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HomeMy WebLinkAboutC04-162 Colorado Department of Public Health and Environment – Tuberculosis Program.. ~~ ~- z - ~ DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIItONMENT DEPARTMENT OR AGENCY NUMBER . FHA CONTRACT ROUTING NUMBER 05-00019 INTERGOVERNMENTAL CONTRACT Tuberculosis Program This Contract is made this 21st day of April, 2004, by and between: the state of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as "the State"; and, BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY, (a political subdivision of the State of Colorado), whose address or principal place of business is 500 Broadway, Eagle , CO, 81631, hereinafter referred to as "the Contractor". WHEREAS, pursuant to 25-4-501, 8 C.R.S., as amended, the General Assembly has declared that tuberculosis is an infectious and communicable disease, that it endangers the population of this state, and that the treatment and control of said disease is a state responsibility; WHEREAS, pursuant to 25-4-511, 8 C.R.S., assistance under section 25-4-501 shall be given to any applicant who is suffering from tuberculosis in any form requiring treatment and is without sufficient means to obtain such treatment; WHEREAS, the General Assembly of the State of Colorado has, for the fiscal year beginning July 1, 2004, (SFY05-06 Long Appropriations Bill) appropriated funding for Tuberculosis control; WHEREAS, as of the made date of this Contract, the State has a currently valid Group II purchasing delegation agreement with the division of finance and procurement within the Colorado Department of Personnel and Administration; WHEREAS, section 29-1-201, C.R.S., as amended, encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function, service, or facility lawfully authorized to each of the cooperating or contracting entities, and to this end all state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code; WHEREAS, as to the State, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Number(s) 100, Organizational Unit Code(s) 4644, 4648, and 4645, Appropriation Code(s) 386 Program Code(s) 9012, and Object Code(s) 5420, 2710, under Contract Encumbrance Number PO FHA EPI05000001, PO FHA EPI05000002; and PO FHA EPI0500019. Page 1 of 16 WHEREAS, all required approvals, clearances, and coordination have been accomplished from and with all appropriate agencies. NOW THEREFORE, in consideration of their mutual promises to each, stated below, the parties hereto agree as follows: A. EFFECTIVE DATE AND TERM. The proposed effective date of this Contract is July 1.2004. However, in accordance with section 24-30-202(1), C.R.S., as amended, this Contract is not valid until it has been approved by the State Controller, or an authorized designee thereof. The Contractor is not authorized to, and shall not, commence performance under this Contract until this Contract has been approved by the State Controller. The State shall have no fmancial obligation to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effecfive date of this Contract. If the State Controller approves this Contract on or before its proposed effective date, then the Contractor shall commence performance under this Contract on the proposed effective date. If the State Controller approves this Contract after its proposed effective date, then the Contractor shall only commence performance under this Contract on that later date. The initial term of this Contract shall commence on the effective date of this Contract and continue through and including June 30, 2005, unless sooner terminated by the parties pursuant to the terms and conditions of this Contract. In accordance with section 24-103- 503, C.R.S., as amended, and Colorado Procurement Rule R-24-103-503, the total term of this Contract, including any renewals or extensions hereof, may not exceed five (5) years. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. Funds provided under this Contract are to assist in supporting tuberculosis (TB) prevention and control activities as stated in section 25-4-501, et sue, C.R.S., as amended, and "Rules and Regulations Pertaining to Epidemic and Communicable Disease Control" (6-CCR-1009-1, Regulation 4). The Contractor shall provide or coordinate the following services for all individuals within its service area according to the statutes and regulations listed above and the CDPHE's Tuberculosis Manual. In no event, however, shall the Contractor provide less duties than those required by the above-referenced statutes and regulations. The Contractor's use of funds under this Contract shall be prioritized as follows: priority 1) fmd all people with active TB in its service area and ensure the completion of appropriate therapy for those people; priority 2) fmd and evaluate the contacts of TB patients and ensure the completion of appropriate therapy, if needed; priority 3) targeted testing of high-risk persons and ensure the completion of therapy for latent TB infection (LTBI), if needed. If a patient has medical insurance, then the Contractor shall utilize that patient's medical insurance as the primary payment source before using funds provided under this Contract. a. Suspected or Confirmed Active TB 1. The Contractor shall provide, or arrange for, chest x-rays and interpretations. 2. The Contractor shall collect, or arrange for the collection of, specimens for mycobacteriology testing on all persons suspected of having tuberculosis. Assure appropriate testing is performed, e.g., smears for acid-fast bacilli, (using concentrated fluorescent method), isolation of mycobacteria (using rapid methods), identification of MTB (using rapid methods), and susceptibility testing (isoniazid, rifampin, ethambutol, and pyrazinamide) on isolates of MTB. The CDPHE Laboratory will, at no charge to the Contractor, supply specimen containers and perform the above testing for the Contractor. The Contractor shall arrange for the transportation of the specimens to the CDPHE Laboratory for testing. Page 2 of 16 . 3. The Contractor shall provide, or arrange for, the placement of patients who require isolation. The Contractor shall contact CDPHE TB Program for assistance, if needed, and to request reimbursement from CDPHE for those costs incurred by the Contractor in isolating a patient. 4. The Contractor shall provide, or arrange for, all other necessary laboratory testing and medical evaluation services. 5. The Contractor shall order TB medications through the CDPHE TB Program. 6. The Contractor shall provide the CDPHE with the medical insurance information for those patients who have medical insurance. 7. The Contract shall provide, or arrange for, the treatment of patients with suspected or confirmed active TB, including directly observed therapy, and ensure that all patients with suspected or active TB complete therapy for all reported cases. 8. The Contractor shall provide, or arrange for, a HN antibody test for all persons diagnosed with TB disease, regardless of their age or the apparent absence of risk factors for HIV infection. In accordance with section 25-4-1401, et sue, C.R.S., as amended, the Contractor shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks associated with HN/TB co-infection. 9. At least monthly, the Contractor shall monitor and evaluate those persons with suspected or confirmed active TB. 10. The Contractor shall provide culturally appropriate patient education and information pertaining to TB treatment and/or follow-up plan. 11. All reports of suspected or confirmed active TB shall include the: reason for initiating, patient name, date of birth, country of birth, demographics, locating information, provider information, TB risk factors, results of diagnostic testing, results of mycobacteriology including susceptibility results, dates of infectious period, treatment information, changes in patients' status, diagnosis, or any other information as appropriate. The Contractor shall report to CDPHE when a TB patient completes treatment, moves, or transfers out of the Contractor's service area. Information may be reported via web-based TB caselcontact management system (TBdb) or via "Tuberculosis Surveillance and Case Management Report" (TB 17), which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment A". Confirmed cases of TB shall include all data elements identified in the "Report of Verified Case of Tuberculosis (RVCT)", which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment B"). The CDPHE shall provide the format and instructions for any additional information requests. b. Contacts to Newly Identified Infectious TB (smear and/or culture positive nuhnonarv of larvneeal 1. The Contractor shall ensure that all contacts to newly identified infectious TB cases are identified, investigated, and receive appropriate evaluation. Contact investigation and any follow-up needed as a result of an occupational exposure shall be conducted by the employer. 2. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations. 3. When indicated, the Contractor shall provide, or arrange for, other laboratory testing, and other necessary medical evaluation services. Page 3 of 16 ' ~ / , 4. The Contractor shall provide, or arrange for, the treatment (including directly observed preventive therapy when appropriate), and ensure the completion of therapy for infected contacts. 5. The Contractor shall order TB medications through the CDPHE TB Program. 6. The Contractor shall provide CDPHE with the medical insurance information for those patients that have medical insurance. 7. The Contractor shall provide, or arrange for, an HN antibody test to all persons with LTBI with HIV risk factors or from an HN endemic area. In accordance with section 25-4-1401, et sue, C.R.S., as amended, the Contractor shall report all known HIV antibody test results to the State. The Contractor shall inform all Individuals whom refuse testing of the risks associated with HNJTB co-infection. 8. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during treatment. 9. The Contractor shall provide culturally appropriate patient education and information pertaining to LTBI treatment and/or follow-up plan. 10. The Contractor shall submit a preliminary Contact Investigation Report, which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment C") to the CDPHE TB Program after initiation of each contact investigation. The Contractor shall submit a final report to CDPHE when a contact investigation is completed. 11. Reports for those persons identified, as part of a contact investigation, with latent TB infection, or those with suspected latent TB infection requiring treatment recommendations from the CDPHE shall include: reason for initiating, patient name, date of birth, country of birth, demographics, locating information, provider information, TB risk factors, results of diagnostic testing, treatment information, or any other information as appropriate. The Contractor report to CDPHE when a LTBI patient completes treatment, moves, or transfers out of the Contractor's service area. Information may be reported via web-based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and Case Management Report" (TB 17). The CDPHE shall provide format and instructions for any additional information requests. c. Hish-Risk Persons with LTBI 1. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations. 2. When indicated, the Contractor shall provide, or arrange for, all other necessary laboratory testing and medical evaluation services. 3. The Contractor shall provide, or arrange for, the treatment (including directly observed preventive therapy when appropriate), and ensure the completion of therapy. 4. The Contractor shall order TB medications through the CDPHE TB Program 5. The Contractor shall provide the CDPHE with the medical insurance information for those patients that have medical insurance. Page 4 of 16 6. The Contractor shall provide, or arrange for, a HIV antibody test to all persons with LTBI with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et sue, C.R.S., as amended, the Contractor shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks associated with HIV/TB co-infection. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during treatment. 8. The Contractor shall provide culturally appropriate patient education and information pertaining to LTBI treatment and/or follow-up plan. Reports of persons with LTBI shall include the: reason for initiating, patient name, date of birth, country of birth, demographics, locating information, provider information, TB risk factors, results of diagnostic testing, treatment information, or any other information as appropriate. Contractor shall report when a LTBI patient completes treatment, moves, or transfers out of the jurisdiction. Information maybe reported via web-based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and Case Management Report" (TB 17). The CDPHE shall provide format and instructions for any additional information requests. 