HomeMy WebLinkAboutC13-120 CO Department of Public Health and Environment DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
ROUTING NO. 13 FLA 55317
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
Department of Public Health and (a political subdivision of the state of Colorado)
Environment 500 Broadway
Prevention Services Division Eagle, Colorado 81631 -0850
4300 Cherry Creek Drive South for the use and benefit of the
Denver, Colorado 80246 Eagle County Public Health Agency
551 Broadway
Eagle, Colorado 81631
TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE:
4/23/2013 Colorado Political Subdivision
PO /SC ENCUMBRANCE NUMBER
PO FLA PSD1355317
TERM: BILLING STATEMENTS RECEIVED:
This Task Order shall be effective upon Monthly
approval by the State Controller, or designee,
or on 06/30/2013, whichever is later. The STATUTORY AUTHORITY:
Task Order shall end on 06/30/2014. Not Applicable
PRICE STRUCTURE: CONTRACT PRICE NOT TO EXCEED:
Cost Reimbursement $50,021.00
PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS: $ 26,562.00
Exempt STATE FUNDING DOLLARS: $ 11,353.00
PRIVATE FUNDING DOLLARS $ 12,106.00
BID/RFP /LIST PRICE AGREEMENT NUMBER MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR
Not Applicable FY 14: $50,021.00
LAW SPECIFIED VENDOR STATUTE:
Not Applicable
STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE:
Greta Klingler or Jody Camp Jennie Wahrer
Department of Public Health And Environment Eagle County Public Health Agency
PSD -FPP PO Box 660
4300 Cherry Creek Drive South Eagle, Colorado 81631
Denver, Colorado 80246
SCOPE OF WORK
Contractor shall provide services for the Colorado Family Planning Initiative (CFPI) and the Family
Planning Program (FPP).
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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 (and its attachments if any — e.g., C -1, C -2, etc.)
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. hi 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 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
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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" and "Exhibit C ".
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
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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 fmal 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
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4
prohibit Contractor from bidding on future contracts. Contractor may contest the fmal 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.
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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 STATE OF COLORADO:
John W. Hickenlooper, GOVERNOR
Board of County Commissioners of Eagle
County (a political subdivision of the state of
Colorado)
for the use and benefit of the
Eagle County Public Health Agency
Legal Name of Contracting Entity
/•, For Executive Director
411kc I! � Department of Public I3eakb and Environment
Si - I f Authorized Officer
• 4ThV
Print Name of Authorized Officd
`A /�� �/ 1':��M ' A,� Department Program Approval:
lJ� 1 1 'C 1 \ 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
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EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 04/23/2013 - Contract Routing Number 13 FLA 55317
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 state, private, and federal funds (see Catalog of Federal Domestic
Assistance (CFDA) number 93.217).
3. The United State Department of * * * * * * * * ** ( "US * * * * "), through the * * * * * * * * ** ( " * * * ") has awarded
federal funds under Award number * * * * * * * * * *, hereinafter "Award ", to perform the following —
* * * * * * * * * **
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.
4. Notwithstanding the terms contained m General Provisions of the Master Contract, Section 27, Annual
Audit, for the purpose of this Task Order, the Contractor is a Vendor as defined by Office of Management
and Budget (OMB) Circular A -133 (Audits of States, Local Govemments, and Non -Profit Organizations).
5. 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 intemet website
http: / /www.colorado.gov /cs/ Satellite /CDPHE- Main/CBON/1251622941228 and is incorporated herein by
reference. 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.
All completed CDPHE Reimbursement Invoice Forms and signature sheets should be PDF'd into one
document. Email completed forms to:
cdphe.pswomenshealth@state.co.us
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 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 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.
To be attached to CDPHE Page 1 of 4 Revised: 12/19/06
Task Order v1.0 (3/12) contract template
EXHIBIT A
Sliding Fee Scale: 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
and is approved by the State. These charges and the sliding fee scale shall be made available to all clients
of the Contractor, the general public, and the State. This document is incorporated and made part of this
SOW by reference and is available on the following website:
http: / /www.colorado.gov /cs/ Satellite /CDPHE- PSD/CBON/1251618366665 under fiscal forms. The content
of electronic documents located on CDPHE and non -CDPHE websites and information contained on
CDPHE and non - CDPHE websites may be updated periodically during the contract term. CDPHE will
notify the contractor of all updates. The Contractor shall comply with all updates. 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.
