HomeMy WebLinkAboutCONSENT PH Consolidated Contracts 615 Sheridan Street
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Consent Agenda
Public Health
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, County Administrator
FROM: Apple Martine, JCPH Director
Veronica Shaw, JCPH Deputy Director
DATE: V nuaky 27 20 ZS—
SUBJECT: Agenda Item — Consolidated Contracts Amendment #1 with the Department
of Health; January 1, 2025 — December 31, 2027; $2,645,323
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #1
between JCPH and State of Washington Department of Health (DOH); January 1, 2025 — December 31, 2027;
funding of $2,645,323.
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:
• DCHS - ELC COVID-19 Response — provides funding for the local health jurisdiction (LHJ) to ensure
adequate culturally responsive testing and investigation to limit the spread of COVID-19 ($15,580)
• Foundational Public Health Services (FPHS) —funds are for LHJ health programs, to build the system's
capacity and increase the availability of FPHS services statewide ($2,333,000)
• Infectious Disease-Syndemic Prevention Services-SSP — provides Syndemic (occuring when two or more
infectious diseases or health conditions cluster and interact within a population) Prevention Services
($89,250)
• Injury &Violence Prevention-LHJ Opioid Campaign Proviso — Opioid abatement settlement account
($31,500)
• Maternal & Child Health Block Grant— supports local interventions that impact the target population of
the Maternal and Child Health Block Grant ($27,525)
• Office of Drinking Water Group A Program — provides funding for conducting sanitary surveys and
providing technical assistance to small community and non-community water systems ($5,400)
• Office of Immunization-Promotion of Immunizations to Improve Vaccination Rates— contracts with local
health to conduct activities to improve immunization coverage rates ($10,000)
Community Health
Developmental Disabilities Environmental Public Health
360-385-9400 360-385-9444
360-385-9401 (f) (f) 360-379-4487
CC-25-001-A 1 Always working for a safer and healthier community
• Office of Resiliency & Health Security-PREP — establishes funding and tasks for LHJs to strengthen their
capacity and capability to prepare for, respond to, and recover from public health threats and
emergencies ($13,754)
• Recreational Shellfish Activities — provided funds for shellfish harvesting safety ($3,700)
• School-Based Health Centers Program —formalizes a grant award to JCPH for a School-Based Heath
Centers operations grant ($59,000)
• Sexual & Reproductive Health Program — provides funding for sexual and reproductive health services
($56,614)
FISCAL IMPACT/COST BENEFIT ANALYSIS
Total consideration for this Contract Amendment is $2,645,323. The Consolidated Contract is funded by DOH,
and comprises both Federal and State funds.
RECOMMENDATION:
JCPH Management recommends BoCC approval of Consolidated Contract Amendment #1 between JCPH and
DOH; January 1, 2025 — December 31, 2027; funding of $2,645,323.
REVIEWED BY:
Mark McCauley, Couv Administrator Dater/
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-25-001-Al
Contract For: Consolidated Contracts, Amendment 1 Term: 1/1/2025 - 12/31/2027
COUNTY DEPARTMENT: Public Health
Contact Person: Veronica Shaw
Contact Phone: x 409
Contact email: veronica@co.jefferson.wa.us
PROCESS:
AMOUNT: $2,645,323 Exempt from Bid Process
Revenue: $2,645,323 Cooperative Purchase
Expenditure: Competitive Sealed Bid
Matching Funds Required: Small Works Roster
Sources(s) of Matching Funds Vendor List Bid
Fund # 127 RFP or RFQ
Munis Org/Obj 12756220 Other:
APPROVAL STEPS:
STEP 1: DEPARTMENT CERTIFIES COMP -A EL a5.080 AND CHAPTER 42.23 RCW.
CERTIFIED: a N/A:1 _ Jan. 14, 2025
Signat •e Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEEN DEBAR D BY ANY FEDERAL, STATE, OR LOCAL
AGENCY. oc CERTIFIED: F N/A: _ Jan. 14,2025
Signature Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 1/17/2025.
STEP 4: PROSECUTING ATTORNEY REVIEW(will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 1/16/2025.
Amendment No. 1 with original 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 61
JEFFERSON COUNTY PUBLIC HEALTH
2025-2027 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH32053 AMENDMENT NUMBER: 1
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as"DOH",and
JEFFERSON COUNTY PUBLIC HEALTH,a Local Health Jurisdiction,hereinafter referred to as"LHJ",pursuant to the
Modifications/Waivers clause,and to make necessary changes within the scope of this contract and any subsequent amendments
thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work,includes the following statements of work,which are incorporated by this reference and located on
the DOH Finance SharePoint,site in the Upload Center at the following URL:
httns:Hstateofwa,sharepoint.com/sites/doh-ofsfundin,zresources/siter)agcs/home asnx?=e1.9a94688da2d94d3ea80ac7fbc32e4d7c
® Adds Statements of Work for the following programs:
DCHS-ELC COVID-19 Response-Effective January 1,2025
Foundational Public Health Services(FPHS)-Effective January 1,2025
Infectious Disease-Syndemic Prevention Services-SSP-Effective January 1,2025
Injury&Violence Prevention-LHJ Opioid Campaign Proviso—Effective January 1,2025
Maternal&Child Health Block Grant—Effective January 1,2025
Office of Drinking Water Group A Program-Effective January 1,2025
Office of Immunization-Promotion of Immunizations to Improve Vaccination Rates-Effective January 1,2025
Office of Resiliency&Health Security-PHEP-Effective January 1,2025
Recreational Shellfish Activities-Effective January 1,2025
School-Based Health Centers Program-Effective Janaury 1,2025
Sexual&Reproductive Health Program-Effective January 1,2025
❑ Amends Statements of Work for the following programs:
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-1 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-0 Allocations as follows:
® Increase of$2,645,323 for a revised maximum consideration of SZ.645,323.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations are attached only for informational purposes.
3. Exhibit C Federal Grant Awards Index,incorporated by this reference,and located in the ConCon,Funding&BARS library at
the URL provided above.
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
Heidi Eisenhour,Chair Date Date
O ZtFORM ONLY APPROVED AS TO FORM ONLY
TpAssistant Attorney General
E
for 01/16/2025
Philip C.Hunsucker, Date Page I of I
Chief Civil Deputy Prosecuting Attorney
CC-25-001-AI
EXHIBIT B-1 Page 2 of 61
Jefferson County Public Health ALLOCATIONS Contract Number: CLH32053
Contract Term:2025-2027 Date: January 1,2025
Indirect Rate as of January 1,2025:27.94%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
FFY24 PHEP BPI-CDC-LHJ Partners NU90TU000055 Amd 1 93.069 333.93.06 01/01/25 06/30/25 07/01/24 06/30/25 $13,754 $13,754 $13,754
FFY24 0132A OID CDC Prevent NU17CE010218 Amd 1 93.136 333.93.13 01/01/25 06/30/25 09/01/24 08/31/25 $49,000 $49,000 $49,000
FFY24 FPHPA Title X Family Plan FPHPA006560 Amd 21 93.217 333.93.21 01/01/25 03/31/25 04/01/24 03/31/25 $8,621 $8,621 $8,621
FFY24 CDC PPHF Ops NH231P922619 Amd 1 93.268 333.93.26 01/01/25 06/30/25 07/01/23 06/30/25 $10,000 $10,000 $10,000
FFY20 ELC EDE LHJs CDC NU50CK000515 Amd 1 93.323 333.93.32 01/01/25 06/30/25 01/15/21 07/31/25 $15,580 $15,580 $15,580
FFY25 HRSA MCHBG LHJ Contracts NGA Not Received Amd 1 93.994 333.93.99 01/01/25 09/30/25 10/01/24 09/30/25 $27,525 $27,525 $27,525
SFY25 SBHC Proviso Amd 1 N/A 334.04.90 01/01/25 06/30/25 07/01/24 06/30/25 $59,000 $59,000 $59,000
SFY25 Drug User Health Program Amd 1 N/A 334.04.91 01/01/25 06/30/25 07/01/24 06/30/25 $40,250 $40,250 $40,250
SFY25 Sexual&Rep Hlth Cost Share Amd I N/A 334.04.91 01/01/25 06/30/25 07/01/24 06/30/25 $47,993 $47,993 $47,993
SFY25 LHJ Opioid Campaign Proviso Amd 1 N/A 334.04.93 01/01/25 06/30/25 07/01/24 06/30/25 $31,500 $31,500 $31,500
Rec ShellfishBiotoxin Amd 1 N/A 334.04.93 01/01/25 06/30/25 07/01/23 06/30/25 $3,700 $3,700 $3,700
SFY25 FPHS-LHJ Funds-GFS Amd 1 N/A -336.04.25 01/01/25 06/30/25 07/01/24 06/30/25 $2,333,000 $2,333,000 $2,333,000
YR 27 SRF-Local Asst(15%)SS Amd I N/A 346.26.64 01/01/25 06/30/25 07/01/23 06/30/25 $2,200 $2,200 $2,200
Sanitary Survey Fees SS-State Amd 1 N/A 346.26.65 01/01/25 06/30/25 07/01/23 06/30/25 $2,200 $2,200 $2,200
YR 27 SRF-Local Asst(15%)TA Amd 1 N/A 346.26.66 01/01/25 06/30/25 07/01/23 06/30/25 $1,000 $1,000 $1,000
TOTAL $2,64.5,323 $2,645,323
Total consideration: s0 GRAND TOTAL $2,645,323
$2,645,323
GRAND TOTAL $2,645,323 Total Fed $124,480
Total State $2,520,843
*Assistance Listing Number fka Catalog of Federal Domestic Assistance
"Federal revenue codes begin with"333". State revenue codes begin with"334".