10. Tuberculin skin testing, chest x-rays, and chest x-ray interpretations are not eligible for reimbursement under this Contract for the following: i. Correctional facility inmates; ii. Persons, other than Class A or B TB immigrants, undergoing immigration medical examinations; iii. Paid or volunteer employees of health care facilities, long-term care facilities, drug treatment centers, correctional facilities, shelters, schools, or child care facilities who undergo skin testing as part of a routine employment skin testing program. d. Class A or B TB Immi rg ants The CDPHE TB Program shall immediately notify the Contractor of all newly arrived Class A or B TB immigrants to the county via a CDC 75.17 form, which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment D". Within thirty (30) calendar days of the Contractor's receipt of written notification from the CDPHE of the arrival of a Class A or B immigrant, the Contractor shall contact that immigrant and conduct a TB screening including a tuberculin skin test, provide or arrange for, sputum collection and testing for acid-fast bacilli x 3, and chest x-ray. The Contractor shall provide appropriate follow-up for an identified immigrant and, complete and return the CDC 75.17 form for an identified immigrant to the CDPHE. Page 5 of 16 e. TB Education and Consultation As needed, the Contractor shall provide consultation services to providers in its service area regarding TB reporting, screening, treatment, and follow-up. f. Reports for contract monitoring The Contractor shall provide the CDPHE with asemi-annual report on TB activities in its service area. A sample of the semi-annual report is incorporated herein by this reference, made part hereof, and attached hereto as "Attachment E". 1. July 1, 2004, through December 31, 2004 -due January 31, 2005; and, 2. January 1, 2005, through June 30, 2005 -due July 31, 2005. g. Tuberculosis Response Plan The CDPHE TB Program shall implement a Tuberculosis Response Plan in the event a county experiences an exceptional TB circumstance (which is described in the Tuberculosis ResponsePlan, which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment F". The Tuberculosis Response Plan provides for the assessment of additional TB response activities, in collaboration with local public health authorities, to ensure comprehensive and prompt response to the situation. h. Confidentiality The Contractor shall maintain internal medical and administrative records in a manner which ensures the confidentiality and security of those records in accordance with all applicable statutes including, but not limited to, 25-1-107, C.R.S., as amended. C. DUTIES AND OBLIGATIONS OF THE STATE. 1. In consideration of those services satisfactorily and timely performed by the Contractor under this Contract, the State shall cause to be paid to the Contractor a sum not to exceed FOUR THOUSAND NINE HUNDRED SEVEN DOLLARS, ($4,907.001 for the initial term of this Contract. Of the total fmancial obligation of the State referenced above, 4$ ,907.00 are identified as attributable to a funding source of the state of Colorado. Payment pursuant to this contract shall be made as earned, in whole or in part, from available State funds encumbered in an amount not to exceed TWENTY THOUSAND DOLLARS ($20,000.0.0_ ) Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2005. Of the total financial obligation of the State referenced above, one hundred percent is derived from the State General Fund. The liability of the State, at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. if there is a reduction in the total funds appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or terminate this Contract in its entirety. Page 6 of 16 Payment pursuant to this contract shall be made as earned, in whole or in part, from available State funds encumbered in an amount not to exceed EIGHT THOUSAND NINE HUNDRED DOLLARS ($8,900.00) Statewide for Tuberculosis Diagnostic Services for State Fiscal Year 2005. Of the total fmancial obligation of the State referenced above, one hundred percent is derived from the State General Fund. The liability of the State, at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or terminate this Contract in its entirety. Description Tuberculosis Control and Outreach Funding Source State Amount $ 4,907.00 Diagnostic Services Direct Observed Therapy ($12.50 per onsite visit) ($25.00 per field visit) TOTAL State State As Administered As Administered $ 4,907.00 2. To receive compensation under this Contract, the Contractor shall submit a signed monthly "Cost Reimbursement Statement". A sample Cost Reimbursement Statement is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment G". A Cost Reimbursement Statement must be submitted within thirty (30) calendar days of the end of the billing period for which services were rendered. Expenditures shall be in accordance with those items identified above. These items may include, but are not limited to: the Contractor's salaries, fringe benefits, supplies, travel, operating, and indirect costs which are allowable and allocable expenses related to its performance under this Contract. Cost Reimbursement Statements shall: reference this Contract by its contract routing number, which number is located on page one of this Contract; state the applicable performance dates, the names of payees; a brief description of the services performed during the relevant performance dates; the incurred expenditures; and, the total requested reimbursement. Reimbursement during the initial, and any renewal or extension, term of this Contract shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Contract. Cost Reimbursement Statements shall be sent to: Barb Stone Tuberculosis Program Colorado Department of Public Health and Environment DCEED-A3 4300 Cherry Creek Drive South Denver, CO 80246 Page 7 of 16 4. Contract Renewal, Extension, and Modification. The State, with the concurrence of the Contractor, may prospectively renew or extend the term of this Contract, or increase or decrease the amount payable under this Contract through a "Limited Amendment" that is substantially similar to the sample form Limited Amendment that is incorporated herein by this reference and identified as "Attachment H". To be effective, this Limited Amendment must be signed by the State and the Contractor, and be approved by the State Controller or an authorized delegate thereof. The parties understand that this Limited Amendment shall be used only for the following: A. To increase or decrease the level of funding during the current term of the Original Contract due to an increase or decrease in the amount of goods and/or level of services being provided based upon the existing Scope of Work and/or established pricing and/or established Budget/pricing; B. To revise specifications within the current Scope of Work and/or Budget that increase/decrease the level of funding during the current term of the Original Contract; C. To renew or extend the term of the contract with appropriate changes in the amount of funding that results in a new total financial obligation of the State based upon: a. the same Scope of Work and pricing, or b. revised specifications to the previously defined Scope of Work. D. To make changes to the specifications to the original Scope of Work, project management/manager identification, notice address or notification personnel, or the period of performance, that result in "no cost" changes to the Budget. Upon proper execution and approval, this Limited Amendment shall become a formal amendment to this Contract. 5. Other Contract Modifications. If either the State or the Contractor desires to modify the terms and conditions of this Contract other than as provided for in paragraph C. 4. above, then the parties shall execute a standard written amendment to this Contract initiated by the State. The standard written amendment must be executed and approved in accordance with all applicable laws and rules by all necessary parties including the State Controller or delegate. D. GENERAL PROVISIONS. Because this Contract involves the expenditure of federal, state, or private funds, this Contract is subject to, and contingent upon, the continued availability of those funds for payment pursuant to the terms and conditions of this Contract. If those funds, or any part thereof, become unavailable as determined by the State, then the State may immediately terminate this Contract. 2. The parties warrant that each possesses actual, legal authority to enter into this Contract. The parties further warrant that each has taken all actions required by its applicable law, procedures, rules, or bylaw to exercise that authority, and to lawfully authorize its undersigned signatory to execute this Contract and bind that party to its terms. The person or persons signing this Contract, or any attachments or amendments hereto, also warrant(s) that such person(s) possess(es) actual, legal authority to execute this Contract, and any attachments or amendments hereto, on behalf of that party. Page 8 of 16 3. The Contractor is a "public entity" within the meaning of the Colorado Governmental Immunity Act (CGIA), section 24-10-101, et sue, C.R.S., as amended. Therefore, at all times during the initial term of this Contract, and any renewals or extensions hereof, the Contractor shall maintain such liability insurance, by commercial policy or self-insurance, as is necessary to meet its liabilities under the CGIA. If requested by the State, the Contractor shall provide the State with written proof of such insurance coverage. The Contractor certifies that, as of the effective date of this Contract, it has currently in effect all required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary to properly perform the services and/or deliver the products specified in this Contract. The Contractor also warrants that it shall maintain all required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary to properly perform this Contract, without reimbursement by the State or other adjustment in the Contract price. Additionally, all employees or subcontractors of the Contractor performing services under this Contract shall hold, and maintain in effect, all required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary to perform their duties and obligations under this Contract. Any revocation, withdrawal or nonrenewal of any required licenses, certifications, approvals, insurance, permits, etc., if any, that are necessary for the Contractor, or its employees and subcontractors, to properly perform its duties and obligations under this Contract shall be grounds for termination of this Contract by the State for default without further liability to the State. 5. To be considered for payment, billings for payments pursuant to this Contract must be received within a reasonable time after the period for which payment is requested; but in no event no later than sixty (60) calendar days after the relevant performance period has passed. Final billings under this Contract must be received by the State within a reasonable time after the expiration or termination of this Contract; but in no event no later than sixty (60) calendar days from the effective expiration or termination date of this Contract. 6. Unless otherwise provided for in this Contract, "Local Match" shall be included on all billing statements, in the column provided therefore, as required by the funding source. 7. The Contractor shall grant to the State, or its authorized agents, access to the records and fmancial statements of the Contractor that directly relate to its performance under this Contract. The Contractor shall retain all such records and financial statements for a period of six (6) years after the date of issuance of a fmal audit report. This requirement is in addition to any other audit requirements contained in other paragraphs of this Contract. 8. Unless otherwise provided for in this Contract, for all contracts with terms longer than three (3) months, the Contractor shall submit a written progress report specifying the progress made for each activity identified in this Contract. These progress reports shall be submitted in accordance with any applicable procedures developed and prescribed by the State. The preparation of progress reports in a timely manner is the responsibility of the Contractor. If the Contractor fails to comply with this provision, then the failure: may result in a delay of payment of funds; or, termination of this Contract. Page 9 of 16 The Contractor shall maintain a complete file of all records, documents, communications, and other materials that directly relate to this Contract. These materials shall be sufficient to properly reflect all direct and indirect costs of labor, materials, equipment, supplies, and services, and other costs of whatever nature for which a contract payment was made. These records shall be maintained according to generally accepted accounting principles and shall be easily separable from other records of the Contractor. Copies of all such records, documents, communications, and other materials shall be the property of the State and shall be maintained by the Contractor, in a central location as custodian for the State, on behalf of the State, for a period of six (6) years from the date of final payment under this Contract, or for such further period as may be necessary to resolve any pending matters, including, but not limited to, audits performed by the federal government. 