HomeMy WebLinkAboutState of Washington Department of Health Consolidated Contracts Amendment 22 - 112524 Page t or 25
JEFFERSON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH31013 AMENDMENT NUMBER: 22
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"LHT",
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:
I. Exhibit A Statements of Work,includes the following statements of work. which arc incorporated by this reference
and located on thc DOH Finance SharePoint sitc in the Upload Center at the following URL:
hnos:/rstatcoRca.sharenoint.comIsiteNdnh-ofsfundineresourccs/sitcaaecc'homc asrx9=c1:949•l6RRda2d94d3cnRUac7thc32c4d7c
® Adds Statements of Work for the following programs:
Injury& Violence Prevention-LHJ Opioid Campaign Proviso-Effective November 1,2024
® Amends Statements of Work for thc following programs:
Infectious Disease-Syndcmic Prevention Services-SSP-Effective January I,2024
Office of Drinking Water Group A Program- Effective January I,2022
Office of Immunization COVID-19 Vaccine- Effective January 1,2022
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-22 Allocations, attached and incorporated by this reference,amends and replaces Exhibit B-21 Allocations
as follows:
❑ Increase of for a revised maximum consideration of
® Decrease of S$22 143 for a revised maximum consideration of S9.852.125.
❑ 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
("0,1 —.------- /,/?<jyy 11/26/2024
Kate Dean,Chair to Date
APPROyF.Di O FORM ONLY APPROVED AS TO FORM ONLY
Assistant Attorney General
�) iii for 11/08/2024
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
Page 1 of 1
CC-22-002-A22
EXHIBIT B-22 Page 2 of 25
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: October 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
Indirect Rate January 1,2024 through December 31,2024:27.94%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
('hart 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 S128,104
FFY23 USDA BFPC Prog Mgmt 7WA700WA1 Amd 21 10.557 333.10.55 10/01/22 12/31/24 10/01/22 09/30/25 $9,413 $47,064
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
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 7WA700WAI Amd 1,17 10.557 333.10.55 01/01/22 09/30/24 10/01/21 09/30/24 S43,389 $43,389
FFY25 USDA WIC Client Svs Contracts NGA Not Received Amd 21 10.557 333.10.55 10/01/24 12/31/24 10/01/24 09/30/25 $1,860 $28,128 $407,314
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
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 21 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $4,718 $160,472
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 23 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $743
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
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 Sys 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 Sys 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 S6,726
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 And 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 And 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) S9,301 $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 01718001 Amd 15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 $30,000 S263,844 $263,844
PS SSI 1-5 OSS Task 4 01/18001 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 01/18001 Amd 2,5,15 66.123 333.66.12 01/01/22 11/30/23 07/01/17 08/31/28 S235,498
Page 1of5
EXHIBIT B-22 Page 3 of 25
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: October 1,2024
Indirect Rate January 1,2022 through December 31,2022:29.23%Public I lealth
Indirect Rate January 1,2023 through December 31,2023:35.35%Public Health
Indirect Rate January 1,2024 through December 31,2024:27.94%Public health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue 1.11.1 Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start(late End Date Start Date End Date Amount SubTotal Total
FFY24 Swimming Beach Act Grant IAR(ECY) 01J74301 Amd 18 66.472 333.66.47 03/01/24 09/30/24 01/01/24 11/30/24 $15,000 S15,000 $45,000
FFY23 Swimming Beach Act Grant 1AR(ECY) 01/74301 Amd 11 66.472 333.66.47 03/01/23 10/31/23 03/01/23 10/31/23 $15,000 S15,000
FFY22 Swimming Beach Act Grant IAR(ECY) 01374301 Amd 2 66.472 333.66.47 03/01/22 10/31/22 01/01/22 11/30/22 $15,000 $15,000
FFY24 PHEP BPI-CDC-LHJ Partners NU90TO000055 Amd 21 93.069 333.93.06 07/01/24 12/31/24 07/01/24 06/30/25 $20,630 $20,630 $20,630
FFY23 PHEP BP5 LHJ Funding NU90TP922043 And 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
FFY24 OD2A OID CDC Prevent NU17CE010218 Amd 22 93.136 333.93.13 09/01/24 12/31/24 09/01/24 08/31/25 $32,667 $32,667 $130,667
FFY23OD2AOIDCDC NU17CE010215 And 17 93.136 333.93.13 01/01/24 08/31/24 09/01/23 08/31/24 $98,000 S98,000
FFY22 Title X Dire Needs FPHPA006495 And 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 FPHPA006560 Amd 24 93.217 333.93.21 04/01/24 12/31/24 04/01/24 03/31/25 $13,747 $31,480 $31,480
FFY24 FPHPA Title X Family Plan FPHPA006560 Arad 19 93.217 333.93.21 04/01/24 12/31/24 04/01/24 03/31/25 $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 And 5 93.217 333.93.21 04/01/22 03/31/23 04/01/22 03/31/23 $27,137 $27,137
COVIDI9 CDC Vaccines NH23IP922619 Anal 22 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 ($278,114) S0 SO
COV1D19 CDC Vaccines NH231P922619 Amd 4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $278,114
COVID19 Vaccines R4 NH231P922619 Amd 21 93.268 333.93.26 07/01/24 12/31/24 07/01/20 12/31/24 $10,966 $10,966 $119,176
COVIDI9 Vaccines R4 NH231P922619 Amd 22 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 (5601,396) $108,210
COVID19 Vaccines R4 NH231P922619 And 4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803
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
FFY25 CDC VFC Ops NGA Not Received Amd 21 93.268 333.93.26 07/01/24 12/31/24 07/01/24 06/30/25 $5,600 $5,600 S11,760
FFY24 CDC VFC Ops NH231P922619 And 15 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $560 $6,160
FFY24 CDC VFC Ops NH231P922619 And 14 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $5,600
FFY23 VFC Ops NH231P922619 And 5 93.268 333.93.26 07/01/22 06/30/23 07/01/22 06/30/23 $5,600 $5,600 S11,200
FFY22 VFC Ops N11231P922619 Amd 3 93.268 333.93.26 01/01/22 06/30/22 07/01/21 06/30/22 $5,600 $5,600
FFYI9COVIDCARES NU50CK000515 Amd2 93.323 333.93.32 01/01/22 04/22/22 04/23/20 07/31/24 $14,664 $14,664 S14,664
Page 2 of 5
EXHIBIT B-22 Page 4 of 25
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: October 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
Indirect Rate January 1,2024 through December 31,2024:27.94%Public Health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LW Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date ,'moon[ S,di 1 oral Total
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 LW 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 LW Allocation NU5OCK000515 Amd 21 93.323 333.93.32 01/01/22 12/31/24 01/15/21 07/31/25 $15,580 $357,402 $357,402
FFY20 ELC EDE LW Allocation NU5OCK000515 Amd 9,21 93.323 333.93.32 01/01/22 12/31/24 01/15/21 07/31/25 ($6,375)
FFY20 ELC EDE LHJ Allocation NU5OCK000515 Amd 4,9.21 93.323 333.93.32 01/01/22 12/31/24 01/15/21 07/31/25 ($90,842)
FFY20 ELC EDE LHJ Allocation NU5OCK000515 Amd 2,9,21 93.323 333.93.32 01/01/22 12/31/24 01/15/21 07/31/25 $439,039
FFY21 CDC COVID-19 PHWFD-LHJ NU90TP922181 Amd 16,20 93.354 333.93.35 07/01/23 12/31/24 07/01/23 06/30/25 $200,000 $200,000 $200,000
FFY22 NEHA Climate&Health Grant NU38OT000300 And 9 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 $11,000 S22,000 $22,000
FFY22 NEHA Climate&Health Grant NU380T000300 And 5 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 SI1,000
FFY22 PH Infrastructure Comp Al-LW NE11OE000053 And 17 93.967 333.93.96 01/01/24 12/31/24 12/01/22 06/30/25 $200,000 $200,000 $200,000
FFY25 HRSA MCHBG LHJ Contracts NGA Not Received And 21 93.994 333.93.99 10/01/24 12/31/24 10/01/24 09/30/25 $9,175 $9,175 $65,741
FFY24 HRSA MCHBG LW Contracts B04MC52960 Amd 15 93.994 333.93.99 10/01/23 09/30/24 10/01/23 09/30/24 S36,700 $36,700
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 And 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 And 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 $10,000 $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
SFY25 Sexual&Rep Hlth Cost Share Amd 20 N/A 334.04.91 07/01/24 12/31/24 07/01/24 06/30/25 $48,323 S48,323 S260,084
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
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 And 15,17 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $42,926
Page 3 of 5
EXHIBIT B-22 Page 5 of 25
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date October 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
Indirect Rate January 1,2024 through December 31,2024:27.94%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 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 07/01/21 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
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
SFY25 LHJ Opioid Campaign Proviso Amd 22 N/A 334.04.93 11/01/24 12/31/24 07/01/24 06/30/25 $24,500 $24,500 $24,500
Rec Shellfish/Biotoxin Amd 20 N/A 334.04.93 07/01/23 12/31/24 07/01/23 06/30/25 $3,000 $14,100 $31,600
Rec Shellfish/Biotoxin Amd 14 N/A 334.04.93 07/01/23 12/31/24 07/01/23 06/30/25 $11,100
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
SFY25 FPHS-LHJ Funds-GFS Amd 21 N/A 336.04.25 07/01/24 12/31/24 07/01/24 06/30/25 $1,166,500 $2,333,000 $4,666,000
SFY25 FPHS-LHJ Funds-GFS Amd 20 N/A 336.04.25 07/01/24 12/31/24 07/01/24 06/30/25 $1,166,500
SFY24 FPHS-LHJ-Funds-GFS Amd 15 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/24 $900,000 $2,333,000
SFY24 FPHS-LHJ-FundsGFS Amd 14 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/24 $1,433,000
Page 4 of 5
EXHIBIT B-22 Page 6 of 25
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: October 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
Indirect Rate January 1,2024 through December 31,2024:27.94%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 8* Code*" Start Date End Date Start Date End Date Amount SubTolal 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) S0 $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(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 27 SRF-Local Asst(15%)SS Amd 22 N/A 346.26.64 01/01/24 12/31/24 07/01/23 06/30/25 $1,800 $1,800 $5,400
YR 26 SRF-Local Asst(15%)SS Amd 22 N/A 346.26.64 01/01/24 12/31/24 07/01/23 06/30/2.5 ($1,800) S0
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
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 27 SRF-Local Asst(15%)TA Amd 22 N/A 346.26.66 01/01/24 12/31/24 07/01/23 06/30/25 $1,000 $1,000 $2,000
YR 26 SRF-Local Asst(15%)TA Amd 22 N/A 346.26.66 01/01/24 12/31/24 07/01/23 06/30/25 (S1,000) SO
YR 26 SRF-Local Asst(15%)TA Amd 19 N/A 346.26.66 01/01/24 12/31/24 07/01/23 06/30/25 $1,000
YR25 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 11 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 $9,852,125 $9,852,125
Total consideration: $10,674,468 GRAND TOTAL $9,852,125
($822,343)
GRAND TOTAL $9,852,125 Total Fed $2,268,885
Total State $7,583,240
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 5 of 5
Page 7 of 25
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Infectious Disease-Syndemic Prevention Services- Local Health Jurisdiction Name: Jefferson County Public Health
SSP-Effective January 1,2024
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: January 1,2024 through December 31,2024 ® State El FFATA(Transparency Act) Li Fixed Price
❑ Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide Syndemic Prevention Services for infectious diseases(HIV,STI,and Adult Viral
Hepatitis),supporting the Office of Infectious Disease(OID)within Department of Health(DOH). Awarded through OID's 2024 Syndemic RFA.
Revision Purpose: To add funding for OD2A for 9/1/24-12/31/24
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY24 DRUG USER HEALTH PROGRAM 12405140 N/A 334.04.91 01/01/24 06/30/24 40,250 0 40,250
SFY25 DRUG USER HEALTH PROGRAM 12405150 N/A 334.04.91 07/01/24 12/31/24 40,250 0 40,250
FFY23 OD2A OID CDC 12405231 93.136 333.93.13 01/01/24 08/31/24 98,000 0 98,000
FFY24 OD2A OID CDC PREVENT 12405241 93.136 333.93.13 09/01/24 12/31/24 0 32,667 32,667
0 0 0
0 0 0
0 0 0
TOTALS 178,500 32,667 211,167
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Syringe Services Programs(SSP):Support for Operations SSP operations outcomes include Enter deliverable data into the Reimbursement of actual
delivering services and tracking: DOH/OID issued database for costs incurred,not to
Provide comprehensive SSP to people who use drugs • number of sterile syringes distributed tracking SSP activities by the exceed$80,500 based on
(PWUD). This plan of action is directed to distribute • number of naloxone kits distributed 15th of each month following funding split below.
syringes to communities that use drugs to prevent • number of participant encounters service.
transmission of infectious disease. SSPs will operate during • number of referrals to health and $40,250 for
scheduled hours to provide all required harm reduction social services 1/1/24-6/30/24
supplies,naloxone,and syringes to prevent transmission of $40,250 for
disease and overdose. SSPs will offer referrals to address 7/1/24-12/31/24
social determinants of health.
Exhibit A, Statement of Work Page 1 of 9 Contract Number CLH31013-Amendment 22
Page 8 of 25
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Priority populations for Syringe Services Programs include
people who use drugs,with a focus on:
• People systemically marginalized and underserved
due to racism—Black/African American,
Latino/Latina/Latine/Latinx,American
Indian/Alaska Native people and other
communities for whom there are documented
health disparities in your region.
• People who are unhoused or unstably housed.
• People engaged in sex work.
• People involved in the criminal legal system.
• Gender expansive/transgender individuals.
• Gay,bi,and other men who have sex with men.
NOTE: See Special Requirements,Terms and
Conditions—Section 4 Syringe Services Programs:
Support for Operations Program Requirements for
additional task information.
Syringe Services Programs:Clinical Services
SSP Clinical services outcomes may
Provide direct access to clinical services to improve the include,but are not limited to,delivering
health and well-being of people who use drugs.At services and tracking:
minimum,services must include onsite,low-barrier access • Number of wound care sessions
to wound care,infectious disease testing, STI and hepatitis • Number of infectious disease tests
C treatment,and medications for opioid use disorder. conducted(hepatitis C,HIV,
Additional services can include mental health services, gonorrhea-chlamydia,syphilis)
sexual and reproductive health care,and other primary care • %positive of infectious disease tests
and psychosocial support services. (hepatitis C,HIV,gonorrhea-
chlamydia,syphilis)
NOTE: See Special Requirements,Terms and • Number of participants started on
Conditions—Section 6 Syringe Services Program, hepatitis C treatment
Clinical Services Requirements for additional task • Number of participants inducted on
information. medications for opioid use disorder
2 Syringe Services Programs:Harm Reduction Service Harm reduction care navigation outcomes Enter deliverable data into the Reimbursement of actual
Navigation include delivering services and tracking: DOH/OID issued database for costs incurred,not to
• number of participants enrolled in care tracking SSP activities by the exceed$98-000-$130,667
Provide appropriate referrals to SSP participants;facilitate navigation services 15th of each month following
access to receive health care and medical services,social • number of care navigation sessions service. $98,000 for
services,behavioral health counseling and other services • number of referrals to health and 1/1/24-8/31/24
including substance use treatment(including medications social services
Exhibit A,Statement of Work Page 2 of 9 Contract Number CLH31013-Amendment 22
Page 9 of 25
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
for opioid use disorder,or MOUD);housing;and advocacy, • number of linkages to care for health $32,667 for
including but not limited to criminal legal involvement, and social services 9/1/24-12/31/24
medical providers,benefits navigation,and family • number of outreach attempts per
reunification. participant
NOTE: See Special Requirements,Terms and
Conditions—Section 5 Syringe Services Program,Harm
Reduction Care Navigation Requirement for additional
task information.
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 Fundine 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 USA Spending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Special Requirements,Terms and Conditions
I. Definitions
a. ANONYMOUS SERVICES-HIV Prevention services including condom distribution,outreach and light touch.
b. CAPACITY BUILDING-The process by which individuals and organizations obtain,improve,and retain the skills,knowledge,tools,equipment,and other
resources needed to do their jobs competently.
c. CONTRACTOR—For the purposes of this Statement of Work Only,the entity receiving funds directly from Washington State Department of Health(DOH)for
client services to prevent or treat conditions named in the statement of work will be referred to as contractor.
d. HARM REDUCTION-Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.
e. INTEGRATED TESTING-For the purpose of this Statement of Work,Integrated Testing includes Human Immunodeficiency Virus(HIV),Gonorrhea(GC),
Chlamydia(CT),Syphilis,Hepatitis C(HCV)and Hepatitis B(HBV).
f. SOCIAL DETERMINANTS OF HEALTH-Social determinants of health(SDOH)are the conditions in the environments where people are born,live, learn,
work,play,worship,and age that affect a wide range of health,functioning,and quality-of-life outcomes and risks.
g. YOUTH-For purposes of this agreement,the term"youth"applies to persons under the age of 18.
2. Submission of Invoice Vouchers
a. On a monthly basis,the CONTRACTOR shall submit complete and correct Al9 invoice vouchers with amounts billable to DOH under this statement of work and the
corresponding OID Expense Summary backup form.All A19 invoice vouchers must be submitted by the 25th of the following month.Prior approval is required for a
different frequency of billing.
Exhibit A, Statement of Work Page 3 of 9 Contract Number CLH31013-Amendment 22
Page 10 of 25
i. The CONTRACTOR must provide all backup documentation as required based on the assigned risk level and/or as identified by DOH program staff to determine
allowability of billed expenses. Risk assessments are completed at the beginning of a new contract for all sub-recipient contracts.Contact your contract manager
if you are unaware of your assigned risk level.
ii. DOH may ask for additional backup information to pay invoices based on the needs of the funding sources supporting the work.
b. The CONTRACTOR shall submit all final claims for payment for costs due and payable under this statement of work by July 31,2025.DOH will pay belated claims at its
discretion,contingent upon the availability of funds.
