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HomeMy WebLinkAboutCA6 Consent Agenda ~.~\ J EFF~~~~~ S~~P~rt~o~!~~~~~ 9~~AL TH www.jeffersoncountypublichealth.org December 21, 2009 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Jean Baldwin, Director DATE: J-ANLtA(2.:'1 \ q ) :;;"0 10 SUBJECT: Agenda Item - Interlocal Agreement with Clark County Public Health for HIV Intervention & Prevention, Amendment #1; January 1, 2009 - December 31, 2009; add'l $481 total $20,183 STATEMENT OF ISSUE: Jefferson County Public Health, Community Health, is requesting Board approval of the Interlocal Agreement with Clark County Public Health for HIV Intervention & Prevention, Amendment #1; January 1, 2009 - December 31, 2009; add'l $481 total $20,183 ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S: This is an ongoing regional service agreement with Clark County Public Health for HIV services. This agreement provides for the intervention and prevention activities including high risk testing and clinic based counseling. This represents additional federal revenue passed along to various counties subcontracting with Clark County for HIV Intervention and Prevention services. The finalized budget resulted in a slight increase in federal funds and a slight reduction in state funding. FISCAL IMPACT/COST BENEFIT ANALYSIS: This is not an increase in services. This is represents an increase in the federal reimbursement rate of 2.40/0. These funds were not anticipated by either Clark County or JCPH. COMMUNITY HEALTH DEVELOPMENTAL DISABILITIES MAIN: (360) 385-9400 FAX: (360) 385-9401 PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER COMMUNITY ENVIRONMENTAL HEALTH WATER QUALITY MAIN: (360) 385-9444 FAX: (360) 379-4487 Consent Agenda RECOMMENDATION: JCPH management request approval of the Interlocal Agreement with Clark County Public Health for HIV Intervention & Prevention, Amendment #1; January 1, 2009 - December 31, 2009; add'l $481 total $20,183 REVIEWED BY: / Ie/;? · istrator Date (Routed to all Public Health Managers) A~ND~NTNU~ERONE A~NDING INTERLOCAL AGREEMENT NUMBER HDC.271 Between CLARK COUNTY And JEFFERSON COUNTY WHEREAS, a Contract Agreement was entered into by both parties and was executed January 1,2009; AND WHEREAS, it has become necessary to reduce the amount funding for service interventions in Region VI; AND WHEREAS, Clark County Public Health Director has been authorized to execute amendments related to contract HDC.271; AND NOW, THEREFORE, IT IS AGREED BY THE PARTIES that the agreement shall be amended as follows; I. Funding Reduction Method and Amount of Funding. Funding for the execution of this agreement shall be obtained from County. Consideration for the period January 1, 2009 through December 31, 2009, is $20,183 for those services provided in the Statement of Work II. Budget The Budget shall be amended as follows: ATTACH~NT "c" 2009 BUDGET The LHJ will provide HIV prevention interventions, as detailed in Attachment E and other activities referenced in Section II of this Agreement in accord with the following budget. Changes to the activities or service budget require prior approval from the Region 6 AIDS Service Network Coordinator. Jefferson County Health and Human Services Budget: January 1.. 2009 - December 31.. 