10. The Contractor authorizes the State, or its authorized agents or designees, to perform audits or make inspections of those records that directly relate to its performance under this Contract. Audits and inspections may be made at any reasonable time during the term of this Contract and for a period of three (3) years after the termination or expiration date of this Contract. The Contractor shall permit the State, or any other duly authorized governmental agent or agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Contract. Monitoring may include, but is not limited to: internal evaluation procedures, examination of program data, special analyses, on-site checks, formal audit examinations, or any other reasonable procedures. All monitoring shall be performed by the State in a manner that does not unduly interfere with the work of the Contractor. 11. Subject to the Public (Open) Records Act, section 24-72-101, et sue, C.R.S., as amended, if the Contractor obtains access to any records, files, or other information of the State in connection with, or during the performance of, this Contract, then the Contractor shall keep all such records, files, or other information confidential and shall comply with all laws and regulations concerning the confidentiality of all such records, files, or information to the same extent as such laws and regulations apply to the State. Any breach of confidentiality by the Contractor, or third party agents of the Contractor, shall constitute good cause for the State to cancel this Contract, without liability to the State. Any State waiver of an alleged breach of confidentiality by the Contractor, or third party agents of the Contractor, does not constitute a waiver of any subsequent breach by the Contractor, or third party agents of the Contractor. 12. Unless otherwise provided for in this Contract, or in a written amendment executed and approved pursuant to the Fiscal Rules of the state of Colorado, all material, information, data, computer software, documentation, studies, and evaluations produced in the performance ofthis Contract for which the State has made a payment under this Contract are the sole property of the State. 13. If any copyrightable material is produced under this Contract, then the State shall have a paid in full, irrevocable, royalty free, and non-exclusive license to reproduce, publish, or otherwise use, and authorize others to use, the copyrightable material for any purpose authorized by the Copyright Law of the United States as now or hereinafter enacted. Upon the written request of the State, the Contractor shall provide the State with three (3) copies of all such copyrightable material. Page 10 of 16 14. If required by the terms and conditions of a state grant, the Contractor shall obtain the prior approval of the State and all necessary third parties prior to publishing any materials produced under this Contract. If required by the terms and conditions of a state grant, the Contractor shall also credit the State and all necessary third parties with assisting in the publication of any materials produced under this Contract. 15. If this Contract is in the nature of personaUpurchased services, then the State reserves the right to inspect services provided under this Contract at all reasonable times and places during the term of this Contract. "Services", as used in this clause, includes services performed or written work performed in the performance of services. If any of the services do not conform with the terms of this Contract, then the State may require the Contractor to perform the services again in conformity with the terms of this Contract, with no additional compensation to the Contractor for the reperformed services. When defects in the quality or quantity of the services cannot be corrected by reperformance, then the State may: require the Contractor to take all necessary action(s) to ensure that the future performance conforms to the terms of the Contract; and, equitably reduce the payments due to the Contractor under this Contract to reflect the reduced value of the services performed by the Contractor. These remedies in no way limit the other remedies available to the State as set forth in this Contract. 16. If, through any cause attributable to the action(s) or inactions) of the Contractor, the Contractor: fails to fulfill, in a timely and proper manner, its duties and obligations under this Contract; or, violates any of the agreements, covenants, provisions, stipulations, or terms of this Contract, then the State shall thereupon have the right to cancel this Contract, in whole or in part, for cause by giving written notice thereof to the Contractor. The written notice shall be given to the Contractor no less than thirty (30) calendar days before the proposed cancellation date and shall afford the Contractor the opportunity to cure the default or state why cancellation is otherwise inappropriate. If this Contract is cancelled for default, then all fmished or unfmished data, documents, drawings, evaluations, hardware, maps, models, negatives, photographs, reports, software, studies, surveys, or any other material, medium or information, however constituted, which has been or is to be produced or prepared by the Contractor under this Contract shall, at the option of the State, become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to, and accepted by, the State. If applicable, the Contractor shall return any unearned advance payment it received under this Contract to the State. Notwithstanding the above, the Contractor is not relieved of liability to the State for any damages sustained by the State because of the breach of this Contract by the Contractor. The State may withhold any payment due to the Contractor under this Contract to mitigate the damages of the State until such time as the exact amount of those damages is determined. If, after canceling this Contract for default, it is determined for any reason that the Contractor was not in default, or that the action(s) or inactions) of the Contractor was excusable, then such cancellation shall be treated as a termination for convenience, and the respective rights and obligations of the parties shall be the same as if this Contract had been terminated for convenience as described below. 17. The State may, when the interests of the State so require, terminate this Contract, in whole or in part, for the convenience of the State. The State shall give written notice of termination to the Contractor. The written notice shall specify the part(s) of the Contract terminated. The written notice shall be given to the Contractor no less than thirty (30) calendar days before the effective date of termination. If this Contract is terminated for convenience, then all fuushed or unfinished data, documents, drawings, evaluations, hardware, maps, models, negatives, photographs, reports, software, studies, surveys, or any other material, medium or information, however constituted, which has been or is to be produced or prepared by the Contractor under this Contract shall, at the Page 11 of 16 option of the State, become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to, and accepted by, the State. If applicable, the Contractor shall return any unearned advance payment it received under this Contract to the State. This paragraph in no way implies that a party has breached this Contract by the exercise of this paragraph. If this Contract is terminated by the State as provided for herein, then the Contractor shall be paid an amount equal to the percentage of services actually performed for, or goods actually delivered to, the State, less any payments already made by the State to the Contractor for those services or goods. However, if less than sixty percent (60%) of the services or goods covered by this Contract have been performed or delivered as of the effective date of termination, then the Contractor shall also be reimbursed (in addition to the above payment) for that portion of those actual "out-of-pocket" expenses (not otherwise reimbursed under this Contract) incurred by the Contractor during the term of this Contract that are directly attributable to the uncompleted portion of the services, or the undelivered portion of the goods, covered by this Contract. In no event shall reimbursement under this clause exceed the total financial obligation of the State to the Contractor under this Contract. If this Contract is canceled for default because of a material breach of this Contract by the Contractor, then the above provisions for cancellation for default shall apply. 18. Neither the Contractor nor the State shall be liable to the other for any delay in, or failure of perfom~ance of, any covenant or promise contained in this Contract to the extent that the delay or failure is caused by a supervening cause. As used in this Contract, "supervening cause" is defined to mean: an act of God, fire, explosion, action of the elements, strike, interruption of transportation, rationing, court action, illegality, unusually severe weather, war, or any other cause which is beyond the control of the affected party and which, by the exercise of reasonable diligence, could not have been prevented by the affected party. A delay or failure to perform that is caused by a supervening cause shall not constitute a material breach of this Contract or give rise to any liability for damages therefor under this Contract. 19. The enforcement of the terms and conditions of this Contract, and all rights of action related to that enforcement, shall be strictly reserved to the State and the Contractor. Nothing contained in this Contract shall give rise to, or allow, any claim or right of action whatsoever to or by any third person. Nothing contained in this Contract shall be construed as a waiver of any provision of the Colorado Governmental Immunity Act, section 24-10-101 et sea., C.R.S., as amended. Any person or entity, other than the State or the Contractor, who may receive services or benefits under this Contract shall be deemed an incidental beneficiary only. 20. To the extent that this Contract maybe executed and performance of the obligations of the parties maybe accomplished within the intent of this Contract, the terms of this Contract are severable. If any term or provision of this Contract is declared invalid by a court of competent jurisdiction, or becomes inoperative for any other reason, then that invalidity or failure shall not affect the validity of any other term or provision of this Contract. 21. The waiver of a breach of a term or provision of this Contract shall not be construed as a waiver of a breach of any other term or provision of this Contract or, as a waiver of a breach of the same term or provision upon subsequent breach. Page 12 of 16 22. If this Contract is in the nature of personaUpurchased services, then, except for accounts receivable, the rights, duties, and obligations of the Contractor shall not be assigned, delegated, or otherwise transferred, except with the prior, express, written consent of the State. , 23. Unless otherwise provided for in this Contract, this Contract shall inure to the benefit of, and be binding upon, the parties hereto and their respective successors and assigns. 24. Unless otherwise provided for in this Contract, the Contractor shall notify the State, within five (5) working days after being served with a summons, complaint, or other pleading in any case that involves any services provided under this Contract and which has been filed in any federal or state court or administrative agency. The Contractor shall deliver copies of any documents that it was served with to the State within five working (5) days of the date of service. 25. This Contract is subject to such modifications as maybe required by changes in applicable law, or the implementing rules, regulations, or procedures of that law. Any required modification(s) shall be automatically incorporated into, and be made a part of, this Contract as of the effective date of the change as if that change was fully set forth herein. Except as provided above, no modification of this Contract shall be effective unless that modification is agreed to in writing by both parties in the form of a written amendment to this Contract that has been previously executed and approved in accordance with the Fiscal Rules of the state of Colorado. 26. Unless otherwise provided for in this Contract, all terms and conditions of this Contract, and the attachments or exhibits hereto, that may require continued performance or compliance beyond the termination or expiration date of this Contract shall survive that termination or expiration date and shall be enforceable as provided for herein. 