Pagel of 1
Page 3 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: DCHS-ELC COVID-19 Response- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ® Reimbursement
❑ ❑
Period of Performance: January 1,2025 through June 30.2025 State Other ®FFATA(Transparency Act)
Fixed Price
❑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 linguistically
responsive testing,investigation and contract tracing resources to limit the spread of COVID-19.
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY20 ELC EDE LHJS CDC 1897140E 93.323 333.93.32 01/01/25 06/30/25 0 15,580 15,580
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 15,580 15,580
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 6 Contract Number CLH32053-Amendment 1
Page 4 of 61
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 Within 30 days of receiving Reimbursement of actual
Department of Health(DOH)Contract Manager. DOH will send using the template provided. any new award for DCHS costs incurred,not to
the"Budget narrative Template","Budget Guidance"and any COVID-19 Response tasks. exceed:
other applicable documents that may be identified.
$15,580 FFY20 ELC
2 1) LHJ Active monitoring activities.In partnership with WA Data collected and reported into DOH Enter performance metrics EDE LHJ
DOH and neighboring Tribes,the LHJ must ensure adequate systems daily. daily into DOH identified ALLOCATION Funding
culturally and linguistically responsive testing, investigation systems (MI 1897140E)Funding
and contact tracing resources to limit the spread disease.LHJs end date 6/30/2025
must conduct the following activities in accordance with the Quarterly performance
guidance to be provided by DOH. reporting updates
a. Allocate enough funding to sustain modest local level
capacity for prioritized case investigation and contact
tracing for COVID-19. This includes efforts to conduct
follow-up on outbreak/cluster investigations in prioritized
high risk settings.
i. Contact tracing
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 6 Contract Number CLH32053-Amendment 1
Page 5 of 61
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 Enter all case investigation data in WDRS
WDRS following DOH guidance. following guidance from-DOH.
a) Strive to enter all case investigation and
outbreak data into CREST as directed by
DOH.
b) Ensure all staff designated to utilize WDRS
have access and are trained in the system.
c) Include if new positive cases are tied to a
known existing positive case or indicate
community spread.
d) Conduct targeted case investigation and
monitor outbreaks.
e) Coordinate with Tribal partners in
conducting case investigations for tribal
members.
3. Ensure contact tracing and case investigation
activities meet DOH Case and Contact Tracing
Metrics. (Metrics to be determined
collaboratively by DOH,LHJs,and Tribes.)
Work with DOH to develop a corrective action
plan if unable to meet metrics.
b. Testing
i. Work with partners and Tribes to ensure testing is
available to every person within the jurisdiction
meeting current DOH criteria for testing and other
local testing needs.
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 COVID- Maintain a current list of entities
19 testing and at what volume.Provide reports to providing COVID-19 testing and at what
DOH on testing locations and volume as requested. volume. Provide reports to DOH Contract
manager on testing locations and volume
as requested.
Exhibit A,Statement of Work Page 3 of 6 Contract Number CLH3 2053-Amendment 1
Page 6 of 61
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. Ensure all COVID positive test results are
i. Ensure all COVID positive lab test results from LHJ entered into WDRS within 2 days of
are entered in to WDRS by 1)entering data directly in receipt
to WDRS,2)sending test results to DOH to enter,or
3)working with DOH and entities conducting tests to
implement an electronic method for test result
submission.
ii. 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 and Quarterly performance updates related to
support for patients and family by coordinating with local culturally and linguistic competency and
tribes if a patient identified as American Indian/Alaska responsiveness,tribal support,infection
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. Partner of all projects listed.
with fanners,agriculture sector and farmworker
service organizations to develop and execute plans
for testing,quarantine and isolation,and social
service needs for migrant and seasonal fannworkers.
ii. Congregate care facilities: In collaboration with the
state licensing agency(DSHS),support infection
prevention assessments,testing. Infection control
and isolation and quarantine protocols in congregate
care facilities.
iii. High risk businesses or community-based
operations. In collaboration with state licensing
agencies and Labor and Industries,partner with
food processing and manufacturing businesses to
ensure adequate practices to prevent COVID-19
exposure,conduct testing and respond to outbreaks.
iv. Healthcare: Support infection prevention and
control assessments,testing,cohorting,and isolation
procedures. Provide educational resources to a
variety of healthcare setting types(e.g.,nursing
homes,hospitals,dental,dialysis).
Exhibit A,Statement of Work Page 4 of 6 Contract Number CLH32053-Amendment I
Page 7 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
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(I&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 I&Q quarantine,and confirmation of
operations identified and confirmed.This location appropriate planning and coordination as
should be sufficient for supporting I&Q services that required.
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 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
current quarter to date
Exhibit A, Statement of Work Page 5 of 6 Contract Number CLH3205 3-Amendment 1
Page 8 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
iii. Planning must incorporate transfer or receipt of
people requiring I&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 I&Q
support,either through mobile teams or the state
facility.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance e,doh.wa.gov.
Federal Fundine Accountability and Transaarency Act(FFATA)(Applies to federal grant awards.)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USAS.pendine.eov 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.eov/grants/documents/General-Term s-and-Condit ion s-Non-Re search-Awards.pd f
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.
Submission of Invoice Vouchers: The LHJ shall submit correct monthly A 19-1 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.
Exhibit A,Statement of Work Page 6 of 6 Contract Number CLH32053-Amendment 1
Page 9 of 61
Exhibit A
Statement of Work
Contract Term:2025-2027
DOH Program Name or Title: Foundational Public Health Services(FPHS)- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance T pe of Payment
❑ Federal<Select One> (check if applicable) Reimbursement
Trans❑ arenc
Period of Performance: January 1,2025 through June 30.2025 ® State ( Development
p y Act) ® Periodic Distribution
El Other FFATA❑Research&Develo ment
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.
NOTE:The full State Fiscal Year(SFY)2025(07/01/24-06/30/25)disbursement of FPHS funds for this statement of work(01/01/25-06/30/25)was made in July/August
2024 during the 2022-2024 consolidated contract term and is being included in this statement of work for informational purposes only. There will not be a reconciliation
of these funds between the 2022-2024 consolidated contract and the new 2025-2027 consolidated contract. There is no requirement to report unused funds from the
07/01/24-12/31/24 period. It is acknowledged that existing obligations for this funding continue forward and remain in effect in the new contract.These obligations
include,but are not limited to,completion of the annual report due after 06/30/25 and fulfillment of all contractual terms and conditions as specified in the prior
consolidated contract term that ended 12/31/24.
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g 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 01/01/25 06/30/25 0 2,333,000 2,333,000
Note: Total SFY25 Allocation is for 07/01/24-06/30/25
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 2,333,000 1 2,333,000
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
FPHS funds to each LHJ—See below in Program Specific Requirements See below in Program Specific See below in Program
I —Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $520,000
Deliverables
Exhibit A, Statement of Work Page 1 of 8 Contract Number CLH32053-Amendment 1
Page 10 of 61
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Assessment Reinforcing Capacity—See below in Program Specific See below in Program Specific See below in Program
2 Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $60,000
Deliverables
Assessment—CHA/CHIP—See below in Program Specific Requirements See below in Program Specific See below in Pry
3 Specific Requirements- $30,000
—Activity Special Instructions for details Requirements-Deliverables Deliverables
Lifecourse-NEW SFY 24 Full Lifecourse Workforce Capacity—See � See below in Program
See below in Program Specific
4 below in Program Specific Requirements—Activity Special Instructions for Specific Requirements- $353,000
details Requirements-Deliverables Deliverables
CD-NEW SFY 24 Immunization Outreach,Education& Response— See below in Program
See below in Program Specific
5 See below in Program Specific Requirements—Activity Special Specific Requirements- $75,000
Instructions for details Requirements-Deliverables Deliverables
EPH-NEW SFY 24 Fully fund Environmental Public Health Policy& See below in Program
See below in Program Specific
6 Leadership Capacity—See below in Program Specific Requirements— Specific Requirements- $150,000
Activi Special Instructions for details Requirements-Deliverables Deliverables
FC-NEW SFY 24 Strengthening Local Finance Capacity—See below See below in Program Specific See below in Program
7 in Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $62,000
Deliverables
FC-NEW SFY 24 Public Health Communications—See below in See below in Program Specific See below in Program
8 Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $200,000
Deliverables
Lifecourse-NEW SFY 24 Illicit Substance Use and Overdose Response See below in Program
9 —See below in Pro rg am Specific Requirements—Activity Special See below in Program Specific Specific Requirements- $150,000
Instructions for details Requirements-Deliverables Deliverables
EPR-NEW SFY 24 Emergency Preparedness& Response—Capacity See below in Program
10 and Capability—See below in Program Specific Requirements—Activity See below in Program Specific Specific Requirements- $178,000
Special Instructions for details Requirements-Deliverables Deliverables
Assessment—Shared Regional Epidemiology—General See below in Program
11 (Assessment/Surveillance,CHA/CHIP)—See below in Program Specific See below in Program Specific Specific Requirements- $150,000
Re uirements—ActivitySpecial Instructions for details Requirements-Deliverables Deliverables
EPH-NEW SFY 24 Social Work Support—See below in Program See below in Program Specific See below in Program
12 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $85,000
Deliverables
EPH Core Team—Safe and Healthy Communities—See below in See below in Program Specific See below in Program
13 Prop-ram Specific Requirements—ActivitySpecial Instructions for details Requirements-Deliverables Specific Requirements- $47,000
Deliverables
EPH Core Team—Climate Change Response—See below in Program See below in Program Specific See below in Program
14 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $80,000
Deliverables
EPH Core Team—Water System Capacity—See below in Program See below in Program Specific See below in Program
15 Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $75,000
Deliverables
Exhibit A,Statement of Work Page 2 of 8 Contract Number CLH32053-Amendment 1
Page 11 of 61
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
EPH Core Team-System-Wide Data Management Improvement.:-See See below in Program
16 below in Program Specific Requirements-Activity Special Instructions for See below in Program Specific Specific Requirements- $63,000
details Requirements-Deliverables Deliverables
EPH Core Team-Homelessness Response-See below in Program See below in Program Specific See below in Program
17 Specific Requirements-Activity Special Instructions for details Requirements-Deliverables Specific Requirements- $55,000
Deliverables
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financeadoh.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.
