HomeMy WebLinkAboutC11-143 Family Planning Program (11-FLA-30081) DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
PSD -FPP
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
11 -30081
AMENDMENT FOR TASK ORDERS #1
This Amendment is made this 28th day of March. 2011, 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, whose address or principal place of
business is 500 Broadway Eagle, Colorado 81631 -0608 for the use and benefit of the EAGLE COUNTY
PUBLIC HEALTH AGENCY, (a political subdivision of the state of Colorado), whose address or principal
place of business, 551 Broadway Eagle, Colorado 81631, hereinafter referred to as the "Contractor ".
FACTUAL RECITALS
The parties entered into a Master Contract, dated January 23, 2007, with contract routing number 08 FAA 00016.
Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated
June 27, 2010, with contract encumbrance number PO FLA FPP1016393, and contract routing number 10 FLA
16393, as amended by Grant Funding Letter #1, contract routing number 11 -FLA- 26917, collectively referred to
herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following:
Contractor shall provide a comprehensive family planning program in accordance with section 1001 of the
Public Health Service Act, 42 U.S.C., 300 et seq., and all applicable federal regulations, as amended,
contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all State Regulations and with the terms of
this contract.
The State promises to pay the Contractor the sum of Forty -Three Thousand, Three Hundred Thirty -One
Dollars, ($43,331.00) in exchange for the promise of the Contractor to continue to perform the work identified in
the Original Task Order Contract for the renewal term of 12 months, ending on June 29, 2012.
NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree
as follows:
1. Consideration for this Amendment to the Original Task Order Contract consists of the payments and
services that shall be made pursuant to this Amendment, and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order
Contract, contract routing number 10 FLA 16393, as amended by Grant Funding Letter #1, contract
routing number 11 -FLA- 26917, 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 Amendment as though they were expressly rewritten, incorporated, and included
herein.
3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified,
altered, and changed in the following respects only:
Page 1 of 5 Rev 3/16/2010
A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified
by contract routing number 10 FLA 16393. This Amendment is for the renewal term of June 30,
2011, through and including June 29, 2012. The maximum amount payable by the State for the
work to be performed by the Contractor during this renewal term is Fortv -Three Thousand,
Three Hundred Thirty -One Dollars, ($43,331.00) for an amended total financial obligation of
the State of NINETY -FIVE THOUSAND, SIX HUNDRED THIRTEEN DOLLARS,
($95,613.00). This is an increase of Forty -Three Thousand, Three Hundred Thirty -One
Dollars, ($43,331.00) of the amount payable from the previous term. Of the maximum amount for
this renewal term Eleven Thousand, Eieht Hundred Ninety -Six Dollars, ($11,896.00) are
attributable to a funding source of the State of Colorado and Thirty -One Thousand, Four
Hundred Thirty -Five Dollars, ($31,435.00) are attributable to a funding source of the United
States Government (see Catalog of Federal Domestic Assistance (CFDA) number 93.217). Of the
amended total financial obligation of the State referenced above Twenty -Six Thousand, Nine
Hundred Ei¢hty -Nine Dollars, ($26,989) are attributable to a funding source of the State of
Colorado and Sixtv -Eight Thousand, Six Hundred Twenty -Four Dollars, ($68,624.00) are
attributable to a funding source of the United States Government. The revised Additional
Provisions is incorporated herein by this reference and identified as "Exhibit D." The revised
Statement of Work is incorporated herein by this reference and identified as "Exhibit E ". The
revised Budget is incorporated herein by this reference and identified as "Attachment E -1 ".
The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original
Task Order Contract are reaffirmed.
4. The effective date of this Amendment is June 30, 2011, or upon approval of the State Controller, or an
authorized delegate thereof, whichever is later.
5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General
Provisions of the Original Task Order 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 Task Order Contract, the terms and provisions of this Amendment shall in all respects
supersede, govern, and control. The Special Provisions and other terms and conditions of the Master
Contract shall always control over other provisions of the Original Task Order Contract or any subsequent
amendments thereto. The representations in the Special Provisions to the Master Contract concerning the
absence of personal interest of state of Colorado employees and the certifications in the Special Provisions
relating to illegal aliens are 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.
Page 2 of 5 Rev 3/16/2010
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Page 3 of 5 Rev 3/16/2010
1
I
IN WITNESS WHEREOF, the parties hereto have executed this Amendment on the day first above written.