2009 Funds awarded under the terms of this Agreement will be used as follows: CTR Syringe Exchange Total State Funds $ 8,684 $ 11,018 $19,702 $ 7,165 $ 13..018 $ 20,183 III. Invoice The Invoice shall be-amended as follows: ATTACHl\fENT "D" INVOICE 2009 Quarterly Omnibus Invoice for Payment Submitting Agency: Jefferson County Health & Human Services Contract: HDC.271 Federal Omnibus CTRPN CTR Services Syringe Exchange 13,018 High Risk Sub Total High Risk 20,183 Interventions Sub Total Other Interventions I TOTAL 20,183 I certify that the services listed above were provided for the period of and that the invoice reflects the actual costs of providing those services. Authorized Signator Date Budget Remainin Olllnibns Federal , 2009, IV. Intervention Plans Intervention Plans shall be amended as follows: ATTACHMENT "E" 1~~~~"""'''''''''''''~~--''''''''''''''''''''''''''':''';'''''''''''''''''''''''''''''~''''''''''~~~''''voo..~~......'''''''';'~...........,"''''''''-~.''''''''''~..''''''.~''''''''''''''-~",,,~..................,..........~~~~.......................-.-.p.~~............................\~__~-...VIA......:;V>........~......,__-....:;.....~~....~............~...................~~...~~................"..,,~"I'^.............................~~...~~~ jProgram Title: 1 ~:;~:t:~~OO-9-~~~~-" lEnd Dat~2/31nOO~ . ~.~~ ~Plan~an~_~~~~ Date:.. I !Agency N~I?e: Je_~~e!:~~n ~~ty P~blic Health _~ f(;;unties Served: . .. .' lRegions: 1 iJefferson iRegion 6 J r~=='~~~~"==--~=:::-'~"~' ,.. .. '" .... -",~.. ., .,,~.~ " ,,,....~,~~.......v._ ,~_,. .u~ .,- ,. ~ '~'~~-'=~~, !~~mary Population I Heterosexual . . . 1 { . ~~_~u,,,_,,._,~_~~,~, ~. ",~___~,~_"_.__-,~~~,~,_,_,_"~~,~~._,_",,,,-,--,_,_~~_,,,,__'__.'n,_~~~,--J iRisk Tr~nsmission IHN-lnfected Persons ! ; CategorIes IIDU L-_"_____w___~_~M ______~~-,--~_______w_._~J lBehavioral Risk I Sharing Needles I l ! I Unprotected Anal Intercourse I IUnprotected Sex (UPS) I IUPS with HIV Positive Person _ ~~ention ~ype_..---- ICo~nselin~ & !es~ing _~ iStudy Name or Justification for Intervention: I iHiggens DL, Galavotti C., et al. (1991) Evidence of the Effects of HIV Antibody Counseling and jTest~g on ~isk Behaviors. Journal of American Medical Ass<>.~iat~on;266(17):2419-2429. I lIs the primary population consistent with those prioritized in the regional HIV Prevention Plan? I I~es :JNo f r' ~_~~~_~_______"'-_~__~_~_~AA'''______'_~'_~~'~'~___~~~~''''^_~__' -~ !Is the intervention type consistent with those prioritized as effective for the population in the I , i iregional HIV Prevention Plan? I I lilY es -1 No i ~,_ _~, . .... ,~_,~~,_ ~. . . ,,_,~ ... . . . . .. .......... .. .... . . .." . . '"" _.. . . -. ... ... ..... ..... .. . . ..... .. - J I Intervention Des~riPtionIThe-goal of voluntary an~nymous -and co~idential H.N CT.R i~ ~o identify I ! i cases of HN and to provIde HN prevention counsehng to mdIvIduals at I' I thigh risk for HIV. HIV CTR is provided by trained JCPH staff, and will be I Iwill be offered to 60 persons engaged in high risk behaviors through the II i !Jefferson County HIV clinic (80% return rate) for a total of 108 contacts., I \ . ! I Clinics will provide services d!lring regular business hours byl i lappointment. For all clients tested, sessions will be client-centered, provide I HN prevention counseling, risk reduction education and skill building lopportunities, HN antibody testing, and post-test counseling. We will I provide post -test counseling~ for 90% of HIV - infected persons identified ithrough the counseling and testing program. PCRS will be explained and Iprovider assistance will be offered to those who test positive. Referral to l . !other health assessments and supportive services will be offered. Elicit Ipartner information for provider follow-up from 75% of persons receiving IPCRS services (2 contac~). We will foll?