• For LHJ questions about the use of funds:
o Chris Goodwin,FPHS Policy Advisor,WSALPHO-ceoodwin(a),wsac.org,564-200-3166
o Brianna Steere,FPHS Policy Advisor,WSALPHO-bsteere swsac.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.
Exhibit A,Statement of Work Page 3 of 8 Contract Number CLH32053-Amendment 1
Page 12 of 61
Disbursement of FPHS funds to LHJs—Unlike other ConCon grants,FPHS bill-back to DOH is NOT required. Half of the annual FPHS funds allocated by the Steering
Committee to each LHJ are disbursed each July and January. The July payments to LHJs and access to FPHS allocation for all other parts of the governmental public health
system occur upon completion of the FPHS Annual Assessment.
Deliverables—FPHS funds are to be used to assure FPHS services statewide. The FPHS accountability process measures how funds are spent,along with changes in system
capacity through the FPHS Annual Assessment,system performance indicators,and other data. DOH, SBOH and local health jurisdictions have agreed to complete:
1. Reporting of spending and spending projections. Process timelines and reporting template are provided by the FPHS Steering Committee via FPHS Support Staff.
2. FPHS Annual Assessment is due each July to report on the previous state fiscal year. Process and reporting template are provided by the FPHS Steering Committee via
FPHS Support Staff. System results are published in the annual FPHS Investment Report available at www.doh.wa.gov/fphs.
BARS Revenue Code: 336.04.25
BARS Expenditure Coding—provided for your reference
562.xx BARS Fxpmdhure Codes for FPHS actMties:see below
10 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 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
Exhibit A, Statement of Work Page 4 of 8 Contract Number CLH32053-Amendment I
Page 13 of 61
50 FPHS Other EPH Outbreak Investigations
51 FPHS Zoonotics includes vectors
52 FPHS Radiation
53 FPHS Land Use Planning
60 FPHS MCH Data&Planning
70 FPHS Chronic Disease,Injury&Violence Prevention Data&Planning
80 FPHS Access/Linkage with Medical,Oral and Behavioral Health Care Services Data&Planning
90 FPHS Vital Records
91 FPHS Laboratory—Centralized PHSKC Only)
92 FPHS Laboratory
Special References(i.e.,RCWs,WACs,etc.):
FPHS Intent-RCW 43.70.512
FPHS Funding—RCW 43.70.515
FPHS Committee&Workgroup Charter
FPHS Steering Committee Consensus Decision Making Model
Activity Special Instructions:
Investments to Each LHJ:
1. FPHS Funds to Each LHJ
These funds are allocated to be used to provide any programs and services within all of the FPHS Definitions.Each LHJ is empowered to prioritize where and how to use
these funds to maximize equitable,effective and efficient delivery of FPHS to every community in Washington.
Use BARS expenditure codes from the list above that most closely align with expenditure made.
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
Exhibit A, Statement of Work Page 5 of 8 Contract Number CLH32053-Amendment 1
Page 14 of 61
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.24,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,DA,F.1-3,G.1-3,I.1-2,J.1-13,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
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—Assurine 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 11
Targeted Investments to Select LHJs—Assurine 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,DA. E.2,EA,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.
Exhibit A,Statement of Work Page 6 of 8 Contract Number CLH3205 3-Amendment 1
Page 15 of 61
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
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
Exhibit A,Statement of Work Page 7 of 8 Contract Number CLH32053-Amendment 1
Page 16 of 61
approaches to healthy community planning,which may include wastewater planning and treatment,seawater intrusion in drinking water,ventilation in public buildings,
HAS contamination,climate change challenges,and other emerging topics identified by the Core Team.
• Use BARS expenditure code: 562.40
14. EPH Core Team—Climate-Chanee Response
This Core Team will address environmental health concerns related to climate and the effects of climate change.
• Model program development will start with Wildfire Smoke and Harmful Algal Blooms,and may include other priorities and topics.
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 8 of 8 Contract Number CLH3205 3-Amendment 1
Page 17 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Infectious Disease-Syndemic Prevention Services- Local Health Jurisdiction Name: Jefferson County Public Health
SSP-Effective January 1.2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through June 30,2025 ® State ❑FFATA(Transparency Act) ❑ 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: N/A
Master Assistance BARS Allocation
Change Index Listing Revenue LHJ Funding Period Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY25 DRUG USER HEALTH PROGRAM 12405150 N/A 334.04.91 01/01/25 06/30/25 0 40,250 40,250
FFY24 OD2A OID CDC PREVENT 12405241 93.136 333.93.13 01/01/25 06/30/25 0 49,000 49,000
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 89,250 89,250
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Syring Service Programs: Support for Operations
1 Syringe Services Programs(SSP): Support for Operations SSP operations outcomes include delivering Enter deliverable data into Reimbursement of
services and tracking: the DOH/OID issued actual costs incurred,
Provide comprehensive SSP to people who use drugs • number of sterile syringes distributed database for tracking SSP not to exceed$40,250
(PWUD). This plan of action is directed to distribute • number of naloxone kits distributed activities by the 15th of
syringes to communities that use drugs to prevent • number of participant encounters each month following
transmission of infectious disease. SSPs will operate during • number of referrals to health and social service.
scheduled hours to provide all required harm reduction services
supplies,naloxone,and syringes to prevent transmission of
disease and overdose. SSPs will offer referrals to address Submit Performance Objectives&Work Submit Performance
social determinants health. Plan within the first six months of contract Objectives& Work Plan
period that will include: by June 30, 2025.
Exhibit A, Statement of Work Page 1 of 11 Contract Number CLH32053-Amendment I
Page 18 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Outcomes aligned with program
Priority populations for Syringe Services Programs include strategies and activities.
people who use drugs,with a focus on: • SMART objectives aligned with
• People systemically marginalized and underserved performance targets
due to racism—Black/African American, • Activities aligned with program
Latino/Latina/Latine/Latinx,American outcomes
Indian/Alaska Native people and other communities • Timeline for implementation(including
for whom there are documented health disparities in staffing of the proposed program,
your region. training,etc.)
• People who are unhoused or unstably housed. . Anticipated capacity building or
• People engaged in sex work. technical assistance needs.
• People involved in the criminal legal system.
• Gender expansive/transgender individuals. NOTE: See Special Requirements,Terms
• Gay,bi,and other men who have sex with men. and Conditions—Section 7 Performance
Objectives&Workplans for additional
NOTE: See Special Requirements,Terms and Conditions deliverable information.
—Section 4 Syringe Services Programs: Support for
Operations Program Requirements for additional task
information.
Syringe Services Programs:Clinical Services
Provide direct access to clinical services to improve the
health and well-being of people who use drugs.At
minimum,services must include onsite,low-barrier access to
wound care, infectious disease testing, STI and hepatitis C
treatment,and medications for opioid use disorder.
Additional services can include mental health services,
sexual and reproductive health care,and other primary care
and psychosocial support services.
NOTE: See Special Requirements,Terms and Conditions
—Section 6 Syringe Services Program,Clinical Services
Requirements for additional task information.
Syring Service Programs: Harm Reduction Services-Overdose Data to Action (OD2A)
2 Syringe Services Programs:Harm Reduction Service Harm reduction care navigation outcomes Enter deliverable data into Reimbursement of
Navigation include delivering services and tracking: the DOH/OID issued actual costs incurred,
• number of participants enrolled in care database for tracking SSP not to exceed$49,000
navigation services activities by the 15th of
Exhibit A,Statement of Work Page 2 of I I Contract Number CLH3205 3-Amendment 1
Page 19 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Provide appropriate referrals to SSP participants;facilitate • number of care navigation sessions each month following
access to receive health care and medical services,social . number of referrals to health and social service.
services,behavioral health counseling and other services services
including substance use treatment(including medications for • number of linkages to care for health and
opioid use disorder,or MOUD);housing;and advocacy, social services
including but not limited to criminal legal involvement, number of outreach attempts per participant
medical providers,benefits navigation,and family
reunification.
Submit Performance Objectives&Work
Plan within the first six months of contract Submit Performance
NOTE: See Special Requirements,Terms and Conditions period that will include: Objectives& Work Plan
—Section 5 Syringe Services Program,Harm Reduction • Outcomes aligned with program by June 30,2025
Care Navigation Requirement for additional task strategies and activities.
information. • SMART objectives aligned with
performance targets
• Activities aligned with program
outcomes
• Timeline for implementation(including
staffing of the proposed program,
training,etc.)
• Anticipated capacity building or
technical assistance needs.
NOTE: See Special Requirements,Terms
and Conditions—Section 7 Performance
Objectives&Workplans for additional
deliverable information.