3. Program Organization—CONTRACTOR must
a. The CONTRACTOR must provide a full updated organizational chart,including Board of Directors with contact information if applicable,and staffing plan referencing
positions described in the budget narrative.
b. The CONTRACTOR must provide job descriptions for any new or changed positions in the updated organizational chart.
i. Any new positions funded through the original contract funds,must have prior DOH approval.
c. The CONTRACTOR must notify their DOH contract manager within 30 days of any staff vacancies related to contracted positions and provide an updated budget.
i. Any new fiscal staff responsible for invoicing on this contract will need to meet with the assigned OID Contract Manager within 60 days for DOH invoice
overview and training.
4. Syringe Services Program:Support for Operations Program Requirements
a. Operate for a minimum of 8 hours per week and 2 days per week.
b. Provide mobile and/or street outreach(note:programs must have a vehicle for mobile outreach.)
c. Offer safer injection supplies(see list of required safer injection supplies below).
d. Submit monthly SSP data in accordance with DOH standards.
e. Attend required capacity building/training opportunities provided by DOH.
f. Participate in annual site visits with DOH staff
g. Demonstrate structure for receiving and incorporating participant feedback about services.
h. Partner with relevant local agencies to ensure effective outreach and service provision.(See Scope of Work narrative below for details on MOUs required.)
i. Develop and maintain a Universal Precautions and Sharps Handling policy and procedure,including clear,written policies on handling biohazardous waste,avoiding
unnecessary handling of sharps,and potential needle stick injuries to staff,volunteers,and participants.Programs should follow the universal precaution guidelines
established by the CDC and OSHA.SSPs may need to adapt those precautions to accommodate the circumstances of their work(e.g.,mobile and outreach settings).
Programs should also anticipate the potential of needlestick injury and have a"post-exposure-prophylaxis"protocol included in this document.
j. All staff and volunteers working directly with participants/clients must complete CPR certification within the first 3 months after contract start date(if not already
complete).
5. Syringe Services Program,Harm Reduction Care Navigation Requirements
a. Includes all requirements for Syringe Service Program operations(see above)
b. Attend Harm Reduction Care Navigation training provided by DOH.
c. Support participant transportation(e.g.,through the provision of bus passes,cab vouchers,or direct transportation).
d. Accompany participants to appointments or provide"warm hand-offs."
e. Full-time care navigators(1.0 FTE)shall not exceed a case load greater than 25 individuals.
f. Submit monthly outcome data in accordance with DOH standards.
6. Syringe Services Program,Clinical Services Requirements
a. Includes all requirements for Syringe Service Program operations(see above)
b. Must have clinical staff licensed to practice in the state of Washington to provide clinical services(e.g.,RN,PA,ARNP,LCSW).
c. If providing advanced level clinical services(e.g.,PA,ARNP,CNM),programs must have appropriate clinical oversight.
Exhibit A, Statement of Work Page 4 of 9 Contract Number CLH31013-Amendment 22
Page 11 of 25
Note:Clinical services can be provided through sub-contractor arrangement or MOU with a Federally Qualified Health Center or other clinical partner if there
is a justification the relationship will support efforts to reach people who use drugs and provide onsite and/or mobile clinical services.Clinical services can also
be provided using telemedicine services with appropriate description of why in-person services cannot be provided and who the telemedicine partner(s)will be.
NOTE: Funds from this contract may not be used to purchase basic safer injection supplies(listed below)—Instead,DOH will provide Contractors with supplies.
Below is the list of required supplies for SSP to be provided to Contractors by DOH:
1) Syringes(1 cc 27 gauge 1/2",28 gauge 1/2",and 29 gauge 1/2"; 1 cc 30 gauge 5/16"; 3 cc 25G 1"and 1.5")
2) Alcohol pads
3) Non-latex tourniquets
4) Sterile water
5) Sterile saline
6) Cookers
7) Cottons and/or cellulose filters
8) Bandages/gauze
9) Sharps containers(1 quart and 2 gallon for distribution,8 gallon for program use)
10) Naloxone
11) Amber bags
The exceptions to these supplies are vendor or manufacturer supply shortages.If a program expects to run out of one of these items,please contact DOH immediately.
7. Performance Objectives&Work Plan:
a. Funded Syndemic Prevention Services agencies are required to submit Performance Objectives and Work Plan that provides both a high-level overview of the period of
performance and a detailed description of the first year of the contract period.The work plan should incorporate related program strategies and activities.Applicants
should propose specific,measurable,achievable,realistic,and time-based(SMART)process and/or outcome objectives for each activity aligned with performance
outcomes.The work plan should include training,capacity building,and TA needs to support the implementation of the funded services.Proposed work plan activities
may be adjusted in collaboration with OID staff to better address the overarching goals of the funded services. OID will provide a template that must be used in
developing the work plan.
b. The applicant should address the following outline in their work plan:
i. Contract Year 1 Detailed Work Plan(For each funded service category)
ii. Program strategies and activities
iii. Outcomes aligned with program strategies and activities
iv. SMART objectives aligned with performance targets
v. Activities aligned with program outcomes
vi. Timeline for implementation(including staffing of the proposed program,training,etc.)
vii. Anticipated capacity building or technical assistance needs.
c. Performance Objectives&Work Plans should be submitted by July 1,2024.
d. OID staff are available to support in developing Performance Objectives&Work Plans in collaboration with funded agencies.
e. Performance Objectives&Work Plans will be reviewed between OID staff and funded agencies at least quarterly.Performance Objectives&Work Plans can be adjusted
throughout the period of performance.
8. Participation in program evaluation activities—The Contractor is expected to participate in program evaluation activities,including evaluation planning,and collecting and
reporting qualitative and quantitative program data,as deemed necessary by OID staff.
Exhibit A,Statement of Work Page 5 of 9 Contract Number CLH31013-Amendment 22
Page 12 of 25
9. Participation in Capacity Building and Technical Assistance Activities designed to increase efficacy of Syndemic Services
a. Opportunities for capacity building and technical assistance for contractor will be offered throughout the contract year by WA DOH and other regional or national
capacity building organizations.
b. Contractors will be expected to meet with WA DOH OID staff on an annual basis to discuss training and will work with DOH to track shared completion of Capacity
Building Needs
c. All contracted staff will be required to complete training in respect to their role.DOH staff and contracted staff will work together to track completion of required
trainings.
10. CLAS Standards—The CONTRACTOR will comply with the National Standards for Culturally and Linguistically Appropriate Services(CLAS)standards(1,5-9).National
Standards for Culturally and Linguistically Appropriate Services(CLAS)in Health and Health Care(allianceforclas.org)
11. Participation in Program Monitoring Activities—
a. DOH will conduct semi-annual or annual performance site visits in the following areas:
i. Integrated testing
ii. Syndemic service navigation
iii. PrEP Housing
iv. Syringe Service Programs
v. Mail-order naloxone distribution programs
vi. Fiscal Monitoring—To be scheduled by the DOH Fiscal Monitoring Unit
b. Corrective Action Plans—DOH may exercise the following options if the CONTRACTOR does not come into compliance or resolution with programmatic and/or fiscal
monitoring corrective action plan by the due date(s)identified in the CAP.i.§200.339 Remedies for noncompliance.
If a non-Federal entity fails to comply with the U.S.Constitution,Federal statutes,regulations or the terms and conditions of a Federal award,the Federal awarding
agency or pass-through entity may impose additional conditions,as described in§200.208.If the Federal awarding agency or pass-through entity determines that
noncompliance cannot be remedied by imposing additional conditions,the Federal awarding agency or pass-through entity may take one or more of the following actions,
as appropriate in the circumstances:
(a)Temporarily withhold cash payments pending correction of the deficiency by the non-Federal entity or more severe enforcement action by the Federal
awarding agency or pass-through entity.
(b)Disallow(that is,deny both use of funds and any applicable matching credit for)all or part of the cost of the activity or action not in compliance.
(c)Wholly or partly suspend or terminate the Federal award.
(d)Initiate suspension or debarment proceedings as authorized under 2 CFR part 180 and Federal awarding agency regulations(or in the case of a pass-through
entity,recommend such a proceeding be initiated by a Federal awarding agency).
(e)Withhold further Federal awards for the project or program.
(f)Take other remedies that may be legally available
12. Contract Management—
a. Fiscal Guidance
i. Indirect—If charging indirect costs,the CONTRACTOR must have a current federally negotiated rate or 10%De Minimus certification of file with DOH.DOH
is not able reimburse indirect costs without an approved indirect cost rate or 10%De Minimus certification on file.
ii. Advance Payments Prohibited—DOH funds are"cost reimbursement"funds.DOH will not make payment in advance or in anticipation of services or supplies
provided.This includes payments of"one-twelfth"of the current fiscal year's funding.
Exhibit A,Statement of Work Page 6 of 9 Contract Number CLH31013-Amendment 22
Page 13 of 25
iii. Duplication of Early Intervention Program(EIP)Services—The CONTRACTOR shall not use contract funds to provide a parallel medication service to EIP.
CONTRACTOR's providing case management services shall make every effort to enroll clients in EIP.
iv. Payment of Cash or Checks to Clients Not Allowed—Where direct provision of service is not possible or effective,vouchers or similar programs,which may
only be exchanged for a specific service(e.g.,transportation),shall be used to meet the need for such services. CONTRACTOR shall administer gift cards
voucher programs to assure that recipients cannot readily convert vouchers into cash.
1. Store gift cards that can be redeemed at one merchant or an affiliated group of merchants for specific goods or services are allowable as incentives for
eligible program participants.
2. General-use prepaid cards are considered"cash equivalent"and are therefore unallowable.Such cards generally bear the logo of a payment network,such
as Visa,MasterCard,or American Express,and are accepted by any merchant that accepts those credit or debit cards as payment.Gift cards that are
cobranded with the logo of a payment network and the logo of a merchant or affiliated group of merchants are general-use prepaid cards,not store gift
cards,and therefore are unallowable.
3. The CONTRACTOR must ensure that a policy for managing gift cards with strong internal controls is in place.
v. Funds for Needle Exchange Programs Not Allowed with Federal Funding—CONTRACTOR shall not expend contract federal funds to support needle
exchange programs using funds from HIV Community Services Tasks.
vi. Travel—Out of staff travel requires prior approval from DOH and must follow GSA guidelines and reimbursement rates.
vii. Supervision,under DOH Community Programs contracts,will be understood as the delivery of a set of interrelated functions encompassing administrative,
educational and supportive roles that work collectively to ensure clinical staff(i.e.,case managers,navigators, coordinators,assistants,coaches)are equipped
with the skills necessary to deliver competent and ethical services to clients that adhere to best practices within applicable fields as well as all relevant Statewide
Standards. Supervisors must meet the criteria set forth within the WA State HIV Case Management Standards and provide the level of interaction and review
detailed in that document.
It is the understanding of DOH that Supervision funded under the direct program portion of this contract include at minimum,the provision of at least two of the
three functions detailed here:administrative,educational or supportive supervision.Supervision that encompasses only administrative functions will not be
considered billable under Direct Program.To that end,it is the expectation of DOH that those personnel identified as Supervisors have no more than one degree
of separation from direct client care.Exceptions to this rule can be presented and considered to and by DOH Contract Management.It will fall to the requesting
organization to satisfactorily demonstrate that any Supervisory positions falling within the scope of Direct Program are meeting the expectation of provision of
educational or supportive supervision with the aim of directly impacting client experiences,quality of services,and adherence to best practices and Statewide
Standards.
viii. Small and Attractive items—Each Contractor shall perform a risk assessment(both financial and operational)on the agency's assets to identify those assets that
are particularly at risk or vulnerable to loss.Operational risks include risks associated with data security on mobile or portable computing devices that store or
have access to state data.Assets so identified that fall below the state's capitalization policy are considered small and attractive assets.The Contractor shall
develop written internal policies for managing small and attractive assets.Internal policies should take into consideration the Office of the Chief Information
Officer(OCIO)IT Security Standard 141 Section 5.8 Mobile Computing and Section 8.3 Media Handling and Disposal at https://ocio.wa.gov/policies.
The Contractor shall implement specific measures to control small and attractive assets in order to minimize identified risks.Periodically,the Contractor should
perform a follow-up risk assessment to determine if the additional controls implemented are effective in managing the identified risks.
Exhibit A,Statement of Work Page 7 of 9 Contract Number CLH31013-Amendment 22
Page 14 of 25
Contractor must include,at a minimum,the following assets with unit costs of$300 or more:
1. Laptops and Notebook Computers
2. Tablets and Smart Phones
Agencies must also include the following assets with unit costs of$1,000 or more:
1. Optical Devices,Binoculars,Telescopes,Infrared Viewers,and Rangefinders
2. Cameras and Photographic Projection Equipment
3. Desktop Computers(PCs)
4. Television Sets,DVD Players,Blu-ray Players,and Video Cameras(home type)
ix. Food and Refreshments—Food and refreshments are not allowable direct costs,unless provided in conjunction with allowable meetings,whose primary
purpose is the dissemination of technical information.Pre-approval is required when food and refreshments are purchased for these meetings.A sign in sheet
with the clients'ID number from the DOH approved data system as well as an agenda is required to receive reimbursement for these charges.
1. The CONTRACTOR shall follow Healthy Nutrition Guidelines for Meetings and Events I Washington State Department of Health when purchasing
food and refreshments for approved meetings.
2. Food for staff meetings/training is unallowable.
PLEASE NOTE: If meals/refreshments are purchased for allowable meetings,food can only be purchased for clients at the per diem rate.Any expenses over
per diem will be denied. U.S.General Services Administration Per Diem Look Up
x. Reimbursement of disallowed costs—The CONTRACTOR agrees to reimburse DOH for expenditures billed to the DOH for costs that are later determined
through audit or monitoring to be disallowed under the requirements of 2 CFR Part 200—Uniform Administrative Requirements,Cost Principles,and Audit
Requirements for Federal Audits.
b. Contract Modifications
i. Notice of Change in Services—The CONTRACTOR shall notify DOH program staff,within 45 days,if any situations arise that may impede implementation of
the services contained in the statement of work.DOH and the CONTRACTOR will agree to strategies for resolving any shortfalls.DOH retains the right to
withhold funds in the event of substantial noncompliance.
ii. Contract Amendments—Effective Date—The CONTRACTOR shall not begin providing services authorized by a contract amendment until the
CONTRACTOR has received a signed and fully executed copy of the contract amendment from DOH.
1. Local Health Jurisdiction(LHJ)Contractors—Request for contract amendments must be received no less than 60 days prior to the Draft Due Date
identified by the CON CON SOW Schedule on the CON CON Dashboard.
2. Non-LHJ Contractors—Request for contract amendments must be received no later than 60 days prior to the end of the Federal Fiscal Year(FFY)and
90 days prior to end of the State Fiscal Year(SFY).
• Amendments must be signed prior to the end of the FFY or SFY end date.
EX.FFY end date is 12/31,contract amendment request due to contract manager by 11/1
13. Content Review and Website Disclaimer Notice
In accordance with all federal guidance,contractors receiving funds through DOH will submit all proposed written materials requiring review for WV-related scientific or
medical accuracy including written materials,audio visual materials,and pictorials,including social marketing and advertising materials,educational materials,social media
communications(e.g.,Facebook,twitter)and other electronic communications,such as intemet/webpages to the OID Content Review Committee.CONTRACTOR shall
submit all materials to be reviewed for scientific or medical accuracy to:
Exhibit A, Statement of Work Page 8 of 9 Contract Number CLH31013-Amendment 22
Page 15 of 25
Michael Barnes,Washington State Department of Health
PO Box 47841
Olympia,WA 98504-7841
Phone: 360-810-1880
Email: Michael.Bames@doh.wa.gov
For social marketing campaigns and media strategies,please adhere to the program guidance on the review of HIV-related educational and informational materials for CDC
assistance programs https://www.cdc.gov/hiv/pdf/funding/announcements/ps12-1201/cdc-hivps12-1201-content-review-guidance.pdf
14. Youth and Peer Outreach Workers
All programs,including CONTRACTORS,using youth(either paid or volunteer)in program activities will use caution and judgment in the venues/situations where youth
workers are placed. Agencies will give careful consideration to the age appropriateness of the activity or venue.Agencies will also ensure that organizational staff and youth
comply with all relevant laws and regulations regarding entrance into adult establishments and environments.Agencies will also maintain and implement appropriate safety
protocols that include clear explanation of the appropriate laws and curfews and clearly delineate safe and appropriate participation of youth in program outreach activities.
15. Whistleblower
a. Whistleblower statue,41 U.S.C.&4712,applies to all employees working for CONTRACTOR,subcontractors,and subgrantees on federal grants and contracts. The
statue(41 U.S.C.&4712)states that an"employee of a CONTRACTOR,subcontractor,grantee,or subgrantee,may not be discharged,demoted,or otherwise
discriminated against as a reprisal for"whistleblowing."In addition,whistleblower protections cannot be waived by an agreement,policy,form,or condition of
employment.
b. The National Defense Authorization Act(NDAA)for Fiscal Year 2013(Pub.L. 112-239,enacted January 2,2013)mandates a pilot program entitled"Pilot Program for
Enhancement of Contractor Employee Whistleblower Protections."This program requires all grantees,their subgrantees,and subcontractors to:
i. Inform their employees working on any federal award they are subject to the whistleblower rights and remedies of the pilot program
ii. Inform their employees in writing of employee whistleblower protections under 41 U.S.C.&4712 in the predominant native language of the workforce;and,
iii. CONTRACTOR and grantees will include such requirements in any agreement made with a subcontractor or subgrantee.
16. Allowable Costs
All expenditures incurred and reimbursements made for performance under this statement of work shall be based on actual allowable costs.Costs can include direct labor,
direct material,and other direct costs specific to the performance of activities or achievement of deliverables under this statement of work.
For information in determining allowable costs,please reference OMB Circulars:
2 CFR200(State,Local and Indian Tribal governments)at: https://www.federalregister.gov/documents/2013/12/26/2013-30465/uniform-administrative-requirements-cost-
principles-and-audit-requirements-for-federal-awards
**Disclosure of information is governed by the Washington Administrative Code(WAC)246-101-120, 520 and 635,and the Revised Code of Washington(RCW)70.24.080,
70.24.084,and 70.24.105 regarding the exchange of medical information among health care providers related to HIV/AIDS or STI diagnosis and treatment.Please note that
CONTRACTORs fit under the definition of"health care providers"and"individuals with knowledge of a person with a reportable disease or condition"in the WAC and
RCW.