~ up with any case report. within j 17 days to offer PCRS aSSIstance. In addItIon to the above, JCPH WIll r~-^m~'~~~w~,---~._.~--"~~~-.,-~~,,~,~,.-.,,,,_,~,_~_,.~-'T~"~m~~~'~_~.~-------~~~..,,~._'_.~-'_.,~--'^--~-~~~'~'~~~'~~-~~'''-~----''~'-.~~'---'---~'-.~'''''''~~~''~----^,_~,^~~~~.~~,,~_~w.~.._,~,'-"~~W~-_'~"'__~'_m~.~~,~W~') I ~support condom distribution to a minimum of 2 sites in East Jefferson I : !County. The goal of this activity is to prevent or reduce HIV transmission I ! I and promote CTR and SEP services. ! r~~'~~:'''--''''''~~~'~~--~'~~~'~''''''-~'-'-~-'''~f~~~'~~~___~~.w_,="'~~_~~__~~~~~~,~~_~_~_~,~_~,.,_,~__''''_~ -SettIngs IHIV C&T sIte j f~~'''"''''~"-~-'~--''--~~'~-~-''''-'~'~~~'-'----'-'''''~Tri-c.-'-w.~-'-''''~~_'-_~''''''"~'~'-'''-__~,~,~,_~,_~~,~..v.-<.m~'~''''''~'_'~'''~''''~~---'_~~..""~'~-~~~,."--"""'~_! jprogram Evaluation IClient satisfaction surveys and observation, feedback and strategizing with I p=-----~"C"7"C" Icounselors on a annual_,~~~~o ' _,_. =~ I i Specific Process Objectives/Activities I -i'""""~'-~~'--~'~- .~-~---~-""- I --~w..~~~---'''~~~'4 'Process Objective: jBegin Date: lEnd-Date: I r~~"""""'-~'--'---'-~~-~-~-"~-~"-------'-,~'~,~~,""""--",,,,,,,-,-,,",_w'---~---::::-i !" w'~"_'___'-"_'_~ 1 Provide HIV CTR to 60 individuals through HIV I ! I jCounseling & Testing Services and provide post 11/112009 112/31/2009 I ite~es~~~:~~O~_?f clie~ Total conta~~s=_~~_~L_ I I , 1 ~ k'--'i I Provide Partner Counseling and Referral Services! i 1 iconsistent with state and federal guidelines to I I I : 100% of HIV - infected persons identified through 11/112009 I. 12/31/2009 III ithe counseling and testing program. (Total I i I i contacts 2) I j ~J F{;=~;;"~k"~ A ~~ '" l iWil1 any new materials be produced'by this intervention that require review as stipulated by the I ]CDC? I lilies ~ No I '~~-'~"V___"'~"____~~-=~~_A,,^,",,~~___'~, ,~~_,_, j Total I I l-~~--~~-o-l I __ ! I 43j ! ~,~--::J ~I 2o.J 411 ~ 5' I Ot .11.. - <:19--~ r 20-29 T - 30~'~ 1 Total I Male [Female I Trans I Male iFemale ITrans I Male I Female ITrans _ I 01 01 01 21. 21 01 31 ~'"71 I ~I___ 51 0f?7fl6r. 01 291 -.1~1 ot".~~~ 8T 51 01291 181 01 321 181 0.111 r- "1 <=19 -'T . 20-29' I -30+-rr;;tal I ,--__ I Male !Female !Tran~-IMale I Female [Trans IMaleIFe~ale-IT~ans_ I~=~~~can fudianlAlaskan 1 01 T~l 01 01' T or T o! lA~a~- _--'--- I. 0 I --or'-or-or-or'~or-or-or-or-'~ 1BI~mAfrkanA~canl~~-~1~- oli~-~ 7 t :pacIfic Islander I I _ I . .. J. . I . . ... J Risk Tra11smissio11 Categories lGeneral population (risk unknown) r-~~- , 1 Heterosexual l I HIV - Infected Persons r.......................... iIDU r----~ IMSM !MSMlIDU r~"""""'~-" !Pregnant women with/at risk for HIV TOT AL A Demographics Ethnicity ~?ic _~r Lat~no INot Hispanic or Latino Demographics Race ~~~-~~'--"~---~~-~~'--~5r~--oT~25f14Ior~~26T'-~--18l- 0 I 96] Local Data Fields t 1 -~~~V'~_"~'_'~'W""_'K~~~'~__~_"'_'_~_~"~_~ -~.... hT' arge""""'t '#'--"-~--'-'-"''''~'-''-~W''~-'~'''''-~--J'~ ~~2~~=="""~"",=~",,,,,,c~,~,,~~,,_ .1..J i . I Carol Burwell ~. -~=--=""==~"--1 iName ofWorker(s) asslgnedlJ 10 D kO I ,- h... , U la ans In j i to t IS Intervention: I D . L I 0 I,; ; enlS ang OIS ^ r~--~"~"_.."