27. Unless otherwise provided for in this Contract, no term or condition of this Contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections, or other provisions of the Colorado Governmental Immunity Act (CGIA), section 24- 10-101, et seq., C.R.S., as amended. Liability for claims for injuries to persons or property arising out of the alleged negligence of the State or the Contractor, their departments, institutions, agencies, boards, officials, and employees is controlled and limited by the provisions of section 24-10-101 ets~, C.R.S., as amended. 28. The captions and headings used in this Contract are for identification only, and shall be disregarded in any construction of the terms, provisions, and conditions of this Contract. 29. The exclusive venue for any action related to this Contract shall be in the City and County of Denver, Colorado. 30. All attachments or exhibits to this Contract are incorporated herein by this reference and made a part hereof as if fully set forth herein. In the event of any conflict or inconsistency between the terms of this Contract and those of any attachment or exhibit to this Contract, the terms and conditions of this Contract shall control. Page 13 of 16 31. This Contract is the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall have any force or effect whatsoever, unless embodied herein in writing. No subsequent novarion, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied in a written amendment to this Contract executed and approved in accordance with applicable law. E. SPECIAL PROVISIONS. 1. CONTROLLER'S APPROVAL. CRS 24-30-202 (1) This contract shall not be deemed valid until it has been approved by the Controller of the State of Colorado or such assistant as he may designate. 2. FUND AVAILABILITY. CRS 24-30-202 (5.5) Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being appropriated, budgeted, and otherwise made available. 3. INDEMNIFICATION. To the extent authorized by law, the contractor shall indemnify, save, and hold harmless the State against any and all claims, damages, liability and court awards including costs, expenses, and attorney fees incurred as a result of any act or omission by the Contractor, or its employees, agents, subcontractors, or assignees pursuant to the terms of this contract. No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protection, or other provisions for the parties, of the Colorado Governmental Immunity Act, CRS 24-10-101, et seq., or the federal tort claims act, 28 U.S.C. 2671 et seq., as applicable as now or hereafter amended. 4. INDEPENDENT CONTRACTOR. 4 CCR 801-2 THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE. NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE CONTRACTOR SHALL BE OR SHALL BE DEEMED TO BEAN AGENT OR EMPLOYEE OF THE STATE. CONTRACTOR SHALL PAY WHEN DUE ALL REQUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON ANY MONIES PAID BY THE STATE PURSUANT TO THIS CONTRACT. CONTRACTOR ACKNOWLEDGES THAT THE CONTRACTOR AND ITS EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE CONTRACTOR OR THIItD PARTY PROVIDES SUCH COVERAGE AND THAT THE STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE. CONTRACTOR SHALL HAVE NO AUTHORIZATION, EXPRESS OR IMPLIED, TO BIND THE STATE TO ANY AGREEMENTS, LIABILITY, OR UNDERSTANDING EXCEPT AS EXPRESSLY SET FORTH HEREIN. CONTRACTOR SHALL PROVIDE AND KEEP IN FORCE WORKERS' COMPENSATION (AND PROVIDE PROOF OF SUCH INSURANCE WHEN REQUESTED BY THE STATE) AND UNEMPLOYMENT COMPENSATION INSURANCE IN THE AMOUNTS REQUIRED BY Page 14 of 16 LAW, AND SHALL BE SOLELY RESPONSIBLE FOR THE ACTS OF THE CONTRACTOR, ITS EMPLOYEES AND AGENTS. 5. NON-DISCRIMINATION. The contractor agrees to comply with the letter and the spirit of all applicable state and federal laws respecting discrimination and unfair employment practices. 6. CHOICE OF LAW. The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation, execution, and enforcement of this contract. Any provision of this contract, whether or not incorporated herein by reference, which provides for arbitration by any extra judicial body or person or which is otherwise in conflict with said laws, rules, and regulations shall be considered null and void. Nothing contained in any provision incorporated herein by reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint, defense, or otherwise. Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this contract to the extent that the contract is capable of execution. At all times during the performance of this contract, the Contractor shall strictly adhere to all applicable federal and State laws, rules, and regulations that have been or may hereafter be established. 7. SOFTWARE PIRACY PROHIBITION GOVERNOR'S EXECUTIVE ORDER. No State or other public funds payable under this Contract shall be used for the acquisition, operation or maintenance of computer software in violation of United States copyright laws or applicable licensing restrictions. The Contractor hereby certifies that, for the term of this Contract and any extensions, the Contractor has in place appropriate systems and controls to prevent such improper use of public funds. If the State determines that the Contractor is in violation of this paragraph, the State may exercise any remedy available at law or equity or under this Contract, including, without limitation, immediate termination of the Contract and any remedy consistent with United States copyright laws or applicable licensing restrictions. 8. EMPLOYEE FINANCIAL INTEREST. CRS 24-18-201 & CRS 24-50-507 The signatories aver that to their knowledge, no employee of the State of Colorado has any personal or beneficial interest whatsoever in the service or property described herein. Page 15 of 16 IN WITNESS WHEREOF, the parties hereto have executed this Contract on the day fast above written. CONTRACTOR: STATE: BOARD OF COUNTY COMMISIONERS OF STATE OF COLORADO EAGLE COUNTY Bill Owens, Governor (a political subdivision of the state of Colorado) By: By: Name: For the E utive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: 846000762 AND ~/NVIRO NT Date: Date: b ' ~V ' V ~ ~`~~~ ra (Seal) ATTEST:: ~ ~ ~~. PROGRAM APPROVAL: ~~ ~ ~~ ~p,O By: _ By: -- City, City and ounty, County, District, or Town Clerk or Equivalent APPROVALS: COLORADO DEPARTMENT OF LAW OFFICE OF THE ATTORNEY GENERAL Ken Salazar, Attorney General By; ~ G~-- Date: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Arthur L. Barnhart By: ~. ' t.-~- ~---t..~. ~~,-.r~--C~~ ~~ j---J r Date: ~ 1 is (~ Page 16 of 16 -~ , TUBERCULOSI JRVEILLANCE AND CASE MAN ;EMENT REPORT ~,.~, Colorado Department of Public Health and Environment ~w o~~ ~,~ Tuberculosis Program r,~~-~~ '~n 4300 Cherry Creek Drive South ~' • ' $ . o DCEED-TB-A3 ATTpGHMENT # ~, ~ ~ ~,. ,~ Denver, Colorado 80246-1530 ~ ly~a ~ (303) 692-2638 phone (303) 691-7749 fax Last Name First Name MI Current Home Address (Number & Street Name) Apt # / / Gender: ^ Male Date of Birth ^ Female City State Zip Code County Race: ^ American Ethnicity: ^ Not HispaniGLatino Indian/Alaskan ^ Hispanic/Latino ^ Asian ^ Black/African Country ^ United States Other Address (Number ~ Street Name) Specify Type American of Birth: ^ Mexico ^ Native ^ Hawaiian/Other Specify other Pacific Is. Date City State Zip Code County ^ White Arrived in US: / ^ Unknown Month/Year Employer ( ) ( ) Home Phone Number Other Phone Number Specify Type Occupation: ^ Health care worker ^ Unknown ( ) ^ Corrections employee ^ Other Work Phone Number ^ Migrant farm worker ^ Unemployed past 24 months Specify other current u No Its exposure, not Intectea u Its, cumcany active / / / / Classification: ^ TB exposure, no evidence of infection ^ TB, not clinically active Date Initiated Date Reported ^ Latent TB infection, no disease ^ TB suspect Local Health Agency (LHA) PCP/Clinic Name LHA Address (Number 8 Street Name) LHA City LHA State LHA Zip Code ( ) LHA Phone Number ^ Mantoux- Aplisol O Mantoux- Unspecified ^ Tine ^ Not done ^ Unknown / / Reading mm Date Given / / TST Result: ^ Positive Date Read ^ Negative ^ Unknown / / Date last Reading mm negative TST PCP/Clinic Address (Number & Street Name) PCP City PCP State PCP Zip Code ( ) PCP Phone Number Reason u furs notitcation- immigrant u Source case Investlgatlon For Test: ^ A/B notification- refugee ^ Suspect case ^ A/B notification- status change ^ Symptomatic ^ Administrative ^ Targeted testing-individual ^ Contact investigation ^ Targeted testing- specific project ^ Culture positive ^ Transfer case/suspect ^ Employment ^ Unknown ^ Known active Result Criteria: ^ No risk factors for TB ^ HIV Positive ^ Recent arrival high prevalence cntry ^ Recent contact to TB case ^ Injection drug user ^ Fibrotic changes on CXR ^ ResidenUemployee high risk setting consistent with old TB ^ Mycobacteriological lab setting ^ Immunosuppressed patients ^ High-risk clinical conditions ^ Other ^ Child exposed to adult in high-risk G:\TBFORMS\Original Forms\T617 Form.xls revised 2/24/04 / / Patient Last ame First Name MI Date of Birth / / CXR Results. ^ Cavitation ^ Non-TB abnormality Date Taken: ^ Infiltrates ^ Normal ^ Pleural disease ^ Other ~ ~ •- Symptoms^ None Atcohot ^ Yes HIV ^ Yes 8~ Length: ^ Cough Abuse: ^ No Test: ^ No ^ Hemoptysis O Unknown ^ Unknown Allergies: ^ Chest pain ^ Weight loss Drug ^ Injecting HIV ^ Positive ^ Night sweats Abuse: ^ Noninjecting Result: ^ Negative Medications: ^ Urinary ^ No ^ Not done ^ Fever ^ Unknown ^ Unknown ^ Other (specify) / / HIV Test Date ~ ~ • ~ • Exposure ^ None ^ Resident of long Medical ^ None ^ Silicosis Risks: ^ Homeless term care facility Risks: ^ Heart disease ^ Immunosuppressive ^ Resident of (if Yes check one) ^ Diabetes mellitus therapy correctional facility ^ Nursing home ^ Weight loss > 10 Ibs ^ Cancer (if Yes check one) ^ Hospital ^ Gastrectomy ^ Hepatitis ^ Federal prison ^ Residential ^ Jejunoileal bypass ^ Renai failure ^ State prison ^ Mental health ^ Local jail ^ Alcohol/drug treatment Special ^ Pregnant EDC / / ^ Juvenile ^ Other Conditions: ^ Postpartum breast feeding ^ Other ^ Unknown ^ Other special conditions ^ Unknown ^ TST conversion in last 2 years ^ Current treatment / / / / ^ Past treatment Therapy Start Date Therapy End Date Treatment Isoniazid mg Reason Therapy ^ Died Plan: Rifampin mg Stopped: ^ Lost to follow-up Pyrazinamide mg ^ Moved Ethambutol mg ^ Adverse treatment event Other ^ Course completed {Specify) mg ^ Uncooperative/refused (Specify) mg ^ Unknown ^ Other • • • •~ ~ • If the person is a contact to an active case complete information on the source case Final Case Status: ^ Closed ^ Moved away ^ Lost contact Last Name First Name ^ Died ^ Pending Current Home Address (Number & Street Name) If Moved New Address (Number & Street Name) City State Zip Code / / to / / City State Zip Code Relation to Source Exposure Dates / / erson comp a in orm ~-` G:\TBFORMS\Original Forms\T617 Form.xls revised 2/24/04 47TACHMENT #~ " Patient's Name: REPORT OF VERIFIED CASE (LasD (First) (M I) OF TUBERCULOSIS Street Address: (Number, Stree[, Cdy, Slate) Zip Code) CDC DEPARTMENT OF HEALTH 6 HUMAN SERVICES PUBLIC HEALTH SERVICE ~ ~ ~ . , ~ • , CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) CENTERS FOR gSEASE CONTROL ATLANTA, GEORGIA 30333 ANO PREVENnON FORM APPROVED OMB NO. 0920.0026 E><p.DNre 1287/01 SOUNDEX 1. State Reporting: 2, ^ ^ ^ ^ State Case Specify: Number: Alpha State Code m CitylCounty Case Number: 3. Date Submitted: By: 4. Address for Case Counting: City m Within City Limits t ^ Yes 2^ No 5. Month-Year Reported: 6. Month-Year Counted: County Mo. Yr m ~ Mo. ((~~Yr. ~ ~ Zip Code - 7. Date of Birth: B. Sex: 9. Race: Mo Day Yr. m m ~ 1 ^ Male 2 ^ Female 1 ^ White 2^ Black 3^ American Indian or Alaskan Native a ^ Asian or Pacific Islander: Speclfy (Optional) 10. Ethnic Origin: 11. Country of Origin: Ii U.S. check here ^ 12. Month-Year Arrived in U.S.: 13. Status at Diagnosis of TB: 1 ^ Hispanic , If not U.S., enter coun- m Mo. Yr. m ~ 1 ^ Alive z^ Not Hispanic try code (see list) z Dead ^ 14. Previous Diagnosis 15. Major Site of Disease: 50^ Miliary 'If site is °Other", of Tuberculosis: oo^ Pulmonary 23^ Lymphatic:Other 50^ Meningeal enter anatomic code (see list) 1 ^ Yes i o^ Pleural 2s^ Lymphatic: Unknown 7(I^ Peritoneal ^ 2^ No 2t^ Lymphatic: Cervical 30^ Bone and/or Joint Bo^ Other' 22^ Lymphatic: Intrathoraclc a0^ Genitourinary 90^ Site not Stated Ii yes, Ilst year of 1 9 ^ previous diagnosis 16. Additional Site of Disease: 'It site is "Other", oo^ Pulmonary 23^ Lymphatic: Other 50^ Miliary enteranato(Seeose t o^ Pleural 29^ Lymphatic: Unknown 60^ Meningeal ^ ^ If more than one previous t episode, check here 2 t ^Lymphatlc: Cervical 30^ Bone and/or Joint 70^ Peritoneal 22^ Lymphatic: Intrathoraclc If more than one ao^ Genitourinary 80^ Other' addilionalsite, ^ a6 check here 17. Sputum Smear: ^ ^ 18. Sputum Culture: ^ ^ 19. Microscopic Exam of Tissue and Other Body Fluids: ^ 1 Positive 3 Not Done t Positive 3 Not D one t ^ Positive 3^ Not Done If pos itive, enter 2^ Negative s^ Unknown 2^ Negative s^ Unknown anatomic code(sj 2^ Negative 9^ Unknown (see list) ^ 20. Culture of Tissue and Other Body Fluids: 21. Chest X-Ray: t ^ Positive 3^ Not Done If positive, enter ^ t ^ Normal 2^ Abnormal 3^ Not Done 9^ Unknown 2^ Negative s^ Unknown anatomic code(s) (see list) ^ If Abnormal ^ ^ ^ t Cavitary 2 Noncavitary h k Noncavitary 3 22. Tuberculin (Mantoux) Skin Test at Diagnosis: (c ec one) Consistent Not Consistent 1 ^ Positive 3^ Not Done Millimeters (mm) of m with TB with TB 2^ Negative s^ Unknown Induration If Abnormal t ^ Stable 3^ Improving If Negative, was patientanergic? t ^ Yes 2^ No s^ Unknown (check one) 2^ Worsening 9^ Unknown Publro reportng burden of this collection of mformahon rs estimated to average 30 minutes per response, including the time for rewewmg instructions, searcmng existing tlata sources, gathering and mamtaimng the data nestled and completing and rewewmg the collection of mformahon An agencyy may not conduct or wonsor, and a person is not regmred to respond to a collection of mformahon unless d displays a currently valid OMB conhd number fiend comments regarding thus burden estimate or any other aspect of 01is collection of mformahon, including suggestrons for reducing this burden to CDC, Protect Clearance Officer, i(i00 Cldton Roatl, MS D-2a, Atlanta, GA 30333, ATTN PRA (09240026) Do not send Me completed form to this address Information contained on this form wh¢h would permd idenhikatron of any mdmdual has been collected with a guarantee that a will be held m strrot confidence, vnll be used only for surveillance purposes, and will not be disclosetl or released without the consent of the mdmdual m accordance with Sectron 306(d) of the Publro Health Servroe Act (42 U.S C 2a2m) CDC 72 9A REV 12/98 1st Copy -State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 1 of 2 REPORT OF VERIFIED CASE OF TUBERCULOSIS REPORT OF VERIFIED CASE OF TUBERCULOSIS 23. HIV Status: o^ Negative 3^ Refused s^ Unknown 24. Homeless Within Past Year: t ^ Positive a^ Not Offered o^ No 2^ Indeterminate s^ Test Done, Results Unknown i ^ Yes 9^ Unknown If Positive, Based on: t ^ Medical Documentation 2 ^ Patient History 9 ^ Unknown If Positive, List: CDC AIDS Patient Number (If AIDS Reported before 1993) State HIV/AIDS Patient Number (It AIDS Reported 1993 or Later) City/County HIV/AIDS Patlent Number (It AIDS Reported 1993 or Later) 25. Resident of Correctional Facility at Time of Diagnosis: o^ No t^ Yes s^ Unknown If Yes, t ^ Federal Prison 3^ Local Jail s^ Other Correctional Facility 2^ State Prison a^ Juvenile g^ Unknown Correctional Facility 26. Resident of Long-Term Care Facility at Time of Diagnosis: o^ No t ^ Yes 9^ Unknown If Yes, t ^ Nursing Home a^ Mental Health Residential Facility s^ Other Long-Term Care Facility 2^ Hospital-Based Facility s^ Alcohol or Drug Treatment Facility s^ Unknown 3^ Residential Facility 27. Initial Drug Regimen: NO YES UNK Isoniazid o^ t^ s^ Rifampin o^ t^ s^ Pyrazinamide o^ t^ s^ Ethambutol o^ t^ s^ Streptomycin o^ t^ s^ 28. Date Therapy Started: Mo. Day Yr m m NO YES UNK. Ethionamide 0^ t^ s^ Kanamycin o^ t ^ s^ Cycloserine o^ t ^ s^ Capreomycin o^ t^ s^ Para-Amino o^ t^ s^ Salicylic Acid 30. Non-Injecting Drug Use Within Past Year: o^ No t ^ Yes s^ Unknown NO YES UNK. Amikacin o^ t ^ s^ Ritabutine o^ t^ s^ Ciprotloxacin o^ t ^ s^ Otloxacin o^ t ^ s^ Other o^ t^ 9^ 29. Injecting Drug Use Within Past Year: o^ No t ^ Yes s^ Unknown 31. Excess Alcohol Use Within Past Year: o ^ No t ^ Yes s ^ Unknown 32. Occupation (Check all that apply within the past 24 months): t ^ Health Care Worker s ^ Migratory Agricultural Worker s ^ Not Employed within Past 24 Months 2^ Correctional Employee a^ Other Occupation s^ Unknown Comments: DC 72 9A REV 72/98 1st Copy -State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2 of 2 Patient's Name: (Last) (First) Street Address: (Number, Street, Cny, State) ~~ • • cerrhRS roR wseASe cormAL AND PREVEMpN Initial Drug Susceptibility Report SOUNDEX Zip Code) REPORT OF VERIFIED CASE OF TUBERCULOSIS DEPARTMENT OF HEALTH 8 HUMAN SERYICES PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL ~ ~ ~ ~ AND PREVENTION (CDC) ATLANTA, GEORGIA 30333 FORM APPROVED OMB NO. 0920-0028 Elrp. Data 12l31At1 (Follow Up Report - 1) State Reporting: Year State Case Counted: Number: Specify: Alpha State Code m m City/County Case Number: Submit this report for all culture-positive cases. 33, Initial Drug Susceptibility Results: Was Drug Susceptibility Testing Done: o^ No t ^ Yes 9^ Unknown if answer is No or Unknown, do not complete rest of report. If Yes, Mo. Day Yr Enter Date First Isolate Collected m m m for Which Drug Susceptibility Was Done? 34. Susceptibility Results: Resistant Susceptible Not Done Unknown Isoniazid t^ 2^ 3^ s^ Rifampin t^ 2^ 3^ s^ Pyrazinamide t^ 2^ 3^ s^ Ethambutol t^ 2^ 3^ s^ Streptomycin t^ z^ 3^ s^ Ethionamide t^ 2^ 3^ s^ Kanamycin t^ 2^ 3^ s^ Cycloserine t^ 2^ 3^ s^ Capreomycin t^ 2^ 3^ s^ Para-Amino t^ z^ 3^ s^ Salicylic Acid Amikacin t^ z^ 3^ s^ Rifabutine t^ 2^ 3^ s^ Ciprofloxacin t^ 2^ 3^ s^ Ofloxacin t^ z^ 3^ s^ Other t^ 2^ 3^ s^ Comments: Public reporting burden of this collectron of information is estimated to average 30 minutes per response, mcludmg the Ume tar reviewing mstructio~, searching existing data sources, gathering antl maintaimng the data needed and completing and revtpwmg the coilechon of mformabon An agency may not conduct or sponsor, and a person is not requued to respond to a collectwn of mformabon unless it displayys5 a currently vald OMB contrd number §end comments re ardorgg this burden estimate or any other aspect of this collectwn of mformabon, mcludmg wggestwns br reducing this burden to CDC, Pro)ect Clearance Gthcer, 1600 CItROD Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address Informalmn contained on this form which would permit idenbficatron of arty individual has been cogected with a guarantee that 4 wtll be heM m strict confidence, wdl be used only for surveillance purposes, antl will not be disclosed or released without the consent of the individual in accordance with Sectgn 308(d) of the Public Health Service Act (42 U.S.C. 242m) (M I CDC 72 9B REV 12/98 1st Copy -State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report -t Patient's Name: REPORT OF VERIFIED CASE (Last) (Frsl) (M.1 ) Street Address: OF TUBERCULOSIS (Number, Street, City, Stale) Zip Code) DEPARTMENT OF HEALTH 8 HUMAN SEAVICES ~~ PUBLIC HEALTH SERVICE ~ . w • , . . • CENTERASND PREIVENT10N0(C COL ATLANTA, GEORGIA 30333 CENTERS FOR DISEASE CONTROL AND PREVEiVTION FORM APPROVED OMB NO. 0920-0026 E:p. Dah 12/31/01 Case Completion Report (f=ollow Up Report - 2) SOUNDEX ^^^ State Reporting: Year State Case Counted: Number: Specify: Alpha State Code m m City/County Case Number: 35. Sputum Culture If Yes, Date Specimen Collected If Yes, Date Specimen Collected on Conversion Documented: on Initial Positive Sputum Culture: First Consistently Negative Culture: o^ No t^ Yes 9^ Unknown Mo Day Yr. m m m Mo. Day Yr. m m m 36. Date Therapy Stopped: 37. Reason Therapy Stopped: Mo. Day Yr. 7 ^ Completed Therapy 3^ Lost 5^ Not 7B 7^ Other m m m 2~ Moved a^ Uncooperative or Refused 6^ Died 9~ Unknown 38. Type of Health Care Provider: 39. Directly Observed Therapy: It Yes, Give Site(s) of Directly Observed Therapy: 7 O Health Department o ^ No, Totally Self-Administered t O In Clinic or Other Facility z ^ Private/Other t a Yes, Totally Directly Observed 2 ~ to the Field 3^ Both Health Department z^ Yes, Both Directly Observed 3^ Both in Facility and in the Field and Private/Other and Self-Administered 9 ^ Unknown s^ Unknown Weeks Number of Weeks of Directly Observed Therapy: 40. Final Drug Susceptibility Results: If Yes, Enter Date Final Isolate Was Follow-up Drug Susceptibilit y Testing Done? 0^ No t ^ Yes 9^ Unk. Collected for Which Drug m Day Susceptibility Was Done: if answer is No or Unknown, do not complete rest of report. 4i. Final Susceptibility Resistant Susceptible Not Done Unknown Resistant Susceptible Not Done Unknown Results: Isoniazid t^ z^ 3^ s^ Capreomycin 7^ 2^ 3^ s^ Rifampin 7^ z^ 3^ g~ Para-Amino 7^ 2^ 3^ Salicylic Acid s^ Pyrazinamide 7^ z^ 3^ s^ Amikacin t^ z^ 3^ s^ Ethambutol 7^ 2^ 3^ s^ Rifabutine t^ 2^ 3^ s^ Streptomycin t^ z^ 3^ s^ Ciprofloxacin 7^ z^ 3^ s^ Ethionamide t^ 2^ 3^ s^ Ofioxacin t^ z^ 3^ s^ Kanamycin 7^ z^ 3^ s^ Other 7^ z^ 3^ s^ Cycloserine 7^ z^ 3^ s^ Comments: Public reporting burden of thus collection of information Is estimated to average 30 minutes per response, including the Ume for reviewing instructions, searching ewshn9 data sources, gathering antl maintaining the data needed and completing and rewewmg the collecton of Information An agency may not conduct or sponsor, and a person Is not required to respond to a collection of Information unless it displays a currently valid OMB control number. Send comments regarding thus burden estimate or any other aspect of this collecton of mformatrcm, including suggestions for reducing [his Girden to CDC, Protect Clearance Officer, t 600 Clifton Road, MS D-24, AtWnta, GA 30333, ATTN. PRA (0920-0026) Do not send the completed form to this address. Information contained on this form which would permit idenhtxatwn of airy indmdual has been collected wdh a guarantee chat n will be held m strict confidence, wnl be used only for survedWnce purposes, and well not be Olscbsed or released without the consent of the mdmdual in accordance wnh Section 308(d) of the Public Health Sernce Act (42 U S C 242m). CDC 72.9C REV 72/98 t st Copy -State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report-2 Colorado Department of Public Health and Environment TUBERCULOSIS CONTACT INVESTIGATION RECORD Name of reporting agency Preliminary report Final report Name of index case Smear Date case reported Culture Infectious period Susceptibilities Date of PPD Results Chest X•ray Diagnosis Type of Country HIV TX Start Comments! Contact Last Contact` of Birth Status Date S toms m y p Exposure Initial Retest D t R lt LTBI A ti Date mm Date mm a e esu s c ve Name; DOB/Age: Relation to source: Name: DOB/Age: Relation to source: Name: DOB/Age: Relation to source: e: DOB/Age: Relation to source: Name: DOB/Age: Relation to source: Type of Contact: Close Contact• C: persons who have shared air with a known or suspected TB case for prolonged and frequent periods of time (e.g. household members, work associates- depending on the type of worklenvironment) Other Contact• OC; persons who do not meet the criteria of a close contact, but have limited exposure to a known or suspected TB case. Skin testing for OC's is indicated only when it is likely that transmission to this group has taken place (e.g. significantly large number of close contacts show positive skin tests) g:ltbformsl0riginal FormslTuberculosis Contact Investigation Record.xls Rp„~~a~ n~mRrvnna -~ a x -{ h Alien (Alieafl, Nance, Address, Phone}: AB, CD C/O EF 123 HOWARD BL• ACH, NY t 1414 Sl;X: L J M [~ TMt\41CRAN'r` A00-000-000 (000) 000-0000 an7noo4 N DATE OF BIRTH (lvloJDay/Yr.): 1/1/1934 [ J CLASS B-1 - Tuhe:TZUlovi~ clinically active, not infectious [X] CLASS B-Z -Tuberculosis, not clinically active, not infecuotts ATTACHMENT # NOTICE OF ARRIVAL OF ALi>EN WTTIi 7'UBERCUt,O5I5 STATC FIEAI TH' OFFICER: Please forvrard the evacuation copy and acconrpanylug report of Medical examinatloa performed abroad (OF-15'17, to the appropriate local health department. Upon arrival in the Un~ed States this alien was requested to report M the Local Health Department at hislher destination. X-ray taken atxoad showed findings consistent with tuberculosis. The person may not have received antituberculosis chemotherapy or Chemoprophylaxis; therefore, the Health Department may wish to initiate preventive treatment. The Local Health Department is requested to submit a report of initial evaluation by 5R8~pQ4 through you to:• Division of Quaratttitte, Data tLigr (E03) Centers [or Disease Control and Prevcntiun (CDC} Atlanta, GA 30333 • Military will sent! direct ro rl~e CUC:. Tlris space is provided for }rou to record dle Local Health llcpartmeat`s report, if desired. ('nC 75.1 ~ (Rev. 02/99) Alien (Alien, Name, AddTCSS, Phone): A13, Cr7 C/0 FF 123 HOVJAItD BEACH, NY I 1414 CLASS ~ TMh7iGRANT' ADO-06D-000 (000) 000-0000 4/27/2004 N Sex: [ ) M [XJ F Date of Birth (IYIo./Day/Yr.): 1/1/1934 [ )CLASS & 1 -Tuberculosis. clinically active, not infectious [XJ CLASS 1~2 - Tuberculosis, not clinically active, Trot infectious LOG1L HEALTff OFFICER: This person recent{y entered the United States and is referred to you because the X•ray shows Fa~dngs consistent with tuberculosis, as indicated in the accompar)ping report of medical examination performed abroad. This person may not have received chemotherapy or t~+emoptophylaxis and is referred to you because you may wish to initiake preventative treatmer+t. Your initial evaluation wou{d be appreciated ('lease check the appropriate boxes bebw and return this form to the State Health Officer,• If the alien does not report by 3I~8/2004 please check here [ )and forward this farm to the State Health Ofticecx Retain for your records the accompanying report of examination performed goad (01=-1 S7]. `Military will tend direct to the CDC. Xour lnitiac (,valuation: C. X-ray (abroad) A. Direct Smear (in U.S.) B. X-r:ty (In U.S.) [ ]Normal [ ]Positive [ ]Norval [ ] Abnormal [ ]Negative [ J Abnormal [ ]Not Doac [ ] NUL Done [ ] Nol bone (] LJnavailablc E.1Tas patient received chemotherapy/prophylaxis in t11e p ast? (] YGS [ J Tio [ ] tlnknawn T. Are you prescr[bing chemotherapylprophylaxis'! []Yes []No STATE HEALTH DFPAR"1'Mr-'N"I" COPY REPORT ON ALIEN ~VITII TUBERCULOSIS D. Presumptive Diagnosis [ J Pulmonary I'F3 -Active [ ] PulnTOnary TB -Not Acti~•e [ ] Pulmonary TB -Activity UndetcaTrined [ ] LxlTaplumunnry TB [ ] 1`TOn-TB Abnormality [) A•o Abnormality SiSrrarnre of Physician: gate of Evaluatiort.