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HomeMy WebLinkAboutC12-220 Colorado Family Planning Initiative (13 FLA 43671) DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ROUTING NO. 13 FLA 43671 APPROVED TASK ORDER CONTRACT — WAIVER #154 This Task Order Contract is issued pursuant to Master Contract made on 01/17/2012, with routing number 13 FAA 00016 STATE: CONTRACTOR: State of Colorado for the use & benefit of the Board of County Commissioners of Eagle County, (a Department of Public Health and political subdivision of the State of Colorado), 500 Environment Broadway, Eagle, Colorado 81631 -0850, for the use and PSD -CFPI benefit of the Eagle County Public Health Agency, 4300 Cherry Creek Drive South 551 Broadway, Eagle, Colorado 81631 Denver, Colorado 80246 TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE: 05/01/2012 Colorado Political Subdivision PO /SC ENCUMBRANCE NUMBER: PO FLA PPG-1343671 TERM: BILLING STATEMENTS RECEIVED: This Task Order shall be effective upon Monthly approval by the State Controller, or designee, or on 07/01/2012, whichever is later. The STATUTORY AUTIIORP1'Y: Task Order shall end on 06/30/2013. NA PRICK STRUCTURE: CONTRACT PRICE NOT TO EXCEED: Cost Reimbursement $30,501.00 PROCUREMENT MP:I'IIOD: FEDERAL FUNDING DOLLARS: $0 STATE FUNDING DOLLARS: $0 Exempt PRIVATE FUNDING DOLLARS: $30,501.00 BID/REP/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR: Not Applicable FY 13: $30,501.00 FY XX: $ • LAW SPECIFIED VENDOR STATUTE: FY XX: $ Not Applicable FY XX: $ FY XX: $ STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE: Greta Klingler Jennnie Wahrer Department of Public Health and Environment Eagle County Public Health Agency PSD -CFPI P.O. Box 660 4300 Cherry Creek Drive South Eagle, Colorado 81631 Denver, Colorado 80246 SCOPE OF WORK: Contractor shall provide comprehensive family planning services under the Colorado Family Planning Initiative (CFPI). Page 1 of 6 Rev 6/25/09 EXHIBITS: The following exhibits are hereby incorporated: Exhibit A - Additional Provisions (and its attachments if any — e.g., A -1, A -2, etc.) Exhibit B - Statement of Work (and its attachments if any — e.g., B -1, B -2, etc.) Exhibit C- Budget GENERAL PROVISIONS The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task Order Contract provide more specificity than these general clauses, the more specific provision shall control. 1. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall be performed according to the standards, terms and conditions set forth in the Master Contract. 2. In accordance with section 24 -30- 202(1), C.R.S., as amended, this Task Order Contract is not valid until it has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not authorized to, and shall not; commence performance under this Task Order Contract until this Task Order Contract has been approved by the State Controller or delegee. The State shall have no financial obligation to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order Contract on or before its proposed effective date, then the Contractor shall commence performance under this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order Contract after its proposed effective date, then the Contractor shall only commence performance under this Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through and including the date specified on page one of this Task Order Contract, unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order Contract and /or the Master Contract. Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of the terms and conditions of this Task Order Contract. 3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made a part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and /or attachments to this Task Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated, the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits and/or attachments), or between this Task Order Contract and its exhibits and /or attachments, such conflicts or inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the Page 2 of 6 Rev 6/25/09 1 Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 4) the Additional Provisions - _Exhibit A, and its attachments if included, to this Task Order Contract; 5) the Scope /Statement of Work - Exhibit B, and its attachments if included, to this Task Order Contract; 6) other exhibits /attachments to this Task Order Contract in their order of appearance. 4. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit B ". 5. The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or decrease the amount payable under this Task Order Contract, or add to, delete from, and /or modify this Task Order Contract's Statement of Work through a contract amendment. To be effective, the amendment must be signed by the State and the Contractor, and be approved by the State Controller or an authorized delegate thereof. This contract is subject to such modifications as may be required by changes in Federal or State law, or their implementing regulations. Any such required modification shall automatically be incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set forth herein. 6. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope /Statement of Work - Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP, then the Contractor shall also meet those standards of performance under this Task Order Contract. 