..,,~..,-'--"'~~~.,'~mm""'-'T-'~'------'-'"-~-""" '----'-'.~-~~---~,,~"'-,-,,~'-,..-..-"--~~--~----"-"--.~.----i ,Volunteers: t i r---~--'-'--~-----r-~'~$OlDOH Grant Feder;IPre~~ntio~--dolla;~~--1 ~ ~"--'~'~~'''''''~''''-'~~-'''~J~,,'~~-'~'-'--~~-'--''''~~.~'m.~,._-~--,---~,-~-"-_.",,,-,J jResources for this I $8, 684 1 . 0 . 0 I !intervention ONLY: I $7,165!State prevention dollars: 50% HISk RIsk I r'"~'~'----~~~'-~""'^ . . . ~~~~"~~"'~~~._-~--_..'''~~-~~ I. __ $0 I Other (inc1.CDC Direct): _~~J Plan Change Log I ~,,~~~,~_,,~~__~,--l ! i ---I I I I ,_,~_J. "~~I i , _~"_'"._'_m,,_~____~~,._~~__~~J I End D~te: .12~/200~_ _J t t ~-=J i i J J ! t i m__,~J j 1 I i ~ I J j I I ~ i .r- _I Reviewed by: i AIDS NET Coordinator 7/7/2009 i State Sent to Region State Confirm Date lProgram Title: ]09 Jefferson IDU Outreach ~~~"'V'd.....-.n.~~""...~............................................~__~......--...........n..... ;Begin Date: 1/1/2009 f'~~~--'- ! Plan Cancelled Date: i------.. w.__~~,'~~,~~~_'" IAgency Name: Jefferson County Public Health 1 Counties Serv~d:~'w-~-,w,,~~~~,------~~- iJefferson I Regio~s: IRe~io~ 6 r ,= ~-, I Primary Population IIDD ~ 'I -~~,= IRisk Transmission !Heterosexual : 1 ,Categories I MSM/IDU ~-~~"'~~'~_~_~~~_';'_~~_._~~~~~_~~__'''w IBehavioral Risk ISharing Needles , IUnprotected Anal Intercourse . . IUn?rotecte~~ex_ (UPS) LIntervention Type IStreet and Community Outreach Intervention f"'''''' '>w' ~"~ .=~~' ,-~" , ' , I Study Name or Justification for Intervention: !Bluethenthal RN, Kral AH, Gee L, et al. (2000). The effect of syringe exchange use on high-risk i injection drug users: a cohort study. AIDS 14: 605-611. r---' '~~"'~'~~~--"~~~'~~:- -,~-~- jIs the primary population consistent with those prioritized in the regional HIV Prevention Plan? jlilY es -.J- No 1 j Is the intervention type consistent with those prioritized as effective for the population in the jregional HIV Prevention Plan? ; lilY es :J No f~~"""'''''''''''''~~'''''''''''''''~''''''''''''''''''''''''''''''''''''~~~'''''''''.'.'''~~~.''''''''''''''~'''''''''''''''''''~~~'''''''''''''''~~~~~'''''''''''~~.'''~~.~''''''''''''''''''~~''''........................................~.........................._~--.-.-......................~...............~~~......,..,.....,~~-..:..~-..:..~~~..............................~............._-..~.-\...._.......~._~...~......................................,...'''''^.....................~~.............................-.~............v..-...................................................-_....................................~.....................................................-...~~...~~......................~...................._~....~~~.................-.v.r..~...........""""'~..~~~-,No.,................................~...-...I~...............<<"'-"":: Intervention Description !The goal of the SEP is to provide syringes, sllpplies, and information in , !order to reduce exposure to HIV among lDUs and their sex partners. This I I will be achieved by providing access to safe injecting equipment including I jsyringes, ties, cookers, cottons, band-aids, water, condoms, lube, and I leducational materials. Health Department personnel will staff SEP clinics. I IRegular SEP hours at the Jefferson County Health Department are I IMondays 1:30 - 3:30 and Wednesdays 1:30 - 3:30. Additional walk-in t Itimes are available based on staff availability. SEP clinics will provide a I jminimum of 3.5 weekly hours