• Nance of Health DeParlrnent: This fom+ is not intended to substitute for ~rntal procedures for reporting tuberculosis to the stale ilealth Dctpartnlent. _ 1~10TF TO STATL- I~ALTH OFFICER: Diviion of Quarantine, Data Mgr (E03) Upon receiving this completed wpy Gom Ccntcrs for Disease Control and Prcvrnliun {CDC) the 1,oca1 Healttl Officer, please forwanl to: Atlanta. GA 30333 CpC 75.17 (Rev. U2199)~'+~ A s~7'+ ~ LOCALIIEALTII DEPAKTIvIEN-I' COPY `~TAGHMEAIT# ._._ Tuberculosis Semi-Annual Progress Report Agency/Person Date Submitted Reporting Time Period -July 1 -December 31 _ January 1 -June 30 Briefly describe TB activities and accomplishments during reporting period. Describe any challenges/obstacles to providing TB services as specified in the CDPHE TB contract during reporting time period. p`C1`ACNMENT ~~ Colorado Department of Public Health & Environment Tuberculosis Response Plan Revised 4/26/2004 Colorado Department of Public Health and Environment Tuberculosis Response Plan Table of Contents I. Introduction .................................................................................................3 Purpose of the Tuberculosis (TB) Response Plan . Defining "Exceptional Circumstances" Requiring Activation of TB Response Plan II. TB Response Team .......................................................................................4 TB Program Staff Other DCEED Staff Centers for Disease Control and Prevention (CDC) staff III. Activation of TB Response Plan ..........................................................................................6 How the TB Response Team Learns of Exceptional TB Circumstances TB Response Team Evaluation of Exceptional TB Circumstances Declaration of a TB Response Plan Activation Internal and External Communications IV. Responses of the TB Response Team ..................................................................................8 TB Responses Other Responsibilities V. Local Public Health Agency Responsibilities ......................................................................9 Establish Authority Other Responsibilities VI. Centers for Disease Control and Prevention (CDC) Notification/Request for Assistance 10 Indications for CDPHE to Notify CDC How to Report to and Request Assistance From CDC VII. Activation of Department-wide TB Response Plan ......................................... .................. VIII. Deactivation of Plan ...........................................................................................................1 l Appendix A - TB Response Report 2 INTRODUCTION Purpose of the Tuberculosis (TB) Response Plan The Colorado Department of Public Health and Environment (CDPHE) TB Program is committed to providing treatment and control of TB in order to protect the public health. The purpose of this plan is to ensure comprehensive and prompt response to exceptional TB circumstances, especially in those areas of the state with insufficient staffing, funding, or expertise to respond quickly without assistance. The plan also provides for tracking and reporting of TB issues. Defining "Exceptional Circumstance" Requiring Activation of TB Response Plan The principle function of the CDPHE TB Program is to support local efforts to discover, interrupt, and prevent TB transmission. Because of the low incidence of TB in Colorado-fewer than 3.5 cases per 100,000-the public-health apparatus for finding TB and for investigating contacts has been reduced to a minimum in many parts of the state. The investigation of a single case in some counties can quickly exhaust available resources, resulting in "an urgent need for assistance or relief." Thus, the definition of an "exceptional TB circumstance" in Colorado depends on the detection of active TB or latent TB infections that meet one or more of the following criteria: Due to the setting, the risk level of the population involved, or the number of cases, active TB or latent TB infections, pose a serious risk of further TB transmission. The capacity of a local public health agency is overwhelmed by the scope of the comprehensive response necessary to "ascertain the existence of all cases of TB in the infectious stages and to ascertain the sources of such infections" (C.R.S. 24-4-506). The local health authority deems, in consultation with CDPHE, that activation of the response plan would be in the best interest of the public. Examples of exceptional TB circumstances that may prompt activation of the TB Response Plan: • A patient with infectious TB is suspected or known to have Mycobacterium tuberculosis resistant to isoniazid and rifampin (multidrug-resistant TB/MDR TB). • Persons with HIV infection or other immune-compromising conditions are suspected or known to be exposed to a case of infectious TB. • A child five years of age or less with confirmed TB for which a source of infection is not discovered after source investigation. • An increase in the number of cases over time or in a particular area is considered significant by a local public health worker or by CDPHE personnel. • A genotype cluster is considered to indicate ongoing transmission. • Extensive TB transmission is confirmed or suspected. These situations may involve workplaces, schools, unconventional social networks, or other circumstances in which screening for TB disease and infection involves large numbers of people or in which multiple cases are suspected. • A TB case generates a great deal of public interest or political pressure. THE TB RESPONSE TEAM All initial TB Response activities are the responsibility of TB Program staff, in collaboration with local public health authorities. Other Disease Control and Environmental Epidemiology Division (DCEED) staff maybe called upon at the discretion of the Director to assist or provide additional support to the TB Response Team or local public health agencies. The purpose of the TB Response Team is to ensure a comprehensive and prompt response to exceptional TB circumstances, especially in those areas of the state with insufficient staffing, funding, or expertise. The following members of the TB Program staff are designated as the TB Response Team. These positions and duties include: TB Program Staff 1. Chief Medical Officer (CMO) a. Provides medical consultation and guidance b. Maintains communications with Executive Director regarding status of and needs related to the TB response c. Makes final decisions with regard to requests for assistance from CDC and activation of department-wide TB Response Plan d. In conjunction with the Director of Communications, reviews and approves all information prior to release to the media e. Serves as a resource for public speaking during a TB response 2. Director, Disease Control and Environmental Epidemiology Division (DCEED) a. Provides management and guidance of activities of the TB Response Team b. Assists in reviewing communications with CDPHE administration, DCEED, local public health agencies, or other parties involved in a TB response c. Provides recommendations and assists with final decisions related to TB responses d. Makes final decisions with regard to onsite assistance for local health agencies, and recommends requests for assistance from CDC, and activation of department-wide TB Response Plan e. Reviews and approves all reports, publications or other documents related to TB responses prior to use or distribution TB Response Team Leader-Gayle Schack, RN (extension 2635) a. Facilitates meetings of TB Response Team (scheduling, agendas, conference calls, etc.) b. Serves as primary liaison (contact person) with local public health authorities c. Assists with case management of TB patients and contacts d. Monitors diagnosis and treatment of TB patients and contacts e. Provides expert consultation and recommendations regarding appropriate measures to control the further spread of TB f. Assists local public health agencies as requested by DCEED Director/Program Manager g. Prepares written reports and documents used related to a TB response (correspondence, publications, summary reports, final response evaluations, etc.) with assistance from TB Response Team and obtains approval of the DCEED Director prior to use or distribution h. Arranges for annual review of this plan by team and DCEED Director 4. TB Program Nurse Consultant-Barbara Schultz, RN (extension 2647) a. Assists Team Leader to monitor diagnosis and treatment of TB patients and contacts b. Assists Team Leader to provide expert consultation and recommendations regarding appropriate measures to control the further spread of TB c. Reports newly discovered TB cases or significant findings related to the TB response to TB Response Team Leader on an ongoing basis d. Serves as a resource for public speaking during a TB response, in collaboration with the Division Director and CMO e. Assists local public health agencies as assigned by DCEED Director/Program Manager. f. Trains State and local TB Program staff on this plan g. Assists Team Leader in preparing written reports and documents used related to a TB response (correspondence, publications, summary reports, final response evaluations, etc.) Contact Investigation Coordinator-Juli Bettridge (extension 2675) a. Consults and/or assists with contact investigations b. Trains local public health agencies on how to conduct interviews of TB patient and contacts c. Tracks contact follow-up activities d. Assists local public health agencies with contact investigations as requested by DCEED Director/Program Manager 6. TB Program Manager/Surveillance Coordinator-Barb Stone (extension 2656) a. Assures quality of ongoing TB surveillance b. Monitors TB activity for exceptional TB circumstances by reviewing TB surveillance data c. Assists in procuring funding and resources for activities related to TB response d. Assists TB Response Team Leader in preparing and compiling written reports and documents used related to a TB response (correspondence, publications, summary reports, final response evaluations, etc.) e. Assigns work activities of TB Program staff 7. TB Response Support Personnel a. Arranges for acquisition and delivery of additional supplies or services required for an effective response b. Provides additional logistical support to TB Response Team as requested c. Recording of TB Response Team meeting minutes Other DCEED Staff Other DCEED staff maybe called upon at the discretion of the DCEED Director to assist or provide additional support to the TB Response Team or local public health agencies (Fiscal Officer, Accounts Manager, Epidemiologists, etc.). Duties may include assistance with procuring additional funding resources, setting up emergency purchase orders, assisting local public health agencies with contact investigations, patient interviews, translation interpretation for persons with limited English proficiency, medication or specimen transport, form completion, etc. Centers for Disease Control and Prevention (CDC) Staff Assistance maybe requested from CDC such as in the event of extensive, confirmed or suspect TB transmission involving workplaces, schools, unconventional social networks, or other circumstances in which screening for TB disease and infection involves large numbers of people or in which multiple cases are suspected. The Epidemiology Intelligence Surveillance (EIS) Officer or other designated CDC health advisors may be needed to provide further consultation and assistance. ACTIVATION OF TB RESPONSE PLAN CDPHE TB Program staff will review information as reported from an outside source (after review by local public health authorities} or as reported directly by local public health authorities. The TB Program staff will then meet to evaluate the suspected cluster or reported crisis to determine if the event meets the "exceptional TB circumstance" criteria specified above. If so, the CDPHE TB Program staff, in consultation with DCEED Director, local public health authorities, and other TB experts (as needed}, will make a final determination of "exceptional TB circumstance" status and the TB Response Plan will be activated. How the TB Response Team Learns of Exceptional TB Circumstances The TB Program conducts ongoing surveillance of reported TB cases. Analysis of routine TB surveillance data and discussions at weekly case management meetings may reveal a suspected cluster or a situation that poses a serious risk of further TB transmission. Additionally, the local public health agency may identify an urgent need for assistance or relief and request assistance from the