DOH statutory authority to have access to the confidential information or limited Dataset(s)identified in this agreement to the Information Recipient: RCW 43.70.050
Information Recipient's statutory authority to receive the confidential information or limited Dataset(s)identified in this Agreement:RCW 70.02.220(7)
Exhibit A,Statement of Work Page 9 of 9 Contract Number CLH31013-Amendment 22
Page 16 of 25
Exhibit A
Statement of Work
Contract Term:2022-2024
DOH Program Name or Title: Injury&Violence Prevention-LHJ Opioid Campaign Local Health Jurisdiction Name: Jefferson County Public Health
Proviso—Effective November 1,2024
Contract Number: CLH31013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑Federal<Select One> (check if applicable) Reimbursement
Period of Performance: November 1,2024 through December 31,2024 ® State ❑FFATA(Transparency Act) ['Fixed Price
❑ Other ❑Research&Development
Statement of Work Purpose: Opioid abatement settlement account—state appropriation is provided solely for the Department of Health to administer grants to local health
jurisdictions for opioid and fentanyl awareness,prevention,and education campaigns.
NOTE: This SOW is part of the 2022-2024 Consolidated Contract term that ends on December 31,2024.A new Consolidated Contract term for 2025-2027 will begin on
January 1,2025.Activities and due dates in this SOW are for state fiscal year 25 that ends on June 30,2025 and will be continued in a new SOW in the next
Consolidated Contract term from January 1,2025 through June 30,2025.The funding allocation in this SOW reflects a portion of the total budget shown in the below
budget table.The remaining funding allocation will be added into the new SOW in the next Consolidated Contract term starting on January 1,2025.
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
SFY25 LHJ OPIOID CAMPAIGN PROVISO 77550853 N/A 334.04.93 11/01/24 12/31/24 0 24,500 24,500
0 0 0
0 0 0
0 0 0
TOTALS 0 24,500 24,500
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
1 Create two(2)banners and 1,000 brochures with prevention Banners will be hung across SR-20 in Port Monthly A 19 and Monthly invoices for actual
messaging and fact-based educational messaging. Townsend;professional brochures will be supporting documentation cost reimbursement will be
distributed at all public health events Monthly Progress Report, submitted to DOH.
throughout the funding period and beyond. November 2024-June 2025
Total of all invoices will not
2 Develop two to four(2-4)public media posts that will occur Two(2)media posts on each channel each Monthly A19 and exceed$24,500 through
each month throughout the year including static images and month throughout the funding period. supporting documentation December 31,2024.
videos on Instagram and Facebook:one(1)video for LHJ's Monthly Progress Report,
YouTube channel. November 2024-June 2025
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH31013-Amendment 22
Page 17 of 25
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
3 Six(6)newspaper and community board advertising Arrange with local newspapers The Leader, Monthly A19 and
purchase to promote awareness and science-based and the Peninsula Daily News for supporting documentation
information about opioid,fentanyl,and MOUD. advertising in the 6-months Jan.—June of Monthly Progress Report,
the funding period November 2024-June 2025
4 Planning Stage: Host four(4)interactive public education Arrange with community partners to decide Monthly Al 9 and
events with community partners at the Nest(OWL 360), on month,date,time for events and space supporting documentation
Recovery Café,Chimacum Grange,and Quilcene Guild them throughout the 2025 funding cycle. Monthly Progress Report,
Hall that focus on de-stigmatization,science-based November 2024-June 2025
education,and community understanding of not only opioid
and fentanyl use in our community but also how
community engagement is a preventative measure.
5 Planning Stage:To work with KPTZ Radio station in Port Live programs will run during a time to be Monthly A 19 and
Townsend to develop and participate in four(4),one-hour determined in a month to be determined for supporting documentation
long,interview programs to educate public and dispel fiscal 2025. Monthly Progress Report,
myths and stigmas related to opioid and fentanyl use November 2024-June 2025
disorders.
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 financeta'�,doh.wa.gov.
Program Specific Requirements
Billing Requirements:DOH awards funding through reimbursement-based billing.Invoices must be submitted monthly on an A19-1A invoice voucher.DOH must receive all
complete final invoices within 60 days of the end of the budget period for this statement of work.
Budget Table
Line Item Allocation Justification
Salaries $19,035 1.5 to 2 hrs./wk(will be assigned/shared with two communications'staff
members.)
Benefits $8,158 "
Goods and Services $16,578
Newspaper ads $7,128 6 Full-page newspaper advertisements: $1,188.00 x 6
Social media boosting $500
Video development and execution $8,200 *
Banners $500 2 banners x$250 each
Exhibit A, Statement of Work Page 2 of 3 Contract Number CLH31013-Amendment 22
Page 18 of 25
Brochures $250
Administrative costs/indirect $12,229 27.94%indirect rate
TOTAL $56,000
*Additional budget negotiation information will be requested and added in the January Statement of Work.
The LHJ must receive written approval from DOH before making any changes to the SOW activities or itemized budget.
Exhibit A, Statement of Work Page 3 of 3 Contract Number CLH31013-Amendment 22
Page 19 of 25
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) 5 Funding Source Federal Compliance Type of Payment
®Federal Contractor (check if applicable) ❑Reimbursement
Period of Performance: January 1,2022 through December 31,2024 El State ®FFATA(Transparency Act) El 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 update funding provided for Sanitary Survey and Technical Assistance activity assigned 1/1/2024 through 12/31/2024.
Master Assistance BARS Allocation
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None Allocation
SANITARY SURVEY FEES 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 0 0 0
YR 26 SRF-LOCAL ASST(15%)SS 24119226 N/A 346.26.64 01/01/24 12/31/24 1,800 -1,800 0
YR 26 SRF-LOCAL ASST(15%)TA 24119226 N/A 346.26.66 01/01/24 12/31/24 1,000 -1,000 0
YR 27 SRF-LOCAL ASST(15%)SS 24119227 N/A 346.26.64 01/01/24 12/31/24 0 1,800 1,800
YR 27 SRF-LOCAL ASST(15%)TA 24119227 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
checklist.
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH31013-Amendment 22
Page 20 of 25
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
The purpose of this statement of work is to 3. Updated Water Facilities Inventory system with four or more connections and each
provide funding to the LHJ for conducting (WFI). community system.
sanitary surveys and providing technical 4. Photos of water system with text
assistance to small community and non- identifying features Payment is inclusive of all associated costs
community Group A water systems. 5. Any other supporting documents. such as travel,lodging,per diem.
*Final Reports reviewed and accepted by Payment is authorized upon receipt and
the ODW Regional Office. acceptance of the Final Sanitary Survey Report
within the 30-day deadline.
Late or incomplete reports may not be accepted
for payment.
2 Trained LHJ staff will conduct Special Provide completed SPI Report and any Completed SPI Reports Upon acceptance of the completed SPI Report,
Purpose Investigations(SPI)of small supporting documents and photos to must be received by the the LHJ shall be paid$800 for each SPI.
community and non-community Group A ODW Regional Office. ODW Regional Office
water systems identified by the ODW within 2 working days Payment is inclusive of all associated costs
Regional Office. of the service request. such as travel,lodging,per diem.
See Special Instructions for task activity. Payment is authorized upon receipt and
acceptance of completed SPI Report within the
2-working day deadline.
Late or incomplete reports may not be accepted
for 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.
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH31013-Amendment 22
Page 21 of 25
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
4 LHJ staff performing the activities under For training attended in person,prior to Annually For training attended in person,LHJ shall be
tasks I,2 and 3 attend periodic required attending the training,submit an paid mileage,per diem,lodging,and
survey training as directed by DOH. "Authorization for Travel(Non- registration costs as approved on the pre-
Employee)"DOH Form 710-013 to the authorization form in accordance with the
See Special Instructions for task activity. ODW Program Contact for approval(to current rates listed on the OFM Website
ensure enough funds are available). http://www.ofm.wa.•ov/resources/travel.asQ
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
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 A19-1A Invoice
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH31013-Amendment 22
Page 22 of 25
Voucher to DOH Grants Management,billing to BARS Revenue Code 346.26.66 under Technical Assistance(TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW.Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance(Field Guide).The sanitary survey will include an
evaluation of the following eight elements:source;treatment;distribution system; finished water storage;pumps,pump facilities and controls;monitoring,reporting and data
verification; system management and operation;and certified operator compliance. If a system is more complex than anticipated or other significant issues arise,the LHJ may
request ODW assistance.
• 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 CLH31013-Amendment 22
Page 23 of 25
Exhibit A
Statement of Work
Contract Term:2022-2024
DOH Program Name or Title: Office of Immunization COVID-19 Vaccine- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2022
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 6 Funding Source Federal Compliance T e of Payment
Z Federal Subrecipient (check if applicable) ►ZI Reimbursement
Period of Performance: January 1.2022 through June 30,2024 ❑ State FFATA(Transparency Act) Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide funding to conduct COVID-19 vaccine activities.
Revision Purpose: The purpose of this revision is to remove funds.
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 Decrease(—) Allocation
COVID19 Vaccines R4 74310259 93.268 333.93.26 01/01/22 06/30/24 709,606 -601,396 108,210
COVID19 CDC Vaccines 74310236 93.268 333.93.26 01/01/22 06/30/24 278,114 -278,114 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 987,720 -879,510 108,210
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
The purpose of this statement of work is to identify activities and provide funding to support COVID vaccine response outreach,education,and operations. The activities may
include other vaccines recommended for the audience population,as long as COVID vaccine is the primary focus and references to other vaccines are secondary.
3.A Identify activity/activities to support COVID vaccine response Summary of the engagement strategies to January 31,Annually Reimbursement for actual
in your community,using the examples below as a guideline. be used with health care providers and costs incurred,not to
other partners,and the locally identified exceed total funding
Example 1:Develop and implement communication strategies population to be reached. consideration amount.
with health care providers,community,and/or other partners to
help build vaccine confidence broadly and among groups
anticipated to receive early vaccination,as well as dispel
vaccine misinformation.Document and provide a plan that
shows the communication strategies used with health care
providers and other partners and the locally identified
population anticipated to reach.
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH31013-Amendment 22
Page 24 of 25
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Example 2:Engage in other vaccination planning activities
such as partnership development,provider education,
vaccination point of dispensing(POD)planning,tabletop
exercises,engagement with communities,leaders,non-
traditional provider,or vulnerable populations to develop
strategies to ensure equitable access to vaccination services
3.B Implement the communication strategies or other activities, Written report describing June 30,annually Reimbursement for actual
working with health care providers and other partners to reach activity/activities and progress made to- costs incurred,not to
the locally identified population,support providers in date and strategies used(template to be exceed total funding
vaccination plans,and support equitable access to vaccination provided) consideration amount.
services.
3.0 Catalog activities and conduct an evaluation of the strategies Written report,showing the strategies used June 30,annually Reimbursement for actual
used and the final progress of the reach costs incurred,not to
(template to be provided) exceed total funding
consideration amount.
3.D As needed to meet community needs,expand operations to Reports summarizing quantity,type,and December 31 and June 30, Reimbursement for actual
increase vaccine throughput(i.e.,providing vaccinations during frequency of activities annually costs incurred,not to
evenings,overnight,and on weekends)or adjust vaccine exceed total funding
delivery approaches to optimize access. Activities may include consideration amount.
vaccine strike teams,mobile vaccine clinics,satellite clinics,
temporary,or off-site clinics to travel and provide vaccination
services in non-traditional settings,or to supplement the work
of local health departments in underserved communities,and
may include administration costs for other vaccines co-
administered at the events.These activities may be done by the
local health department or in collaboration with community
partners.(see Restrictions on Funds below)
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financer7a,doh.wa.gov.
Federal Fundine Accountability and Transparency Act(FFATA1
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.
Exhibit A,Statement of Work Page 2 of 3 Contract Number CLH31013-Amendment 22
Page 25 of 25
Program Specific Requirements
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
Coverage of co-administration costs for other vaccines administered at vaccination events does NOT apply to the FEMA Mass Vaccination funding. Coverage of co-
administration costs only applies to the vaccine funding(COVID19 Vaccine R4,MI 74310230)allocated for Task 3 of the consolidated contract. FEMA Mass Vaccination
funding is only available to cover the costs for COVID vaccine administration and cannot be used for co-administration costs of other vaccines.
Unallowable Costs:
There are limitations from the funding source on allowable costs for this contract.If the contractor is unsure if a cost is allowable,they should contact the contract manager for
approval of the cost prior to making the purchase or charge.
• Advertising costs(e.g.,conventions,displays,exhibits,meetings,memorabilia,gifts,souvenirs)
• Alcoholic beverages
• Building,purchases,construction,capital improvements
• Clinical care(non-immunization services)
• Entertainment costs
• Fundraising Cost
• Goods and services for personal use
• Honoraria
• Independent Research
• Land acquisition
• Legislative/lobbying activities
• Interest on loans for the acquisition and/or modernization of an existing building
• Payment of a bad debt,collection of improper payments
• Promotional and/or incentive materials(e.g.,plaques,clothing,and commemorative items such as pens,mugs/cups,folders/folios,lanyards,magnets,conference bags)
• Purchase of food/meals(unless part of required travel per diem costs)
• Vehicle Purchase
Exhibit A,Statement of Work Page 3 of 3 Contract Number CLH31013-Amendment 22
615 Sheridan Street
Port Townsend, WA 98368
c9ellason www.JeffersonCountyPublicHealth.org
Public Health
Consent Agenda
Hea
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: Now oe 25, ?vZ
SUBJECT: Agenda Item — Consolidated Contracts Amendment #22 with the Department
of Health; January 1, 2022 — December 31, 2024; decrease of $822,343 for a
total of $9,852,125
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #22
between JCPH and State of Washington Department of Health (DOH); January 1, 2022 — December 31, 2024;
decrease of $822,343 for a total of $9,852,125.
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:
• Injury & Violence Prevention-LHJ Opioid Campaign Proviso - adds Statements of Work.
• Infectious Disease-Syndemic Prevention Services - amends Statement of Work.
• Office of Drinking Water Group A Program - amends Statement of Work.
• Office of Immunization COVID-19 Vaccine - amends Statement of Work.
• Exhibit B-22 indicates decreases in funding.
FISCAL IMPACT/COST BENEFIT ANALYSIS :
Total consideration for this Contract Amendment is a decrease of $822,343 for a total of $9,852,125. 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) 0) 360-379-4487
Always working for a safer and healthier community
CC-22-002-A22
RECOMMENDATION:
JCPH Management recommends BoCC approval of Consolidated Contract Amendment #22; January 1 2022 —
December 31, 2024; decrease of $822,343 for a total of $9,852,125.
REVIEWED BY:
//07,z
Mark McCauley, Cou 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 Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: State of WA Dept of Health Contract No: CC-22-002-A22
Contract For: Consolidated Contracts, Amendment 22 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: Decreased $822,343 for a total of$9,852,125 PROCESS: zExempt from Bid Process
Revenue: ($822,343) Cooperative Purchase
Expenditure: Competitive Sealed Bid
Matching Funds Required: Small Works Roster
Sources(s)of Matching Funds Vendor List Bid
Fund # 127 _ RFPorRFQ
Munis Org/Obj 12756220 Other:
APPROVAL STEPS: s
STEP 1: DEPARTMENT CERTIFIES COMPj.d. CE WI,T1i C-3.55.080 AND CHAP' 1 42_23 RCW.
CERTIFIED: n N/A: � f ` - /J' " ,
ignatnre Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEEN-'DEBARRED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
3
nr
CERTIFIED: E N/A: Ka
Signature - Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 11/21/2024.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 11/8/2024.
Amendment No. 22. All prior amendments and original contract
attached.
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 55
JEFFERSON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH3I013 AMENDMENT NUMBER: 21
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as"DOH",and
JEFFERSON COUNTY PUBLIC HEALTH,a Local Health Jurisdiction,hereinafter referred to as"LHP",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:
I. 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:
'' .. _`-,i•aarE�tmc¢3j!!;",LI ���+h :e ?S .'r i,tv`.t,c<?,c;ti'.
►mot Adds Statements of Work for the following programs:
Office of Immunization COVID-I9 Vaccine-Effective July I,2024
Office of Immunization-Promotion of Immunizations to Improve Vaccination Rates-Effective July 1,2024
Office of Resiliency&Health Security-PHEP-Effective July 1,2024
►s Amends Statements of Work for the following programs:
DCHS-ELC COVID-I9 Response-Effective January I,2022
Foundational Public Health Services(FPHS)-Effective July 1,2024
Maternal &Child Health Block Grant-Effective January I,2022
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 8-21 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-20 Allocations as follows:
►# Increase of$1,258,189 for a revised maximum consideration of$10.674,460.