3 The LHJ will engage in OD2A-S evaluation activities for Quarterly submission of collected data and Enter quarterly data into
work completed using OD2A-S funds.Evaluation activities answers to qualitative questions(as it applies the DOH/OID issued
will involve: to your OD2A-S activities)on a DOH- template on the following
• As applicable,collecting data on CDC performance provided template dates:
measures to support DOH evaluation plan. • For reporting
o Total number of harm reduction service period 1/l/25-
encounters(e.g.,in-person,mail,telephone, 3/31/25
online) April 1,2025
o Zip code where harm reduction services were • For reporting
provided(list"unknown"when location is
period 4/1/25-
unknown) 5
o Total number of navigators located in a harm July
1 J
reduction settingor other settinguly ,2025
Exhibit A,Statement of Work Page 3 of 11 Contract Number CLH3205 3-Amendment 1
Page 20 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
o Number of referrals to harm reduction services • For reporting
for each race ethnicity period 7/1/25-
o If possible,total number of hours spent by each 8/31/25
navigator on linkage to care or referral efforts
October 1,2025
o Type of organization where naloxone was
distributed(SSP,faith-based organizations,
schools,etc.)
o Zip code where naloxone was distributed(list
"unknown"when unknown)
o Number of naloxone doses distributed at each
type of organization
o Number of service encounters involving drug
checking
o Zip code for drug checking encounters(list
"unknown"when unknown)
o Number of referrals to MOUD for each
race/ethnicity
o Number of referrals to behavioral health
treatment only(without MOUD)for each
race/ethnicity
o Number of other referrals,if not to MOUD and
behavioral health,with a description of the type
of referral
• Providing answers to contextual performance measures
questions.
o How has access to care or treatment has been
improved,and what new/existing community
assets were leveraged?
o What are the barriers for people accessing harm
reduction services in your jurisdiction?
o What are barriers to accessing or receiving
naloxone?
o Describe what types of navigators are included
in the data reported
o Describe methods to support navigators
• Collaborating with the DOH evaluator on a Targeted
Evaluation Project(TEP)that will provide a greater
understanding of navigation activities.
• Supporting other evaluation tasks as requested,to meet
overall CDC evaluation requirements.
Exhibit A,Statement of Work Page 4 of 11 Contract Number CLH32053-Amendment 1
Page 21 of 61
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance(a-)doh.wa.gov.
Federal Fundine Accountability and 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 USASpendin,g.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Special Requirements,Terms and Conditions
1. 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 A 19 invoice vouchers with amounts billable to DOH under this statement of work and the
corresponding OID Expense Summary backup form. All A 19 invoice vouchers must be submitted by the 25th of the following month. Prior approval is required for a
different frequency of billing.
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.
Exhibit A, Statement of Work Page 5 of 11 Contract Number CLH3205 3-Amendment 1
Page 22 of 61
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.
L 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.
OD2A-S September 1,2024-Au ust 31,2025 Bud et Funds
Salaries $30,618.13
Benefits $12,247.25
Other $660.00
Supplies $33,073
Indirect rate $21,401.59
TOTAL $98,000
* The LHJ must receive written approval from DOH before making any changes to the OD2A-S SOW activities or OD2A-S itemized budget
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.
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.
Exhibit A,Statement of Work Page 6 of 11 Contract Number CLH32053-Amendment 1
Page 23 of 61
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 second year of the contract period.The work plan should incorporate related program strategies and activities. Contractors
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.Note.Syndemic Contract Year 2 is anticipated to be established for July 1,2025 to June 30,2026 dependent on funding allocation.
b. The contractor should address the following outline in their work plan:
i. Contract Year 2 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 June 30,2025.
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.
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.
Exhibit A, Statement of Work Page 7 of 11 Contract Number CLH32053-Amendment 1
Page 24 of 61
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(all ianceforclas.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.
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.
Exhibit A,Statement of Work Page 8 of 11 Contract Number CLH32053-Amendment 1
Page 25 of 61
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. Restriction on OD2A-S Funds:The purchase of naloxone cannot be reimbursed using OD2A-S funds.Please refer to the guidance on allowable and
unallowable expenses using OD2A-S funds for a comprehensive list of allowable and unallowable spending.
vii. Travel—Out of staff travel requires prior approval from DOH and must follow GSA guidelines and reimbursement rates.
viii. 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.
ix. 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:Hocio.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.
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
Exhibit A, Statement of Work Page 9 of 11 Contract Number CLH32053-Amendment 1
Page 26 of 61
Agencies must also include the following assets with unit costs of$1,000 or more:
l) 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)
X. 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
Xi. 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 HIV-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 internet/webpages to the OID Content Review Committee.CONTRACTOR shall
submit all materials to be reviewed for scientific or medical accuracy to:
Michael Barnes,Washington State Department of Health
PO Box 47841
Olympia, WA 98504-7841
Exhibit A,Statement of Work Page 10 of 11 Contract Number CLH32053-Amendment 1
Page 27 of 61
Phone: 360-810-1880
Email: Michael.Barnes@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. ov/hiv/pdf/funding/an noun cements/ps12-1201/cdc-hiv-ps12-1201-content-review-gui dance.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.federairegister.gov/documents/2013/12/26/2013-30465/uniform-administrative-requirements-cost-
princ ip l es-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 11 of 11 Contract Number CLH3205 3-Amendment 1
Page 28 of 61
Exhibit A
Statement of Work
Contract Term:2025-2027
DOH Program Name or Title: Injury&Violence Prevention-LHJ Opioid Campaign Local Health Jurisdiction Name: Jefferson County Public Health
Proviso—Effective January 1.2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ® Reimbursement
Period of Performance: January ® State 1,2025 through June 30,2025 El Other ❑ FFATA(Transparency Act)
❑ Fixed Price
❑Research&Development
Statement of Work Purpose: Opioid abatement settlement account—state appropriation is provided solely for the department to administer grants to local health jurisdictions for
opioid and fentanyl awareness,prevention,and education campaigns.
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g 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 01/01/25 06/30/25 0 31,500 31,500
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 31,500 31,500
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 The LHJ will create 2 banners which will be hung across • Development timeline of brochures Monthly progress reports to Monthly invoices for
state route 20 in Port Townsend and 1,000 brochures to be and banners? DOH for updates on the actual cost
distributed at all Port Townsend events. Brochures to include 0 What kinds of messages have been implementation of all tasks. reimbursement will be
Spanish translation. disseminated on the banners and in submitted to DOH.
the brochures. Due Dates:
• Timeline of when the banners will be January due February 1,2025. Total of all invoices will
displayed. February due March 1,2025 not exceed$31,500
• Audience that the brochures will be March due April 1,2025 through June 30,2025
targeted to. April due May 1,2025
May due June 1,2025
2 The LHJ will develop 2-4 public media posts that will occur • Timeline of the development of the All June due June 30,2025
each month throughout the year including static images and media posts.
videos on Instagram and Facebook:one video for our • Messaging on the media posts and
YouTube channel. what are the static images of?
Exhibit A,Statement of Work Pagel of 4 Contract Number CLH3205 3-Amendment 1
Page 29 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Content of the You Tube video?Use
of local people?Messaging?
3 The LHJ will purchase 6 newspaper and community board . What kinds of messaging was
advertising to promote awareness and science-based developed?
information about opioid,fentanyl,and MOUD. . Where are you getting the science-
based information from?
• What areas are the community boards
located in?
• What is the audience you are
targeting?
4 The LHJ will host 4 interactive public education events with . How is the planning going?Dates for
community partners at the Nest(OWL 360),Recovery Cafe, any of the events?
Chimacum Grange,and Quilcene Guild Hall that focus on de- • How are you choosing which
stigmatization,science-based education,and community community partners and which times
understanding of not only opioid and fentanyl use in our and places?
community but also how community engagement is a • How are you sending the message at
preventative measure the events?I.e.PowerPoint, lecture,
community members?
• Where is the information coming from
that you are planning to use?
5 The LHJ will work with KPTZ Radio station in Port • Development of questions for
Townsend to develop and participate in 4,one-hour long, interview
interview programs to educate public and dispel myths and • Who is the audience you are targeting?
stigmas related to opioid and fentanyl use disorders. . How messaging is being tailored for
specific groups.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@doh.wa.gov.
Program Specific Requirements
Billing Requirements:
DOH awards funding through reimbursement-based billing.Invoices must be submitted monthly on an A19-IA invoice voucher.DOH must receive all complete final invoices
within 60 days of the end of the budget period for this statement of work.
Special Instructions:
This SOW is the Consolidated Contracts period 2025-2027 that ends on June 30,2025.Activities and due dates in this SOW are for the state fiscal year 25 that ends on 6/30.The
budget allocation in this contract reflects a portion of the total budget shown in the below budget table.
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH3205 3-Amendment 1
Page 30 of 61
Budeet Table
Line Item Allocation Justification
Salaries $19,035 8 and 8.5 hours/wk.-0.2-0.21 FTE(Nov 2024—June,2025).
Benefits $8,158 42.85%of salary amount
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 *Producer: $85 per hour 12 hrs.time:meeting with client,refine
messaging,story,concept,testimonial questions/prompts, location
scouting,scheduling,and other logistics.
Director: $800.00 per day 1-day 800.00:Oversees production and
conducts interviews
Videographer$1,000.00 per day 2 days 2,000.00
Sound recordist/Production Assistant: $400.00 per day 1 day 400.00
Media mgt.Copy files,back-up,organize and label in project,prep
interviews for transcription: $85 per hr.6 hrs. 510.00
Supplementary Media Selection&Procurement:Find and procure any
additional media(stills,video,motion graphic assets,etc.)$85 pre hr.6
hrs.5 10.00
Music:Time spent working with the client to identify and select tracts:
$85 per hr.: 1 hr. 85.00
1 st Cut: Assemble content from interviews,layer w/b-roll and
placeholders for graphics(titles/credits,feedback:$85 per hrs.: 12 hrs.