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE:
BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO
OF EAGLE COUNTY for the use and benefit of the John W. Hickenlooper, Governor
EAGLE COUNTY PUBLIC HEALTH AGENCY
(a political subdivision of the state of Colorado
( 1
At 'EWA By:
` ure of Authorized Officer For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
Th (N � AND ENVIRONMENT
Print Name of Authorbfed Officer
OktM reli■A+
Print Title of Authorized Officer
PROGRAM APPROVAL: •
By:
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS §24 -30 -202 requires the State Controller to approve all State Contracts. This Contract is not valid until
signed and dated below by the State Controller or delegate. Contractor is not authorized to begin
performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not
obligated to pay Contractor for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER
David J. McDermott, CPA
By:
Date:
Page 4 of 5 Rev 3/16/2010
I I
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•
•
Page 5 of 5 Rev 3/16/2010
EXHIBIT D
ADDITIONAL PROVISIONS
To Task Order Contract Dated 03/28/11- Contract Routing Number 11 FLA 30081
1. This Task Order Contract contains federal funds (see Catalog of Federal Domestic Assistance (CFDA)
number 93.217)
2. The United State Department of Health and Human Services ( "US DHHS "), through the Colorado General
Assembly has awarded federal funds, hereinafter "Award ", to perform — a comprehensive family planning
program. The State has formulated a comprehensive State plan, with associated budgets, to disburse these
funds throughout the state of Colorado. Under this comprehensive State plan, the State shall allocate these
funds to qualified entities to provide comprehensive family planning services to the citizens of the state of
Colorado on behalf of the State.
If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as
of the effective date of that Award, then the State shall reimburse the Contractor for any allowable and
allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective
date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable
and allocable expenses of a contractor as of the effective date of that Award, then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by
the Contractor on or after the effective date of this Task Order Contract, with such effective date being the
later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the
State Controller or delegee.
3. To receive compensation under this Task Order Contract, the Contractor shall submit a signed Monthly
Family Planning Program (FPP) Cost Reimbursement Statement in a format acceptable to the State. A
FPP Cost Reimbursement Statement is incorporated and made part hereof by reference. This document
is located at: http: / /www.cdphe. state. co. us /pp /womens/ FPNursingConsntsForms.html ?col2 =open. A FPP
Cost Reimbursement Statement must be submitted within sixty (60) calendar days of the end of the billing
period for which services were rendered. FPP Cost Reimbursement Statements must be accompanied by
detailed cost ledger to reflect all purchases being invoiced under that contract and should include date of
payment, payee name and amount, and check or voucher number, when available. Expenditures shall be in
accordance with the Statement of Work attached hereto as Exhibit E. These items may include, but are
not limited to, the Contractor's salaries, fringe benefits, supplies, travel, operating, indirect costs which are
allowable, and other allocable expenses related to its performance under this Task Order Contract.
FPP Cost Reimbursement Statements shall: 1) reference this Task Order Contract by its contract routing
number, which is located on page one of this Task Order Contract; 2) state the applicable performance
dates; 3) state the names of payees; 4) include a brief description of the services performed during the
relevant performance dates; and, 5) show the total requested payment. Payment during the initial, and any
renewal or extension, term of this Task Order Contract shall be conditioned upon affirmation by the State
that all services were rendered by the Contractor in accordance with the terms of this Task Order Contract.
FPP Cost Reimbursement Statements shall be sent to:
Fiscal Officer
Family Planning Program
Prevention Services Division
Colorado Department of Public Health and Environment
PSD - A4
4300 Cherry Creek Drive South
Denver, CO 80246
To be attached to CDPHE Page 1 of 2 Revised: 12/19/06
Task Order v1.0 (11/05) contract template
EXHIBIT D
Final billings under this Task Order Contract must be received by the State within a reasonable time after
the expiration or termination of this Task Order Contract; but in no event no later than sixty (60) calendar
days from the effective expiration or termination date of this Task Order Contract.
4. The Contractor is authorized to make limited transfers of funds from one line item in its Budget to another
line item in its Budget but must notify the Program Director by email prior to the transfer. A transfer from
one line item to another line item may not exceed ten percent (10 %) or One Thousand Dollars ($1000),
whichever is less, of the total amount of the line item from which the transfer is made unless prior written
approval is received from the Program Director. If the Contractor desires to transfer more than ten percent
(10 %) or One Thousand Dollars ($1000), whichever is less, from one line item in its budget to another line
item in its budget then the Contractor shall request and receive prior written approval from the Program
Director by completing and submitting a Budget Revision Request Form, incorporated and made part
hereof by reference. This document is located at:
http: / /www. cdph e.state. co.us /pp/ womens /FPNursi ngConsntsForms. htm l ?colt =open.