7. STATEWIDE CONTRACT MANAGEMENT SYSTEM [This section shall apply when the Effective Date is on or after July 1, 2009 and the maximum amount payable to Contractor hereunder is $100,000 or higher] By entering into this Task Order Contract, Contractor agrees to be governed, and to abide, by the provisions of CRS §24- 102 - 205, §24- 102 - 206, §24- 103 -601, §24 -103.5 -101 and §24 -105 -102 concerning the monitoring of vendor performance on state contracts and inclusion of contract performance information in a statewide contract management system. Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order Contract, State law, including CRS §24- 103.5 -101, and State Fiscal Rules, Policies and Guidance. Evaluation of Contractor's performance shall be part of the normal contract administration process and Contractor's performance will be systematically recorded in the statewide Contract Management System. Areas of review shall include, but shall not be limited to quality, cost and timeliness. Collection of information relevant to the performance of Contractor's obligations under this Task Order Contract shall be determined by the specific requirements of such obligations and shall include factors tailored to match the requirements of the Statement of Project of this Task Order Contract. Such performance information shall be entered into the statewide Contract Management System at intervals established in the Statement of Project and a final review and rating shall be rendered within 30 days of the end of the Task Order Contract term. Contractor shall be notified following each performance and shall address or correct any identified problem in a timely manner and maintain work progress. Should the final performance evaluation determine that Contractor demonstrated a gross failure to meet the performance measures established under the Statement of Project, the Executive Director of the Colorado Department of Personnel and Administration (Executive Director), upon request by the Colorado Department of Public Health and Environment and showing of good cause, may debar Contractor and Page 3 of 6 Rev 6/25/09 prohibit Contractor from bidding on future contracts. Contractor may contest the final evaluation and result by: (i) filing rebuttal statements, which may result in either removal or correction of the evaluation (CRS §24- 105 - 102(6)), or (ii) under CRS §24 -105- 102(6), exercising the debarment protest and appeal rights provided in CRS § §24 -109 -106, 107, 201 or 202, which may result in the reversal of the debarment and reinstatement of Contractor, by the Executive Director, upon showing of good cause. 8. If this Contract involves federal funds or compliance is otherwise federally mandated, the Contractor and its agent(s) shall at all times during the term of this contract strictly adhere to all applicable federal laws, state laws, Executive Orders and implementing regulations as they currently exist and may hereafter be amended. Without limitation, these federal laws and regulations include the Federal Funding Accountability and Transparency Act of 2006 (Public Law 109 -282), as amended by §6062 of Public Law 110 -252, including without limitation all data reporting requirements required there under. This Act is also referred to as FFATA. Page 4 of 6 Rev 6/25/09 THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT * 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: STA fE OF COLORADO: John W. Hickenlooper, GOVERNOR Board of County Commissioners of Eagle County for the use and benefit of the Eagle County Public Health Agency Legal Name of Contracting Entity For Executive Director Department of Public Health and Environment Signature of Authorized Officer pe"1rt; (4) �a Print Name of Authorized Office /� Department Program Approval: radi` i By Print Title of Authorized Officer 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 5 of 6 Rev 6/25/09 This page left intentionally blank. Page 6 of 6 Rev 6/25/09 EXHIBIT A ADDITIONAL PROVISIONS To Task Order Contract Dated 05/01/2012 - Contract Routing Number 13 FLA 43671 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. The list of acronyms attached hereto as Attachment A -1 may be referenced to in Exhibit A, Exhibit B, and all and any attachments thereof in this Task Order Contract. 2. This Task Order Contract contains private funds. 3. To receive compensation under this Task Order Contract, the Contractor shall submit a signed monthly CDPHE Reimbursement Invoice Form. This form is accessible from the CDPHE internet website http: / /www.cdphe. state. co. us /StandardizedInvoice /index.html. CDPHE will provide technical assistance in accessing and completing the form. The CDPHE Reimbursement Invoice Form must be submitted within sixty (60) calendar days of the end of the billing period for which services were rendered. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B and incorporated herein and the associated Budget attached hereto as Exhibit C and incorporated herein. Submit completed CDPHE Reimbursement Invoice Form to: Colorado Department of Public Health and Environment Fiscal Officer PSD- WHB- CFPI -A5 4300 Cherry Creek Drive South Denver, CO 80246 To be considered for payment, billings for payments pursuant to this Task Order 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 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. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. 4. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The State has determined that this Task Order Contract does not constitute a Business Associate relationship under HIPAA. 5. Contractor must notify the State within thirty (30) days of a change of the Project Director or Principal Investigator responsible for the performance of services provided under this Task Order Contract. 