1,020.00
2ndCut: Refine for content,add music,and natural sound layering,
feedback: $85 per hour 8 hrs.680.00
3rd Cut: Final content adj,add graphics(animation,titles/credits),color
correction,audio mixing,final feedback.$85 per ho 8 hrs.680.00
Final Cut: Final adj.to graphics,color,and sound$85 per hour: 7 hrs.
595.00
Export and delivery:$85 per hr. 1 hour: 85.00
Banners $500 2 banners x$250 each
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH32053-Amendment 1
Page 31 of 61
Brochures $250 200 brochures at standard price is$238.00 at Chill Printing.Best Printer
USA 200 brochures for$232.00.Locally at the Printery,the estimated
cost for 250 brochures is:ballpark: $349.55(depending on artwork)
Administrative costs/indirect $12,229 27.94%indirect rate
TOTAL $56,000
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 4 of 4 Contract Number CLH3 2053-Amendment 1
Page 32 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Maternal&Child Health Block Grant— Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through September 30,2025 ❑ State ®FFATA(Transparency Act) ❑ 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: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY25 HRSA MCHBG LHJ CONTRACTS 78101251 93.994 333.93.99 01/01/25 09/30/25 0 27,525 27,525
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 27,525 27,525
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# 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 16,2025 Reimbursement for actual
from October 1,2024 through March 31,2025. Budget Workbook to DOH Community costs,not to exceed total
Consultant. funding consideration.
Monthly Reports must only
lb Develop 2025-2026 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 5,2025 reflect activities paid for
October 1,2025 through September 30,2026 using Community Consultant. with funds provided in this
DOH-provided template. I I statement of work for the
]c Participate in DOH-sponsored annual MCHBG meeting. LHJ Contract Lead or designee will attend September 30,2025 specified funding period.
meeting.
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH32053-Amendment 1
Page 33 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
See Program Specific
Requirements and Special
Billing Requirements.
Implementation
2a Report 2024-25 MCHBG-funded activities and Submit monthly reports to DOH Community January 15,2025 Reimbursement for actual
outcomes using DOH-provided reporting template.As a Consultant.Describe in your updates within February 15,2025 costs,not to exceed total
foundation of your MCHBG work determine how each activity of the monthly report how you are March 15,2025 funding consideration.
processes and programs can close gaps in health intentionally focused on closing gaps in health April 15,2025 Monthly Reports must only
outcomes. outcomes. May 15,2025 reflect activities paid for
June 15,2025 with funds provided in this
July 15,2025 statement of work for the
August 15,2025 specified funding period.
Se tember 15,2025
2b Develop 2025-26 MCHBG reporting document for Submit MCHBG reporting document to DOH Draft—August 15,2025 See Program Specific
October 1,2025 through September 30,2026 using Community Consultant. Final—September 12,2025 Requirements and Special
DOH- rovided template. Billing Requirements.
Children and Youth with Special Health Care Needs(CYSHCN)
3 a Complete intake and renewal,per reporting guidance Submit data to DOH per CYSHCN Program January 15,2025 Reimbursement for actual
supplied by DOH,on all infants and children served by guidance. April 15,2025 costs,not to exceed total
the CYSHCN Program as referenced in CYSHCN July 15,2025 funding consideration.
Program guidance.If no CYSHCN care coordination Monthly Reports must only
(enabling service)is provided in a given quarter,email reflect activities paid for
the CHIF administrator at DOH-CHIFAdoh.wa. ov and with funds provided in this
indicate that zero clients were served during the quarter. statement of work for the
No spreadsheet is necessary when zero clients are specified funding period.
served.
See Program Specific
3b Identify unmet needs for CYSHCN on Medicaid and Submit completed Health Services 30 days after forms are Requirements and Special
refer to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment completed. Billing Requirements.
Diagnostic and Treatment funds as needed. Fund requests directly to the CYSHCN
Pro ram as needed.
3c Review your program's entry on ParentHelp123.gM Document in the Administrative box on your September 30,2025
annually for accuracy. MCHBG report that you have updated
information on your local CYSHCN program
with WithinReach/Help Me Grow.
3d Support improvements to the local system of care Submit updates as part of monthly reporting January 15,2025
(public health services and systems/policy,systems,and document. February 15,2025
environment)for CYSHCN.Refer to the Focus of Work March 15,2025
document for example activities and priority areas. April 15,2025
May 15 2025
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment 1
Page 34 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
June 15,2025
July 15,2025
August 15,2025
Se tember 15,2025
MCHBG Assessment and Evaluation
4a As part of the ongoing 5-year MCHBG Needs Submit documentation as requested by DOH. September 30,2025 Reimbursement for actual
Assessment,participate in activities developed and costs,not to exceed total
coordinated by DOH using DOH-provided reporting funding consideration.
template. Monthly Reports must only
reflect activities paid for
with funds provided in this
statement of work for the
specified funding period.
See Program Specific
Requirements and Special
Billing Re uirements.
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 USASpending.gov by DOH as required by P.L. 109-282.
Program Specific Requirements
Special 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 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:
CYSHCN Information and Resources:
Children and Youth with Special Health Care Needs Website(wa.gov)
Health Services Authorization(HSA)Form
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH32053-Amendment 1
Page 35 of 61
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
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 (1)(D)].
Monitoring Visits(i.e.,frequency,type,etc.):
Check-ins with DOH Community Consultant as needed.
Billing Requirements:
Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable A19-1A 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 Community Consultant for approval of expenses not reflected in approved budget workbook.
Exhibit A,Statement of Work Page 4 of 4 Contract Number CLH3 2053-Amendment 1
Page 36 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Drinking Water Group A Program - Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1.2025
Contract Number: CLH32053
SOW Type: Revision Revision#(for this SOW) 0 Funding Source Federal Compliance Type of Payment
® Federal<Select One> (check if applicable) ❑ Reimbursement
Period of Performance: January 1,2025 through December 31,2027 ® State ®FFATA(Transparency Act) ® Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non-community Group A water systems
Revision Purpose: 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
SANITARY SURVEY FEES SS-STATE 24232522 N/A 346.26.65 01/01/25 12/31/25 0 2,200 2,200
YR 27 SRF-LOCAL ASST 15% SS 24119227 N/A 346.26.64 01/01/25 12/31/25 0 2,200 2,200
YR 27 SRF-LOCAL ASST 15% TA 24119227 N/A 346.26.66 01/01/25 12/31/25 0 1,000 1,000
0 0 0
0 0 0
0 0 0
TOTALS 0 1 5,400 1 5,400
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
1 Trained LHJ staff will conduct sanitary surveys of Provide Final*Sanitary Survey Reports Final Sanitary Survey Upon ODW acceptance of the Final
small community and non-community Group A to ODW Regional Office.Complete Reports must be Sanitary Survey Report,the LHJ shall be
water systems identified by the DOH Office of Sanitary Survey Reports shall include: received by the ODW paid$400 for each sanitary survey of a non-
Drinking Water(ODW)Regional Office. 1. Cover letter identifying significant Regional Office within community system with three or fewer
deficiencies, significant findings, 30 calendar days of connections.
See Special Instructions for task activity. observations,recommendations,and conducting the sanitary
referrals for further ODW follow- survey. Upon ODW acceptance of the Final
The purpose of this statement of work is to provide up. Sanitary Survey Report,the LHJ shall be
funding to the LHJ for conducting sanitary surveys 2. Completed Small Water System paid$800 for each sanitary survey of a non-
and providing technical assistance to small checklist. community system with four or more
community and non-community Group A water 3. Updated Water Facilities Inventory connections and each community system.
systems. (W FI).
4. Photos of water system with text Payment is inclusive of all associated costs
identifying features such as travel, lodging,per diem.
Exhibit A,Statement of Work Page 1 of 4 Contract Number CLH3205 3-Amendment I
Page 37 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
5. Any other supporting documents.
Payment is authorized upon receipt and
*Final Reports reviewed and accepted by acceptance of the Final Sanitary Survey
the ODW Regional Office. Report within the 30-day deadline.
Late or incomplete reports may not be
accepted for payment.
2 Trained LHJ staff will conduct Special Purpose Provide completed SPI Report and any Completed SPI Reports Upon acceptance of the completed SPI
Investigations(SPI)of small community and non- supporting documents and photos to must be received by the Report,the LHJ shall be paid$800 for each
community Group A water systems identified by ODW Regional Office. ODW Regional Office SPI.
the ODW Regional Office. within 2 working days
of the service request. Payment is inclusive of all associated costs
See Special Instructions for task activity. such as travel, lodging,per diem.
Payment is authorized upon receipt and
acceptance of completed SPI Report within
the 2-working day deadline.
Late or incomplete reports may not be
acce ted for payment.
3 Trained LHJ staff will provide direct technical Provide completed TA Report and any Completed TA Report Upon acceptance of the completed TA
assistance(TA)to small community and non- supporting documents and photos to must be received by the Report,the LHJ shall be paid for each
community Group A water systems identified by ODW Regional Office. ODW Regional Office technical assistance activity as follows:
the ODW Regional Office. within 30 calendar • Up to 3 hours of work: $250
days of providing • 3-6 hours of work:$500
See Special Instructions for task activity. technical assistance. • More than 6 hours of work: $750
Payment is inclusive of all associated costs
such as consulting fee,travel,lodging,per
diem.
Payment is authorized upon receipt and
acceptance of completed TA Report within
the 30-day deadline.
Late or incomplete reports may not be
acce ted for payment.