TB Response Team. When an exceptional TB circumstance is discovered or reported to the TB Program, a "TB Response Report" (Appendix A) will be completed by the person receiving the information. The report will be given immediately to the TB Response Team Leader for further review. Additional information may need to be obtained from the local public health agency staff to assist with evaluation of the TB situation. Communications with the local public health agency staff will be initiated by the TB Response Team Leader, in collaboration with the DCEED Director. TB Response Team Evaluates Exceptional TB Circumstances The Team Leader will inform the TB Response Team of an exceptional TB circumstance. Details regarding the situation will be shared with TB Response Team members and reviewed to 6 determine whether it meets the definition of an exceptional TB circumstance. If so, the TB Response Team will initiate a request for activation of the TB Response Plan. Declaration of a TB Response Plan Activation The DCEED Director will be responsible for declaring the need to activate the TB Response Plan as appropriate. Depending upon the type of response needed, duties will be assigned consistent with predetermined responsibilities of the team. Internal and External Communications The DCEED Director will be responsible for informing the CMO (303) 692-2662 and the Director of Office of Communications (303) 692-2013 of new or updated information, as appropriate. The Office of Communications will be responsible for preparing news articles and for arranging TV interviews, radio interviews, and other public announcements. The TB Response Team members maybe asked to assist by providing general information as requested. Once the plan is activated, the TB Response Team will meet on a regularly scheduled basis, at a frequency determined at the initial evaluation meeting, in order to maintain internal communications with regard to the status of all TB response activities. The TB Response Team Leader will be responsible for ensuring that meeting notices, locations and times are distributed to all team members, with assistance by TB Response Team support personnel. Each team member will have an opportunity at each meeting to report on his/her progress, new findings, or to ask questions. Each TB circumstance will be evaluated by the TB Response Team on a case-by-case basis to determine whether a special "hotline" should be activated at CDPHE to enhance external customer communications. Ahotline can be used to provide pre-recorded information and/or serve as a devoted telephone line for callers seeking information specific to an exceptional TB circumstance. If it is determined that a hotline is needed, the DCEED Director will obtain approval for the hotline and assist in developing apre-recorded telephone message. The Telecommunications Manager at (303) 692-2117 can assist in setting up a local telephone line in approximately 30 minutes or a wide area telephone system (WAYS) line in two days. Local telephone lines include: • "Call-in line" primarily used for short, pre-recorded messages. Customers can leave a voicemail message if they have further questions. • "Call box" for longer, pre-recorded messages and a telephone tree that directs the caller to other extensions for additional information. A call box can also track the number of calls made to that number. The hotline pre-recorded message will be reviewed at least weekly by TB Response Team and revised updated as needed. TB Response Team members will maintain open communications with public health agencies and private providers, in collaboration with the DCEED Director. This includes routine telephone consultation or conference call on an "as-needed" basis. All information received by the TB Program from outside sources, should be channeled through local health agencies. The Team Leader will discuss exceptional TB circumstances with the TB Elimination Cooperative Agreement Project Officer at CDC, Division of TB Elimination (404) 639-8126. The TB Response Team will provide recommendations with regard to guidance or assistance needed by CDC and relay these requests to the TB Response Team Leader. RESPONSES OF TB RESPONSE TEAM TB Responses Each exceptional TB circumstance must be individually evaluated to determine the scope of assistance needed by the TB Response Team. Not every response will require the same actions. Possible responses include: • Monitor events through the Team Leader and Public Health Nurse Consultant • Request additional information from the local agency through the Team Leader or designee • Designate a team member to provide telephone consultation to the agency involved • Establish authority, in collaboration with local public health agencies, for implementing interventions and strategic programmatic changes (see "Responsibilities of Local Public Health Agency") • Provide prompt internal and external communications to the extent needed in each situation • Provide weekly TB epidemiological analysis reports • Ensure availability of appropriate laboratory testing, including DNA fingerprinting and specimen transport, for purposes of prompt diagnosis and epidemiological investigation • Provide documentation and written reports with regard to TB Response Team activities as needed and as requested by DCEED Director, or CDPHE senior management • Provide onsite assistance and consultation to the local public health agency, as resources allow. This includes, but is not limited to, assigning one or more members of the TB Response Team to investigate contacts, conduct intensified surveillance, collect and/or transport specimens, apply TB skin tests, assist with implementing appropriate engineering controls, occupational hazard evaluation, etc. • Provide public speaker(s) to address affected citizens' groups (e.g. parents, employees, employers, schools, organizations) • Assist local public health agencies arrange for resources needed at the local level (e.g. personal protection supplies, interpreters, translated patient education materials, quarantine facilities, laboratory resources, packaging and distribution of mass drug orders) as resources allow • Request emergency supplemental funding from CDC or attempt to find additional funding resources needed for TB response activities • Other actions as recommended by CDC • No further action All activities will be conducted in compliance with state statues (C.R.S. 25-4-501-513) and may require additional assistance from other DCEED staff. If so, the DCEED Director will authorize specific staff and duties needed for the TB response. Other persons involved in the TB response (e.g. Epidemiology Intelligence Surveillance (EIS) Officer, if one is available at CDPHE) maybe included in all TB Response Team meetings and activities. Other Responsibilities The TB Response Team will review and update the TB Response Plan on an annual basis and update/revise as needed. Other DCEED staff may be required to provide TB response assistance and will receive training as needed. LOCAL PUBLIC HEALTH AGENCY RESPONSIBILITIES Establish Authority It is the responsibility of the CMO and local public health agencies in Colorado to conduct activities in order to discover, interrupt, and prevent TB transmission in their counties, through contractual agreements with the TB Program at CDPHE. In the event of an exceptional TB circumstance, however, authority for local TB control efforts must be established, based on availability and ability of the local resources to implement interventions and strategic programmatic changes needed to interrupt TB transmission. Such decisions will be made in collaboration with local public health authorities. Authority may remain solely with the local public health agency, other persons designated to direct activities at the local level (e.g. EIS Officer), or to a member of the TB Response Team. All counties in Colorado have designated persons who should be contacted in the event of an exceptional TB circumstance. Such persons have agreed to be responsible for sharing information to others in their agencies or communities, as appropriate. Other Responsibilities Local Public Health Agencies involved with an exceptional TB circumstance can assist the TB Response Team by: • Building consensus with state and other TB control advisors regarding investigative strategy • Establishing accountable systems of communication, evaluation, response and tracking of TB cases • Notifying appropriate local officials • Providing a list of available personnel and their skills • Providing a list of available quarantine resources if needed, including a list and location of negative air flow rooms available in the county • Designating one person to communicate with TB Response Team Leader on an agreed-upon schedule, in coordination with other media relations • Adjusting investigation strategies based on new information obtained during TB response efforts • Designating a person to communicate with local media relations • Recommending the type of written publications and reports needed to assist them in TB response efforts • Additional assistance offered by local public health agency CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) NOTIFICATION/REQUEST FOR ASSISTANCE Indications for CDPHE to Notify CDC CDC requests the following instances of TB transmission be reported: Infectious source patient with high-risk exposures and there is at least one of the following circumstances: a. The source patient is suspected or known to have Mycobacterium tuberculosis resistant to isoniazid and/or rifampin, with or without resistance to other drugs. b. The exposure involves contacts with HIV infection or other immune-compromising condition. c. The exposure involves contacts in high-risk settings. 2. A child five years of age or less with confirmed TB for which a source of infection is not discovered after source investigation. 3. A cluster of cases in place and time. In one or more counties in a state over a period of approximately six months, compared to the previous equal time span, any increase in the number of cases that is considered significant by the TB Program or by the Division of TB Elimination (DTBE) personnel. 4. A genotype cluster considered to exhibit ongoing transmission. 5. Situations for which extensive TB transmission is confirmed or suspected. These situations may involve workplaces, schools, unconventional social networks, or other circumstances in which screening for TB disease and infection involves large numbers of people or in which multiple cases are suspected. 6. Instances in which transmission is suspected or confirmed among patients in multiple states. In this circumstance, an infectious source patient has exposed persons in multiple states, or transmission has been discovered among specific members of a group that resides or travels to multiple states, such as homeless persons who visit shelters in multiple states. 7. Instances in which false-positive AFB smears or cultures are suspected. False-positive AFB smears or cultures may be responsible for misdiagnosis of TB, and unnecessary tests, treatment, and toxicities for patients. Most false-positive AFB smears or cultures are based on laboratory cross-contamination, but may also be due to clerical errors and mislabeling. How to Report to and Request Assistance from CDC Specific instances of TB transmission specified above should be reported to the TB Cooperative Agreement Grant Program Consultant at CDC, Division of TB Elimination--DTBE (404) 639- 10 8126. The TB Response Team Leader will work with the TB Program Manager in reporting to CDC. The CDC Program Consultant can provide procedures for requesting assistance. ACTIVATION OF DEPARTMENT-WIDE EMERGENCY RESPONSE PLAN If the TB response requires additional assistance beyond the scope of TB Response Team and CDC, a request for assistance should be forwarded through the CDPHE Emergency Response Plan. This request for assistance must be initiated and approved by the DCEED Director through the CMO. Careful consideration must be given to leadership, authority and coordination of all TB response activities when assistance at this level is needed. DE-ACTIVATION OF TB RESPONSE FLAN TB Response Plan de-activation procedures will be conducted by the TB Response Team when the situation no longer supports the need for intensified TB response activities. These procedures include: 1. Debriefing --TB Response Team meeting to review all activities and outcomes related to the specific TB response 2. Change of Command --If the TB response required modification of authority, leadership, or responsibilities during the investigation, a change will be made to restore local public health agency responsibilities, as previously conducted. 3. Exit Interview --TB Response Team will conduct an exit interview with the local public health agency and others involved in the TB response to review response activities and outcomes and collect any additional information with regard to the response. 