6. Contractor shall request prior approval in writing from the State for all modifications to the Statement of Work/Work Plan or for any modification to the Budget in excess of ten percent (10 %) of the total budget. Contractor shall submit a Budget Revision Request Form to request prior approval for all budget modifications in excess of ten percent (10 %) of the total budget. The Budget Revision Request Form is incorporated herein by reference and is located at http: / /www.cdphe. state. co. us /pp/ womens/ FPNursingConsntsForms.html ?col2 =open. Any request for modification to the Budget in excess of thirty percent (30 %) of the total budget or $1,000,000.00, whichever is less, shall be submitted to the State by February 28, 2013 and may require an amendment in To be attached to CDPHE Page 1 of 3 Revised: 12/19/06 Task Order v1.0 (3/12) contract template EXHIBIT A accordance with Section 5 of this Task Order Contract. Requests for modifications to the Statement of Work/Work Plan may require an amendment regardless of dollar amount. 7. Contractor shall submit an Annual Family Planning Work Plan and semi - annual work progress reports by due dates specified by the State at http: / /www.cdphe.state.co.us /pp/ womens / FPNursingConsntsForms.html ?col2 =open and in a format acceptable by the State. Failure to submit acceptable reports by the due date may result in a delay or denial of the reimbursement request. 8. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9, Rights in Data, Documents and Computer Software or Other Intellectual Property, unless otherwise provided for, all data collected or produced or derived exclusively from the Contractor's or subcontractor's work under this Task Order Contract shall remain the sole property of the State, whether in individual, aggregate, identified or de- identified form or any other form required by the State. To facilitate follow -up, research, surveillance and evaluation, any such data collected, used or acquired shall be made available in any form required by the State, to the State and any other entity designated by the State. Any such data collected, used or acquired shall be used solely for the purposes of this Task Order Contract. The Contractor and its subcontractors agree not to release, divulge, publish, transfer, sell, or otherwise make known any such data to unauthorized persons without the express prior written consent of the State or as otherwise required by law. This includes a prior written request by the Contractor to the State for submission of abstracts or reports to conferences, which utilize data collected under this Task Order Contract. Notwithstanding the foregoing, the Contractor shall be entitled to retain a set of any such data collected or work papers necessary to perform its duties under this Task Order Contract and in accordance with professional standards. 9. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9, Rights in Data, Documents and Computer Software or Other Intellectual Property, or Section 23.i, General Provisions, Media or Public Announcements, the State of Colorado, specifically the Department of Public Health and Environment, shall be the owner of all printed materials, graphic representations, educational materials, audio- visual products, or any other media, in whatever form, created under this Task Order Contract. This requirement applies, but is not limited to, any brochure, flyer, presentation, billboard, radio spot, website, banner advertisement. The State reserves the right to require logos, or other wording on any material, representation, product or other media form created under this Task Order Contract. Any material, representation, product or other media form that will use the State's or logo or information must be approved by the State prior to production and distribution. A minimum of ten (10) business days is required for the review and approval process. 10. Notwithstanding terms contained in General Provisions of the Master Contract, Section 23f, Assignment and Change in Ownership, Address, Financial Status, Contractor is responsible for all work performed under this Task Order Contract by subcontractor(s) and shall maintain, at a minimum, a Memorandum of Understanding or other binding contractual agreement with all subcontractor(s) performing work under this Task Order Contract. Contractor shall provide a list of all current subcontractor(s) to the State within fifteen (15) calendar days of the execution date of this Task Order Contract and shall provide a list of any new subcontractor(s) at a minimum of fifteen (15) calendar days prior to the execution of any subcontract agreement. Contractor shall maintain records of any subcontractors in accordance with the time periods specified in General Provisions of the Master Contract, Section 11, Records, Maintenance, Performance Monitoring & Audits. 