4 LHJ staff performing the activities under tasks 1,2 For training attended in person,prior to Annually For training attended in person,LHJ shall
and 3 attend periodic required survey training as attending the training,submit an be paid mileage,per diem,lodging,and
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). httD://www.ofm.wa.jzov/resources/travel.aW
Exhibit A,Statement of Work Page 2 of 4 Contract Number CLH32053-Amendment I
Page 38 of 61
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financegdoh.wa.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 USASpendinggov 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$4,400 for Task 1,and$1,000 for Task 2,Task 3 and Task 4 combined during the contracting period,to be paid at the
rates specified in the Payment Method/Amount section above. When invoicing for sanitary surveys,bill half to BARS Revenue Code 346.26.64 and half to BARS Revenue Code
346.26.65.
When invoicing for Task 1,submit the list of WS Name,ID#,Amount Billed,Survey Date and Letter Date for which you are requesting payment.
When invoicing for Task 2-3,submit the list of WS Name,ID#,TA Date and description of TA work performed,and Amount Billed.
When invoicing for Task 4,submit receipts and the signed pre-authorization form for non-employee travel to the ODW Program Contact below and a signed A19-IA Invoice
Voucher to DOH Grants Management,billing to BARS Revenue Code 346.26.66 under Technical Assistance(TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW.Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance(Field Guide).The sanitary survey will include an
evaluation of the following eight elements: source;treatment;distribution system; finished water storage;pumps,pump facilities and controls;monitoring,reporting and data
verification; system management and operation;and certified operator compliance. If a system is more complex than anticipated or other significant issues arise,the LHJ may
request ODW assistance.
Exhibit A,Statement of Work Page 3 of 4 Contract Number CLH3205 3-Amendment 1
Page 39 of 61
• No more than 3 surveys of non-community systems with three or fewer connections be completed between January 1,2025,and December 31,2025.
• No more than 4 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2025 and
December 31,2025.
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 CLH3205 3-Amendment 1
Page 40 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Immunization-Promotion of Immunizations to Local Health Jurisdiction Name: Jefferson County Public Health
Improve Vaccination Rates-Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: January 1.2025 through June 30,2025 ❑ State ®FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to contract with local health to conduct activities to improve immunization coverage rates.
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DON Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY24 CDC PPHF OPS 74310246 93.268 333.93.26 01/01/25 06/30/25 0 10,000 10,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 10,000 10,000
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Upon approval of proposal,implement the plan to increase Written report describing the progress made on January 15,2025 Reimbursement for actual
immunization coverage rates with the target population reaching milestones for activities identified in costs incurred,not to
identified. the plan(template will be provided) exceed total funding
consideration amount.
2 Within six(6)months of the start of the contract provide a Submission of Budget Forecast form provided January 15,2025
Budget Forecast. by Department of Health stating spend down of
remaining funds.
3 Develop final report to include comparison of change or Final written report including measured and/or June 16,2025
improvement of targeted outcome from start of the observed outcomes[what was achieved as a
project/intervention[This can be short-term or intermediate result of the activity/intervention?].
outcomes with overall goal to increase immunization rates]
Examples: (Template will be provided)
■ Increased partner knowledge on immunization
guidelines
■ Change in attitudes about childhood vaccines
Exhibit A,Statement of Work Page 1 of 2 Contract Number CLH32053-Amendment 1
Page 41 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
■ 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 financenea doh.wa.eov.
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 USASpending.gov 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
• 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 2 of 2 Contract Number CLH32053-Amendment 1
Page 42 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Office of Resiliency&Health SecuritY-PHEP- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through June 30,2025 ❑ 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.
This Statement of Work includes 40%of the total allocation of these funds.Once all invoices from the July -December 2024 Statement of Work have been submitted and paid,
any funds remaining from the previously awarded 60%will be added in an amendment to this 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
Index Listing Revenue LHJ Funding Period Current Change Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY24 PHEP BPI -CDC-LHJ PARTNERS 31602241 93.069 333.93.06 01/01/25 06/30/25 0 13,754 13,754
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 13,754 13,754
Task# Activity Deliverables/Outcomes Due Date Payment Information
and/or Amount
1 Submit names,position titles,email addresses,and Submit any changes within 30 days Within 30 days of the Reimbursement for
Contact Information phone numbers of key LHJ staff responsible for this of the change. change. actual costs not to
statement of work,including management,Emergency exceed total funding
Framework 2— Response Coordinator(s),and accounting and/or End-of-year reports on template June 30,2025 allocation amount.
Enhance Partnerships financial staff. provided by DOH.Note any
changes or no changes.
Exhibit A,Statement of Work Page 1 of 8 Contract Number CLH3205 3-Amendment 1
Page 43 of 61
Task# Activity Deliverables/Outcomes Due Date Payment Information
and/or Amount
2 Submit LHJ Performance Measure Data as requested on LHJ Performance Measure Data on June 30,2025
LHJ Performance the form provided by DOH. the form provided by DOH.
Measures
Framework 6—
Modernize data
collection and systems
3 Submit additional information as requested by DOH to Information requested by DOH. As requested by DOH.
Additional comply with federal grant requirements.
Information
Required by CDC Complete reporting templates as requested by DOH to
comply with program and federal grant requirements,
Framework 4— including the mid-year and end-of-year reports.
Improve
administrative and
budget preparedness
systems
4 Complete the public health disaster risk assessment Public Health Disaster Risk June 30,2025
Risk Assessment developed by the University of Washington(UW) Assessment
(available early February 2025)reflecting the needs of
Framework I the whole LHJ.
Develop threat-
specific approach DOH and/or UW will provide the tool and technical
assistance.
Framework 3—
Expand local support
Framework 8—
Incorporate health
equity practices
5 Complete multiyear integrated preparedness plan using Multiyear integrated preparedness June 30,2025
Planning lessons learned from emergency responses,with critical plan.
response and recovery partners.
Framework 4—
Improve Engage partners to incorporate health equity principles.
administrative and
budget preparedness Including(but not limited to):
systems •Administrative preparedness plans.
•Recovery operations.
Framework 8— •Incident response improvement plan data elements.
Exhibit A, Statement of Work Page 2 of 8 Contract Number CLH3205 3-Amendment 1
Page 44 of 61
Task# Activity Deliverables/Outcomes Due Date Payment Information
and/or Amount
Incorporate health
equity practices
6 Review LHJ public health preparedness and response End-of-year reports on template June 30,2025
Planning-IPPW capabilities and identify gaps,priorities,and training provided by DOH.
needs.
Framework 2— Participation in IPPW.
Enhance Partnerships Participate in the DOH Integrated Preparedness
Planning Workshop(IPPW).The Workshop is planned
Framework 5—Build for early 2025.
workforce capacity
Framework 10—
Prioritize community
recovery efforts
7 Develop or update crisis and emergency risk End-of-year reports on template June 30,2025
Communication& communication and information dissemination plans. provided by DOH.
Planning
Framework 7—
Strengthen risk
communication
activities
8 Complete training to ensure baseline competency and End-of-year reports on templates June 30,2025
Training integration with preparedness requirements. provided by DOH,including title,
date(s),sponsor of the training or
Framework 5—Build Participate in at least one public health emergency conference,and summary of what
workforce capacity preparedness,response,or recovery training. 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 to review public health preparedness and
response plans and identify gaps,priorities,and training
needs.
Integrate administrative and budget preparedness
recommendations into training.
Exhibit A,Statement of Work Page 3 of 8 Contract Number CLH3 2053-Amendment 1
Page 45 of 61
Task# Activity Deliverables/Outcomes Due Date Payment Information
and/or Amount
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
•IS-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.
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.
Exhibit A,Statement of Work Page 4 of 8 Contract Number CLH32053-Amendment 1
Page 46 of 61
Task# Activity Deliverables/Outcomes Due Date Payment Information
and/or Amount
9 Participate in at least one exercise by June 30,2025. End-of-year reports on template June 30,2025
Exercising •Include critical response and recovery partners. provided by DOH.
•Engage partners to incorporate health equity
Framework 2— principles. Improvement Plans available upon
Enhance Partnerships •Integrate administrative and budget preparedness request.
recommendations.
Framework 3— •Complete AAR/IP for the exercise by June 30th,2025.
Expand local support
to improve Note:
jurisdictional This may include developing and conducting exercises
readiness to or participating in exercises developed and conducted by
effectively manage another organization,such as other LHJs.
public health
emergencies
10 Identify and implement communication monitoring End-of-year reports on template June 30,2025
Communication& media relations,and digital communication strategies in provided by DOH.
Exercising exercises.
Framework 7— Include communications and/or Public Information
Strengthen risk Officer in exercises or real world event to identify and
communication implement communication monitoring,media relations,
activities and digital communication.This may include one or
more exercises by June 30,2025.
11 Maintain ability to procure,store,manage,and End-of-year reports on template June 30,2025
MCM distribute medical materiel. provided by DOH.
Framework 1 — Maintain ability to dispense and administer medical
Develop threat- countermeasures(MCM).
specific approach
Attend an MCM quarterly meeting for the non-CRI
Framework 10— LHJs.
Prioritize community Continue to show capabilities by submitting updated
recovery efforts MCM plans as needed.
12 Provide immediate notification to DOH Duty Officer at End-of-year reports on template June 30,2025
DOH Duty Officer 360-888-0838 or hanalert@doh.wa.gov for all response provided by DOH.
incidents involving use of emergency response plans
Framework 7— and/or incident command structures.
Strengthen risk
communications Produce and provide situation reports(sitreps)
activities documenting LHJ activity during all incidents.Sitre
Exhibit A.Statement of Work Page 5 of 8 Contract Number CLH3205 3-Amendment 1
Page 47 of 61
Task# Activity Deliverables/Outcomes Due Date Payment Information
and/or Amount
may be developed by the LHJ or another jurisdiction
that includes input from LHJ.