4. Evaluation of Results --TB Response Team and others, as appropriate, will conduct an evaluation of activities and outcomes related to the TB response. Evaluation will include identification of areas of improvement as well as areas of success. This information will be used to direct future TB responses and changes in procedures, if needed. 5. Final Report --TB Response Team Leader will prepare a final written report, as appropriate, with regard to the TB response (including all documents related to the TB response such as correspondence, publications, summary reports, final response evaluations, etc.) with the assistance from the TB Program Nurse Consultant and TB Program Manager/Surveillance Coordinator. The final report will be approved by the DCEED Director prior to distribution. 6. Long-term follow-up ofcontacts--The local public health agency or their designee will follow contacts identified during the TB response. Information will be reported to the Contact Investigation Coordinator initially and at the completion of follow-up (maybe several months after initial response). Contact follow-up information will be added to the final report. . 11 Appendix A TUBERCULOSIS RESPONSE REPORT Initial Report Information Date of Report: Report Source: ^ Epidemiological TB Data Analysis ^ TB Case Management Review ^ Local Public Health Agency/Other State or Federal Agency: Agency Name Contact Phone Number ^ Other: (specify and include phone numbers if applicable) Nature and Summary of Report (note if any TB cases are drug-resistant, HIV-infected, in congregate settings, or foreign-born and/or if there is extensive transmission, involves a public figure or is ahigh-profile case): Clinical findings of case(s): (include symptoms and chest x-ray results, if known) Laboratory Results: Evidence of ongoing transmission? If yes, please specify (e.g. secondary cases, increased rate of skin test conversions): Estimated number of contacts: 12 Initial TB Response Activities Date report given to TB Response Team Leader: Date of initial TB Response Team evaluation meeting: TB Response Team members present at initial meeting: Date TB Response Team Recommendations submitted to DCEED Director: Declaration of need to activate TB Response Plan? If yes, date: Name/phone number of State and local public health agency staff identified as having authority for overseeing ongoing TB control efforts for this situation: Date of next TB Response Team meeting: InternaUExternal Communications: Chief Medical Officer Notified? If yes, date: By whom?: Office of communications needed to set up a special hotline or WATS line? If yes, date request was initiated: Appropriate local public health agency representative(s) notified? If yes, date and who was notified: TB Cooperative Agreement Program Consultant/CDC notified? If yes, date and who was notified: Describe initial TB response activities and control measures: 13 On~oin~ TB Response Team Activities (repeat this section as needed) Date: Type of activity (meeting, conference call, meeting with local public health agency staff, educational session, etc.): New findings and recommendations: Signed: Date: De-Activation of TB Response Plan Checklist ^ Debriefing of TB Response Team and others as appropriate to review all activities and outcomes related to the situation (include dates) ^ Change of command restored ^ Exit Interview ^ Evaluation of results of all activities and outcomes (specify): ^ Final TB response report completed, if indicated, and submitted to DCEED Director (attach all previously written correspondence, publications, summary reports) ^ Long term follow-up of contacts complete 14 INVOICE NUMBER CONTRACT REIMBURSEMENT STATEMENT T0: Colorado Department of Public Health & Environment FROM: DCEED(A3 4300 Cherry Creek Drive South Denver, CO 80246 Fax (303) 691-7749 Attn: TB Contract Administrator Federal ID Number: Date of Expenditures From: To: Final Bill Yes No Description of Expenditure Local Agency Match Reimbursement Total Amount Re uested Grand Total: This is to certify that the above expenses were incurred per Contract # and we are requesting reimbursement for same. SIGNATURE (CONTRACTOR): DATE: I hereby certify that all contract requirements have been met and the amounts are correct. Payment is authorized. AUTHORIZED DESIGNEE (STATE): DATE: a a c~ x m Z i~ pTYACNMENT #~ DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIItONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER ** ***** LIMITED AMENDMENT #* This Limited Amendment is made this **** day of *********, 200*, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South Denver, Colorado 80246, hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY, (legal tvue of entity), whose address or principal place of business is Street Address, City. State & Zip Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a contract dated ******** ** ****, with contract encumbrance number PO *** ********** and contract routing number ** *** *****, whereby the Contractor was to provide to the State the following: ~brietly describe what the Contractor ~i~as to do under the original contract -indent this paragraph] [Please choose one of the following four options and then delete this heading and the other three options not selected:] The State promises to [choose one anct delete the other)increaseldecrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) during the current term of the Original Contract in exchange for the promise of the Contractor to perform the [choose one and delete the other increased/decreased work under the Original Contract. The State promises to pay the Contractor the sum of ********** Dollars, $*.** in exchange for the promise of the Contractor to continue to perform the work identified in the Original Contract for the renewal term of **** years/months, ending on ******** **, ****. The State promises to [choose one and delete the other increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) for the renewal term of **** [choose one and delete tl~e other[years/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the [choose one and delete tl-e otherjincreased/decreased specifications to the Scope of Work described herein. The State hereby exercises a "no cost" change to the [insert those that apply and delete those that don'tjbudget, specifications within the Scope of Work, project management/manager identification, notice address or notification personnel, or performance period within the [choose one and delete the other current term of the Original Contract or renewal term of the Original Contract. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: Consideration for this Limited Amendment to the Original Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the original contract, contract routing number ** *** *****, ]insert the following language here if previous amendment(s), change order(s), renewal(s) have been processedJas amended by (include all previous amendment(s), change order(s), renewal(s) and their routing numbersJ, (insert the following word here if previous amendment(s), change order(s), renewal(s) have been processed collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Limited Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Contract is and shall be modified, altered, and changed in the following respects only: A. (ilse this paragraph when changes to the funding Ievel of the Original Contract occur during the current term of the Original ContractjThis Limited Amendment is issued pursuant to paragraph *;*. of the Original Contract identified by contract routing number ** *** *****. This Limited Amendment is for the current term of ********* ** ****, through and including ********* ** ****. The maximum amount payable by the State for~the work to be performed by the Contractor, during this current term is (choose one and delete the other]increased/decreased by ********** Dollars, $( *.**) for an amended total fmancial obligation of the State of ********** DOLLARS, *.** . [delete and portion of this sentence that is not applicable]The revised specifications to the original Scope of Work and the revised Budget, if any, are incorporated herein by this reference and identified as "Attachment *" and "Attachment *". The first sentence in paragraph *. *. of the Original Contract is modified accordingly. All other terms and conditions of the Original Contract are reaffirmed. A. [Use this paragraph when the Original Contract Hill be rene~~~ed for another termJThis Limited Amendment is issued pursuant to paragraph *_*. of the Original Contract identified by contract routing number ** *** *****. This Limited Amendment is for the renewal term of ********* ** **** through and including ********* ** ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars. $( *.**) for an amended total fmancial obligation of the State of ********** DOLLARS, ($* **). This is an [choose one and delete tl~e other]increase/decrease of ********** Dollars, ($* **) of the amount payable from the previous term. (delete and portion of this sentence that is not applicahleJThe revised specifications to the original Scope of Work and revised Budget, if any, for this renewal term are incorporated herein by this reference and identified as "Attachment *" and "Attachment *". The fast sentence in paragraph *_*. of the Original Contract is modified accordingly. All other terms and conditions of the Original Contract are reaffirmed. A. Ji?se this paragraph when there are "no cost changes" to the Budget, the specifications within the original Scope of Work, allowable contract provisions as noted, or performance period.]This Limited Amendment is issued pursuant to paragraph *_*. of the Original Contract identified by contract routing number ** *** *****. This Limited Amendment [choose those that appl~• and delete those that don'tJmodifies the Budget in [identify location in contractJ, modifies the specifications to the Scope of Work in (identif~• location in contractJ, modifies the project management/manager identification in (identify location in contract), modifies the notice address or notification personnel in (identifyy- location in contractJ, modifies the period of performance in [idevtif~ location in contractJ of the Original Contract. The revised Jchoose those that apply and delete those that don'tJBudget, specifications to the original Scope of Work, project management/manager identification, notice address or notification personnel, or period of performance is incorporated herein by this reference and identified as "Attachment *". All other terms and conditions of the Original Contract are reaffirmed. 4. The effective date of this Amendment is date, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. Except for the General Provisions and Special Provisions of the Original Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Contract, the terms and provisions of this Amendment shall in all respects supersede, govern, and control. The Special Provisions shall always control over other provisions of the Original Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Original Contract concerning the absence of personal interest of state of Colorado employees is presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. IN WITNESS WHEREOF, the parties hereto have executed this Form Amendment on the day first above written. CONTRACTOR: STATE: [LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (legal type of entity} Bill Owens, Governor By: By: Name: Title: FEIN: ATTEST: If the Contractor is a corporation or governmental entity, then an attestation is required. (Seal, if available.) By: City, City and County, County, Special District, or Town Clerk or Equivalent Corporate Secretary or Equivalent (Delete inapplicable language.] For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for goods and/or services provided. STATE CONTROLLER Arthur L. Barnhart By: Date: Form: LATIO-31-03GN Addendum to Contract Number C04-109-60 Contractor agrees to provide trick riding for one additional date: July 31, 2004 @ PRCA Rodeo at 7:OOpm in the amount of $400.00 Total amount of contract $4,000.00 STATE OF COLORADO Bill Owens, Governor Douglas H. Benevento, Executive Director Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr. S. Laboratory Services Division Denver, Colorado 80246-1530 8100 Lowry Blvd. Phone (303) 692-2000 Denver, Colorado 80230-6928 TDD Line (303) 691-7700 (303) 692-3090 Located in Glendale, Colorado http://www.cdphe.state.co. us June 18, 2004 Dear Contractor, ~~~~~ V ~® JUN 2 5 2004 HEALTH & HUMAN SERVICES OF ~~LO ~~~ ~ ~ O *~* * 1876 ~ Colorado Department of Public Health and Environment Enclosed please find your fully approved contractual document with the Colorado Deparhnent of Public Health and Environment, Disease Control and Environmental Epidemiology Division. Please keep these original documents for your records. If you have any questions or require further information, please feel free to contact me. Sincerely, ~~I,ii~i j(~ l~.Cc~JE``~ Tanya Schrimpscher Contracts Administrator Disease Control and Environmental Epidemiology Phone: (303) 692-2712 Fax: (303) 782-0904 E-mail : Tanya.Schrimpscher a~state.co.us ~ ~~ ~ z ~ 2004