11. The State may require forms attached to this Task Order Contract and incorporated herein to be updated by the Contractor during the term of this Task Order Contract. The State shall notify the Contractor of newly To be attached to CDPHE Page 2 of 3 Revised: 12/19/06 Task Order v1.0 (3/12) contract template EXHIBIT A developed forms. Forms may be sent to the Contractor or posted on http: / /www.cdphe. state .co.us / /pp /womens /famplan.html. 12. Notwithstanding the terms contained in the General Provisions of the Master Contract, Section 25, Conformance with Law, the Contractor shall comply with the provisions of Section 601 of Title VI of the Civil Rights Act of 1964, as amended, which states that "no person in the United States shall on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program actively receiving Federal financial assistance." The Office for Civil Rights has established that it is the responsibility of any program that is a recipient of federal funds to ensure that any Limited English Proficient (LEP) person or beneficiary have meaningful access to programs, services and information. The Contractor and contract personnel shall adopt and implement policies and procedures in which reasonable steps are taken to provide language assistance in order to ensure equal access to LEP persons or beneficiaries. The Contractor and contract personnel shall advise LEP individuals that language assistance will be provided at no cost to the LEP person or beneficiary. 13. Contractor agrees to provide services to all Program participants and employees in a smoke -free environment in accordance with Public Law 103 -227, also known as "the Pro - Children Act of 1994 ", (Act). Public Law 103 -227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where Women, Infants and Children (WIC) coupons are redeemed. Failure to comply with the provision of Public Law 103 -227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and /or the imposition of an administrative compliance order on the responsible entity. By signing this Task Order Contract, Contractor certifies that Contractor shall comply with the requirements of the Act and shall not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. Contractor agrees that it shall require the language of the Act be included in any subcontracts which contain provisions for children's services and that all subcontractors shall sign and agree accordingly. 14. Notwithstanding the terms contained in the General Provisions of the Master Contract, Section 10, Confidential or Proprietary Information, the Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order Contract. Except for purposes directly connected with the administration of this Task Order Contract, no information about or obtained from any applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with the exception of information protected by Colorado Statute as it applies to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal guardian must provide consent or as otherwise properly ordered by a court of competent jurisdiction. Contractor shall have written policies governing access, duplication, and dissemination of all such information. Contractor shall advise its employees, agents, servants, and any subcontractors that they are subject to these confidentiality requirements. 15. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding Letter substantially equivalent to Attachment A -2. The Grant Funding Change Letter is not valid until it has been approved by the State Controller or designee. To be attached to CDPHE Page 3 of 3 Revised: 12/19/06 • Task Order v1.0 (3/12) contract template Attachment A -1 Commonly Used Acronyms and Abbreviations That May Be Referenced In the Scope of Work: ACS American Cancer Society ACNS Alamosa County Nursing Service ACF Administration for Children and Families ADA Americans with Disabilities Act ADAD Alcohol and Drug Abuse Division AHA American Heart Association AIDS Acquired Immune Deficiency Syndrome ALA American Lung Association ALA(C) American Lung Association (of Colorado) AMCHP Association of Maternal Child Health Programs ANR Americans for Non- Smokers' Rights ARC Addiction Recovery Centers ARRA American Recovery and Reinvestment Act ASC Adams State College ASSIST American Stop Smoking Intervention Study ASTHO Association of State and Territorial Health Office B &G Boys & Girls BACCHUS BACCHUS Peer Education Network BAG Build a Generation BBLHC Boulder Broomfield Latino Health Coalition BC Boulder County BCCP Breast and Cervical Cancer Program BCHD Bent County Health Dept BCPH Boulder County Public Health BCPHA Baca County Public Health Agency BCDSS Baca County Dept Social Services BCTEPP Bent County Tobacco Education Prevention Partnership BGC Boys & Girls Club BGCMD Boys & Girls of Metro Denver BHS Broomfield High School BMTF Baby & Me Tobacco Free BOCES Board of Cooperative Educational Services BOH Board of Health BRFSS Behavioral Risk Factor Surveillance System BVBAG Buena Vista Build a Generation BVSD Boulder Valley School District Bx Biopsy C Choice CAD Coronary Artery Disease CASB Colorado Association of School Board CB Community-based System CBE Clinical Breast Exam CBO Community -based Organization CC Clear Creek CC Custer County CC Community Coordination/Coordinator CCAP Larimer County Child Care Assistance Program CCC Colorado Cancer Coalition CCCHE Colorado Community Coalition for health Equity CCGC Colorado Clinical Guidelines Collaborative C,CMC Colorado Clinical Managed Care Network CCMC Commission for Case Manager Certification CCPD Cancer, Cardiovascular, and Pulmonary Disease CCIAA Colorado Clean Indoor Air Act CCTCI Colorado Chew Tobacco Collaborative Initiative Page 1 of 6 Attachment A -1 CCTEPP Custer County Tobacco Education Prevention Partnership CDC Centers for Disease Control and Prevention CDE Colorado Department of Education CDPHE Colorado Department of Public Health and Environment CDU Chronic Disease Unit CEC Career Education Center CEO Chief Executive Officer CFDA Catalog of Federal Domestic Assistance CFFC Colorado Foundation for Families and Children CFPI Colorado Family Planning Initiative CHIN Community Health Information Network CICP Colorado Indigent Care Program CJD Colorado Judicial Department CM Case Management CMC Colorado Mountain