❑ 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
014f/494 _ 09/11/2024
Kate Dean,Chair Date I Date
APPROVED AS)DORM ONLY APPROVED AS TO FORM ONLY
Assistant Attorney General
/'
for 09/05/2024
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
Page 1 of 1
CC-22-002-A21
EXHIBIT B-21 Page 2 of 55
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: August 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
Indirect Rate January I,2024 through December 31,2024:27.94%Public Health
11011 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#* Cade** Start Date End Date Start Date End Date Amount SubTotal Total
FFY24 USDA BFPC Frog Mgmt 7WA700WAI Amd 15 10557 333.10.55 10/01/23 09/30/24 10/01/23 09/30/24 $37,651 S37,651 $128,104
FFY23 USDA BFPC Prog 3Igmt 7WA700WAI Amd 21 10.557 333.10.55 10/01/22 12/31/24 10/01122 09/30/25 59,413 $47,064
FFY23 USDA BFPC Prog Mgmt 7WA700WAI Amd 10,17 10.557 333.10.55 10/01/22 12/31/24 10/01/22 09/30/25 $28,238
FFY23 USDA BFPC Frog Mgmt 7WA700WA1 Amd 8,10, 17 10557 333.10.55 10/01/22 12/31/24 10/01/22 09/30/25 $9.413
FFY22 USDA BFPC Prog Mgmt 7WA700WAI Amd 1, 17 10.557 333.10.55 01/01/22 09/30/24 10/01/21 09/30124 $43,389 $43,389
FFS'251SDA WIC:Client Svs Contends NGA Not Received Amd 21 10.557 333,10,55 10/01/24 12/31/24 10/01/24 09/30/25 $1.860 528,128 $407314
FFY25 USDA WIC Client Sys Contracts NGA Not Received Amd 17 10.557 333.10.55 10/01/24 12/31/24 10/0.124 09/30/25 $26.268
FFY24 USDA WIC:Client Sys Contracts 7WA700WA7 Amd 21 10.557 333.10,55 10/01/23 09/30/24 111101/23 0e/3024 $4,718 $160.472
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 23 10.557 333.10.55 10/01/23 09/30/24 10/01/23 00130/24. $743
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 18 10.557 333.10.55 10/01/23 09/30/24 10/01/23 09130/24 $48,183
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 And 17 10.557 333.10.55 10/01:23 09/30/24 10/01/23 09/30124 $79.090
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 And 15 10.557 333.10.55 10/1)1/23 09.-30/24 10101/23 09/:30/24 $2,500
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 And 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 Sys Contracts 7WA700WA7 Anal 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 09130123 10'01/22 09/3023 $21,218
FFY23 USDA WIC Client Sys Contracts 7WA700WA7 Amd 10 10.557 333.10.55 10/01/22 09/30/23 10/01/22 0:3023 $75.713
FFY23 USDA WIC Client Svs Contracts 7WA700WA7 And I 10.557 333.10.55 10101/22 09/30/23 10/01/22 09/3(1 23 $23,750
FFY22 USDA WIC Client Sys 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 And 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 I 10.557 333.10.55 01/01/22 09/30122 10/01/21 09/30/22. $74,050
FFY23 USDA WIC Frog Mgmt CSS 7WA700WA7 And 10 10.557 333.10.55 01/01/23 09/30/23 10/01/22 09/3023., $2.800 $2,800 $2.800
FFY24 USDA FMNP Frog Mgmt 7WA810WA7 Amd 19 10.572 333.10.57 05/01/24 09/30/24 10/01/23 09/30/24 $496 $496 $1508
FFY23 USDA FMNP Frog Mgmt 7WA810WA7 Amd 15 10.572 333.10.57 06/01/23 09/30/23 10/0122 09/30/23 $496 $496
FFY22 USDA FMNP Prog Mgmt 7WA810WA7 Amd 4 10.572 333.1057 05/01/22 09/30/22 10/01/21 0913022 $516 $516
FY24 LW COVID-19 ARPA SLFRP0002 And 19 21.027 333.21.02 07/01/23 02/29/24 07/01/23 ((6//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 07101/23 06./30/25 $46,740
LW COVID-19 Gap Supplemental SLFRP0002 Amd 13 21.027 333.21.1)2 01/01/23 06/30/23 01101/23 06/30/23 $35,651 $35,651 $35,651
PS SSI 1-5 OSS Task 4 01318001 Amd 15 66.123 333.66.12 01/01/22 11/30/23 07/01 17 08/31/228 $30,000 $263,844 $263,844
PS SSI 1-5 OSS Task 01318001 Amd 7, 15 66.123 333.66.1 01/01/22 11/30/23 07/01/17 08/31128 ($1.654)
PS SSI 1-5 OSS Task.4 01318001 .And 2.5,15 66.123 333.66.12 01/01/22 11/3023 07/01/17 08/31/28 $235,498
Page 1 of 5
EXHIBIT B-21 Page 3 of 55
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Tern:2022-2024 Date: August 1,2024
Indirect Rate January I,2022 through December 31,2022:29.23%Public Health
Indirect Rate January 1,2023 through December 31,2023:35.85%Public health
Indirect Rate January 1,2024 through December 31,2024:27.94%Public Health
1)011 Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue L.HJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification 8 Amend 4 List t4 Code" Start Date End,Date Start.Date End Date Amount SubTotal Total
FFY24 Swimming Beach Act Grant IAR(ECY) 01374301 Amd 18 66.472 333.66.47 03/01/24 09/30/24 01/01/24 11/13024 $15,000 S15,000 $45,000
FFY23 Swimming Beach Act Grant LAR(ECY I 01/74301 Amd II 66.472 333.6647 03/01/23 10/31/23 03/01.'23 10/31/23 $I5.000 $15.000
FFY22 Swimming Beach Act Grant 1AR(ECY) 01174301 And 2 66.472 333.66.47 03/01/22 10/31/22 01/01:22 11/30/22 $15,000 $15,000
FFY24 PHEP RPl-CDC-LHJ Partners NL790TU000055 And 21 93.069 333,93,06 07/01/24 12/31/24 07101/24 06/30/25 $20,630 $20,630 $20,630
FFY23 PHEP BPS LHJ Funding 611.190TP922043 Amd 15 93.069 333.93.1)6 07/01/23 06/30/24 07,0123 06/30124 $34,384 $34,384 $82,522
FFY22 PHEP BP4 LHJ Funding NU90TP922043 Amd 7 93.069 333.93.06 07/01122 06/30/23 07/01/22 06/30123 $34,384 S34,384
FFY2I PHEP 13P3 LW Funding NUJ901P922043 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 N1117CE010218 Amd 17 93.136 333.93.13 01/01/24 08/31/24 09/0123 08/3124 $98,000 $98,000 $98,000
FFY22 Title X Dire Needs FPHPA006495 Amd 2 93.217 33393.21 01/14/22 03/31/22 01/14/22 03/31/22 $4,066 $4,066 $4,066
FFY23 FPHPA'fide X Family Plan FPIIPA006560 Anal 24 93.217 333.93.21 04/01/24 1231/24 _04/01/24 03/31/25 S13,747 $31,480 531.480
FFY24 FPHPA Title X Family Plan FPIIPAOO6560 And19 93.217 333.93.21 04/01/24 12/31/24 04/01/24 03131125 $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 3 93,217 333.93.21 04/01/22 03/31/23 04/0122 03/31/23 $27,137 $27,137
COVIDI9 Vaccines NH231P922619 Amd 4 93.268 333.93,26 01/01/22 06/30/24 07/01/20 06/30124 $278,114 $278,114 $278.114
COVIDI9 Vaccines R4 N11231P922619 Auld 21 93.268 333.93.26 07/01/24 12/31124 i 07/01/20 12/3124 S10,966 S10,966 S720,572
COVID19 Vaccines R4 NH2311'922619 And 4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803 5709,606
COVID19 Vaccines R4 NH231P922619 Amd I 93.268 333.93.26 01/01122 06/30/24 07/01/20 06/30124 S354.803
FF\2S CDC VFC Ops NCA Not Received Amd 21 93.268 333.93.26 07101/24 12/3Ii24 07/01/24 0613025. 55,600 55,600 511,760
FFY24 CDC VFC Ops NH23IP922619 And 15 93.268 333.93.26 07/01/23 06/30/24 07/0123 06/30/24 $560 $6,160
FFY24 CDC VFC Ops NH231P922619 Amd 14 93.268 333.93 26 07/01/23 06/30/24 07101/23 06/30124 $5,600
FFY23 VFC Ops NH231P922619 And 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 NH2311,922619 And 3 93.268 33393.26 01/01/22 06/30/22 07/01/21 06/30/22 $5,600 $5,600
FFYI9 COVID CARES NU5OCK000515 And 2 93.323 333.93.32 01/01/22 04/22/22 '0423/20 07/31/24 $14,664 $14,664 $14,664
FFYI9 ELC COVID Ed LHJ Allocation NU5OCK000515 Amd 7 93,323 333.93.32 01/01/22 10/1822 05/1920 10/18/22 ($2,281 7 $1,737 $1,737
FFYI9 ELC COVID Ed LIU Allocation NU5OCK000515 Amd 4 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 (S78,694)
FFYI9 ELC COVID Ed LHJ Allocation NU5OCK000515 And 2 93.323 333.93.32 01/01/22 10/18/22 05/19 20 10/18/22 $82,712
Page 2 of 5
EXHIBIT B-21 Page 4 of 55
Jefferson County Public Health ALLOCATIONS Contract Number: CLH310I3
Contract Term:2022-2024 Date: August 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
Indirect Rate January 1,2024 through December 31,2024:27.94%Public Health
DOH 1'se 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 8• Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY20 ELC EDE LHJ Allocation Nl'S0CK000515 Amd 21 93.323 333.93.32 01/01/22 12/31,24 (11/15(21 07/31/25 $15,580 $357,402 $357,402
FFY20 ELC EDE LHJ Allocation NU5OCK000515 Amd 9,21 93.323 333.93.32 01/012 12/.11/24 01/15;21 07/3125 ($6.375)
FFY20 ELC EDE LHI A I location NU5OCK000515 Amd 4,9.21 93.323 333.93.32 01/01/22 12/31/24 01 15.21 07131/25 ($90,842)
FFY20 ELC EDE LHJ Allocation NU5OCK000515 And 2,9,21 93.323 333.93.32 01/01/22 12/31/24 01/15/21 07/3 U25 $439.039
FF Y2I CDC COVID-19 PHWFD-LH1 N1J901P922181 And 16,20 93.354 333.93.35 07/01/23 122/31/24 07/01/23 06130 25 $200.000 S200,000 $200.000
FFY22 NEHA Climate&Health Grant NU380T000300 And 9 93.421 333.93.42 04/11/22 12/31/22 04.0122 12/31/22 $11.000 S22,000 $22,000
FFY22 NEHA Climate&Health Grant N11380T000300 Amd 5 93.421 33393.42 04/11/22 12/31/22 04/01/22 12/31:22 $11,000
FFY22 PH Infrastructure Comp Al-LW NEI1OE000053 Amd 17 93.967 333.93.96 01/01 24 12/31/24 1210122 06/3025 $200,000 $200,000 $200,000
FFY25 HRSA.NCIIBG LHJ Contracts NGA Not Received Amd 21 93.994 333.93.99 10/81/24 12131//24 10101 24 09/30/25 S9,175 .S9.175 S65,741
FFY24 URSA MCHBG LHJ Contracts B04MC52960 Amd 15 93.994 333.93.99 10/01/23 09/30/24 10/01/23 09/30124 S36,700 S36,700
FFY23 HRSA MCHBG LW Contracts B04MC47453 Amd 15 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 ($16.8341 $19,866
FFY23 HRSA MCHBG LW Contracts B04MC47453 Amd 7 93.994 333.93.99 10/01/22 09/30123 10/01/22 09/30/23 $36,700
FFY22 HRSA MCHBG Special Proj B04MC45251 Amd 15 93.994 333.93.99 1010122 09/30/23 10/01/22 09/30/23 $16,834 516,834 S16,834
FFY22 MCHBG LW Contracts B04MC45251 Anal 1 93.994 333.93.99 01/01/22 09/30/22 10/01/21 09/30/22 $27,525 S27,525 $27,525
SFY25 SBHC Proviso And19 N/A 334.04.9(1 0701/24 12/31/24 07/01/24 06130/25 $29,000 $91,000 S246,000
SFY25 SBHC Proviso Amd 14 N/A 334.04.90 07/01 24 12/31/24 07/01/24 06130;25 $62.000
SFY24 SBHC Proviso _ And19 N/A 334.04.90 07/01/23 06/30/24 07/01/23 06/30/24 $10,000 $155,000
SFY24 SBHC Proviso Amd 16 N/A 334.04.90 07/01.'23 06/30/24 07/01/23 06130,24 $35,000
SFY24 SBHC Proviso And 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 And 5 N/A 334.04.90 07/0122 06130.23 07/01/22 06/30/23 $150,000 $150,000 $150,000
SFY25 Sexual&Rep Hlth Cost Share And 20 N/A 334.04.91 07/01/24 12/31/24 07/01/24 06/3025 $48,323 $48,323 $260,084
SFY24 Sexual&Rep Hlth Cost Share Amd 18 N/A 334.04.91 07/01/23 06/30/24 07/01/23 06130/24 $1.800 S87,652
SFY24 Sexual&Rep Hlth Cost Share Amd 17 NIA 334.04.91 07/01/23 06/30/24 07/01/23 06/30/24 $42,926
SFY24 Sexual&Rep Filth Cost Share And 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 070122 06/30/23 07/01/22 06/30/23 $40,357 $80,009
SFY23 Sexual&Rep Filth Cost Share Amd 7, 10 N/A 334.04.91 07/01/22 06/30/23 07/01/22 06/30123 $39,652
SFY22 Sexual&Rep Hlth Cost Share And 5 N/A 334.04.91 (11/01/22 06/30/22 07/01/21 06/30/22 $5,880 $44,100
SFY22 Sexual&Rep Hlth Cost Share And 1 N/A 334.04.91 01/01/22 06/30/22 07/01 21 06/30/22 $38220
Page 3 of 5
EXHIBIT B-21 Page 5 of 55
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: August 1,2024
Indirect Rate January 1,2022 through December31,2022:29.23%Public Health
Indirect Rate January 1,2023 through December 31.2023:35.85%Public Health
Indirect Rate January I,2024 through December 31,2024:27.94%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 N Amend k List 0* code., Start Date End Date Start Date End Date Amount SubTotal Total
SFY25 Drug User Health Program Amd 17 N/A 334.04.91 07/01/24 12/31/24 07/01/24 06130/25 $40,250 S40,250 $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 S40,250
SFY24 Drug User Health Program Amd 14 N/A 334.04.91 07/01/23 12/31/23 07/01:23 06,130124 $7,500 $7,500
State Drug User Health Program And 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 I N/A 334.04.91 01/01/222 06/30/22 07/01/21 06/30/23 $7.500 $7,500
LHJ COVID-19 GFS Amd 19 N/A 334.04.92 0701123 06/30124 07/01/23 06130/24 $37.439 S37,439 $37.439
Rec Shellfish/Biotoxin Amd 20 N/A 334.04.93 07/01/23 12/31124 07/01/23 0630/25 $3,000 S14,100 $31,600
Rec ShelltishLBiotoxin Amd 14 N/A 334.04.93 07/01/23 12.31/24 07/0123 00/30/25 $11,100
Rec Shellfish/Biotoxin And 9 N/A 334.04.93 01/01/22 06/30/23 07/01/21 0613023 $7.000 S17,500
Rec Shellfish/Biotoxin And 1 N/A 334.04.93 01/01/22 06/30123 07/01/21 06130123 $10,500
Small Onsite Management(ALEA) Amd 14 N/A 334.04.03 07/01/24 12/31/24 07/01/23 06/30125 $33,333 $33,333 $104,166
Small Onsite Management(ALEA) Amd 14 N/A 334.04.93 •07/01/23 06/30/24 07101/23 06130/25 $33,333 $33,333
Small Onsite Management(ALEA) Amd 12 N/A 334.04.93 07/01122 06/30/23 07101/21 06/30/23 $9,375 $24,375
Small Onsite Management(ALEA) And 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 06/30/223 ($9,375) $13.125
Small Onsite Management tALEA) Amd 1 N/A 334.04.93 01/01/22 06/30122 07/01/21 06130/23 $22,500
Small Onsite ManagementtGFS) 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 07/01/224 12/31/24 07/01/23 07/01/25 $31.970
SFY25 Wastewater Management-OFS And 16 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 $31,970 S31,970 $61 970
Wastewater Management-GFS Amd I N/A 334.04.93 07701/22 06/30/23 07/01/21 063023 $30,000 S30,000
SFY23 FPHS-LHJ-GFS And 6.9 N/A 336.04.25 :07/01/22 06/30/23 07/0121 06/30/23 $1,433,000 $1,433,000 $1,433,000
• SFY25 FPHS-LHJ Funds-f F'S Amd 21 NIA 336.04.25 97/01/24 12/31/24 1(7/01124 06/30:25 S1.166.500 $2333.000 $4,666,000 •
SFY25 FPHS-LHJ Funds-GFS And 20 N/A 336.04.25 07/01/24 12/31124 0710124 06/30/25 S1.166.500
SFY24 FPHS-LHJ-Funds-GFS And 15 N/A 336.04.25 07/01/23 06:30/24 07/0123 06/30/24 $900,000 $2,333,000
SFY24 FPHS-LHI-Funds-GFS And 14 N/A 336.04.25 07/01/23 0630/24 07/01/23 ((6/30/24 S1.433.000
FPHS-LHJ-Proviso(YR2) Amd 7 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 (S550,000) $0 $445,181
FPHS-LHJ-Proviso(YR2) And I N/A 336.04.25 07/0122 06130/23 07/01/21 06130/23 $550,000
Page 4 of 5
EXHIBIT B-21 Page 6 of 55
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Tenn:2022-2024 Date: August 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
Indirect Rate January I,2024 through December 31,2024:27.94%Public Health
D011 Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue 1.HJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification 8 Amend g List 8* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FPHS-LHJ-Proviso(YR11 Amd 10 N/A 336.04.25 01/01/22 06130/22 07/0121 06.'30'23 S22681 $445.181
FPHS-LHJ-Proviso(YRI) AIM 4 N/A 336.04.25 01/01/22 06/30/22 07.0121 0630/23 (111137,500)
FPHS-LHJ-Proviso(YRI) Amd I N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/3023 $550.000
YR26SRF-Local Asst(15%)SS And 16 N/A 346.26.64 01/01/24 1231/24 07/01/23 06./30/25 $1.800 $1,800 $5,400
YR 25 SRF-Local Asst(15%)SS And 11 N/A 346.26.64 01/01/23 12/31/23 01/01/23 12131 23 $2,200 $2,200
YR 24 SRF-Local Asst(15%)(F0-SW)SS Amd I N/A 346.26.64 01/01/22 12/31/22 07/01/21 06;30.2 3 $L400 $1,400
Sanitary Survey Fees SS-State Arad 16 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12131:24 SI.800 $5,400 $5,400
Sanitary Survey Fees SS State Amd 11,16 N/A 346.26.65 01/01/22 12/31/24 0710131 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 And 19 N/A 346.26.66 01/01/24 12/31/24 07/01/23 06/30/25 $1 000 $1,000 $2,000
YR25 SRF-Local Asst(15%)T.A Arnd 19 N/A 346.2666 01/01/23 12/31/23 01/01/23 12/31/23 ($1,000) $0
YR 25 SRF-Local Asst(15%)TA Amd 11 N/A 346.26.66 01/01/23 12/31/23 01/01/23 12/3 1123 $1,000
YR24 SRF-Local Asst(15%)(FO-SW)TA And I N/A 346.26.66 01/01j22 12/31/22 07/01/21 06/30123 $1,000 $1,000
TOTAL $10.674.468 $10,674,468
Total consideration: $9,416,279 GRAND TOTAL S10.674,468
S1,258,189
GRAND TOTAL $10,674,468 Total Fed $3,115.728
Total State S7,558,740
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 5 of 5
Page 7 of 55
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: DCHS-ELC COVID-19 Response- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2022
Contract Number: CLH3I013
SOW Type: Revision Revision#(for this SOW) 4 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 supplemental funding for the LHJ to ensure adequate culturally and lingquistically
responsive testing, investigation and contract tracing resources to limit the spread of COV ID-19.