5. The services or activities under this Contract may be carried out by the Contractor, or through subcontracts
with other providers or, through collaborative partnerships with other community partners. The State
authorizes the Contractor to subcontract some, or all, or the services that are to be performed under this
Contract. However, a subcontractor is subject to all of the terms and conditions of this Contract.
Additionally, the contractor remains ultimately responsible for the timely and satisfactory completion of all
work performed by any subcontractor(s) under this Contract. The Contractor shall maintain, at a minimum
a Memorandum of Understanding or other binding contractual agreement. The Contractor shall provide a
list of all current family planning subcontractors to the Family Planning Program Director within 15 days
of executing this Contract and any new subcontractors at least 15 calendar days prior to an agreement being
executed. The Contractor shall maintain records of any subcontractors for a minimum of three years.
6. The Contractor shall comply with section 1001 of the federal Act and all applicable federal regulations, as
amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all applicable state regulations.
7. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The
State has determined that this contract does not constitute a Business Associate relationship under HIPAA.
8. Under this Task Order Contract, the Contractor shall refer families participating in any and all programs in
its agency such as WIC, Early and Periodic Screening, Diagnosis and Treatment (EPSDT), Immunization
Clinics, HCP, Prenatal Plus (PNP), etc. to appropriate enabling and direct care service programs in the
community. All pregnant women in need of resources for prenatal medical care are provided with
information about programs such as WIC, PNP, etc. as needed; all children ages birth through two years
who may be eligible for early intervention services are referred to Early Intervention Colorado.
9. The State may require forms attached to this contract and incorporated herein by reference by updated
during the term of this contract. The Contractor will be informed of the new forms as they are developed.
Forms may be sent to contractors or will be available on the Family Planning website:
http://www.cdphe.state.co.us/pp/womens/famplan.html_
10. Notwithstanding anything herein to the contrary, the parties understand and agree that all terms and
conditions of this Task Order Contract and the exhibits and attachments hereto which may require
continued performance, compliance or effect beyond the termination date of this Task Order Contract shall
survive such termination date and shall be enforceable by the State as provided herein in the event of such
failure to perform or comply by the Contractor.
To be attached to CDPHE Page 2 of 2 Revised: 12/19/06
Task Order v1.0 (11/05) contract template
EXHIBIT E
STATEMENT OF WORK
To Task Order Contract Dated 03/28/2011 - Contract Routing Number 11 FLA 30081
1. The Contractor shall conduct a comprehensive family planning program ( "the program ") in Eagle County.
This program shall comply with section 1001 of the federal Act and all applicable federal regulations, as
amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all applicable state regulations.
(Federal funding from HHS, CFDA #93.217 FP Services). The funding for this program will be spent in
accordance with the Budget, Budget Narrative and FY12 Estimated Funding Amounts attached hereto and
referred to as Attachment E -1.
2. The Contractor shall make its program available to men and women in their reproductive years and shall offer
the following services, as appropriate:
A. Outreach services and/or other program efforts designed to improve client recruitment;
B. Nursing and medical services, which shall include a comprehensive health and social history and
physical examination administered in accordance with all applicable Title X regulations and, all
applicable nursing- medical policies or procedures which have been, or may be, established by the
State's Women's Health Unit ( "WH ");
C. Contraceptive information, education, and supplies regarding all family planning methods;
D. Education and counseling services regarding family planning, family planning methods, child spacing,
infertility, sterilization, nutrition, sexually transmitted diseases, HIV /AIDS, adolescent counseling and
other related health issues, as outlined in the Nursing and Administrative Manual;
E. Follow -up and/or referral services, as appropriate.
3. The services provided by the Contractor to the clients it serves shall be performed pursuant to law in accordance
with prevailing medical standard of care for the same or similar medical, nursing and professional services. The
services provided shall also comply with applicable Title X regulations, WHU nursing - medical policies and
procedures, and any applicable fiscal or administrative policies of the State or Federal government which can be
located at http://www.cdphe.state.co.us/pp/womens/famplan.html?col2=open. Contractor acknowledges that it
has reviewed these policies and procedures.