College CMS Contract Management System CMS Creative Media Solutions CNCC Colorado Northwestern Community College CNS County Nursing Service CO Colorado COD Colorado Donated Dental Services Program COPAN Colorado Physical Activity and Nutrition Program COV Colorado Van Program CPCF Colorado Parent and Child Foundation CPHA Colorado Public Health Association CPT Current Procedural Technology CRUE Culturally Responsive Urban Education CSAP Colorado Student Assessment Program CSH Coordinated School Health CSU Colorado State University CSU -P Colorado State University- Pueblo's CTC Connect to Care CTEPA Colorado Tobacco Education and Prevention Alliance CTFK Campaign for Tobacco -Free Kids CTRP Colorado Tobacco Research Program CTP Crossroads Turning Point CU University of Colorado, Boulder CWCCI Colorado Women's Cancer Control Initiative CY Contract Year DAISI Denver At -home Intervention Service Initiative DASH Division of Adolescent & School Health (CDC) DCMH Delta County Memorial Hospital DH Denver Health DHHA Denver Health and Hospital Authority DHS Department of Human Services DHHS Unites States Department of Health and Human Services DOR Department of Revenue DOS Delta Opportunity School DSS Department of Social Services E &I Education and Information EAP Employee Assistance Program EBHV Evidence -Based Horne Visiting to Prevent Child Maltreatment Grant Program ECC Early childhood council ECC Electrocardiogram ECCLC Early Childhood Council of Larimer County ECLC Early Childhood Leadership Council /Commission E.D. Executive Director EHS Early Head Start Page 2 of 6 Attachment A -1 EMR Electronic Medical Record EMT Emergency Medical Technicians EPA Environmental Protection Agency EPE Epidemiology Planning and Evaluation ESL English as a Second Language ETS Environmental Tobacco Smoke (a.k.a. secondhand smoke) FIRC Family and Intercultural Resource Center FICA The Federal Insurance Contribution Act FDA Food and Drug Administration FNA Final Needle Aspiration FPP Family Planning Program FPL Federal Poverty Level FRCC Front Range Community College FTE Full Time Equivalent FTP File Transfer Protocol FY Fiscal Year FYI Family Youth Initiatives GASO Great American Smoke -out GED General Education Development GASP CO Group to Alleviate Smoking Pollution of Colorado Get R!EAL (GR) Resist! Expose Advertising Lies (Youth Empowerment Program) GLBT Gay, Lesbian, Bisexual, and Transgender GYN Gynecological HCP Health Care Program For Children with Special Needs HCYS Huerfano County Youth Services HHS Health and Human Services HIPPA Health Insurance Portability and Accountability Act of 1996 HIPPY Home Instruction for Parents of Preschool Youngster HIT Health improvement Team HIV Human Immunodeficiency Virus HPV Human Papillornamavirus HR Human Resources hr hour HRSA Health Resources and Services Administration HSL High School Leadership ID Identification IIK Invest in Kids ISHT Interagency School Health Team IT Information Technology JAC Juvenile Assessment Center KIS Keeping in STEPP KMH Keefe Memorial Hospital KPC Kevin Patrick Caleum LAHCDHD Las Animas Huerfano Counties District Health Department LBW Low Birth Weight LC Learning Community LGBT Lesbian, Gay, Bisexual, Transgender LEM Latinas en Movimiento LHA Local Health Agency LHD Local Health Department LLC Limited Liability Company LRCC Latino Regional Community Coalition LRPC Latino a Research and Policy Center LST Life Skills Training LSTPEN Latino Statewide Tobacco Prevention and Education Netw LWB Live Well Broomfield MCHA Montezuma Housing Authority MCHD Montezuma County Health Department • Page 3 of 6 Attachment A -1 MCHS Montezuma- Cortez High School MCPN Metro Community Provider Network MCRC Media Campaign Resource Center — CDC MD Medical Doctor MHCBBC Mental Health Center Serving Boulder and Broomfield Counties MIECHV Maternal, Infant and Early Childhood Home Visiting Program MO Month MOB Medical Office Building MOU Memorandum of Understanding MPA Master of Public Administration in Health and Human Services MPH Master of Public Health MRI Magnetic Resonance Imaging Scan MS Master of Science MSA Master Settlement Agreement MUH Multi -user Housing MYAT Multi- Disciplinary Youth Assessment Team N/A Not Applicable NACCHO National Association of County and City Health Officials NACR Native American Cancer Research NAQC North American Quitline Consortium NASBE National Association of State Board of Education NCHD Northeast Colorado Health Department NCI National Cancer Institute NE North East NFP Nurse - Family Partnership NFPNSO Nurse - Family Partnership National Service Office NHVP Nurse Home Visitor Program NIDA National Institute on Drug Abuse NIH National Institute of Health NJH National Jewish Medical and Research Center N-0-T Not -on- Tobacco, (ALA's Youth Smoking Cessation Program) NP Nurse Practitioner NPP Nurturing Parenting Program NRT Nicotine Replacement Therapy NSBA National School Boards Association OSH Office on Smoking or Health (CDC) OTC Over the Counter PA Physician's Assistant PAC Prevention Awareness Crew PACT Partners Assessing Chew Tobacco PAT Parents as Teachers PCCHD Pueblo City- County Health Department PPC Personal Care Providers PE Presumptive Eligibility PEN Parent Engagement Network PVCHC Peak Vista Community Health Center PHN Public Health Nurse PIO Public Information Officer PM Peer Mentor PMC Parkview Medical Center PMR Planning Management Region PN Patient Navigator PO Purchase Order PPC Policy Partner Committee PPFC Pikes Peak Family Connections PPN Prevention Policy Network PRA Policy Resource Alliance PRAMS Pregnancy Risk