o~.syringe exchange reaching 48 contacts I I annually (average 4 contacts per month. SEP clinics will also provide I !weekly outreach at the SEP, reaching at least 10 contacts annually. I IOutreach activities to include safe injection practices including blood- I lbome pathogen risk reduction methods and education. SEP will also i t 1 lprovide condoms, syringe exchange and HIV CT information (Syringe I IAccesslWho should get tested/Where to get tested) to a minimum of two I Isites annually. The SEP provides I-for-l exchange and no fees are charged i !for SEP services. We anticipate offering HIV CTR to 5 contacts annually. I IIn 2009, we will be assessing the barriers and motivations for secondary I lexchange behaviors, as the majority of our clients are secondary I lexchangers. We will interview 7 clients in this project. OUf hope is to learn I Imore regarding barriers to primary exchange and to adjust our services to I lengage more primary exchangers in services. J ~~-~ IAct~eo~eoch -~~~ I ] IClinic/health care facility 1 ~ . . . ~ } r~~"""""""'~~~""'I'f'o._~"""'~~~~~~~~~""~-'."""""~~~~""""""""""""""""""",~~~--~~",--",~~""""""",-""""""""~~,;,,,,~~~~~~~~~-.Avv.:o.~....",.........................~.................................,.;.~-....._................~...~~._~~........................-............................,.,~......~~~~................_...................~...........................................................~..._~...-.......-_............................:."'lo...........~~"o:o:'o~~~...........~..~~......,......~........m~~...~-..v..~..;......;.........."""".~~~~ !Program Evaluation IQuantitative: #1 distribution of syringes and materials, #2 assessing I ! Isharing and needle use behav~ors: Qualitative: evaluating barriers to access I ; Ito SEP for end users and motIvatIon for secondary exchangers. ! f:-;;'=:~:;:;'='~::''O'~;;;''~'''"=~=~~~-'~~~~-'--' - -;:-" .", ''''::..~~-:;~:::;"=;;::=~===.......~~=-"~"-=~~~;:::.:,:;:::~~;~~~~=~,,,,,,~,,~ i. .. Specific Process Objectives/Activities I ~~~~A~~'~' .. . . . 'A~" "",:>,'~~-"~'-~"-..,-----~-~~m~-~T~~~'-'"~~'~''''''''''''-''''''''''''''-~-m......,v..<t 'Process Objective: I Begin Date: lEnd Date: 1 r~~---~~"~'-'-""--'-'~--'----~~-'---'------'~~'~-'-----r----..-----~_,,~,~A-~""~'~~~--~--'+___--~~-,.--- -~-'-'1 !Provide a minimum of 3.5 weekly hours of one- I ' I !for-one syringe exchange reaching 48 contacts ! 1/1/2009 12/31/2009 I ] annually I I r------~"-'-"~--"- .r______~--'"-r- ! jProv.ide outreach at the SEP, reaching at least 10 11/1/2009 112/31/2009' I !duplIcated contacts annually I I ! r~--'--~......_~"""-,w--_._~~~~~~-~- r...~'..._~....-A--'-...--~-~~-'~~~--~--~~,... 1 J Conduct key informant interviews with 7 I I I ! sec~nda:Y exchangers t? better u~derstand. 11/112009 112/31/2009 i I motIvatIon for exchangIng behavIor and barrIers I I I !to primary exchanging behavior. I I I ~';;;.~'!"^~~::::::;;:;:;:::::-:.':':.................--:::....:.::.~~~.:.:.~...............,..................~~......==::::...-..:::::::::=......'...::.;...~;;;;...."..--:::::::;:..~~........'":..'"::'...:;.--:~_=.:.:::::::.~~.;:;::::::::;:::..,."-:::..:;:::..~~~:;:.:::;.;:..~~__.~~v..:....".,~~~~~~~_::....'":.:....'"::.......... -.w.-.-........ ..,.......".:-'-~':.':,':..~..~~ IWil1 any new materials be produced by this intervention that require review as stipulated by the I iCDC? J I DYes ;z) No I ~__"--mm__"_----"-_-_"---~-------"m~-,----"-" Total j IGeneral population (risk unknown) I oj f-~-~-~~'-'--,.