Fiscal and Spending Contract Award: It is important that accurate expenses are reflected in each contract
budget. The Contractor must spend the entire awarded and budgeted amount for services identified in the
annual approved project budget. Failure to provide projected services, submit invoices in a timely manner,
and/or failure to spend the award at a rate that results in the full award being expended at the end of the
program year may result in reduced funds the following year and/or lack of eligibility for mid -year and
other additional funding opportunities.
6. Time Limit For Acceptance Of Deliverables.
a. Evaluation Period. The State shall have thirty (30) calendar days from the date a deliverable is
delivered to the State by the Contractor to evaluate that deliverable, except for those deliverables
that have a different time negotiated by the State and the Contractor.
b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design
specifications for that particular deliverable, or is otherwise deficient, then the State shall notify
the Contractor of the failure or deficiencies, in writing, within thirty (30) calendar days of: 1) the
date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or
deficiency at the time of delivery; or 2) the date the State becomes aware of the failure or
deficiency. The above time frame shall apply to all deliverables except for those deliverables that
have a different time negotiated by the State and the Contractor in writing pursuant to the State's
fiscal rules.
c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed
deliverable, the Contractor shall have a reasonable period of time, not to exceed ten (10) calendar
days, to correct the noted deficiencies. If the Contractor fails to correct such deficiencies within
ten (10) calendar days, the Contractor shall be in default of its obligations under this Task Order
Contract and the State, at its option, may elect to terminate this Task Order Contract or the Master
Contract and all Task Order Contracts entered into pursuant to the Master Contract.
7. 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_
8. 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 twenty-five percent (25 %) of the total
budget. Contractor shall submit a Budget Revision Request Form to request prior approval for all budget
modifications in excess of twenty -five percent (25 %) of the total budget. The Budget Revision Request
Form is incorporated herein by reference and is located at http: / /www.colorado.gov /cs /Satellite /CDPHE-
PSD/CBON/1251618366665 under Fiscal Forms tab. Any request for modification to the Budget in excess
of twenty-five percent (25 %) of the total budget or $250,000.00, whichever is less, shall be submitted to the
To be attached to CDPHE Page 2 a4 Revised: 12/19/06
Task Order v1.0 (3/12) contract template
EXHIBIT A
State at least 90 days prior to the end of the contract period and may require an amendment in accordance
with Section 5 of this Task Order Contract.
9. 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 Task Order 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).
If the State receives new poverty guidelines during the term of this Task Order Contract, then the State will
immediately notify the Contractor. The Contractor shall use these new poverty guidelines, if any, upon
receipt of notification thereof from the State.
10. All money received by the Contractor from the State under this Task Order Contract shall be used by the
Contractor to provide contraceptive services to qualified family planning clients.
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
developed forms. Forms are incorporated herein by reference and located on
http: / /www.colorado.gov /cs/ Satellite /CDPHE- PSD/CBON/1251618366665 under Administrative Forms
tab.
12. 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.
13. 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.
To be attached to CDPHE Page 3 of 4 Revised: 12/19/06
Task Order v1.0 (3/12) contract template
EXHIBIT A
14. 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.
15. 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.
16. 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.
17. 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 4 of 4 Revised: 12/19/06
Task Order v1.0 (3/12) contract template
a
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 Matemal 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
CCIAA Colorado Clean Indoor Air Act
CCMC Colorado Clinical Managed Care Network
CCMC Commission for Case Manager Certification
CCPD Cancer, Cardiovascular, and Pulmonary Disease
Page 1 of 6
•
Attachment A -1
CCTCI Colorado Chew Tobacco Collaborative Initiative
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
CRC Colorectal Cancer
CRCCP Colorectal Cancer Screening Program
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 Home Visiting to Prevent Child Maltreatment Grant Program
ECC Early childhood council
ECC Electrocardiogram
ECCLC Early Childhood Council of Larimer County
Page 2 of 6
Attachment A -1
ECLC Early Childhood Leadership Council/Commission
E.D. Executive Director
EHR Electronic Health Record
EHS Early Head Start
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
FIT/FOBT Fecal Immunochemical Test/Fecal Occult Blood Test
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 Vino
HPV Human Papillomamavirus
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 Latins 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
Page 3 of 6
Attachment A -1
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
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
NCCRT National Colorectal Cancer Round Table
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 -O -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
Page 4 of 6
Attachment A- 1
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
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
Page 5 of 6
a
Attachment A -1
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
TDG Tobacco Disparities Grant
TDS Tobacco Disparities Subcommittee
TEACH Teaching Equity to Advance Community Health
TEFAP The Emergency Food Assistance Program
TEPCGP Tobacco Education Prevention and Cessation Grant 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 Titre 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
URL Uniform Resource Locator
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: I State Fiscal Year: 1 Grant Funding Change Letter # 1 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 ❑ 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 Dated 04/23/2013 - Contract Routing Number 13 FLA 55317
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract
specified above.