Assessment and Monitoring Survey Page 4 of 6 Attachment A -1 PRIDE Pure Respect Initiative Direct Education PSA Public Service Announcement PSD Prevention Service Division PTEPP Pueblo Tobacco Education and Prevention Partnership PVC Prairie View Clinic Q1 Quarter One Q2 Quarter Two Q3 Quarter Three Q4 Quarter Four QI Quality Improvement QOL Quality of Life RDAC Regional Disparities Advisory Council RFA Request for Applications RFP Request For Proposals RIE Reach, Implementation and Effectiveness RIHEL Regional Institute for Health and Environment RMC Rocky Mountain Center for Health Promotion & Education RMRH Rocky Mountain Rural Health RMYC Rocky Mountain Youth Corps RN Registered Nurse Rx Prescription RY Reconnecting Youth SafeCare SAMHSA Substance Abuse Mental Health Services Administration SB School -based System SBAG Salida Build A Generation SBHC School -Based Health Centers SCYC School Community Youth Coalition SCRHC Southern Colorado Regional Health Collaborative SD Service Delivery SECH Southeast Colorado Hospital SEMHS Southeast Mental Health Services SES Socio- Economic Status SEW School Employee Wellness SGR Surgeon General's Report SHAC Smoke -free Housing Action Committee SHI School Health Index SHS Secondhand Smoke SIDS Sudden Infant Death Syndrome SLV San Luis Valley SMART Staying Motivated at Reducing Temptations SMART OUTCOME OBJECTIVE Specific, Measurable, Achievable, Realistic, Time -Bound SMSU Self Management Service Unit SRO School Resource Officer STD Sexually Transmitted Disease STEPP State Tobacco Education and Prevention Partnership STW Straight -to -Work SVVSD St. Vrain Valley School District SWOT Strengths, Weaknesses, Opportunities, Threats SYNAR Synar Regulation TA Technical Assistance TABS Tobacco Attitudes and Behavior Survey TAG Technical Advisory Group (for evaluation & TPEG) TANF Temporary Aid to Needy Families TARP Tobacco Advocacy and Resource Partnership TBD To Be Determine TCP Tobacco Control Partners TDAC Tobacco Disparities Advisory Council Page 5 of 6 Attachment A -1 TDG Tobacco Disparities Grant TDS Tobacco Disparities Subcommittee TEACH Teaching Equity to Advance Community Health TEFAP The Emergency Food Assistance Program TEPP Tobacco Education Prevention Partnership TFCCI Tobacco -Free Colorado Communities Initiative TFLC Tobacco Free Larimer County TFS Tobacco -Free Schools TFS Law Tobacco -Free Schools Law TGYS Tony Grampsas Youth Services Title V Title V of the Social Security Act TND Project Toward No Drug Abuse TPEG Tobacco Program Evaluation Group TPI Tobacco Prevention Initiative TRC Tobacco Education and Prevention and Cessation Program Review Committee TRI Tobacco Rapid Improvement Activity TRIA Tobacco Rapid Improvement Assessment TTI Tony Grampsas Tobacco Initiative UCD University of Colorado — Denver UCDHSC Health Sciences Center at UCD (sometimes abr. UCHSC) UCDHSC University of Colorado at Denver and Health Sciences Center US United States of America USSTC US Smokeless Tobacco Company VP Vice President Well COA Wellness Councils of America WHU Women's Health Unit WIC Women, Infants, Children WWC Women's Wellness Connection Y @C Youth at Crossroads YE Youth Empowerment YPH Youth Partnership for Health Yr Year YRBS Youth Risk Behavior Survey YSAP Youth Substance Abuse Prevention Coalition YTS Youth Tobacco Survey YVMC Yampa Valley Medical Center 5 A's Ask, Advise, Assess, Assist, Arrange 2A's R Ask, Advise, Refer Page 6 of 6 Attachment A -2 GRANT FUNDING CHANGE LETTER Date: State Fiscal Year: Grant Funding Change Letter # CMS Routing # TO: Insert Grantee's name In accordance with Section of the Original Contract routing number , [insert the following language here if previous amendment(s), renewal(s) have been processed] as amended by [include all previous amendment(s), renewal(s) and their routing numbers], [insert the following word here if previous amendment(s), renewal(s) have been processed] between the State of Colorado, Department of Public Health and Environment and Contractor's Name beginning Insert start date <insert start date of original contract> and ending on Insert ending date <insert ending date of current contract amendment >, the undersigned commits the following funds to the Grant: The amount of grant funds available and specified in Section of <insert contract amendment number and routing number> is ❑ increased or n decreased by $amount of change to a new total funds available of $ < insert new cumulative total> for the following reason: . Section is hereby modified accordingly. This Grant Funding Change Letter does not constitute an order for services under this Grant. The effective date of hereof is upon approval of the State Controller or , whichever is later. STATE OF COLORADO John W. Hickenlooper, GOVERNOR Department of Public Health and Environment PROGRAM APPROVAL: By: Lisa Ellis, Purchasing & Contracts Unit Director By: Date: ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER CRS §24 -30 -202 requires the State Controller to approve all State Grants. This Grant is not valid until signed and dated below by the State Controller or delegate. Grantee is not authorized to begin performance until such time. If Grantee begins performing prior thereto, the State of Colorado is not obligated to pay Grantee for such performance or for any goods and /or services provided hereunder. STATE CONTROLLER David J. McDermott, CPA By: Date: Page 1 of 1 Effective Date: 1/6/09 -Rev 8/25/09 EXHIBIT B STATEMENT OF WORK To Task Order Contract Dated 05/01/2012 - Contract Routing Number 13 FLA 43671 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. I. Project