Revision Purpose: Extend Period of Performance and ELC EDE LHJ Funding End Date from 07/31/23 to 12/31/24,adjust allocation,and update MI code.
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
FFY19 ELC COVID ED ALLOCATION 1897129G 93.323 333.93.32 01/01/22 10/18/22 1,737 0 1,737
FFY20 ELC EDE LHJ ALLOCATION 1897140E 93.323 333.93.32 01/01/22 12/31/24 341,822 15,580 357,402
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 343,559 15,580 359,139
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Participate in public health emergency preparedness and 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
• Testing
• Case Investigation/Contact Tracing
• Sustainable isolation and quarantine
• Care coordination
• Surge management
• Data reporting
Exhibit A,Statement of Work Page 1 of 7 Contract Number CLH31013-Amendment 21
Page 8 of 55
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
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.
DCHS COVID-19 Response
1 Establish a budget plan and narrative to be submitted to the Submit the budget plan and narrative using Within 30 days of Reimbursement of actual
Department of Health(DOH)Contract Manager. DOH will the template provided. receiving any new award costs incurred,not to
send the"Budget narrative Template",`Budget Guidance"and for DCHS COVID-19 exceed:
any other applicable documents that may be identified. Response tasks.
$1,737 FFY19 ELC
I) LHJ Active monitoring activities.In partnership with WA Data collected and reported into DOH Enter performance metrics COVID ED LHJ
DOH and neighboring Tribes,the LHJ must ensure systems daily. daily into DOH identified ALLOCATION Funding
adequate culturally and linguistically responsive testing, systems (MI 1897129G)
investigation and contact tracing resources to limit the Funding end date
spread disease.LHJs must conduct the following activities 10/18/2022
in accordance with the guidance to be provided by DOH. Quarterly performance
reporting updates S35-.402 311.322 FFY20
a. Allocate enough funding to ensure the following ELC EDE LHJ
Contact Tracing and Case Investigation Support:Hire a ALLOCATION Funding
minimum of 1.0 data entry FTE to assure system (MI 18971420E)Funding
requirements for task 2.1.a. end date 12/31 2024
i. Contact tracing =-31 2023
1. Strive to maintain the capacity to conduct Enter all contact tracing data in CREST
targeted investigations as appropriate. following guidance from-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.
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.)
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH310I3-Amendment 21
Page 9 of 55
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
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.
a) Strive to enter all case investigation and Enter all case investigation data in WDRS
outbreak data into CREST as directed by following guidance from-DOH.
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.
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.
iii. Maintain a current list of entities providing Maintain a current list of entities providing
COVID-19 testing and at what volume. Provide COVID-19 testing and at what volume.
reports to DOH on testing locations and volume Provide reports to DOH Contract manager
as requested. on testing locations and volume as
requested.
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH31013-Amendment 21
Page 10 of 55
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
c. Surveillance FTE support at a minimum of.5 FTE
Epidemiologist to support daily reporting needs below.
i. Ensure all COVID positive lab test results from Ensure all COVID positive test results are
LHJ are entered in to WDRS by 1)entering data entered into WDRS within 2 days of
directly in to WDRS,2)sending test results to DOH receipt
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.
d. Tribal Support. Ensure alignment of contact tracing Quarterly performance updates related to
and support for patients and family by coordinating culturally and linguistic competency and
with local tribes if a patient identified as American responsiveness,tribal support, infection
Indian/Alaska Native and/or a member of a WA tribe. prevention and control for high-risk
populations,community education and
e. Support Infection Prevention and control for high-risk regional active monitoring activities.
populations Performance update should include status
i. Migrant and seasonal farmworker support. of all projects listed.
Partner with farmers,agriculture sector and
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-l9
exposure,conduct testing and respond to
outbreaks.
Exhibit A,Statement of Work Page 4 of 7 Contract Number CLH31013-Amendment 21
Page 11 of 55
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
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 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(1&Q) Quarterly performance updates to include
measures in accordance with WAC 246-100-045 name,address and capacity of identified
(Conditions and principles for isolation or quarantine). location that can support isolation and
i. Have at least one(1)location for conducting l&Q quarantine,and confirmation of
operations identified and confirmed.This location appropriate planning and coordination as
should be sufficient for supporting l&Q services required.
that are adequate for the population for your
jurisdiction and have an ability to expand if
needed.This can be through contract/formal
agreement;alternatively,the jurisdiction may
establish with an adjacent jurisdiction a formal
Exhibit A,Statement of Work Page 5 of 7 Contract Number CLH31013-Amendment 21
Page 12 of 55
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
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 and Report census numbers to include historic
quarantine for your population. total by month and monthly total for
iii. Planning must incorporate transfer or receipt of current quarter to date
people requiring 1&Q support to and from
adjacent jurisdictions or state facilities in the
event of localized increased need.
iv. Planning must incorporate indicators for
activating and surging to meet demand and
describe the process for coordinating requests for
state 1&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@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(UE1)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USAS,pending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
All work will be performed in accordance with the revised and approved project plans to be submitted to DOH.
Restrictions on Funds(what funds can be used for which activities,not direct payments,etc)
CDC Funding Regulations and Policies
https://www.cdc.gov/grants/documents/General-Terms-and-Cond itions-Non-Research-Awards.pdf
Monitoring Visits(frequency,type)
The DOH program contact may conduct monitoring visits during the life of this project.The type,duration,and timing of visit will be determined and scheduled in cooperation
with the subawardee.The DOH Fiscal Monitoring Unit may conduct fiscal monitoring site visits during the life of this project
Special Billing Requirements
Payment: Upon approval of deliverables and receipt of an invoice voucher,DOH will reimburse for actual allowable costs incurred. Billings for services on a monthly fraction of
the budget will not be accepted or approved.
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH31013-Amendment 21
Page 13 of 55
Submission of Invoice Vouchers: The LHJ shall submit correct monthly A19-1 A invoice vouchers for amounts billable under this statement of work to DOH by the 25th of the
following month or on a frequency no less often than quarterly.
Other: Required activities,deliverables,and funding is for the entire project period:January 2021 through specified date above. Unspent funds and tasks not completed by
December 31,2021,were reauthorized for work in this new consolidated contract term beginning January 1,2022. It is the LHJ's responsibility to assure that the unspent funding
amount carried forward to this statement of work does not exceed the remaining available balance from the 2018-2021 contract.
Exhibit A, Statement of Work Page 7 of 7 Contract Number CLH31013-Amendment 21
Page 14 of 55
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Foundational Public Health Services(FPHS)- Local Ilealth .luri,diction Name: Jefferson County Public Health
Effective July 1,2024
Contract Number: GLH31013
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
❑Federal<Select One> (check if applicable) ❑ Reimbursement
Period of Performance: July 1,2024 through December 31,2024 ®State El FFATA(Transparency Act) ® Periodic Distribution
❑Other ❑ Research& Development
Statement of Work Purpose: Per RCW 43.70.512,Foundational Public Health Services(FPHS)funds are for the governmental public health system: local health jurisdictions,
Department of Health,state Board of Health,sovereign tribal nations and Indian health programs. These funds are to build the system's capacity and increase the availability of
FPHS services statewide.
Revision Purpose: The purpose of this revision is to add the entire SFY25 allocation.
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
SFY25 FPHS-LHJ FUNDS-GFS 99210850 N/A 336.04.25 07/01/24 12/31/24 1,166,500 1,166,500 2,333,000
0 0 0
Oi 0 0
0' 0 0
0 0 0
0 0 0
TOTALS 1,166,500 1,166,500 2,333,000
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
I Amount
l FPHS funds to each LHJ—See below in Program Specific See below in Program Specific See below in Program Specific S 26OO.N00
Requirements—Activity Special Instructions for details i Requirements-Deliverables Requirements-Deliverables S5 0 000
Assessment Reinforcing Capacity—See below in Program Specific j See below in _Program Specific See below in Program Specific $40.000
Requirements—Activity Special Instructions for details Requirements- Deliverables Requirements-Deliverables S60.000
3 Assessment—CHA/CHIP—See below in Program Specific See below in Program Specific See below in Program Specific $5,000
Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements- Deliverables $30.000
Lifecourse-NEW SFl 24 Full Lifecourse Workforce Capacity—See See below in Program Specific See below in Program Specific $176,500
4 below in Program Specific Requirements—Activity Special Instructions Requirements-Deliverables Requirements- Deliverables $353.000
for details
Exhibit A, Statement of Work Page 1 of 7 Contract Number CLH31013-Amendment 21
Page 15 of 55
Payment
Task Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
CD-NEW SFY 24 Immunization Outreach, Education & Response See below in Program Specific See below in Program Specific $3-7400
5 -See below in Program Specific Requirements 1ctiyitl Special ; Requirements-Deliverables Requirements- Deliverables S75.000
Instructions for details
EPH-NEW SFY 24 Fully fund Environmental Public Health Policy See below in Program Specific See below in Program Specific $75.000
6 & Leadership Capacity-See below in Program Specific Requirements Requirements-Deliverables Requirements-Deliverables 5151).011/1
-Activity Special Instructions for details
FC-NEW SFY 24 Strengthening Local Finance Capacity-See ISee below in Program Specific See below in Program Specific $31,000
7 below in Program Specific Requirements-Activity Special Instructions Requirements-Deliverables Requirements-Deliverables $62,000
for details
8 FC-NEW SFY 24 Public Health Communications-See below in See below in Program Specific See below in Program Specific S•t00:000
Program Specific Requirements-Activity Special Instructions for details Requirements- Deliverables Requirements- Deliverables $200.000
Lifecourse-NEW SFY 24 Illicit Substance Use and Overdose See below in Program Specific See below in Program Specific $73:000
9 Response-See below in Program Specific Requirements-Activity Requirements-Deliverables Requirements-Deliverables Sl50,0IJ0
Special Instructions for details —
EPR-NEW SFY 24 Emergency Preparedness& Response- See below in Program Specific See below in Program Specific $89.000
10 Capacity and Capability-See below in Program Specific
Requirements-Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables Si78,000
Assessment-Shared Regional Epidemiology-General See below in Program Specific See below in Program Specific $737000
11 (Assessment/Surveillance,CHA/CHIP)-See below in Program Requirements-Deliverables Requirements-Deliverables S/50.000
Specific Requirements-Activity Special Instructions for details
12 EPH-NEW SFY 24 Social Work Support-See below in Program See below in Program Specific See below in Program Specific S4-2,500
Specific Requirements-Activity Special Instructions for details 1 Requirements-Deliverables Requirements-Deliverables S85,000
13 EPH Core Team-Safe and Healthy Communities-See below in See below in Program Specific See below in Program Specific $2-3-300
Program Specific Requirements-Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables S-17.000
14 EPH Core Team-Climate Change Response-See below in Program See below in Program Specific See below in Program Specific $40400
Specific Requirements-Activity Special Instructions for details ; Requirements-Deliverables Requirements-Deliverables S80,000
15 EPH Core Team-Water System Capacity-See below in Program See below in Program Specific See below in Program Specific $3300
Specific Requirements-Activity Special Instructions for details I Requirements-Deliverables Requirements-Deliverables S75,000
EPH Core Team-System-Wide Data Management Improvement. See below in Program Specific See below in Program Specific $31,500
16 See below in Program Specific Requirements-Activiecial Requirements-Deliverables Requirements-Deliverables S63,000
Instructions for details
17 EPH Core Team-Homelessness Response-See below in Program I See below in Program Specific See below in Program Specific S277500
Specific Requirements-Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables $55,000
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.
FPHS staff from DOH and the Washington State Association of Local Public Health Officials(WSALPHO)will coordinate and communicate together to build and assure common
systemwide approaches per FPHS Steering Committee direction and the FPHS framework intent.
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH31013-Amendment 21
Page 16 of 55
• For LHJ questions about the use of funds:
o Chris Goodwin, FPHS Policy Advisor,WSALPHO—cgo ddwin@wsac.org,564-200-3166
o Brianna Steere, FPHS Policy Advisor,WSALPHO--bsteere@wsac.org,564-200-3171
The intent of FPHS funding is outlined in RCW 43.70.512.
Foundational Public Health Services Definitions and related information can be found here: www.doh.wa.gov/fphs.
Stable funding and an iterative decision-making process—The FPHS Steering Committee's roles and responsibilities are outlined in the FPHS Committee&Workgroup
Charter The Steering Committee is the decision making body for FPHS and operates under a consensus-based decision making model,outlined here.The Steering Committee use
an iterative approach to decision making meaning additional tasks and/or funds may be added to a local health jurisdiction's(LHJ)FPHS Statement of Work(SOW)as funding
decisions are made.
Spending of FPHS funds—FPHS funds do not require pre-approval or pre-authorization to spend.FPHS funds are to assure FPHS services are available in each jurisdiction based
on the FPHS Definitions(link)and as reflected in the SOW.Assurance includes providing FPHS as part of your jurisdiction's program operations,contracting with another
governmental public health system partner to provide the service,or receiving the service through a new service delivery model such as cross jurisdictional sharing or regional
staff.FPHS funds are eligible starting at the beginning of each state fiscal year(July 1)regardless of when funds are received by the LHJ,even if the expenditure
occurred before the LHJ's contract was signed.
These funds are not intended for fee-based services such as select environmental public health services.As state funding for FPHS increases,other funds sources(local revenue,
grants,federal block grants)should be directed to the implementation of additional important services and local/state priorities as determined by each agency/jurisdiction.
Annual Allocations—The legislature appropriates FPHS funding on an annual basis and the FPHS Steering Committee allocates funds annually through the FPHS Concurrence
Process for the State Fiscal Year(SFY):July -June.
The Legislature appropriates FPHS funding amounts for each fiscal year of the biennium. This means that funds must be spent within that fiscal year and cannot be carried
forward. Any funds not spent by June 30°'each year must be returned to the State Treasury. Funding allocations reset and begin again at the start of the next fiscal year(July 1).
This Statement of Work is for the period of July 1,2024-December 31,2024 and may be included in multiple Consolidated Contracts(ConCons)which are based on the calendar
year and renewed every three years.
Disbursement of FPHS funds to LHJs—Unlike other ConCon grants,FPHS bill-back to DOH is NOT required. Half of the annual FPHS funds allocated by the Steering
Committee to each LHJ are disbursed each July and January. The July payments to LHJs and access to FPHS allocation for all other parts of the governmental public health
system occur upon completion of the FPHS Annual Assessment.
Deliverables—FPHS funds are to be used to assure FPHS services statewide. The FPHS accountability process measures how funds are spent,along with changes in system
capacity through the FPHS Annual Assessment,system performance indicators,and other data. DOH,SBOH and local health jurisdictions have agreed to complete:
1. Reporting of spending and spending projections. Process timelines and reporting template are provided by the FPHS Steering Committee via FPHS Support Staff.
2. FPHS Annual Assessment is due each July to report on the previous state fiscal year.Process and reporting template are provided by the FPHS Steering Committee via
FPHS Support Staff. System results are published in the annual FPHS Investment Report available at www.doh.wa.gov/fphs.
BARS Revenue Code: 336.04.25
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH31013-Amendment 21
Page 17 of 55
BARS Expenditure Coding provided for y our reference.
562.xx BARS Expenditure Codes for FPHS activities: see below
10 1 FPHS Epidemiology& Surveillance
11 FPHS Community Health Assessment
12 FPHS Emergency Preparedness& Response
13 FPHS Communication
14 FPHS Policy Development
15 FPHS Community Partnership Development
16 FPHS Business Competencies
17 FPHS Technology
20 FPHS CD Data& Planning
21 FPHS Promote Immunizations
23 FPHS Disease Investigation—Tuberculosis(TB)
24 FPHS Disease Investigation—Hepatitis C
25 FPHS Disease Investigation—Syphilis,Gonorrhea&HIV
26 FPHS Disease Investigation—STD(other)
27 FPHS Disease Investigation—VPD
28 FPHS Disease Investigation—Enteric
29 FPHS Disease Investigation—General CD
40 FPHS EPH Data& Planning
41 FPHS Food
42 FPHS Recreational Water
43 FPHS Drinking Water Quality
44 I FPHS On-site Wastewater
45 FPHS Solid&Hazardous Waste
46 FPHS Schools
47 FPHS Temporary Worker Housing
48 FPHS Transient Accommodations
49 FPHS Smoking in Public Places
50 FPHS Other EPH Outbreak Investigations
51 FPHS Zoonotics(includes vectors)
52 FPHS Radiation
53 FPHS Land Use Planning
60 FPHS MCH Data& Planning
70 FPHS Chronic Disease, Injury &Violence Prevention Data& Planning
80 FPHS Access/Linkage with Medical, Oral and Behavioral Health Care Services Data&Planning
90 FPHS Vital Records
91 FPHS Laborator—Centralized(PHSKC Only)
92 FPHS Laboratory
Special References(i.e., RCWs,WACs,etc.):
FPHS Intent- RCW 43.70.512
FPHS Funding—RCW 43.70.515
FPHS Committee& Workgroup Charter
FPHS Steering Committee Consensus Decision Making Model
Exhibit A,Statement of Work Page 4 of 7 Contract Number CLH31013-Amendment 21
Page 18 of 55
Activity Special Instructions:
Investments to Each LHJ:
1. FPHS Funds to Each LHJ
These funds are allocated to be used to provide any programs and services within all of the FPHS Definitions.Each LHJ is empowered to prioritize where and how to use
these funds to maximize equitable,effective and efficient delivery of FPHS to every community in Washington.