Project Description:
The goal of the Colorado Family Planning Initiative (CFPI) and The Colorado Department of Public Health
Family Planning Program (FPP) is to reduce unintended pregnancy by insuring access to quality reproductive
health services to all Coloradoans. Services include but are not limited to contraceptive, preventative health
counseling and education services, reproductive health related testing and screening and referrals. Contractor shall
conduct a comprehensive family planning program, herein referred to as "the program ". 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).
Funding is based on the number of clients served. The goal for the number of clients served annually is outlined in
the associated Budget attached hereto as Exhibit C and incorporated herein.
Project Term: June 30, 2013 -June 30, 2014
II. Performance Requirements/Deliverables:
1. The Contractor shall:
a. Provide comprehensive family planning services to sustain the total number of qualifying family planning
clients served in the previous calendar year (fertile clients receiving contraceptive services).
b. Provide outreach services and/or other program efforts designed to improve client recruitment;
c. Supply 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, specifically
the Health Service and Connections Branch ;
d. Supply contraceptive information, education, and supplies regarding all family planning methods;
e. Provide 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;
f. Follow -up and/or provide referral services, as appropriate.
g. Purchase long acting reversible methods of contraception. These are limited to Intrauterine Devices (IUD)
Mirena and Paraguard, and contraceptive implants.
h. Provide the referral process and cover the actual costs of tubal ligation and vasectomy procedures.
i. Notwithstanding the foregoing, under no circumstances shall private funding be used to purchase any pills,
patches, Depo - Provera injections, condoms, or emergency contraceptive.
Page 1 of 3
Exhibit B- Statement of Work
V1/MAR2012
4
EXHIBIT B
2. Guidelines and Manuals: 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 CFPI, Title X regulations,
CDPHE FPP nursing- medical policies and procedures, and any applicable fiscal or administrative policies of the
State or Federal government. This document is incorporated and made part of this SOW by reference and is
available on the following website: http: / /www.colorado.gov /cs/ Satellite /CDPHE- PSD/CBON/1251618366665.
The content of electronic documents located on CDPHE and non -CDPHE websites and information contained on
CDPHE and non -CDPHE websites may be updated periodically during the contract term. CDPHE will notify the
contractor of all updates. The Contractor shall comply with all updates. Contractor acknowledges having
reviewed and accepted 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: CFPI requirements, 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, CDPHE 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. Data Submission: 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 document is incorporated and made part of this SOW by
reference and is available on the following website: http: / /www.colorado.gov /cs/Satellite /CDPHE-
PSD/CBON/1251618366665 under Title X Administrative Manual section. Contractor also agrees to respond to
other data requests required by the program.
5. Reporting:
a. Within thirty (30) calendar days of receipt of a written request from the State, the Contractor shall submit
nursing- medical chart audits, client satisfaction surveys, Full Time Equivalent (FTE) reports and other
documentation required for the Family Planning Annual Report (FPAR) to the State.
b. Expenditure Revenue Reports: Contractor shall provide the State with the semi - annual Family Planning
Expenditure/Revenue Reports. The first report is for the months of July through December (due January
31 annually); the second report is for the months of January through June (due July 30 annually). The
Expenditure/Revenue Report form is incorporated and made part of this SOW by reference and is
available on the following website: http://www.colorado.gov/cs/Satellite/CDPHE-
PSD/CBON/1251618366665 under Fiscal Forms section.
c. Progress Report: Contractor shall participate in state -level evaluation efforts as requested by the State
including, but not limited to, progress reports on the implementation and accomplishments of the
approved Work Plan in a format provided by the State. Progress reports shall be due in January 31
annually (for activity July- December) and July 30 annually (for activity January- June).