Description: Under the Colorado Family Planning Initiative (CFPI), Contractor shall conduct a comprehensive family planning program, herein referred to as "the program" in Eagle County. The 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). Contractor shall make its program available to men and women in their reproductive years and shall offer the services under Title X family planning program. H. Performance Requirements /Deliverables: 1. All money received by the Contractor under this Task Order Contract shall be used by the Contractor to provide contraceptive services. Contractor shall make its program available to men and women in their reproductive years and shall offer the following services under the CFPI: a. Utilize CFPI funding to purchase long acting reversible methods of contraception and contraceptive rings. These are limited to Intrauterine Devices (IUD) Mirena and Paraguard, contraceptive implants and contraceptive rings. b. Utilize CFPI funding to provide the referral process and cover the actual costs of tubal ligation and vasectomy procedures. c. Provide comprehensive family planning services to sustain the total number of qualifying family planning clients (fertile clients receiving contraceptive services) receiving services, 441 clients, in FY13. Pre- approved activities include 1) Sustaining capacity; 2) Outreach; 3) Media and Marketing; 4) Training and Education; 5) Information Technology and Data Management; 6.) Third Party Billing and Coding Resources; and 7) Other approved activities. 2. 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, CDPHE Family Planning Program (FPP) 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 /FPNursingPolicies.html ?colt =open. Contractor acknowledges that it has reviewed these policies and procedures. 3. The services provided by the Contractor must be deemed acceptable and in good faith, by the State. For a service to be "acceptable" it must comply with all applicable: Title X regulations, CDPHE FPP 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, CFPHE FPP 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 Task Order Contract. 4. Contractor shall identify a Primary Data Coordinator who shall annually submit to the State a list of Family Planning data system users. Contractor shall notify the State within thirty (30) days of a change of the Primary Data Coordinator. Page 1 of 3 Exhibit B- Statement of Work V1 /MAR2012 EXHIBIT B 5. On a monthly basis, Contractor shall collect and provide to the State, by the fifteenth calendar day of the following month unless otherwise specified by the State, all pertinent data as defined by the State regarding all services offered, and all family planning clients served, by its program during the preceding month, submitted through the Family Planning data system. This data shall be verified on a quarterly basis to help assure • accuracy. Contractor also agrees to respond to other data requests required by the program. 6. In addition to the submission of specified reports in accordance with Additional Provisions of this Task Order Contract, Contractor shall provide the State with the semi - annual Family Planning Expenditure/Revenue Reports. This document is located at: http: / /www.cdphe. state. co. us /pp/ womens /FPNursingConsntsForms.html ?colt =open, under the "Fiscal Forms" tab under the "Expenditure Revenue Report" topic towards the middle. 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 the State. 7. Contractor shall refer families participating in any and all programs in its agency such as the Special Supplemental Program for Women, Infants and Children (WIC), Early and Periodic Screening, Diagnosis and Treatment (EPSDT), Immunization Clinics, Health Care Program for Children with Special Health Care Needs (HCP), Prenatal Plus (PNP), etc. to appropriate enabling and direct care service programs in the community. Contractor shall provide all pregnant women in need of resources for prenatal medical care information about programs such as WIC, PNP, etc. as needed and shall ensure that children ages birth through two years who may be eligible for early intervention services are referred to Early Intervention Colorado. 8. Contractor shall participate in meetings or trainings as requested by the State. 9. 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. HI. Personnel: Contractor shall follow personnel requirements as specified in most recent CDPHE FPP nursing and administrative manuals. Professional health care providers must be in compliance with State and Federal licensing requirements and regulations. IV. Monitoring: 1. 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. 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 CDPHE Family Planning website at http: / /www.cdphe. state. co. us /pp/ womens /FPNursingPolicies.html ?col2 =open 2. If necessary, the Contractor shall comply with all recommendations, including development and implementation of a Performance Improvement Plan, made by the State's family planning program consultants and /or administrators after a periodic site visit, data review, fiscal review or other evaluations that are necessary to bring its program into compliance with all program requirements and 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 Page 2 of 3 Exhibit B-Staternent of Work V 1/MAR2012 EXHIBIT B 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 this Task Order Contract without liability if it has solely determined that Contractor's noncompliance places the health, safety or welfare of persons receiving services in jeopardy. 