period: The time period for which the funding is budgeted.
• There are four federal budget periods
January 1,2022 through September 30,2022;
October 1,2022 through September 30,2023;
October 1,2023 through September 30,2024;
October 1,2024 through December 31,2024.
2. Billing Information:
a. Billings are submitted on an A-19-1A invoice. These invoices are provided by the Department in the WIC Budget Workbook and include accounting codes for different
budget categories.
b. A-19s are submitted monthly and must be received by the Department within 60 30 days following the close of each calendar month.Additional A-19s may be submitted
at any time,but must be received within 90 60 days of the close of the federal budget period.
c. Funds are allocated by budget categories and by federal budget periods(refer to the budget spreadsheet).
d. Funds are encumbered or spent only during the budget period;no carry forward from previous time periods or borrowing from future time periods is allowed.
e. Payments are limited to the amounts allocated for the budget period for each budget category.
f. Billings are based on actual costs for completed activities.Advance payments are not allowed. Back up documentation must be retained by the LHJ and available for
inspection by the Department or other appropriate authorities.
g. Payments will be made only for WIC approved expenditures.Refer to the Washington State WIC Nutrition Program Policy and Procedure Manual Volume 2,Chapter 4—
Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards.
h. If billing for indirect costs,a Cost Allocation Plan or Federal Indirect Cost Agreement must be submitted prior to payment.
Special Instructions:
The LHJ shall:
1. Maintain complete,accurate,and current accounting of all local,state,and federal program funds received and expended.
2. Provide,as necessary,a single audit in accordance with the provisions of 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for
Federal Awards. This circular requires all recipients and sub-recipients of federal funds to have a single audit performed should they spend$750,000 or more of federal grants
or awards from all sources. Contractors spending less than$750,000 in federal grants or awards may also be subject to audit.
3. Use Breastfeeding Peer Counseling(BFPC)Program funds only to support the peer counseling program. Once the program is established and peer counselors are trained,the
majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs see Volume 2,Chapter 4—Allowable
Costs. The priority use of BFPC funds is to hire and train peer counselors to provide breastfeeding peer counseling services to WIC participants.
SPECIAL REQUIREMENTS
Contract Funding Period Time Period special Amount Special Requirement Description
requirement funds are available
January 2022 to September 2024 January 2022 to September 2022 $2,800 Added in the USDA WIC Client Services Contracts category to cover training and travel
expenses for all local WIC staff to participate in WIC-related trainings.
January 2023-September 2023 January 2023-September 2023 $2,800 This funding is for all WIC staff to participate in WIC-related training.Added in the USDA
WIC Client Services Contracts category to cover training registrations,travel expenses,staff
time to participate in training(salary/benefits or contractor),and other approved WIC
training expenses.
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH31013-Amendment 18
Page 22. .
October 2023-September 2024 October 2023-September 2024 $2,500 This funding is for all WIC staff to participate in WIC-related training. Added in the USDA
WIC Client Services Contracts category to cover training registrations,travel expenses,staff
time to participate in training(salary/benefits for part-time or contractors),and other
approved WIC training expenses.
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
Exhibit A,Statement of Work Page 7 of 7 Contract Number CLH31013-Amendment 18