Use BARS expenditure codes from the list above that most closely align with expenditure made.
Targeted Investments to Each LHJ:
2. Assessment Reinforcing Capacity(FPHS definition G.2)
Support LHJ assessment capacity with flexible funds to meet locally identified needs. BARS expenditure codes: 562.10 or 11
3. Assessment-CHA/CHIP(FPHS definitions G.3)
Support any CHA/CHIP activity or service(e.g.,data analysis,focus groups,report writing,process facilitation)and may be used to contract with other agencies for staff
time or services. Use BARS expenditure codes:562.11
4. Lifecourse-NEW SFY 24 Full Lifecourse Workforce Capacity(FPHS definitions D,E,F)
Infrastructure and workforce investments to each LHJ to meet fundamental needs in three areas:Maternal/Child/Family Health; Access/Linkage with Medical,Oral and
Behavioral Health Services;and Chronic Disease,Injury and Violence Prevention.Use BARS expenditure codes: 562.60,562.70,and/or 562.80
5. CD-NEW SFY 24 Immunization Outreach,Education &Response(FPHS definition C.3)
Promote immunization education and use of the statewide immunization registry through evidence-based strategies.Funding can also be used to support vaccine-
preventable disease response. BARS expenditure codes: 562.21 and/or 562.27
6. EPH-NEW SFY 24 Fully fund Environmental Public Health Policy& Leadership Capacity(FPHS definitions B.2,A.C,J.1-3,K.1-2,L.1)
These funds are to be used for staffing costs for environmental health responsibilities and functions(that are not directly fee-based)within leadership,policy development,
foundational public health services implementation,evaluation,or administration,including(but not limited to)Environmental Health Directors.Examples of funded
roles include work relating to general policy,statewide and/or system-wide,and/or cross jurisdictional work, legislation,and rulemaking,SBOH engagement,leadership
support and/or development,workforce development, leadership within health equity,climate,and environmental justice.Use BARS expenditure codes:562.14,562.40—
562.53
7. FC-NEW SFY 24 Strengthening Local Finance Capacity(FPHS definitions L.2-4,L.6,L.8)
Capacity and infrastructure to assure fiscal management and contract and procurement policies and procedures are effectively implemented to support programs and
services.Use BARS expenditure codes:562.16
8. FC-NEW SFY 24 Public Health Communications(FPHS definitions I.1-2)
Capacity to enhance the frequency,accuracy,and accessibility of public health communications to diverse populations via various media to support programs and
services.Use BARS expenditure codes:562.13
9. Lifecourse-NEW SFY 24 Illicit Substance Use and Overdose Response(FPHS definitions D.1-2,D.4,F.1-3,G.1-3,1.1-2,J.l-J.3,K.1-2)
Capacity and infrastructure related to addressing overdose crisis.This includes but is not limited to:Overdose response trainings,convening stakeholders or coordination
groups,data analysis,and community education.Use BARS expenditure codes: 562.13, 562.14,562.15,562.60,562.70,562.80
Exhibit A, Statement of Work Page 5 of 7 Contract Number CLH31013-Amendment 21
Page 19 of 55
10. EPR-NEW SFY 24 Emergency Preparedness& Response—Capacity and Capability(FPHS definitions H. 1-4)
Capacity and infrastructure to support and enhance the local delivery of FPHS Emergency Preparedness and Response services and activities across critical subject matter
areas. Use BARS expenditure codes: 562.12
Targeted Investments to Select LHJs—Assuring FPHS Available for/in Multiple Jurisdictions:
11. Assessment—Shared Regional Epidemiology—General(Assessment/Surveillance,CHA/CHIP)(FPHS definitions G.1,2)
Increase assessment and epidemiology capacity via regional/shared epidemiologist model to meet locally identified needs. Use BARS expenditure codes: 562.10 or II
Targeted Investments to Select LHJs—Assuring FPHS Available in Own Jurisdiction
12. EPH -NEW SFY 24 Social Work Support(FPHS definitions B.1-3,B.6-7,D.1,D.2,D.4. E.2,E.4,F.2-3,J.1-2,K.1-2,L.3,L.5)
This investment is intended to support non-traditional responses to environmental health complaints and challenges in the context of social work support and care coordination
with social service providers.Activities include: assessment of complaints and challenges; identifying cases and circumstances for engaging in social work support and care
coordination;and engagement with social service providers. Funds may be used to support these activities,as well as related staffing and training expenses. Use BARS
expenditure codes:562.14,562.15, 562.40,562.47,562.48
EPH--Core Teams(Applies to all EPH Core Team FPHS Investments)(FPHS definition B.1-7)
Each EPH Core Team investment is for LHJ staff to participate in a cross jurisdictional topic-specific Core Team.The Core Teams are each tasked with developing one or
more model program(s),intended to offer guidance for scalable environmental public health responses relating to their specific sub-topic area(s). Where it makes sense to
do so,the Core Teams may also work on implementation of these model programs.The content and output of these model programs will vary depending on the needs and
approaches specific to each sub-topic area.
Recipients of these Core Team FPHS funds are required to participate in the associated Core Team for each investment. Recipients may spend these funds towards
staffing time necessary to participate and on FPHS-qualifying activities for the specific sub-topic area(s)attached to its associated investment. Each Core Team FPHS
investment is distinctive from all other Core Team FPHS investments.
Core Teams exist outside the FPHS structure, in partnership between LHJs and WA DOH,with one co-lead from each. Model programs developed through Core Team
work will be made available to all Washington public health agencies.
There are currently six EPH Core Teams.They are listed below,with their sub-topic area(s),as applicable.
• System-Wide Data Management Improvement
• Climate-Change Response
• Lead Exposure
• Water System Capacity
• Homelessness Response
• Safe&Healthy Communities
Jefferson is receiving funds to participate in these EPH Core Teams:
EPH--Core Teams(Applies to all EPH Core Team FPHS Investments)(FPHS definition B.1-7)
Each EPH Core Team investment is for LHJ staff to participate in a cross jurisdictional topic-specific Core Team.The Core Teams are each tasked with developing one or
more model program(s), intended to offer guidance for scalable environmental public health responses relating to their specific sub-topic area(s). Where it makes sense to
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH31013-Amendment 21
Page 20 of 55
do so,the Core Teams may also work on implementation of these model programs.The content and output of these model programs will vary depending on the needs and
approaches specific to each sub-topic area.
Recipients of these Core Team FPHS funds are required to participate in the associated Core Team for each investment. Recipients may spend these funds towards
staffing time necessary to participate and on FPHS-qualifying activities for the specific sub-topic area(s)attached to its associated investment. Each Core Team FPHS
investment is distinctive from all other Core Team FPHS investments.
Core Teams exist outside the FPHS structure, in partnership between LHJs and WA DOH,with one co-lead from each. Model programs developed through Core Team
work will be made available to all Washington public health agencies.
There are currently six EPH Core Teams.They are listed below,with their sub-topic area(s),as applicable.
• System-Wide Data Management Improvement
• Climate-Change Response
• Lead Exposure
• Water System Capacity
• Homelessness Response
• Safe& Healthy Communities
Jefferson is receiving funds to participate in these EPH Core Teams:
13. EPH Core Team—Safe& Healthy Communities
This Core Team develops system capacity to advance EPH perspectives into planning processes such as State Environmental Policy Act(SEPA)work,Health Impact
Assessments,Comprehensive Plans,and related environmental review opportunities.The Core Team will develop one or more model program(s)to provide scalable
approaches to healthy community planning,which may include wastewater planning and treatment,seawater intrusion in drinking water,ventilation in public buildings,
PFAS contamination,climate change challenges,and other emerging topics identified by the Core Team.
• Use BARS expenditure code:562.40
14. EPH Core Team—Climate-Change Response
This Core Team will address environmental health concerns related to climate and the effects of climate change.
• Model program development will start with Wildfire Smoke and Harmful Algal Blooms,and may include other priorities and topics.
15. EPH Core Team—Water System Capacity
The goal of this Core Team is to increase LHJ capacity for water resource management and planning.
• Use BARS expenditure code: 562.43 or 53.
16. EPH Core Team—System-Wide Data Management Improvement
This Core Team will identify and employ a strategy for data sharing,storage and consistency across the state.
• Use BARS expenditure code: 562.40.
17. EPH Core Team—Homelessness Response
This Core Team will develop one or more model program(s)for a scalable response to homelessness-related public health concerns.
• Use BARS expenditure code: 562.40
Exhibit A.Statement of Work Page 7 of 7 Contract Number CLH31013-Amendment 21
Page 21 of 55
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Maternal and Child Health Block Grant- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2022
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 3 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: January 1,2022 through December 31,2024 El State El FFATA(Transparency Act) D Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to support local interventions that impact the target population of the Maternal and Child Health
Block Grant.
Revision Purpose: The purpose of this revision is to provide additional funding,add activities and deliverable due dates,and extend the period of performance and funding
period from September 30,2024 to December 31,2024,for continuation of MCHBG related activities,and update Program Specific Requirements.
NOTE: The FFY25 funding allocation in this SOW is for the period of October 1,2024 through December 31,2024. Deliverables with due dates after December 31,2024
are shown for informational purposes only.A new SOW will begin in the next consolidated contract term on January 1,2025 for continuation of this project through
September 30,2025.Any funds unspent from October 1,2024 through December 31,2024 will be added to the new SOW in an amendment in Spring 2025.
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 MCHBG LHJ CONTRACTS 78101221 93.994 333.93.99 01/01/22 09/30/22 27,525 0 27,525
FFY23 HRSA MCHBG LHJ CONTRACTS 78101231 93.994 333.93.99 10/01/22 09/30/23 19,866 0 19,866
FFY22 HRSA MCHBG SPECIAL PROJECTS 7811022A 93.994 333.93.99 10/01/22 09/30/23 16,834 0 16,834
FFY24 HRSA MCHBG LHJ CONTRACTS 78101241 93.994 333.93.99 10/01/23 09/30/24 36.700 0 36,700
FFY25 HRSA MCHBG LHJ CONTRACTS 78101251 93.994 333.93.99 10/01/24 12/31/24 0 9,175 9,175
0 0 0
TOTALS 100,925 9,175 110,100
Task I Due Date/ Payment Information
# Activity Deliverables/Outcomes I Time Frame and/or Amount
Maternal and Child Health Block Grant(MCHBG)Administration
la Report actual expenditures for the six-month period Submit actual expenditures using the MCHBG May 27,2022 Reimbursement for actual
October I,2021 through March 31,2022 Budget Workbook to DOH contract manager costs,not to exceed total
lb Develop 2022-2023 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 9,2022 funding consideration.
October 1,2022 through September 30,2023 using DOH contract manager Monthly Reports must only
provided template. reflect activities paid for with
Exhibit A,Statement of Work Page 1 of 7 Contract Number CLH31013-Amendment 21
Page 22 of 55
Task Activity Deliverables/Outcomes I Due Date/ Payment Information
# I Time Frame and/or Amount
'1c Participate in DOH sponsored MCHBG fall regional Designated LHJ staff will attend regional September 30,2023 funds provided in this
meeting. meeting. statement of work for the
Id Report actual expenditures for October I,2021 through Submit actual expenditures using the MCHBG December 2,2022 specified funding period.
September 30,2022. Budget Workbook to DOH contract manager. See Program Specific
1e Develop 2022-2023 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 9,2022 Requirements and Special
October 1,2022 through September 30,2023 using DOH contract manager. Billing Requirements.
provided template.
I f Report actual expenditures for the six-month period from Submit actual expenditures using the MCHBG May 19,2023
October I,2022 through March 31,2023. Budget Workbook to DOH contract manager.
1g Report actual expenditures for October 1,2022 through Submit actual expenditures using the MCHBG I December I.2023
September 30,2023. Budget Workbook to DOH contract manager.
lh Develop 2023-2024 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 8,2023
October 1,2023 through September 30,2024 using DOH contract manager.
provided template.
I i Report actual expenditures for the six-month period from Submit actual expenditures using the MCHBG May 17,2024
October 1,2023 through March 31,2024. Budget Workbook to DOH contract manager. 1
li Report actual expenditures for October 1. 2023 through Submit actual expenditures using the .11CI-IBG December 6, 202-1
September 30, 2024. Budget Workbook to DOH contract manager.
I A Report actual expenditures for the six-month period from Submit actual expenditures using the .11Cl/BG Ala} /6. 2025
October 1. 2024 through March 31, 2025. Budget Workbook to DO1I contract manager.
II Develop 2025-2026 AICHBG Budget ll'orkbook,/or Submit.1.ICHBG Budget Workbook to DOH .September 5. 2025
October 1. 2025 through September 30. 2026 using DOH contract manager.
provided template.
I nt Participate in DOII sponsored,11(71BGJizll regional Lf11 Contract lead or designee will attend September 30. 2025
meeting. regional meeting.
Implementation
2a Report activities and outcomes of 2022 MCHBG Action Submit quarterly Action Plan reports to DOH January 15,2022 Reimbursement for actual
Plan using DOH-provided template. Contract manager. April 15,2022 costs,not to exceed total
July 15,2022 funding consideration.
2b Develop 2022-2023 MCHBG Action Plan for October 1, Submit MCHBG Action Plan to DOH Draft August 19,2022 Monthly Reports must only
2022 through September 30,2023 using DOH-provided contract manager. Final-September 9,2022 reflect activities paid for with
template. funds provided in this
2c Report activities and outcomes of 2023 MCHBG Action Submit monthly Action Plan reports to DOH ; July-Sept 2022 quarterly statement of work for the
Plan using DOH-provided template. Contract manager. report due October 15, specified funding period.
2022
November 15,2022
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH31013-Amendment 21
Page 23 of 55
Task ' Due Date/ Payment Information
# - Activity Deliverables/Outcomes ---1 Time Frame and/or Amount
I December 15,2022 See Program Specific
January 15,2023 Requirements and Special
February 15,2023 Billing Requirements.
March 15,2023
April 15,2023
May 15,2023
June 15,2023
July 15,2023
August 15,2023
September 15,2023
2d Develop 2023-2024 MCHBG Action Plan for October 1, Submit MCHBG Action Plan to DOH Draft-August 18,2023
2023 through September 30,2024 using DOH-provided contract manager. Final-September 8,2023
template.
2e Report activities and outcomes of 2023-24 MCHBG- Submit monthly reports to DOH contract September report due
funded work using DOH-provided reporting template. manager. October 15,2023
November 15,2023
December 15,2023
January 15,2024
February 15,2024
March 15,2024
April 15,2024
May 15,2024
June 15,2024
July 15,2024
August 15,2024
I September 15,2024
2f Develop 2024-2025 MCHBG reporting document for Submit MCHBG reporting document to DOH Draft-August 16,2024
October 1,2024 through September 30,2025 using DOH- contract manager. Final-September 6,2024
provided template.
2g Support statewide roll-out of Universal Developmental Submit updates as part of monthly reporting September 30,2024
Screening Strong Start system as requested by DOH. document as requested by DOH.
2h Determine how processes and programs can become more Describe in your activities within each November 15,2023
equitable,as a foundation of your MCHBG work. Domain of the monthly report how you are December 15,2023
intentionally focused on equity in your work. January 15,2024
February 15,2024
March 15,2024
April 15,2024
May 15,2024
June 15,2024
July 15,2024
August 15,2024
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH31013-Amendment 21
Page 24 of 55
Task Activity Deliverables/Outcomes Due Date/ Payment Information
Time Frame and/or Amount
September 15,2024
7' Report activities and outcomes of 2024-25 MCHBG- Submit monthly,reports to DOH contract September report due
funded work using DOH-provided reporting template. manager. October/5, 2024
November 15, 2024
December 15. 2024
January 15, 2025
February 15. 2025
March 15. 2025
April 15, 2025
May 15, 2025
June 15. 2025
July 15. 2025
August 15. 2025
September 15. 2025
2j Develop 2025-26 AlClIBG reporting document for Submit AICHBG reporting document to DOH Draft—August 15, 2025
October 1, 2025 through September 30. 2026 using DOH- contract manager. Final—September 12.
provided template. 2025
2k Determine how processes and programs can become more Describe in your updates within each activity September report due
equitable. as a foundation oj'your 41CHBG work. of the monthly report how you are October 15, 2024
intentionally focused on equity in your work.
November 15, 2024
December 15, 2024
January 15. 2025
February 15, 2025
Alarch 15, 2025
April 15. 2025
May 15, 2025
June 15, 2025
July 15. 2025
August 15. 2025
September 15. 2025
Children and Youth with Special Health Care Needs(CYSHCN)
3a Complete Child Health Intake Form(CHIF)using the Submit CHIF data into Secure Access January 15,2022 Reimbursement for actual
CHIF Automated System on all infants and children Washington website: April 15,2022 costs,not to exceed total
served by the CYSHCN Program as referenced in https://secureaccess.wa.gov July 15,2022 funding consideration.
CYSHCN Program guidance. Monthly Reports must only
3b Identify unmet needs for CYSHCN on Medicaid and refer Submit completed Health Services 30 days after forms are reflect activities paid for with
to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment completed. funds provided in this
Diagnostic and Treatment funds to meet the need.
Exhibit A. Statement of Work Page 4 of 7 Contract Number CLH31013-Amendment 21
Page 25 of 55
Task Activity Deliverables/Outcomes Due Date/ Payment Information
# Time Frame and/or Amount
Fund requests directly to the CYSHCN statement of work for the
Program as needed. specified funding period.
3c Work with partners to share updated local CYSHCN Review resources for your local area on September 30,2022 See Program Specific
resources with Within Reach/Help Me Grow(HMG). ParentHelp 123.org annually for accuracy and Requirements and Special
submit any updates to Within Reach. Billing Requirements.
3d Complete intake and renewal,per reporting guidance Submit data to DOH per CYSHCN Program October 15,2022
supplied by DOH,on all infants and children served by the guidance. January 15,2023
CYSHCN Program as referenced in CYSHCN Program April 15,2023
guidance. July 15,2023
3e Identify unmet needs for CYSHCN on Medicaid and refer Submit completed Health Services 30 days after forms are
to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment completed.