13 Maintain Washington Secure Electronic End-of-year reports on template June 30,2025
WASECURES Communications,Urgent Response and Exchange provided by DOH.
System(WASECURES)as the primary notification
Framework 7— system.
Strengthen risk
communication Participate in DOH-led notification drills.
activities 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 emergency End-of-year reports on template June 30,2025
Communication& risk communication activities that meet the diverse provided by DOH.
Communities of needs of local community based organizations that
Focus support people who may be disproportionally impacted
by the public health impacts of a disaster.
Framework 10—
Prioritize community DOH will work with LHJs to serve the needs of the
recovery efforts socially vulnerable community members in their
jurisdictions with a focus on public health equity.
15 During each reporting period(Jul—Dec and Jan-Jun), End-of-year reports on template June 30,2025
Healthcare Coalition participate in two or more of the following activities provided by DOH.
(HCC)Participation with the Northwest Healthcare Response Network
(NWHRN)or the Healthcare Alliance(HCA):
Framework 3— •Meetings
Expand local support •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 financegdoh.wa.gov.
Exhibit A,Statement of Work Page 6 of 8 Contract Number CLH32053-Amendment 1
Page 48 of 61
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 USASpendinggov 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 1 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 1
2024-2028 PHEP Cooperative Agreement Guidance/Budget Period I f State and Local Readiness I CDC
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.
Exhibit A,Statement of Work Page 7 of 8 Contract Number CLH3205 3-Amendment 1
Page 49 of 61
Note:Preapproval is no longer required for paying overtime.
See also DOH A19 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 A19 with backup documentation appropriate for risk level.DOH will provide A19 and risk level.
• If invoices include indirect costs,there must be a DOH approved indirect rate cost agreement.
• If there are no expenses related to this Statement of Work for a month,let the 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 CLH3205 3-Amendment 1
Page 50 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Recreational Shellfish Activities- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance T pe of Payment
❑Federal<Select One> (check if applicable) Reimbursement
Period of Performance: January 1,2025 through June 30,2025 ® State ❑ FFATA(Transparency Act) ❑ Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide funds for shellfish harvesting safety
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
REC. SHELLFISH BIOTOXIN 26402600 N/A 334.04.93 01/01/25 06/30/25 0 3,700 3,700
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 1 0 1 3,700 1 3,700
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
1 Biotoxin Monitoring Submit annual report on DOH approved Email Report to DOH by $3,500
• Collect monitoring samples on schedule according to format of activities for the year,including February 18,2025
Department of Health(DOH)Biotoxin Monitoring Plan, the number of sites monitored and samples
coordinate deviations from the schedule with DOH,notify collected,and number and names of (See Special Instructions below.)
DOH in advance if samples cannot be collected. beaches posted with signs.
• Conduct emergency biotoxin sampling when needed.
• Post/remove recreational shellfish warning and/or
classification signs on beaches and restock cages as
needed.
• Issue biotoxin news releases during biotoxin closures in
Jefferson County.
• This task may also include recruiting,training,and
coordination of volunteers,and fuel reimbursement funds
for volunteer biotoxin monitoring.
Exhibit A,Statement of Work Page 1 of 2 Contract Number CLH32053-Amendment 1
Page 51 of 61
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
2 Outreach Submit annual report including the number Email Report to DOH by $200
• Staff educational booths at local events. of events staffed and amount of educational February 18,2025
• Distribute safe shellfish harvesting information. materials distributed.
See Special Instructions below.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financeAdoh.wa.g_o_v.
Program Specific Requirements
Program Manual,Handbook,Policy References:
Department of Health's Biotoxin Monitoring Plan
Special References(i.e.,RCWs,WACs,etc.):
Chapter 246-280 WAC
https://doh.wa.gov/commun ity-and-environment/shelIfish/recreational-sheI Ifish
https://doh.wa.gov/about-us/program s-and-services/environmental-pub I i c-h ealth/env ironmental-health-and-safety/about-she I Ifi sh-program/about-biotoxins-and-i I lness-prevention-
program
Special Instructions:
Report for work performed in 2024 must be submitted via email to Liz Maier(liz.maier@doh.wa.gov)by February 18,2025.
The report format will be provided by DOH and may be modified throughout the period of performance via email announcement.
Exhibit A,Statement of Work Page 2 of 2 Contract Number CLH3205 3-Amendment 1
Page 52 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: School-Based Health Centers Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑Federal<Select One> (check if applicable) ® Reimbursement
❑
Period of Performance: January 1,2025 through June 30,2025 ® State ❑ FFATA(Transparency Act) Fixed Price
El
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to fulfill the legislative mandate,RCW 43.70.825,and formalize a grant award to Jefferson
County Public Health for a School-Based Heath Centers(SBHC)operations grant. An SBHC is defined as, "a student-focused health center located in or adjacent to a school that
provides integrated medical,behavioral health,and other health care services such as dental care."
Jefferson County Public Health will complete infrastructure and capacity building tasks and activities outlined in the contract to operate,expand,and/or improve a school-based
health center at Quilcene,Chimacum,and Port Townsend School Districts.Activities include participation in trainings,technical assistance,and contract meetings;expanding,
sustaining,and/or improving SBHC services;engaging the community about the SBHC;and reporting on performance.
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY25 SBHC PROVISO 78310850 N/A 334.04.90 01/01/25 06/30/25 0 59,000 59,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 59,000 59,000
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Provide updates to DOH on progress of SBHC operations, Quarterly report Quarterly, $8,000($4,000 per report)
project,and workplan completion. April 15
• Include status report of SBHC operations(hours of July 15
operation,staffing model,and services provided)
Include milestones,successes,challenges,and barriers
2 Attend bi-monthly contract meetings with DOH to discuss Quarterly report that includes: Quarterly, $4,000($2,000 per report)
progress,support needs,barriers/challenges. • List of contract meetings attended during April 15
the reporting eriod I July 15
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH32053-Amendment 1
Page 53 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Participate in at least one key training,support,and/or • List of trainings and TA meetings
technical assistance activity per quarter,as recommended by attended during the reporting period
DOH or WA School-Based Health Alliance(SBHA). List of any additional resources or training
needed
Identify additional resources or training needed;collaborate
with DOH to participate in and/or get access to resources, if
needed.
3 Implement health equity plan and provide progress updates: Quarterly report Quarterly, $5,000($2,500 per report)
• Can include pictures,products,stories,and/or April 15
testimonials July 15
Include successes,challenges,and any barriers to completing
this activity
4a Provide updates on implementation of evaluation plan; Quarterly report Quarterly, $4,000($2,000 per report)
review and update evaluation plan,as needed.Include April 15
successes,challenges,and any barriers to completing this July 15
activity.
4b Collect and report on required performance measures,using Quarterly performance measure report Quarterly, $6,000($3,000 per report)
provided DOH performance measure spreadsheet. April 15
July 15
4c Submit SBHC evaluation report using measures and goals SBHC evaluation report June 30,2025 $32,000
outlined in your evaluation plan.Use provided DOH
evaluation report template.
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financegdoh.wa.gov.
Program Specific Requirements
Special Requirements: Quarterly progress reports will be submitted to the DOH contract manager on a quarterly basis,using a provided template.
• Reports should include progress on deliverables to date, successes,barriers/challenges,and support needs and include:
o General updates on the progress on other deliverables
o Challenges/barriers to completing deliverables
o Support needs from DOH
o Specific deliverables/products requested
• Specific/separate reports should be submitted separately and on the specified due date.
Special References(i.e.,RCWs,WACs,etc.): In accordance with RCW 43.70.825:Concerning School Based Health Centers(2021),the Washington State Department of Health
(DOH)contemplates awarding a contract to Jefferson County Public Health(LHJ)to operate a school-based health center.
Definitions: A school-based health center is defined in the law as"a student-focused health center located in or adjacent to a school that provides integrated medical,behavioral
health,and other health care services such as dental care."Upon execution of the contract,the SBHC must meet the minimum requirements outlined below:
• Be open during regular school hours
Exhibit A, Statement of Work Page 2 of 3 Contract Number CLH32053-Amendment 1
Page 54 of 61
• Provide on-site primary care services by a nurse practitioner,physician's assistant,medical doctor,and/or doctor of osteopathy,at least once a week
• Coordinate clinic services
• Provide behavioral health care services by a behavioral health provider that is on-site,through telehealth,and/or through mobile units. If a behavioral health provider is
not licensed,they must be supervised by a licensed behavioral health provider.
Billing Requirements:
• The LHJ will invoice no more than monthly and no less than quarterly.
• Due dates and deliverables can be negotiated on and changed,as needed,with prior approval from the contract manager.
• Invoices will be submitted on the DOH A 19 form with a copy of the general ledger(or grant budget and spending documentation) and agreed upon back-up
documentation.Invoices must reference this contract number and provide detailed information as requested.
• All invoices must be approved by DOH prior to payment;approval will not be unreasonably withheld. DOH will authorize payment only upon satisfactory completion
and acceptance of deliverables and for allowable costs as outlined in the statement of work and/or budget.DOH will issue payment within 30 days of receiving a correct
and complete invoice and approving the deliverable(s).
• DOH will return all incorrect or incomplete invoices and will not pay for services that occur outside the period of performance.
• The LHJ will not invoice for services if they are entitled to payment,have been,or will be paid by any other source for that service.
• The LHJ may bill incrementally for progress on objectives,but the entire product will be delivered for the amount specified regardless of time spent on the tasks for each
objective.