3. CDPHE's monitoring of this Task Order Contract for compliance with performance requirements will be conducted throughout the contract period by the Program's Manager. Methods used will include review of documentation reflective of performance to include progress reports, site visits, surveys, cost reimbursements and electronic data. The Contractor's performance will be evaluated at set intervals and communicated to Contractor. A Final Contractor Performance Evaluation will be conducted at the end of the life of this Task Order Contract. V. Resolution of Non - Compliance: The Contractor will be notified in writing within thirty (30) calendar days of discovery of a compliance issue. Within sixty (60) calendar days of discovery, the Contractor and the State will collaborate, when appropriate, to determine the action(s) necessary to rectify the compliance issue and determine when the action(s) must be completed. The action(s) and time line for completion will be documented in writing and agreed to by both parties. If extenuating circumstances arise that requires an extension to the time line, the Contractor must email a request to the Program Manager and receive approval for a new due date. The State will oversee the completion /implementation of the action(s) to ensure time lines are met and the issue(s) is resolved. If the Contractor demonstrates inaction or disregard for the agreed upon compliance resolution plan, the State may exercise its rights under the Remedies section of the General Provisions of this Task Order Contract. Page 3 of 3 Exhibit B- Statement of Work V l/MAR2012 FAMILY PLANNING AND COLORADO FP INITIATIVE BUDGET APPLICATION WORKSHEET APPLICANT:; Eagle County Public Health Agency Exhibit C i Federal Title X June 30, 2012 - June 29, 2013 FOR THE BUDGET PERIOD: I State Title X July 1, 2012 - June 29, 2013 CFPI July 1, 2012 - June 30, 2013 Salary % Time CDPHE -WHU CDPHE -WHU NON -CDPHE TOTALS SEE ABOVE Family Planning Program FOR BUDGET JULY 1, 2012 - JUNE 30, 2012 - Funding JULY 1, PLEASE ROUND ALL FIGURES PERIODS BY JUNE 30, 2013 2012 -JUNE 30, JUNE 30, 2013 TO THE NEAREST DOLLAR GRANT 2013 FTE FEDERAL & CFPI NON- CDPIIE CDPHE PLUS STATE TITLE X NON -CDPHE 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) $0 Ann Curtis, CNM $56,160 100% $37,375 $8,204 $10,581 $56,160 Taneshia Lozano, Program Assistant $37,440 70% $26,208 $26,208 Jennie Wahrer, Nurse Manager $85,010 15% $ 12,751 $12,751 Sub -total Salary Expenses $37,375 $8,204 $49,540 $95,119 Fringe Benefit Rate and Expenses $28,543 $28,543 Total Personnel Expenses $37,375 $8,204 $78,083 $123,662 CONTRACTUAL: (Independent contractor for tubal ligation, Essure, vasectomy, physicians, nurse practitioners, etc.In CFPI portion ONLY, add referral fee in this section. $0 16 Vasectomies x $675 each I $10,800 $10,800 Medical Officer Oversight $2,700 $2,700 Pharmacy Consulation j j 52,000 $2,000 Total Contractual Expenses $0 $10,800 $4,700 $15,500 OPERATING: $0 'Contraceptive Methods(for CFPI portion ONLY, 10% admin fee can be included in this line.) $10,497 $2,000 $12,497 Training costs - which includes registration fees, travel I $1,000 $1,000 iChlamydiatests $1,000 $1,000 Other Lab tests $6,500 $6,500 ( Educational materials (brochures, etc) $160 $160 Clinical supplies (prescript pads, postage) $120 $120 ; Office operating supplies (papers, charts, pens, etc) j $650 $650 .Office expense (rent, utilities, maintenance)(bankfew for credit card tx) $504 $504 ;OTHER (Specify): Liability Insurance for CNM & license renewal $765 $765 I i I $0 $0 Total Operating Expenses $0 $11,497 $11,699 $23,196 EQUIPMENT: (Computers, Office furnitures) $0 $0 $0 Total Equipment Expenses 50 $0 $0 $0 TOTAL DIRECT EXPENSES $37,375 $30,501 $94,482 $162,358 INDIRECT: Indirect rate: Indirect Expense $0 ADMINISTRATIVE (I0% CFPI Sustainability Grant. Do NOT calculate the 10% admin rate on one -time expencs, contraceptive methods, training, or contractors for tubals, Essurc, vasectomy, etc) $0 ONE -TIME EXPENSE (For CFPI Sustainability Grant only) ill=11 $0 TOTAL AMOUNT REQUESTED $37,375 $30,501 $94,482 $162,358 i Yellow cells are not included in the CFPI admin fee calculation. I 1 Page 1 of 2 Exhibit C BUDGET NARRATIVE FY13 CFPI Methods, Training and Sustainability APPLICANT: Eagle County Public Health Agency FOR THE PERIOD: July 1, 2012 - June 30, 2013 For Personnel category list title of position Relationship to project How is the total amount required Total For all other categories list the line calculated? item from the budget PERSONNEL EXPENSES: $8,204.00 Annual salary of $93,600 x 60% _ 0.6 fte Title X Clincian Provider (100% time $56,160. $8,204 of sustainability Ann Curtis, CNM is in Title X) funds applied to salary. $8,204.00 CONTRACTUAL SERVICES: $10,800.00 Vasectom Signed contract with Eagle Care Clinic and Contract for 8 vasectomies @ $675 y Northstar Urology. each $5,400.00 Vasectom Signed contract with Mountain Family Health Contract for 8 vasectomies @ $675 y _Center. each $5,400.00 OPERATING EXPENSES: $11,497.00 Includes Mirena, ParaGuard, NuvaRing, and Nexplanon, shipping costs, and a 10% admin LARC Contraceptive Methods fee limited to the costs of ordering, Based on previous use. $10,497.00 maintaining inventory and stocking. 3 staff x annual FP training Hotel x 3 nights x $ 150 = $450 Training Costs Includes registration fees, meals, hotel and 300 miles (Denver) x 0.555 = $167 travel. ( ) $1,000.00 Meals x 3 x $70 per diem = $210 Fees = $173 ADMINISTRATIVE EXPENSES: ONE -TIME EXPENSES: $0.00 None 1 Total Project Costs: $30,501.00 Page 2 of 2