4. The services provided by the Contractor must be deemed acceptable, in good faith, by WH. For a service to be
"acceptable" it must comply with all applicable: Title X regulations, WH nursing - medical policies and
procedures, and any applicable fiscal and administrative policies and procedures of the State and Federal
government. All applicable Title X regulations, WH nursing - medical policies and procedures, and all
applicable fiscal or administrative policies of the State have been provided to the Contractor by the State as of
the effective date of this Contract.
5. The Contractor shall provide the State's family planning program consultants and administrators with
reasonable access to its operations to perform: periodic site reviews, data reviews, fiscal reviews or other
evaluations of the Contractor's family planning program. Evaluations of the Contractor's program shall be .
based on established standards and policies of the State or the Federal government. The Contractor shall
cooperate during all periodic site visits, data reviews, fiscal reviews or other evaluations conducted by the State.
The established standards and policies for the Family Planning Program can be located in the Family Planning
Administrative Manual and the Family Planning Nursing Manual located on the Family Planning website at
http://www.cdphe.state.co.us/pp/womens/famplan.html.
6. If necessary, the Contractor shall comply with all recommendations made by the State's family planning
program consultants and /or administrators after a periodic site visit, data review, fiscal review or other
To be attached to CDPHE Page 1 of 3 Revised: 12/19/06
Task Order v1.0 (11/05) contract template
EXHIBIT E
evaluations that are necessary to bring its program into compliance with all applicable federal and state laws,
policies and regulations. The Contractor shall be in full compliance with a recommendation, if any, within three
(3) months of the date a recommendation is made by the State. If the Contractor cannot obtain full compliance
within this three (3) month period, then on or before the expiration date of that three (3) month period the
Contractor shall present sufficient written evidence to the State: to show that continuing progress is being made
towards full compliance; and, the date when full compliance shall occur. In no event, however, shall full
compliance with a recommendation occur any later than six (6) months after the date that a recommendation
was initially made by the State. If the Contractor fails to correct such deficiencies, the Contractor shall be in
default of its obligations under this Task Order Contract and the State, at its option, may elect to withhold
payment or terminate this Task Order Contract or the Master Contract and all Task Order Contracts entered into
pursuant to the Master Contract. Notwithstanding the foregoing provisions, the State may disregard these cure
periods and immediately terminate the contract without liability if it has solely determined that Contractor's
noncompliance places the health, safety or welfare of persons receiving services in jeopardy.
7. On a monthly basis, the Contractor shall collect and provide to the State, by the fifteenth calendar day of the
following month, all pertinent data regarding all services offered, and all family planning clients served, by its
program during the preceding month, submitted through the IRIS data system. This data shall be verified on a
quarterly basis to help assure accuracy. The Contractor must adhere to the Data Security, Use and
Confidentiality Agreement (also known as the Secure External User form), incorporated and made part hereof
by reference. This document is located at:
http: / /www.cdphe. state. co. us /pp /womens /FPNursingConsntsForms. html ?co I2 =open.
8. Within thirty (30) calendar days of receipt of a written request from the State, the Contractor shall submit
nursing- medical chart audits to the State.
9. The Contractor shall only use program income generated from client fee collections and donations for family
planning purposes that further the objectives of the legislation under which this Contract is entered into. In
accordance with Title X guidelines, the Contractor shall not charge for any Title X required services provided to
clients who are at or below 100% of the official poverty line as defined by the Federal Register by the U.S.
Department of Health and Human Services under the authority of 42 U.S.C. 9902 (2). A copy of this guideline
has been provided to the Contractor by the State as of the effective date of this Contract. If the State receives
new poverty guidelines during the term of this Contract, then the State shall immediately forward those new
poverty guidelines to the Contractor. The Contractor shall use these new poverty guidelines, if any, upon
receipt thereof from the State.
10. The Contractor's charges for services to clients who are above 100% of poverty level shall be based on a sliding
fee scale that takes into account a client's family size and/or individual income. These charges and the sliding
fee scale shall be made available to all clients of the Contractor, the general public, and the State. This most
current version of this document is available on the Family Planning website
http: / /www.cdphe. state. co. us /pp/ womens /FederalPovertyGuidelines.html, Charges shall be based upon the
Contractor's actual costs to provide these services as determined by a cost analysis. The Contractor and the
State shall review these costs annually. The Contractor shall insure that all clients understand that they will not
be denied services because of an inability to pay any of the Contractor's sliding fee charges.
11. All money received by the Contractor from the State under this Contract shall be used by the Contractor to
provide contraceptive services to qualified family planning clients (fertile clients receiving contraceptive
services) includin g approximately 505 target family planning clients (target clients are defined as all
clients under the age of 20 years and clients at or below 150% of the Federal Poverty Level Guidelines).