Failure to submit acceptable reports by the due date may result in a delay or denial of the reimbursement
request.
•
6. Laboratory: Contractor shall either use a cytology laboratory chosen by the State or, a laboratory proposed by the
Contractor and approved by the State.
7. Referral: 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
Page 2 of 3
Exhibit B- Statement of Work
V 1/MAR2012
EXHIBIT B
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. Meetings: Contractor shall participate in meetings or trainings as requested by the State.
9. Staffmg: Contractor shall require any new family planning coordinator or fiscal staff working on Family Planning
Program services to participate in Program and Fiscal Orientation within forty-five (45) days of employment.
III. 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. This document is incorporated and made part of this SOW by reference and is
available on the following website: http: / /www.colorado.gov /cs/ Satellite /CDPHE- PSD/CBON/1251618366665
Data Coordinator: 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.
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.
IV. Monitoring
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted throughout
the contract period by the FPP Unit Manager. Methods used will include review of documentation reflective of
performance including progress reports and other documentation as applicable. The Contractor's performance will
be evaluated at set intervals and communicated to the contractor. A Final Contractor Performance Evaluation will
be conducted at the end of the life of the contract.
VI. Resolution of Non - Compliance
The Contractor will be notified in writing within 30 calendar days of discovery of a compliance issue.
Within 45 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 family planning unit manager and receive approval for a new due date. The State will oversee the
completion/impleinentation 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 contract.
Page3of3
Exhibit B- Statement of Work
V 1/MAR2012
s r
Exhibit C
c.
Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
• Contract Routing # 13 FLA 55317
Colorado Department
of Public Health
and Environment
Program Contact Name, Title, Jennie Wahrer, Maternal & Child Health
Contractor Name Board of County Commissioners of Eagle County Phone and Email Manager, Public Health, 970- 328 -2604,
jennie.wahrer @eaglecounty.us
Fiscal Contact Name, Title, Wendi Gill, Fiscal & Operations Program
Budget Period 6/30/13 - 6/30/14 Phone and Email Support Technician, 970- 328 -8804,
wendi.gill@eaglecounty.us
Project Name Eagle County Public Health Family Planning Number of Target Clients (19 -years and younger, 150% FPL or below) to be
Program served in 2013 -2014: 506
Total
Match or In-
Amount
Expenditure Categories Kind (If
Applicable) Requested
from CDPHE
Gross or Percent of
Personal Services Fringe FTE on
Annual Salary
Prniart
List SOW
Description of Work objective /activity
(for hourly employees, please include the hourly number(s) this
Position Title /Employee rate and number of hours in your description). budget item
Name Include If of months budgeted. supports
Provides the health needs of family planning
Ann Curtis, CNM clients, $46.35/hr x 24 hr x 52 weeks = $57,845 $57,844.80 $ 5,031 100.00% $24,960.80 $37,915.00
Taneshia Lozano, Medical Assists CNM during clinic hours, provides follow -up
Assistant outside clinic hours, $18.54 x 28 hr x 52 weeks $38,563.20 $16,870.00 70.00% $38,803.24 $0.00
Jennie Wahrer, MCH Provides program administration, $40.87 x 4hr x 52
Manager weeks $85,009.60 $26,200.00 10.00% $11,120.96 $0.00
Wendi Gill, Fiscal &
Operations Program Invoices, submits & tracks bills, etc. , $21.50 x lhr x
Support Technician 52 weeks $44,720.00 $21,912.00 2.30% $1,532.54 $0.00
Total Personal Services
(including fringe benefits) $226,137.60 $70,013.00 1.82
$76,417.54 $37,915.00
Supplies & Operating Expenses
List SOW
objective /activit
y number(s) this Match or In Total Amount
budget item kind (if Requested from
Item Description of Item supports Rate Quantity applicable) CDPHE
Contraceptive methods birth control pills, condoms 600.00 4 $2,400 $0.00