Diagnostic and Treatment funds as needed. Fund requests directly to the CYSHCN
Program as needed.
3f Work with partners to share updated local CYSHCN Review resources for your local area on September 30,2023
resources with Within Reach/Help Me Grow(HMG). ParentHelp123.org annually for accuracy and
submit any updates to Within Reach.
3g Complete intake and renewal,per reporting guidance Submit data to DOH per CYSHCN Program October 15,2023
supplied by DOH,on all infants and children served by the guidance. January 15,2024
CYSHCN Program as referenced in CYSHCN Program April 15,2024
guidance. July 15,2024
3h Identify unmet needs for CYSHCN on Medicaid and refer Submit completed Health Services 30 days after forms are
to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment. completed.
Diagnostic and Treatment funds as needed.
3i Review your program's entry on ParentHelp 123.org Document in the Administrative box on your September 30,2024
annually for accuracy. MCHBG report that you have updated
information on your local CYSHCN program
with Within Reach/Help Me Grow.
3i (-unr/,let,'intake and renewal. per reporting guidance Submit data to DO11 per C)•SHCV Program October 15. 2024
supplied by DOII, on all infants and children served by guidance. January 15. 2025
the CYSTIC\ Program as referenced in CYSIIC.V April 15. 2025
Program guidance. if no CYSHCN care coordination .i tly 15. 2(125
(enabling service) is provided in a given quarter. email
the CHIF administrator at DOH-C'll//•a:doh.era.goy and
indicate that'Zero clients were served during the quarter.
.\n.spreadsheet is necessary w hen;ere clients ore served.
3k Identif}'unmet needs fgt.('Y.SIIC;V on.l fedicaid and refer Submit completed Health Services 30 days after forms are
to DOH CVSHC.V Program for approval to access Authorization forms and Central 7reat,nent completed.
Diagnostic and Treatment funds as needed Fund requests directly to the C YSIIC.V
Program as needed.
Exhibit A, Statement of Work Page 5 of 7 Contract Number CLH31013-Amendment 21
Page 26 of 55
Task Activity Deliverables/Outcomes Due Date/ Payment Information
Time Frame and/or Amount
31 Review your program's entry on ParentHelp123.org Document in the Administrative box on your September 30. 2025
annually for accuracy. ;t9CHBG report that you have updated
information on your local CI'S/kW program
with O'ithinReach Help Ate Grow.
3m Support improvements to the local system of care(public Submit updates as port of monthly reporting September report due
health services and systems.-policy-. systems, and document. October 15. 2024
environment)for C}'SHC'N. Refer to the Focus of Work
document for example activities and priority areas. November /5, 2024
December 15. 2024
January 15. 2025
February 15. 2025
March 15, 2025
April 15. 2025
May 15, 2025
.June 15, 2025
July /5. 2025
August 15. 2025
September 15. 2025
MCHBG Assessment and Evaluation
4a As part of the 5-year MCHBG Needs Assessment, Submit documentation using guidance September 30,2024 Reimbursement for actual
participate in activities developed and coordinated by provided by DOH. costs,not to exceed total
DOH,as requested. funding consideration.
4b Provide summary of outcomes of AIC11BGi funded work Submit documentation as requested by DOH. December 31, 2024 Monthly Reports must only
completed from October 1. 2023 through September 30, reflect activities paid for with
2024 using DOH-provided reporting template. funds provided in this
4c As part of the ongoing 5-year MCHBG Needs Assessment Submit documentation as requested by DOiI. September 30. 2025 statement of work for the
participate in activities developed and coordinated by specified funding period.
DOH using DOH-provided reporting template.
See Program Specific
Requirements and Special
Billing Requirements.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH...FinanceSharePoim site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance o doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal subrecipient funding.)
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.
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH31013-Amendment 21
Page 27 of 55
Information about the LHJ and this statement of work will be made available on USASpendin ov by DOH as required by P.L. 109-282.
Program Specific Requirements
All training costs and all travel expenses for such training(for example:per diem,hotel,registration fees)must be pre-approved,unless identified in pre-approved Budget
Workbook. Submit a paragraph to your Community Consultant(contract manager)explaining why the training is necessary to implement a strategy in the approved work plan.
Details should also include total cost of the training and a link to or brochure of the training.Retain a copy of the Community Consultant's approval in your records.
Program Manual,Handbook,Policy References:
Children and Youth with Special Health Care Needs Manual -
Children and Youth with Special Health Care Needs Manual (wa.=ov)
Health Services Authorization(HSA)Form
http://www.doh.wa.gov/Portals/l/Documents/Pubs/910-002-ApprovedH SA.docx
Restrictions on Funds:
1. At least 30%of federal Title V funds must be used for preventive and primary care services for children and at least 30%must be used for services for children with
special health care needs. [Social Security Law,Sec.505(a)(3)].
2. Funds may not be used for:
a. Inpatient services,other than inpatient services for children with special health care needs or high-risk pregnant women and infants,and other patient services approved by
Health Resources and Services Administration(HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land,the purchase,construction,or permanent improvement of any building or other facility,or the purchase of major medical
equipment.
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. Payment for any services furnished by a provider or entity who has been excluded under Title XVIII(Medicare),Title XIX(Medicaid),or Title XX(social services block
grant).[Social Security Law,Sec 504(b)].
3. If any charges are imposed for the provision of health services using Title V(MCH Block Grant)funds,such charges will be pursuant to a public schedule of charges;will not
be imposed with respect to services provided to low-income mothers or children;and will be adjusted to reflect the income,resources,and family size of the individual
provided the services. [Social Security Law, Sec.505(I)(D)].
Monitoring Visits:Telephone calls with DOH contract manager as needed.
Billing Requirements: Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable A 19-1A invoice voucher. Payment to completely expend the
"Total Consideration"for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly by the
30th of each month following the month in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a monthly fraction
of the"Total Consideration"will not be accepted or approved.
Special Instructions: Contact DOH contract manager for approval of expenses not reflected in approved budget workbook.
Exhibit A, Statement of Work Page 7 of 7 Contract Number CLH31013-Amendment 21
Page 28 of 55
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Immunization COVID-19 Vaccine- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July I,2024
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: July 1,2024 through December 31. 2024 CI state ® FFATA(Transparency Act) Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide funding to conduct COVID-19 vaccine activities.
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(+) I Allocation
COVID 19 VACCINES R4 74310259 93.268 333.93.26 07/01/24 I2/31/24 0 10,966 10,966
01 0 0
0 0 ! 0
0 0 0
0 0j 0
01 0 ' 0
TOTALS 0 10,966 10,966
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# - and/or Amount
The purpose of this statement of work is to identify activities and provide funding to support COVID vaccine response outreach,education,and operations. The activities may
include other vaccines recommended for the audience population,as long as COVID vaccine is the primary focus and references to other vaccines are secondary.
3.A Identify activity/activities to support COVID vaccine response Summary of the engagement strategies to September 30,2024 Reimbursement for actual
in your community,using the examples below as a guideline. be used with health care providers and costs incurred,not to
other partners,and the locally identified exceed total funding
Example 1: Develop and implement communication strategies population to be reached. consideration amount.
with health care providers,community,and/or other partners to
help build vaccine confidence broadly and among groups Within the first 90 days of the contract,
anticipated to receive early vaccination,as well as dispel provide a budget for FY25 funding
vaccine misinformation.Document and provide a plan that showing full expenditure of funds based
shows the communication strategies used with health care on engagement strategies.
providers and other partners and the locally identified
population anticipated to reach.
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH31013-Amendment 21
Page 29 of 55
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Example 2: Engage in other vaccination planning activities
such as partnership development,provider education,
vaccination point of dispensing(POD)planning,tabletop
exercises,engagement with communities,leaders,non-
traditional provider,or vulnerable populations to develop
strategies to ensure equitable access to vaccination services
3.B Implement the communication strategies or other activities, Written report describing November I,2024 Reimbursement for actual
working with health care providers and other partners to reach activity/activities and progress made to- costs incurred,not to
the locally identified population,support providers in date and strategies used(template to be exceed total funding
vaccination plans,and support equitable access to vaccination provided) consideration amount.
services.
Forecast of expected spend down of
remaining funds through remainder of
contract(if extended past December 31,
2024)in DOH template provided).
3.0 Catalog activities and conduct an evaluation of the strategies Written report,showing the strategies used December 31,2024 Reimbursement for actual
used and the final progress of the reach costs incurred,not to
(template to be provided) exceed total funding
consideration amount.
3.D As needed to meet community needs,expand operations to Reports summarizing quantity,type,and December 31,2024 Reimbursement for actual
increase vaccine throughput(i.e.,providing vaccinations during frequency of activities costs incurred,not to
evenings,overnight,and on weekends)or adjust vaccine exceed total funding
delivery approaches to optimize access. Activities may include consideration amount.
vaccine strike teams,mobile vaccine clinics,satellite clinics,
temporary,or off-site clinics to travel and provide vaccination
services in non-traditional settings,or to supplement the work
of local health departments in underserved communities,and
may include administration costs for other vaccines co-
administered at the events.These activities may be done by the
local health department or in collaboration with community
partners.(see Restrictions on Funds below)
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@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.
Exhibit A, Statement of Work Page 2 of 3 Contract Number CLH31013-Amendment 21
Page 30 of 55
Program Specific Requirements
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
Coverage of co-administration costs for other vaccines administered at vaccination events does NOT apply to the FEMA Mass Vaccination funding. Coverage of co-
administration costs only applies to the vaccine funding(COV ID19 Vaccine R4,MI 74310230)allocated for Task 3 of the consolidated contract. FEMA Mass Vaccination
funding is only available to cover the costs for COVID vaccine administration and cannot be used for co-administration costs of other vaccines.
Unallowable Costs:
There are limitations from the funding source on allowable costs for this contract. If the contractor is unsure if a cost is allowable,they should contact the contract manager for
approval of the cost prior to making the purchase or charge.
• Advertising costs(e.g.,conventions,displays,exhibits, meetings,memorabilia,gifts,souvenirs)
• Alcoholic beverages
• Building,purchases,construction,capital improvements
• Clinical care(non-immunization services)
• Entertainment costs
• Fundraising Cost
• Goods and services for personal use
• Honoraria
• Independent Research
• Land acquisition
• Legislative/lobbying activities
• Interest on loans for the acquisition and/or modernization of an existing building
• Payment of a bad debt,collection of improper payments
• Promotional and/or incentive materials(e.g.plaques,clothing,and commemorative items such as pens,mugs/cups, folders/folios, lanyards,magnets,conference bags)
• Purchase of food/meals(unless part of required travel per diem costs)
• Vehicle Purchase
• Vaccine Purchase
Exhibit A.Statement of Work Page 3 of 3 Contract Number CLH31013-Amendment 21
Page 31 of 55
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Immunization-Promotion of Immunizations to Local Health Jurisdiction Name: Jefferson County Public Health
Improve Vaccination Rates - Effective July I.2024
Contract Number: CLH3 1013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: July I,2024 through December 31,2024 ❑ State ® FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑Research &Development
Statement of Work Purpose: The purpose of this statement of work is to contract with local health to conduct activities to improve immunization coverage rates.
NOTE: Deliverables with due dates after December 31,2024,are shown for informational purposes only and will be included in a new SOW in the next Consolidated
Contract term starting January 1,2025.
Revision Purpose: N/A
l
Master Assistance BARS AllocationLHJ 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
FFY25 CDC VFC Ops 74310251 93.268 333.93.26 07/01/24 12/31/24 0 5,600 5,600
0 0 0
0 0 0
0 0 0
_ 0 0 0
0 0 0
TOTALS 0 5,600 i 5,600
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Develop a proposal to improve immunization coverage rates for Written proposal summarizing project plan September 15,2024 Reimbursement for actual
a target population by increasing promotion activities and and method of assessing/observing change costs incurred,not to
collaborating with community partners(can use pre and post in target population. exceed total funding
qualitative or quantitative collection methods consideration amount.
Examples of qualitative&quantitative methods/measures: (Template will be provided)
• Surveys,Questionnaires, Interviews
• Immunization coverage rates expressed in percentages
• Observations(i.e.,feedback from surveys/interviews,
social media posts comments)
• Analytic tools(i.e.,google analytics measuring
website traffic,page views etc.)
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH31013-Amendment 21
Page 32 of 55
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
2 Within the first 90 days of the contract provide a budget for Sumit completed Budget Template September 30,2024
FY25 funding. provided by Department of Health
3 Upon approval of proposal,implement the plan to increase Written report describing the progress Reimbursement for actual
immunization coverage rates with the target population made on reaching milestones for activities January 15,2025 costs incurred,not to
identified. identified in the plan(template will be exceed total funding
provided) consideration amount.
4 Within 6 months of the start of the contract provide a Budget Submission of Budget Forecast form January 15,2025
Forecast. provided by Department of Health stating
spend down of remain funds.
5 Develop final report to include comparison of change or Final written report including measured Reimbursement for actual
improvement of targeted outcome from start of the and/or observed outcomes[what was June 16,2025 costs incurred,not to
project/intervention [This can be short-term or intermediate achieved as a result of the exceed total funding
outcomes with overall goal to increase immunization rates] activity/intervention?]. consideration amount.
Examples:
• Increased partner knowledge on immunization (Template will be provided)
guidelines
• Change in attitudes about childhood vaccines
• Increase in school district immunization coverage
rates
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH._Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@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_,ov by DOH as required by P.L. 109-282.
Program Specific Requirements
Unallowable Costs:
There are limitations from the funding source on allowable costs for this contract. If the contractor is unsure if a cost is allowable,they should contact the contract manager for
approval of the cost prior to making the purchase or charge.
• Advertising costs(e.g.,conventions,displays,exhibits, meetings,memorabilia,gifts,souvenirs)
• Alcoholic beverages
• Building,purchases,construction,capital improvements
• Clinical care(non-immunization services)
• Entertainment costs
Exhibit A,Statement of Work Page 2 of 3 Contract Number CLH31013-Amendment 21
Page 33 of 55
• Fundraising Cost
• Goods and services for personal use
• Honoraria
• Independent Research
• Land acquisition
• Legislative/lobbying activities
• Interest on loans for the acquisition and/or modernization of an existing building
• Payment of a bad debt,collection of improper payments
• Promotional and/or incentive materials(e.g.,plaques,clothing,and commemorative items such as pens,mugs/cups,folders/folios, lanyards,magnets,conference bags)
• Purchase of food/meals(unless part of required travel per diem costs)
• Vehicle Purchase
Exhibit A, Statement of Work Page 3 of 3 Contract Number CLH31013-Amendment 21
Page 34 of 55
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Resiliency&Health Security-PHEP- Local Health Jurisdiction Name: Jefferson County Public Health
Effective July 1,2024
Contract Number: CLH3I013
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: July I,2024 through December 31,2024 ❑ State ® FFATA(Transparency Act) ❑ Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to establish funding and tasks for LHJs to strengthen their capacity and capability around the Public
Health Response Readiness Framework(CDC)to prepare for,respond to,and recover from public health threats and emergencies through a continuous cycle of planning,
organizing,training,equipping,exercising,evaluating,and implementing corrective actions as described in the Public Health Emergency Preparedness(PHEP)Cooperative
Agreement. Many LHJs support a position responsible for public health emergency preparedness and response. LHJs use different titles for these positions. DOH wants to be
respectful of this diversity and refers to the people who fill these important roles as Public Health Emergency Response Coordinators(PHERCs).
Note:The current Consolidated Contract ends December 31,2024.Once a new contract is in place,the program plans to submit a new statement of work for January I - June 30,
2025. Deliverable due dates after December 31,2024 are referenced in this statement of work for informational purposes only and will be updated in the January-June 2025
statement of work.
This statement of work(ending 12/31/24)includes 60%of the total allocation of these funds.The January -June 2025 statement of work will reflect the remaining 40%.Once all
invoices have been submitted and balances are reconciled for this statement of work(ending 12/31/24),any remaining funds will be added to a revised January-June 2025
statement of work.
Guidance Documents-LHJs are strongly encouraged to use the Guidance Documents listed in the Program Specific Requirements in the bottom section of this Statement of Work.
Revision Purpose: NA
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
FFY24 PHEP BPI -CDC-LHJ PARTNERS 31602241 93.069 333.93.06 07/01/24 12/31/24 0 20,630 20,630
0 0 0
0 0 0
0 0 0
0 ' 0 0
__ 0 0 0
TOTALS 0 20,630 , 20,630
Exhibit A,Statement of Work Page 1 of 8 Contract Number CLH31013-Amendment 21
Page 35 of 55
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Submit names, position titles,email addresses,and Submit information by September 1,2024 Reimbursement for
Contact Information phone numbers of key LHJ staff responsible for September 1,2024,and any actual costs not to
this statement of work,including management, changes within 30 days of the Within 30 days of the exceed total funding
Framework 2—Enhance Emergency Response Coordinator(s),and change. change. consideration amount.
Partnerships accounting and/or financial staff.
Mid-and end-of-year reports on December 31,2024
template provided by DOH.Note June 30,2025
any changes or no changes.
2 Submit LHJ Performance Measure Data as LI IJ Performance Measure Data June 30,2025
LHJ Performance Measures requested on the form provided by DOH. on the form provided by DOH.
Framework 6—Modernize
data collection and systems
3 Submit additional information as requested by Information requested by DOH. As requested by DOH.
Additional Information DOH to comply with federal grant requirements.
Required by CDC
Complete reporting templates as requested by
Framework 4—Improve DOH to comply with program and federal grant
administrative and budget requirements, including the mid-year and end-of-
preparedness systems year reports.
4 Complete the public health disaster risk Public Health Disaster Risk June 30,2025
Risk Assessment assessment developed by the University of Assessment
Washington(UW)(available early February 2025)
Framework I —Develop reflecting the needs of the whole LHJ.
threat-specific approach
DOH and/or UW will provide the tool and
Framework 3—Expand technical assistance.
local support
Framework 8—Incorporate
health equity practices
5 Complete multiyear integrated preparedness plan Multiyear integrated preparedness June 30,2025
Planning using lessons learned from emergency responses, plan.
with critical response and recovery partners.
