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HomeMy WebLinkAboutC14-218 Colorado Department of Public Health and Environment (15-67517) DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
PSD-STEPP
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
15-67517
AMENDMENT FOR TASK ORDERS#3
This Amendment is made this 18th day of April,2014,by and between the State of Colorado,acting by and through
the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place of
business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as the"State";and,
BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY,(a political subdivision of the State of
Colorado),500 Broadway,Eagle,Colorado 81631-0850,for the use and benefit of the Eagle County Public
Health Agency,whose address or principal place of business is 551 Broadway,Eagle,Colorado 81631,
hereinafter referred to as the"Contractor".
FACTUAL RECITALS
The parties entered into a Master Contract,dated January 17,2012,with contract routing number 13 FAA 00016.
Pursuant to the terms and conditions of the Master Contract,the parties entered into a Task Order Contract,dated
August 31,2012,with contract encumbrance number PO FLA PPG1348290,and contract routing number 13 FLA
48290,as amended by Contract Amendment#1,Contract Routing Number 14 FLA 55276,Contract
Amendment#2 and Contract Routing Number 14 FLA 58645, collectively referred to herein as the"Original
Task Order Contract,whereby the Contractor was to provide to the State the following:
To increase tobacco cessation,reduce initiation of tobacco use,decrease tobacco prevalence
among youth and decrease exposure to secondhand smoke.
The State promises to increase the amount of funds to be paid to the Contractor by One Hundred and Thirty-
Eight Thousand,Two Hundred and Fifty Dollars,($138,250.00)for the renewal term of one year,ending on
June 30,2015,in exchange for the promise of the Contractor to perform the increased work described herein.
NOW THEREFORE,in consideration of their mutual promises to each other, stated below,the parties hereto agree
as follows:
1. Consideration for this Amendment to the Original Task Order Contract consists of the payments and
services that shall be made pursuant to this Amendment,and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order
Contract,contract routing number 13 FLA 48290,as amended by Contract Amendment#1,Contract
Routing Number 14 FLA 55276 and Contract Amendment#2,Contract Routing Number 14 FLA
58645,collectively referred to herein as the Original Contract,which is by this reference incorporated
herein. All terms,conditions,and provisions thereof,unless specifically modified herein,are to apply to
this Amendment as though they were expressly rewritten,incorporated,and included herein.
3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified,
altered,and changed in the following respects only:
A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified
by contract routing number 13 FLA 48290. This Amendment is for the renewal term of July 1,
2014,through and including June 30,2015. The maximum amount payable by the State for the
Amendment Task Order_083010 Page 1 of 5
C -216
work to be performed by the Contractor during this renewal term is One Hundred and Thirty-
Eight Thousand,Two Hundred and Fifty Dollars,($138,250.00)for an amended total financial
obligation of the State of THREE HUNDRED AND EIGHTY-ONE THOUSAND,EIGHTY-
TWODOLLARS,($381,082.00). This is an increase of One Hundred and Thirty-Eight
Thousand,Two Hundred and Fifty Dollars,($138,250.00)of the amount payable from the
previous term. The revised Additional Provisions are incorporated herein by this reference and
identified as"Exhibit G".The revised Statement of Work is incorporated herein by this
reference and identified as"Exhibit H". The revised Budget is incorporated herein by this
reference and identified as"Exhibit I".
The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original
Task Order Contract are reaffirmed
4. The effective date of this Amendment is July 1,2014,or upon approval of the State Controller,or an
authorized delegate thereof,whichever is later.
5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General
Provisions of the Original Task Order Contract,in the event of any conflict,inconsistency,variance,or
contradiction between the terms and provisions of this Amendment and any of the terms and provisions of
the Original Task Order Contract,the terms and provisions of this Amendment shall in all respects
supersede,govern,and control. The Special Provisions and other terms and conditions of the Master
Contract shall always control over other provisions of the Original Task Order Contract or any subsequent
amendments thereto. The representations in the Special Provisions to the Master Contract concerning the
absence of personal interest of state of Colorado employees and the certifications in the Special Provisions
relating to illegal aliens are presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR
ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED,BUDGETED,
AND OTHERWISE MADE AVAILABLE.