• Quarterly report deadlines and invoice amounts are as follows(invoice amount listed below is an estimate and is flexible based on deliverables completed):
o January-March deliverables,due by April 15,2025: $13,500
o April-June deliverables,due by July 15,2025: $45,500
• DOH must receive correct and complete invoices within 60 days of the budget period.Late invoices will be paid at the discretion of DOH and are contingent upon the
availability of funds.
o Submit all final billings within 60 days of the end of the contract
o Submit all required program reports and deliverables within 60 days
Exhibit A,Statement of Work Page 3 of 3 Contract Number CLH32053-Amendment 1
Page 55 of 61
Exhibit A
Statement of Work
Contract Term: 2025-2027
DOH Program Name or Title: Sexual&Reproductive Health Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2025
Contract Number: CLH32053
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2025 through June 30,2025 ® 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 SR14P 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 1-4 of the contract,which runs January 1,2022—March 31,2026.
For state funding,due dates after June 30,2025 are for reporting only.LHJs may not bill under this contract for work done after June 30,2025.
For federal funding,due dates after March 31,2025 are for reporting only. LHJs may not bill federal funds under this contract for work done after March 31,2025.
Revision Purpose: N/A
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY24 FPHPA TITLE X FAMILY PLAN 78430240 93.217 333.93.21 01/01/25 03/31/25 0 8,621 8,621
SFY25 SEXUAL&REP HLTH COST SHARE 78430150 N/A 334.04.91 01/01/25 06/30/25 0 47,993 47,993
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 56,614 56,614
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Sexual and Reproductive Health Program • A19 invoice vouchers submitted in a timely No more than monthly Billing must be based
(SRHP)&Title X(TX)Services—excluding manner accompanied by an R&E workbook and no less than on a current cost
abortion and other surgical procedures related to showing revenue and expenses for the month quarterly. analysis approved by
SRHP. billed and any other required back up DOH(see Reporting
documentation per DOH policy. Requirements below).
A. Comply with Washington State SRHP Manual,
federal Title X requirements and all state and • All reports described in Reporting Requirements
federal laws.Also see Program Manual, below.
Exhibit A, Statement of Work Page 1 of 7 Contract Number CLH32053-Amendment 1
Page 56 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Handbook,Policy References under Reporting As described in DOH reserves the right
Requirements(below). • Other data and documentation in format requested by Reporting to withhold payment
DOH.(Includes copies of program and financial audits Requirements below until:
B. Complete required Agency Information Request and reviews including summaries conducted by other • Compliance issues
including Title X Assurance of Compliance and entities.) As requested by DOH or a previous SOW
National Provider Identifier(NPI)billing are resolved in a
numbers • To facilitate DOH/TX desk reviews—requested way accepted by
documentation available to DOH in requested format. DOH
C. Provide medical services,community education • Current data is
and outreach,and staff training,consistent with To facilitate DOH/TX site-visits—appropriate staff submitted to,and
state requirements: and documentation readily available prior to and accepted by,
during review. Ahlers.
1. LHJ is responsible for making sure all staff • A19 back up
have the knowledge to carry out the DOH performs site visits.Follow-up site visits are documentation
requirements of the SOW. performed until identified issues are resolved. required by DOH
has been submitted
2. Medical,laboratory,and other services and approved.
related to abortion are not covered by this • Other deliverables
task. have been met.
3. Community education services must be Payment is limited to
based on the needs of the community.LHJ
the maximum funds
must have an Information&Education available for funding
(I&E)committee with five(5)or more source.
members that is broadly representative of
the population or community for which DOH will reimburse
materials are intended.The committee for:
must review a batch of patient-facing • Actual allowable
materials annually(at least 15 products or
15%of the total number of materials, costs according whichever is smaller);meet at least your approved cost
annually and establish a written record of analysis(see
its determination.(42 CFR 59[59.61) Reporting
Requirements
4. Outreach is to ensure all populations in or below).
your community understand the services • The amount
available.Focus your outreach efforts on
increasing equity. remaining in the
SOW divided by
Washington State Sexual and Reproductive the number of
Health Network priority populations are: months remaining
• Teens in the funding
source,plus one,
whichever is less.
Exhibit A,Statement of Work Page 2 of 7 Contract Number CLH32053-Amendment 1
Page 57 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• People who are uninsured or
underinsured,and/or low-income Payment will be
(at or below 250%of the federal calculated by R&E
poverty line) provided by DOH(see
• Rural communities Reporting Requirements
• Hispanic below).
• Black, Indigenous,People of Color All services through the
Extra efforts should be made to provide end of this contract
information and services to people who period must be billed
intersect with multiple priority population within 60 days.
categories.
5. Provide all services in accordance with:
• DOH SRHP&Title X Manual
• Other state and federal
requirements
• Reporting Requirements(see
below)
D. Collect,maintain,and provide data about each
family planning clinic visit as defined in the CVR data submitted to DOH data contractor(Ahlers& �
SRH CVR Manual. Associates)electronically in a format compatible with The 15 of the
1. Maintain a computer system that includes Ahlers software. following month.
safety precautions against loss of
information. • Data for each month Within thirty(30)days
2. Ensure data entry personnel protect of receiving
confidentiality of CVR data. • Corrected CVR data error/rejection report or
3. Have ability to retrieve all information for request from DOH
auditing and monitoring by DOH or its Sexual and
designee. Reproductive Health
data manager.
E. Notify DOH contract manager of all:
• Key staff and organizational changes.
Email briefly describing change. As needed to keep
• Proposed clinic site additions.New clinic
information current.
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.
Exhibit A,Statement of Work Page 3 of 7 Contract Number CLH32053-Amendment 1
Page 58 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Any other change that might affect LHJ's
ability to provide the sexual and
reproductive services described in this
SOW.
Reporting Requirements
1 Agency Information Request This information must be reported using the template April 30'f'during each
or format provided by DOH.All signatures and forms year of this contract.
DOH SRHP requires updated information from all must be completed by April 30'during each year of
members of the SRHP Network to ensure accurate this contract. Requested information will include: AND
records of LHJ's organization and the services it
provides. Information about your agency contacts and your As needed or requested
organization's staffing to maintain accuracy of
In addition,elements of this report allow DOH to A. Head of Organization information.
ensure that SRHP&Title X requirements including B. Head of Finance
client fees and required services are met.The C. Medical Director
updated information also assists DOH to manage D. NPI numbers used to bill Medicaid
this SOW and the Sexual&Reproductive Health E. The following(one person might fill more than one
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 anal
was approved by DOH at the bey-inningof f 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.
Exhibit A, Statement of Work Page 4 of 7 Contract Number CLH32053-Amendment 1
Page 59 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
a. Sliding fee schedule must be based on cost
analysis described above.
b. Fee schedule must be resubmitted for
reapproval anytime there are any significant
changes,which may include changing of
services,fees,etc.
c. LHJ must not implement a revised fee
schedule until it has been approved in writing
by DOH.
d. Income conversion tables must be updated Submit an updated
annually and approved by DOH income conversion
table by March 15 of
Information related to current Community Outreach Plan: each year of the
contract.
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 Program Updates This information must be reported using the template During quarterly check
or format provided by DOH. It will include information ins and as requested by
Summary of ongoing activities related to the SRH about contractor's work during current and past DOH
Program.This informs quality improvement of the sows:
Washington State SRH Network.
A. Community education and outreach strategies and
activities and a discussion of their effectiveness.
B. Staff training.
4 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 Number of: end of the grant(2027).
data. All information is for the calendar year A. Pap tests with an ASC or higher result
(January through December).The subsequent B. Pap tests with an HSIL or higher result
agreements sent to the agency will request that these C. HIV Positive confidential tests
data be collected and reported on within the D. HIV Anonymous tests
statement of work period of performance. E. FTE required to provide sexual and reproductive
health services:
• Physicians
Exhibit A,Statement of Work Page 5 of 7 Contract Number CLH32053-Amendment 1
Page 60 of 61
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Physician assistants+nurse practitioners+
certified nurse midwives
• Registered nurses with expanded scope of practice
who are trained and permitted by state specific
regulations to perform all aspects of the physical
assessment.
Financial data emailed to DOH Contract Manager
R&E showing Other Revenue through 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
erformance.(FPAR due 0 1-31 annually through 2027
5 Clinic Visit Reports(CVRs) Clinic visit records must include all elements specified The 15'of the
in the Clinic Visit Record(CVR)Manual available at: following month.
httus://www.doh.wa.eov/Portals/1/Documents/Pubs/930-
139-CVRManual.udf. Within thirty(30)days
of receiving error or
CVR data must be submitted to DOH data contractor rejection report or
(Ahlers&Associates)electronically in a format compatible request from DOH
with Ahlers software. SRH data manager.
- Each month's CVR data
- Corrected CVR data
Data elements will be changed in 2024. CVRs
submitted start 01-01-24 must be done so based on the
new re orting requirements.
6 Revenue and Expense Reports(R&E) Completed R&E for time period that shows all revenue Submitted with each
(including program income)that support Task 1 SRH invoice(A19).No
Services and all expenses related to providing those more than monthly and
services. R&E workbook will be provided by DOH. no less than quarterly.
A. Expenses must match General Ledger. R&E showing all
B. Other revenue/program income must reflect revenue sources of revenue that
actually received in the reporting month. support services must
All entries on"Other"rows must be accompanied by a be billed within 45
description of the revenue source or expense, including any days of the budgetperiod.December
calculations uses. billings must be
submitted by February
loth.
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 e,doh.wa.gov.
Exhibit A,Statement of Work Page 6 of 7 Contract Number CLH3 205 3-Amendment 1
Page 61 of 61
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 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-FPRHManualCompletepdf(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://doh.wa.gov/sites/default/files/2024-10/930-139-CVRManual.pdf)
• LHJ'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 Emereency 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 CLH3205 3-Amendment 1