CFPI LARC methods Nexplanon - $325 each x 29 325.00 29 $9,425.00
Training Registration fee for 1 national training $500 $0.00
Lab tests annual projection for lab fees, includes Chlamydia $7,500 $0.00
Outreach advertising, educational materials (brochures, etc) $160 $0.00
table paper, gloves, speculums, capes, autoclave
Clinical Supplies supplies, etc. 200.00 12
$2,400 $0.00
Office operating supplies medical instrument replacement cost $750 $0.00
Data processing service Ahlers annual fee
$650 $0.00
Bank Fees projected fees for credit card use in billing clients $504 $0.00
Biomedical waste Disposal of biomedical waste - $100 /month x 12 mo 100.00 12 $1,200 $0.00
RN License renewal for CNM - required $160 $0.00
Malpractice Insurance for CNM - required $650 $0.00
Total Supplies
& Operating Expenses $16,874 $9,425.00
Page 1 of 3
I .. d
Exhibit C
4i . Colorado Department of Public Health and Environment
4 Mk
-j . PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
' ' Contract Routing # 13 FLA 55317
Colorado Department
of Public Health
and Environment
Program Contact Name, Title, Jennie Wahrer, Maternal & Child Health
Contractor Name Board of County Commissioners of Eagle County Manager, Public Health, 970 - 328 -2604,
Phone and Email
jennie.wahrer @eaglecounty.us
Fiscal Contact Name, Title, Wendi Gill, Fiscal & Operations Program
Budget Period 6/30/13 - 6/30/14 Phone and Email Support Technician, 970- 328 -8804,
wendi.gill@eaglecountv.us
Eagle County Public Health Family Planning Number of Target Clients (19-years and younger, 150% FPI or below
Project Name g ( Y Y g below) to be
Program served in 2013 -2014: 506
Travel
List SOW
objective /activit
Item y number(s) this Match or In Total Amount
budget item kind (if Requested from
Description of Item supports Rate Quantity applicable) CDPHE
site visit to Eagle Care Clinic to review contract compliance and
outreach. Quarterly round trip will average 42 miles, reimbursement at
Mileage $.565 /mile.
0.565 168 $95 50.00
Meals based on county government daily rate for 3 staff for annual FP
Meals training (1 day). $70 /per person /trip; 3 staff 70 3 $210 $0.00
Lodging 150 hotel rate /night; 3 people (2 rooms) 150 2 5300 $0.00
2 Trainings /year for 3 staff, 1 vehicle, RT average 300, reimbursement
Mileage rate = $.565 /mile 0.565 600 $339 50.00
Total Travel
$944 $0.00
Contractual (payments to third parties or entities)
List SOW
objective / activit
Item y number(s) this Match or In Total Amount
budget item kind (if Requested from
Subcontractor Entity Name and /or Description of Item. supports Rate Quantity applicable) CDPHE
CFPI - Vasectomies Eagle Care Clinic will provide 4 vasectomies @ $675 each 675 4 $19 52,681.00
Pharmacy Consult Pharmacy oversight - 4 monitoring visits /yr x $250 each 250 4 $1,000
Medical Director Clinical Supervision of program and staff @ $225 /month x 12 mo 225 12 $2,700 $0.00
Total Contractual
$3,719 52,681.00
SUB -TOTAL BEFORE INDIRECT
550,021.00
Page 2 of 3
9
Exhibit C
h
° ``t. Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
' ,1,1 t i6' Contract Routing # 13 FLA 55317
Colorado Department
of Public f fcalth
and Eneiroo ncnl
Program Contact Name, Title, Jennie Wahrer, Maternal &Child Health
Contractor Name Board of County Commissioners of Eagle County Manager, Public Health, 970- 328 -2604,
Phone and Email
jennie.wahrer(n)eaglecounty.us
Fiscal Contact Name, Title, Wendi Gill, Fiscal & Operations Program
Budget Period 6/30/13 - 6/30/14 Support Technician, 970- 328 -8804,
Phone and Email
wendi.gi llPeaglecou nty.us
Project Name Eagle County Public Health Family Planning Number of Target Clients (19 -years and younger, 150% FPL or below) to be
Program served in 2013 -2014: 506
Indirect
Match or In Total Amount
Item Description of Item (description is not necessary for the negotiated rate agreement) kind (if Requested from
applicable) CDPHE
Negotiated Indirect cost —
rate (Federal or CDPHE) 50.00 $0.00
Indirect (other): please list
specific indirect costs in
description if no rate exists
— $0.00 50.00
Indirect (other): Modified
budget item rate, if
applicable
$0.00 $0.00
Total Indirect $o.00_ $o.00_
TOTAL MATCH OR IN KIND $97,954
TOTAL $50,021.00
Page 3 of 3