Amendrnent_TaskOrder 083010 Page 2 of 5
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Amendment Task Order 083010 Page 3 of 5
IN WITNESS WHEREOF,the parties hereto have executed this Amendment on the day first above written.
*Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE:
BOARD OF COUNTY COMMISSIONERS OF STATE OF COLORADO
EAGLE COUNTY(a political subdivision of the John W.Hickenlooper,Governor
State of Colorado)for the use and benefit of the
Eagle County Public Health Agency
/ 0
i i' .-L ./1. L— By:
ignature of Authorize Officer For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
i/� ?r / AND ENVIRONMENT
Print Name of Authorized Of cer
lYtilL441(Y, 61)
Print Title of Authorized Officer
PROGRAM APPROVAL:
By:
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Contracts.This Contract is not valid until
signed and dated below by the State Controller or delegate.Contractor is not authorized to begin
performance until such time.If Contractor begins performing prior thereto,the State of Colorado is not
obligated to pay Contractor for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER
Robert Jaros,CPA,MBA,JD
By:
Date:
Amendment Task Order_083010 Page 4 of 5
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Amendment Task Order_083010 Page 5 of 5
EXHIBIT G
ADDITIONAL PROVISIONS
To Task Order Contract Dated 08/31/2012-Contract Routing Number 13 FLA 48290
Contract Amendment Routing Number 15 FLA 67517
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order
Contract specified above.
1. This Task Order Contract contains state funds.
2. To receive compensation under the 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 and made
part of this Task Order Contract by reference. CDPHE will provide technical assistance in accessing and
completing the form. The CDPHE Reimbursement Invoice Form and Expenditure Details page must be
submitted no later than forty-five(45)calendar days after the end of the billing period for which services
were rendered. Expenditures shall be in accordance with this Statement of Work and Budget.
Scan the completed and signed CDPHE Reimbursement Invoice Form into an electronic document. Email
the scanned invoice and Expenditure Details page to: Tobacco Program Generalist at
cdphe stepp pg@,,state.co.us
Final billings under the Task Order Contract must be received by the State within a reasonable time after
the expiration or termination of the Task Order Contract;but in any event no later than forty-five(45)
calendar days from the effective expiration or termination date of the Task Order Contract.
Unless otherwise provided for in the Task Order Contract,"Local Match",if any, shall be included on all
invoices as required by funding source.
The Contractor shall not use state funds to satisfy federal cost sharing and matching requirements unless
approved in writing by CDPHE.
3. 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 thirty(30)
calendar days,to correct the noted deficiencies. If the Contractor fails to correct such deficiencies
within thirty(30)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.
To be attached to CDPHE Page 1 of 3 Revised: 12/19/06
Task Order v1.0(3/12)contact template
EXHIBIT G
4. Health Insurance n e 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 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 direct costs in excess of twenty-five percent(25%)of the
total budget for direct costs. Any request for modifications to the Budget in excess of twenty-five percent
(25%)of the total budget for direct costs or$250,000.00,whichever is less,shall be submitted to the State
at least 90 days prior to the end of the contract period and may require an amendment in accordance with
General Provisions, Section 5,of this Task Order Contract.
6. If Contractor indicates full expenditure of funds under this Task Order Contract by March 1 of each grant
year and the full expenditure does not occur,CDPHE has the option to reduce current or upcoming Task
Order Contract by said amount or a percent deemed reasonable by CDPHE.The State will notify the
Contractor of the potential need to decrease the current or upcoming budget. If the Contractor indicates at a
later date than March 1 of each grant year an expectation of surplus of funds or inability to fully expend said
funds for unforeseen circumstances that Contractor had not anticipated byMarch 1,CDPHE will reallocate
unspent funds without any penalties to the Contractor.
Upon receipt of timely written notice of an objection by the State for inability to fully expend funds,the
Contractor shall have a reasonable period of time not to exceed ten(10)calendar days to respond to the
action. If no dispute is received by the State within ten(10)calendar days,the State has the option to
reduce the current budget for the current year and any upcoming budget for future contractual agreements.