Framework 4—Improve
administrative and budget Engage partners to incorporate health equity
preparedness systems principles.
Exhibit A.Statement of Work Page 2 of 8 Contract Number CLH31013-Amendment 21
Page 36 of 55
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Framework 8—Incorporate Including(but not limited to):
health equity practices • Administrative preparedness plans.
• Recovery operations.
• Incident response improvement plan data
elements.
6 Review LHJ public health preparedness and Mid-and end-of-year reports on December 31,2024
Planning-IPPW response capabilities and identify gaps, priorities, template provided by DOH. June 30,2025
and training needs.
Framework 2—Enhance IPPW Workbook provided by
Partnerships Complete the Integrated Preparedness Planning DOH.
Workshop(IPPW) Workbook provided by DOH.
Framework 5—Build Participation in IPPW.
workforce capacity Participate in the DOH Integrated Preparedness
Planning Workshop(IPPW).The Workshop is
Framework 10—Prioritize planned for early 2025.
community recovery efforts
7 Develop or update crisis and emergency risk Mid-and end-of-year reports on December 31,2024
Communication& Planning communication and information dissemination template provided by DOH. June 30,2025
plans.
Framework 7—Strengthen
risk communication
activities
8 Complete training to ensure baseline competency Mid-and end-of-year reports on December 31,2024
Training and integration with preparedness requirements. templates provided by DOH, June 30,2025
including title,date(s),sponsor of
Framework 5—Build Participate in at least one public health emergency the training or conference,and
workforce capacity preparedness,response,or recovery training. summary of what you learned.
Participation in a conference related to public
health emergency preparedness,response,or
recovery may be used to meet this requirement.
Work with Public Health Emergency Response
Coordinators(PHERCS)to review public health
preparedness and response plans and identify gaps,
priorities,and training needs.
Exhibit A, Statement of Work Page 3 of 8 Contract Number CLH31013-Amendment 21
Page 37 of 55
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Integrate administrative and budget preparedness
recommendations into training.
Recommended Training
Public health preparedness and recovery staff,
including exercise planning staff:
• Incident Command System(ICS) 100:
Introduction to ICS
• ICS 700:An Introduction to the National
Incident Management System(NIMS)
• ICS 800:National Response Framework.
An Introduction
• IS-120.C:An Introduction to Exercise
• 1S-2900.A:National Disaster Recovery
Framework(NDRE)Overview
• Homeland Security Exercise and Evaluation
Program
• Preparation for Resource Providers
Health Department supervisory positions:
• ICS 200:Basic ICS for Initial Response
• Independent Study(IS)-2200: Basic
Emergency Operations Center Functions
Staff with designated response roles:
• ICS 300:Intermediate ICS for Expanding
Incidents
• Crisis and Emergency Risk Communication
(CERC)
Senior staff who support the management of
large/complex responses
(incidents across multiple locations or over a large
area):
• ICS 400:Advanced ICS
Notes:
Prior approval from DOH is required for any out-
of-state travel paid for with PREP funding.
Exhibit A,Statement of Work Page 4 of 8 Contract Number CLH31013-Amendment 21
Page 38 of 55
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Participation in an activation,exercise or real-
world event may be considered additional training.
but does not take the place of the requirement to
participate in at least one training as described
above.
9 Participate in at least one exercise by June 30, Mid-and end-of-year reports on December 31,2024
Exercising 2025. template provided by DOH. June 30,2025
• Include critical response and recovery
Framework 2—Enhance partners. Improvement Plans available
Partnerships • Engage partners to incorporate health equity upon request.
principles.
Framework 3—Expand • Integrate administrative and budget
local support to improve
jurisdictional readiness to preparedness recommendations.
effectively manage public • Complete AAR/IP for the exercise by June
health emergencies 30t,2025.
Note:
This may include developing and conducting
exercises or participating in exercises developed
and conducted by another organization,such as
other LHJs.
10 Identify and implement communication Mid-and end-of-year reports on December 31,2024
Communication& monitoring media relations,and digital template provided by DOH. June 30,2025
Exercising communication strategies in exercises.
Framework 7—Strengthen Include communications and/or Public Information
risk communication Officer in exercises or real world event to identify
activities and implement communication monitoring,media
relations,and digital communication.This may
include one or more exercises by June 30,2025.
11 Note:This activity applies to non-CRI LHJs only. Mid-and end-of-year reports on December 3I,2024
MCM—Non-CRI LHJs template provided by DOH. June 30,2025
Maintain ability to procure,store,manage,and
Framework 1 —Develop distribute medical materiel.
threat-specific approach
Maintain ability to dispense and administer
Framework 10—Prioritize medical countermeasures(MCM).
community recovery efforts
Exhibit A, Statement of Work Page 5 of 8 Contract Number CLH31013-Amendment 21
Page 39 of 55
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and;ur ttmuunt
Attend an MCM quarterly meeting for the non-
CRI LHJs.
Continue to show capabilities by submitting
updated MCM plans as needed.
12 Provide immediate notification to DOH Duty Mid-and end-of-year reports on December 31,2024
DOH Duty Officer Officer at 360-888-0838 or hanalert@doh.wa.gov doh.wa.gov template provided by DOH. June 30,2025
for all response incidents involving use of
Framework 7—Strengthen emergency response plans and/or incident
risk communications command structures.
activities
Produce and provide situation reports(sitreps)
documenting LHJ activity during all incidents.
Sitrep may be developed by the LHJ or another
jurisdiction that includes input from LHJ.
•
13 Maintain Washington Secure Electronic Mid-and end-of-year reports on December 31, 2024
WASECURES Communications,Urgent Response and Exchange template provided by DOH. June 30,2025
System(WASECURES)as the primary
Framework 7—Strengthen notification system.
risk communication
activities Participate in DOH-led notification drills.
Conduct at least one LHJ drill using the LHJ-
preferred staff notification system.
Notes:
• Registered users must log in(or respond to
an alert)quarterly at a minimum.
• DOH will provide technical assistance to
LHJs on using WASECURES.
• LHJ may choose to use another notification
system in addition to WASECURES to alert
staff during incidents.
14 Identify and implement specific crisis and Mid-and end-of-year reports on December 31,2024
Communication & emergency risk communication activities that meet template provided by DOH. June 30,2025
Communities of Focus the diverse needs of local community based
organizations that support people who may be
Framework 10—Prioritize disproportionally impacted by the public health
community recovery efforts impacts of a disaster.
Exhibit A, Statement of Work Page 6 of 8 Contract Number CLH31013-Amendment 21
Page 40 of 55
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
DOH will work with LHJs to serve the needs of
the socially vulnerable community members in
their jurisdictions with a focus on public health
equity.
15 During each reporting period(Jul—Dec and Jan- Mid-and end-of-year reports on December 31, 2024
Healthcare Coalition (HCC) Jun),participate in two or more of the following template provided by DOH. June 30,2025
Participation activities with the Northwest Healthcare Response
Network(N WHRN)or the Healthcare Alliance
Framework 3—Expand (HCA):
local support • Meetings
• Communication
• Planning
• Training
• Exercises
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.
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
Special Requirements:
Guidance Documents-LHJs are strongly encouraged to use the following documents to inform their implementation of activities in this statement of work:
Washington State Doctrine for Enhancing Resiliency,Health Security, Response, and Recovery. DOH will provide a copy.
Public Health Response Readiness Framework(CDC)--2024-2028 PHEP Program Priorities—Defines Excellence in Response Operations
Implementing Public Health Response Readiness Framework I State and Local Readiness I CDC
Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal.and Territorial Public Health
Public Health Emergency Preparedness and Response Capabilities I State and Local Readiness I CDC
2024 PHEP Cooperative Agreement Guidance Budget Period/
2024-2028 PHEP Cooperative Agreement Guidance/Budget Period 1 I State and Local Readiness I CDC
Exhibit A.Statement of Work Page 7 of 8 Contract Number CLH31013-Amendment 21
Page 41 of 55
Follow all Federal requirements for use of Federal funds:
Code of Federal Regulations(CFR),Title 2,Subtitle A,Chapter II,Part 200
Uniform Administrative Requirements,Cost Principle,and Audit Requirements for Federal Awards
CFR ::2 CFR Part 200—Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards
The following expenses are not allowable with these funds:
• Clothing(except for vests to be worn during exercises or responses).
• Incentives.
• Items to be given to community members(members of the public).
• Salaries at a rate more than Executive Level II(Federal Pay Scale).
• Vehicles(with preapproval,funds may be used to lease vehicles).
Preapproval from DOH is required to use these funds for:
• Contracting.
• Purchasing food or beverages(unless employees are in travel status,then reimbursement of food and beverages is allowable).
• Purchasing equipment(see definition of equipment in 2 CFR 200,link above).
• Disposition of equipment with a current value of(see 2 CFR 200,link above).
• Leasing vehicles.
• Out of state travel.
Note: Preapproval is no longer required for paying overtime.
See also DOH A 19 Documentation Matrix for additional expenses that may require preapproval.
Billing:
All expenses on invoices must be related to statement of work tasks.
Submit invoices monthly on a signed A 19 with backup documentation appropriate for risk level.DOH will provide A19 and risk level.
• I f your invoice includes indirect costs,you must have an indirect rate cost agreement approved by DOH.
• If you have no expenses related to this contract for a month,let your DOH Fiscal Contact know via email.
• Submit final billing within 60 days of the end of the contract period.
Exhibit A, Statement of Work Page 8 of 8 Contract Number CLH31013-Amendment 21
Page 42 of 55
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 I,2022
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 11 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January I,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 December 31,2024 are for reporting only.LHJs may not bill state funds under this contract for work done after December 31.2024.
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$13,747 to FFY24 FPHPA Title X Family Plan Funds for the period of 04/01/2024- 12/31/2024.
Master Assistance BARS 1 Allocation '
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code I Start Date End Date Allocation Increase(+) Allocation
SFY22 Sexual&Rep Hlth Cost Share 78430120 N/A 334.04.91 i 01/01/22 06/30/22 44,100 0 44,100
FFY22 Title X Dire Needs 78430222 93.217 333.93.21 1 01/14/22 03/31/22 4,066 0 4,066
FFY22 Title X Family Planning 78430225 93.217 333.93.21 1 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 i 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 17,733 13,747 31,480
SFY25 Sexual&Rep Hlth Cost Share 78430150 , N/A 334.04.91 07/01/24 12/31/24 48,323 0 48,323
0 01 0
1
01 0j 0
0 ; Oi 0
r--
TOTALS 339,842 13,747 1 353,589
Exhibit A,Statement of Work Page 1 of 7 Contract Number CLH31013-Amendment 21
Page 43 of 55
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
SRH P. required back up documentation per DOH policy. DOH (see Reporting
A. Comply with Washington State SRHP Manual, • All reports described in Reporting Requirements table As described in Requirements table).
federal Title X requirements and all state and below. Reporting
federal laws.Also see Program Manual, Requirements table DOH reserves the right
Handbook,Policy References under Reporting • Other data and documentation in format requested by below. to withhold payment
Requirements below. DOH.(Includes copies of program and financial until:
audits and reviews including summaries conducted by As requested by DOH • Compliance issues
B. Complete required Agency Information Request other entities.) or a previous
including Title X Assurance of Compliance and invoice are
National Provider Identifier(NPI)billing • To facilitate DOH/TX desk reviews—requested resolved in a way
numbers. documentation available to DOH in requested format. accepted by DOH
• Current data is
C. Provide medical services,community education • To facilitate DOH/TX site-visits--appropriate staff submitted to,and
and outreach,and staff training,consistent with and documentation readily available prior to and accepted by,
state requirements: during review. Ahlers.
1. LHJ is responsible for making sure all staff • A 19 back up
have the knowledge to carry out the • Site review directed by DOH SRHP. Follow-up site documentation
requirements of the SOW. visits as needed until identified issues are resolved. required by DOH
2. Medical, laboratory,and other services As requested by DOH has been submitted
related to abortion are not covered by this • Submit documentation to DOH SRHP as requested for and approved.
task. a desk review prior to site visit. • Other deliverables
3. Community education services must be have been met.
based on the needs of the community.LHJ • Appropriate staff and documentation readily available
must have an Information&Education to DOH SRHP prior to and during site visit. Payment is limited to
(I&E)committee with five(5)or more the maximum funds
members that is broadly representative of available for funding
the population or community for which source.
materials are intended.The committee must
review a batch of patient-facing materials DOH will reimburse
annually(at least 15 products or 15%of for:
your total number of materials,whichever •
is smaller);meet at least annually and Actualallowable
establish a written record of its costs acccorordidinggtto
your approved cost
determination.(42 CFR 59[59.6])
analysis(see
4. Outreach is to ensure all populations in Reporting
your community understands the services Requirements
available. Focus your outreach efforts on table).
increasing equity. or
• The amount
remaining in the
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH31013-Amendment 21
Page 44 of 55
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
Frame and/or Amount
Washington State Sexual and Reproductive Health R&E divided by
Network priority populations are: the number of
• Teens months remaining
• People who are uninsured or underinsured, in the funding
and/or low-income(at or below 250%of the source,plus one,
federal poverty line) whichever is less.
• Rural communities
• Hispanic Payment will be
• Black, Indigenous,People of Color The 15'of the calculated by R&E
Extra efforts should be made to provide information following month. provided by DOH(see
and services to people who intersect with multiple CVR data submitted to DOH data contractor(Ahlers& Within thirty(30)days Reporting
priority population categories. Associates)electronically in a format compatible with of receiving Requirements table).
Ahlers software. error/rejection report
Provide all services in accordance with: or request from DOH All services must be
• DOH SRHP&Title X Manual • Data for each month Sexual and billed within 60 days of
• Other state and federal requirements Reproductive Health the budget period,with
• Reporting Requirements(see below) • Corrected CVR data data manager. the exception of the
December billing that is
D. Collect,maintain,and provide data about each due within 45 days to
family planning clinic visit as defined in the meet federal reporting
SRH CVR Manual. As needed to keep requirements.
1. Maintain a computer system that includes Email briefly describing change. information current.
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 SRHP/Title
X funding.
• Expected clinic site closures.Note:DOH
may.at its sole discretion, recalculate LHJ's
funding allocation if it closes a clinic site.
• Any other change that might affect LHJ's
ability to provide the sexual and
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH31013-Amendment 21
Page 45 of 55
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
Frame and/or Amount
reproductive services described in this
SOW.
Reporting Requirements
1. Agency Information 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 from must be completed by April 30'during each year of
all members of the SRHP Network to ensure this contract. Requested information will include: AND
accurate records of LHJ's organization and the
services it provides. Information about your agency contacts and your As needed or
organization's staffing requested to maintain
In addition,elements of this report allow DOH A. Head of Organization accuracy of
to ensure that SRHP&Title X requirements B. Head of Finance information.
including client fees and required services are C. Medical Director
met.The updated information also assists DOH D. NPI numbers used to bill Medicaid
to manage this SOW and the Sexual& E. The following(one person might fill more than one
Reproductive Health Network 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 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.
B. Sliding fee schedule that includes all services required
in the SRH Manual.Additional SRH-related services
as outlined in Task 1 may also be included on LHJ's
sliding fee schedule. Submit an updated
a. Sliding fee schedule must be based on cost income conversion
analysis described above. table by March 15 of
Exhibit A, Statement of Work Page 4 of 7 Contract Number CLH31013-Amendment 21
Page 46 of 55
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
Frame and/or Amount
b. Fee schedule must be resubmitted for reapproval each year of the
anytime there are any significant changes,which contract.
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.
This process must include the following steps:
A. Utilize the state level priority populations,county
level demographic data,and agency profile to
identify 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.
2. Progress 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 current and past requested by DOH
SRH Program. SOWs:
It informs quality improvement of the A. Community education and outreach strategies and
Washington State SRH Network. activities and a discussion of their effectiveness.
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).
(January through December).The subsequent A. Pap tests with an ASC or higher result
agreements sent to the agency will request that B. Pap tests with an HSIL or higher result
these data be collected and reported on within C. HIV Positive confidential tests
the statement of work period of performance. D. HIV Anonymous tests
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.
Exhibit A,Statement of Work Page 5 of 7 Contract Number CLH31013-Amendment 21
Page 47 of 55
Task Activity Deliverables/Outcomes Due Date/Time Payment Information
Frame and/or Amount
Financial data emailed to DOH Contract Manager
R&E showing Other Revenue through the end of the grant
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 15th of the
in the Clinic Visit Record(CVR) Manual available at: following month.
https://www.doh.wa.Qov/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
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. sources of revenue that
All entries on"Other"rows must be accompanied by a support services must
description of the revenue source or expense,including any be billed within 45
calculations uses. days of the budget
period. December
billings must be
submitted by February
10'''.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance n doh.wa.gov.
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.
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH31013-Amendment 21
Page 48 of 55
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)
• LH1's approved Agency Information 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 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 7 of 7 Contract Number CLH31013-Amendment 21
Page 49 of 55
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) 12 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 FFY25 USDA WIC CLIENT SVS CONTRACTS,FFY24 USDA WIC CLIENT SVS CONTRACTS, and FFY24 USDA BFPC PROG MGMTfunds.
Master Assistance BARS Allocation
LHJ Funding Period Change
Index Listing Revenue CurrentTotal
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 9,413 47,064
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 09/30/24 155,754 4,718 160,472
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 1,860 28,128
FFY24 USDA FMNP MGMT 76540241 10.572 333.10.57 05/01/24 09/30/24 496 0 496
0 0 0
TOTALS 523,735 15,991 539,726
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 CLH31013-Amendment 21
Page 50 of 55
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
18b 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 21
Page 51 of 55
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 finance@doh.wa.eov.
Federal Funding Accountability and Transparency Act(FFATAj(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 21
Page 52 of 55
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 CLH3 1 0 13-Amendment 21
Page 53 of 55
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 CLH31013-Amendment 21
Page 54 of 55
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-IA 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 21
Page 55 of 55
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 CLH3I013-Amendment 21
Signature: ' '
Bread Hen;kson(Sep 11,2U2i 15:52 POT)
Email: Brenda.Henrikson@DOH.WA.GOV