---~----~"---~~-~~-~--A--"~~-"-~--"~~~~----r.._.~~--~'--- ~ I Heterosexual I 81 lHIV-fufe~ted P~~;on~-~"~-'---"--r~- oj lIDU -". -~~"___~m~--r' 521 rMS~~- . - _~___~~~. -==-== I~^_-=--------~~ ~~"-'-''''''''''''''-'~~~~'''''''''''''''''''''''''''''''"''f'ok.'............~...............~......~....~~....~~.................................~..~-.:-......................~~..........~~..........'.,~-.J..-J.,~~~~~...................~~~......,.,........ .....~...........~...-.......~~~....,.,....v..-.---...-..................-......................',......~~~~~...........................................~......~~~..........."....__...........,.,..................-----~~'~~.....i...............-..--..........-........................~...~~.".....,~~~~~.....~~~.............">/..............~.......~~....~~~~-.-.-_........-.:..~..r.~-.............~....................................~............-..-..........,..~~..............j : MSM/IDU I 5' ;_--,~''''''~"~~'''~,.."..w.,,_,,~,,~~~~~'''_--'..,...._,__..~''w,,x~,.'''_-_~,w_~w~''''w__~~_w~~~~"~"""""_,__~,,,~'_''''''''''~~'_,,",,,,,,,-~~~_,w+_.'_'.-~.4..~__~~~__m""_'__.~"_W_'_'-_'_.""'_Wh~"_'----v-.~-,-i !Pregnant women with/at risk for HIY i 01 -='~====-r=--' ,_lll~;_-T <=19 I .20-29 ... I 30+. ~ ~anic-or L~tin~-~--T~~~~f~~rMarm~ra~6faIJf~e~aIWr~~ 'Not Hispanic o~Lati~~------or--6l-TTo-r49T.~51 _._~~_._____.__~~-~:~l ~~=~=~~~ :9~=_~~~ <=19 I 20-29 I 30+1 Total __ ~em;~lThan~tM~Femal~ran;rM;le !Fe;-ale 1Th~ N atl v e . . . .. I I. . . m i ; I. i IAsian . I Ofoi--OfOI .. mol . 01 01 o~ jIlli;k or African American !OIoT---o!OT 0 I 0 I 0 I 01 0 I -0 I r,~~~HaWatianillO~~I~-~I~~I.. . ~.~.~ :Pa~c Islander I I i I I JI I I i r~ite----------r-olol6T~0149T---4fOT651 rMor~th~-One R~~;~--or 0 I ~-Or~"Or.. Or-~.()fOIo-1 or--oI016l6lor---49f~--TOBII I . : F=,~~=;'~~~:;;,'.=-.,.--=:;....~n--;';.~__~n-===,:;",-=;;:~ ,~' _ ,.;.--;...-::;::==='::,._---"_... . . _-=;.=~=,~~"-==n~~~.;.:.~=;::---~ Local Data Fields ! -~,~~~~ , -"~~~'--~n-'__'.-~-'-~-~~.-----'-.h'~-'~-'''--c_~~~n~'~~"'."n~_~__u~n'~__~~"~n,_"'...J : Description lTarget # 1 r..'-_-~~n',-,"~~v.-"~--"--n---~""--,_,",,,-~-~-'~'~ , . ,_~_"",..4_____..........wm___-'''-,~~~'-'___n~''-~_,-,"n......''''''''~~..-n'_._'_-~,_,_,w",j !Increase the number of new IDUs utilizng SEP services in "5. I i2008 I 'Increase the number of SEP IDUs recieving HN CTR in 15 --1 2008 i ;~eas;the n~mber of S~P IDUs re~rting rei~~follOwl5 ~J ~ Serve alL ot~er Jefferson Co. ZipCodes ___ 110 I iServe IOU III non-east Jefferson Co. ZIP code 11 I IServe !nUs in ZIP code 98368 J10 -J LServe SEP :!ients who rep~rt se_condary exchange . 130 ~ i i 1 I ICarol Burwell !Name of Worker(s) assigned IJulia Danskin ]to this intervention: iDenis Langlois j iLisa McKenzie ~-----,_.,'-~--,.~'---~---~- lYolunteers: I JR;sources for this r-- $0 IDOH Grant Federal Prevention dollars lintervention ONLY: r ~1;:~1~ I State prevention dollars: 50% Hisk Risk ~ ~ ..... ~ TOTAL A Demographics Ethnicity Total B Denlographics Race ~ J ~ I ! I by: AIDS NET Coordinator 7/7/2009 State 9/29/2008 Sent to Region 10/1/2008 State Confirm Date $0 (incL CDC Direct): Plan Change Log All other provisions of the contract remain unaltered. B j#'"'h"ji" i, ~_~c"~=~""_ -, "._,,,~ ~ ./7~. if v'\,.=..".",,-,"~r- John Wi~sman, Director \,J Clark County Public Health By Signator Jefferson County Health and Human Services .- - i'>.1."; i. 'V