12. The Contractor shall either use a cytology laboratory chosen by the State or, a laboratory proposed by the
Contractor and approved by the State.
13. During the term of this Contract, the Contractor agrees to provide the State with the semi - annual Family
Planning Expenditure/Revenue Reports, incorporated and made part hereof by reference. This document is
To be attached to CDPHE Page 2 of 3 Revised: 12/19/06
Task Order v1.0 (11/05) contract template
EXHIBIT E
located at: http: / /www.cdphe. state. co. us /pp/ womens /FPNursingConsntsForms.html ?colt =open. The first report
is for the months of July through December; the second report is for the months of January through June. These
reports will be due on dates specified by CDPHE.
14. During the term of this Contract, the Contractor agrees to provide the State with an Annual Family Planning
Work Plan and to submit semi - annual work plan progress reports by dates specified by CDPHE.
15. The Contractor shall protect the confidentiality of all client records and other materials that are obtained,
created, or maintained by the Contractor under this contract. Except for purposes directly related to the
administration of this contract, no information about, or obtained from, any client shall be disclosed by the
Contractor in any form that would identify that client without the prior written consent of that client. As of the
acceptance date of this contract by the Contractor, the Contractor shall have written policies governing the
access to and, the duplication and dissemination of, all such information. The Contractor shall advise its
directors, officers, employees, agents, servants, and subcontractors, if any, that they are subject to these •
confidentiality requirements.
16. The Contractor shall participate in meetings or trainings as requested by the State.
17. Funding adjustments may be made during the term of this contract. The State makes funding adjustments on
this contract using a Funding Letter substantially equivalent to Exhibit C and bearing the approval of the State
Controller or his designee; the funding letter shall not be deemed valid until the State Controller or his designee
has approved it.
18. The Contractor shall require any new family planning coordinator or fiscal staff working on Family Planning
Program services to participate in Fiscal Orientation within forty -five (45) days of employment.
To be attached to CDPHE Page 3 of 3 Revised: 12/19/06
Task Order v1.0 (11/05) contract template
Attachment E -1
WORKSHEET
APPLICANT: Eagle County Public Health
Federal Title X June 30, 2011- June 29, 2012
FOR THE BUDGET PERIOD: State Title X July 1, 2011 - June 29, 2012
CFPI July 1, 2011- June 30, 2012
,
Salary
% Time CDPHE -WHU
!
SEE ABOVE 1 f {
FOR BUDGET
PLEASE ROUND ALL FIGURES PERIODS BY
TO THE NEAREST DOLLAR GRANT
FTE
FEDERAL &
STATE TITLE X
PERSONNEL EXPENSES: (Include name
& title for each employee charged to CDPHE
funding. You do not need to list the name and title
for employees charged only to Non -CDPHE
funding)
Tammy Brunk, CNM $44,460 100% $37 ,440 _
Michelle Valencia, Clinic Assistant $37,856 40% $5,891 r° �'-
Jennie Wahrer, Nurse Manager $85,490 10%
$43,331
Fringe Benefit Rate and Expenses f
3 r, r °s $43,331
CONTRACTUAL: (Independent contractor for tubal ligation, Essure, vasectomy, € ,
nurse practitioners,
'-3
etc. In CFPI portion ONLY, add referral fee in this
physicians, P
section.
Vasectomies contractor TBD 16 procedures
Tubals & Essure Contractor TBD 3 procedures
Medical Officer /Pharmac Consultation -_ F .
$0 s
j _
OPERATING:
ontraceptive Met o • s or FPI portion • , 1 ' o a' min ee can
be included in this line.) j -11,1 _
Training costs - which includes registration fees, travel
Chlamydia tests 11
Other Lab tests -:
Educational materials (brochures, etc.) t?
Clinical supplies .- _
Office operating supplies (papers, charts, pens, etc.)
Office expense (rent, utilities, maintenance) ■ t'r_'I
OTHER: Systems upgrade to be compatible w/billing requirements
Page 1 of 4
Attachment E -1
OTHER (Specify): CNM malpractice liability insurance � LLr°' `
[ E ( .�� )1?tJ n 33d�i:? 3 1, °za1 ° _ $0 » :�'1 c3 »rtv
EQUIPMENT: (Computers, Office furniture) , �k t.� r =t
3
1 >i i> 3 : <i $43
1
I
i a■f Tr s z Ali'- t'� y7a. :1
k
Yellow cells are not included in the CFPI admin fee calculation.
Feel free to add cells as needed. Be sure to us date the total formulas if this is needed.
Page 2 of 4
Attachment E -1
, - 43J � , } j T' ,'" .. k 8 .} F
_�..,._ , t _. ; 1 ' . I ( x j Pith' B r \, Aa ;,,w t 3 9 x i g , :1 ! 7 S 1 e 9 i T p , s E. .,. .F., = ' z , I ^': .1
APPLICANT: Eagle County Public Health
FOR THE PERIOD: June 30, 2011 - June 29, 2012
For Personnel category list
title of position
How is the total amount required
For all other categories list the Relationship to project calculated? Total
line item from the budget
6 _ _ , , 1
Tamm Brunk 0.4 FTE Title X CNM Provider Annual Sala of $37,440 $37,440.00
Annual Salary of $37,856 x 40% —
$15,142. $5,891 is charged to Title X
and the remaining $9,251 is NON -
Michelle Valencia 0.4 FTE Clinic Assistant CDPHE and paid by grantee. $5,891.00
Annual Salary of $85,490 x 10% =
Jennie Wahrer 0.1 FTE Nurse Manager $8,549. 100% is NON - CDPHE. $0.00
Fringe Benefits are 47% of salaries at
the following rates: FICA 6.2 %,
Medicare 1.45 %, Retirement 6 %,
Workers Compensation 2.5 %, Health
Insurance 32.85% = $28,746. 100% is
Fringe Benefit Rate & Expenses NON -CDPHE and paid by grantee. $0.00
Drew Warner, MD Medical Officer Annual Contractual fee is $4,575. 100% $0.00
is NON -CDPHE and paid by grantee.
John Baston Pharmacist Consultant Annual Contractual fee is $2,000. 100% $0.00
• is NON -CDPHE and paid by grantee.
Includes LARC methods including: Mirena, Annual cost based on past history is
Contraceptive Methods ParaGuard, NuvaRing, shipping costs, and a 10% $8,000. 100% is NON - CDPHE and $0.00
admin fee limited to the costs of ordering,
by grantee.
maintaining inventory and stocking.
Annual cost based on past history is
Chlamydia tests $1,000. 100% is NON -CDPHE and paid $0.00
by grantee.
Annual cost based on past history is
Other Lab tests Paps, HPV, HIV, TSH, Hbg. $4,800. 100% is NON -CDPHE and paid $0.00
by grantee.
Annual cost based on past history is
Educational materials Prescription pads, pocket cards $100. 100% is NON -CDPHE and paid $0.00
by grantee.
Annual cost based on past history is
Clinical supplies Gloves, speculums, gowns, medical forms $250. 100% is NON -CDPHE and paid $0.00
by grantee.
CNM Malpractice Insurance Annual fee is $3,515. 100% is NON- $0.00
C and .aid b 9 antee.
NONE
741;1,7,3 i �'� i uF - a -_ �� � a, x-
4 1 b = k. : 3... Lv., ? j i a te. s� " `S` -11:16;}'%„:4-k'.:4,7—,, @r�
��,•*�,a� � _� .'��* *� � �`�,�� °� emu.:. ; �s��� � r ,tm , ����� �z�� •����..
NONE
Page 3 of 4
Attachment E -1
STATE OF COLORADO
John W. Hickenlooper, Governor
Christopher E. Urbina, MD, MPH OF �o�
`` yo
Executive Director and Chief Medical Officer � - -�: -.:
Dedicated to protecting and improving the health and environment of the people of Colorado *
r*
4300 Cherry Creek Dr. S. Laboratory Services Division is7s�
Denver, Colorado 80246 -1530 8100 Lowry Blvd.
Phone (303) 692 -2000 Denver, Colorado 80230 -6928 Colorado Department
Located in Glendale, Colorado (303) 692 -3090
of Public Health
http: / /www.cdphe.state.co.us and Environment
Title X Family Planning
FY12 ESTIMATED FUNDING AMOUNTS
FOR BUDGET WORK SHEET AND BUDGET NARRATIVE
AGENCY NAME: Eagle County Public Health Agency
Federal Federal Title X $ 31,435 June 30, 2011 - June 29, 2012
Title X,
State CDPHE -WH -STATE $ 11,896 July 1, 2011 — June 29, 2012
I � t � � a � i l .. � •� � � a ts �" Est � � '.
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