7. 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.
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,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 2 of 3 Revised: 12/19/06
Task Order v1.0(3/12)contract template
EXHIBIT G
9. Funds provided under this Task Order Contract may not be used to:supplant funding for any existing
programs/models;develop new cessation programs/models;develop curricula for youth or adults not
reviewed and approved by the State;pay for-individual cessation aids or nicotine replacement therapy;fund
capital improvements;or fund costs of enforcement of state or local laws and ordinances.
10. The Contractor affirms that it maintains no affiliations or contractual relationships,direct or indirect,with
tobacco companies,owners,affiliate,subsidiaries,holding companies or companies involved in any way in
the production,processing,distribution,promotion,sales,or use of tobacco.
11. The State of Colorado,specifically the Colorado Department of Public Health and Environment,shall be
the owner of all equipment as defined by Federal Accounting Standards Advisory Board(FASAB)
Generally Accepted Accounting Principles(GAAP)purchased under this Task Order Contract. At the end
of the term of this Task Order Contract,the State shall approve the disposition of all equipment.
12. The Contractor shall not use funds provided under this Task Order Contract for the purpose of lobbying as
defined in Colorado Revised Statutes(C.R. S.)24-6-301(3.5)(a).
13. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding
Letter substantially equivalent to Attachment G-1.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 G-1
GRANT FUNDING CHANGE LETTER
Date: State Fiscal Year: Grant Funding Change Letter# I 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), renewals; 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 McGovern, Purchasing &Contracts Unit By:
Director
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
Robert Jaros, CPA, MBA, JD
By:
Date:
Grant_Funding_Change_Letter OSC_082509 Page 1 of 1
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Exhibit 1
C°F��`� Colorado Department of Public Health and Environment
� - PREVENTION S ERVICES DIVISION-BUDGET
,"`�"� Contract Routing# 15 FLA 67517
Colorado Department
of Public Health
and Environment
Contractor Name Program Contact Name,Title, Karen Koenemann,Project Director 970-328-2610,
Eagle County Government
Phone and Email karen.koenemann @eaglecounty.us
Budget Period 7/1/14-6/30/15 Fiscal Contact Name,Title, Wendi Gill,Fiscal Lead Specialist,970-328-8804,
Phone and Email Wendi.gill @eaglecounty.us
Project Name West Mountain Tobacco Program
Expenditure Categories
Personal Services
Salaried Employees
List SOW
deliverable/ Match or
primary task Gross or Percent of
Position Title/Employee Name Description of Work number(s) Fringe Time on In-Kind(If Total Amount Requested
Annual Sala
this budget Salary Required from CDPHE
Project
tern by RFA)
supports
Ms.Koenemann provides oversight of staff,
programming,and ensures fiscal responsibility of the
Project Director,Karen Koenemann budget including subcontracts. All
Fringe detail-FICA:$4,342.48 Medicare:$1,015.58 $70,040.00 $ 23,873 20% $18,782.52
County Retirement:4,202.40 Workers Comp:210.12
County Wellness:$450.00 County Insurance:$13,652
•
Collaborate with health care and dental health
providers evaluating current protocols and practices
related to patient tobacco use information and referral
systems.Train health care and dental health providers
in evidence-based model of 5 A's and AAR.Support
health care providers implement the 5 A's and AAR
model and Colorado Outline dissemination.
Collaborate with four Colorado Mountain Colleges to
Project Coordinator,TBD implement at least one tobacco cessation campaign All
and/or educational opportunity and conduct a tobacco $51,000.00 $21,216.50 100% $72,216.50
use and attitudes survey.Collaborate with County
Human Resource and Health and Human.Services to
strengthen current tobacco policies and promote
tobacco cessation and education into worksite wellness
initiatives. Fringe Detail-FICA:$3,162.00 Medicare:
$739.50 County Retirement:3,060.00 Workers Comp:
153.00 County Wellness:$450.00 County Insurance:
$13,652
Page 1 of 5
V.1 Jan 2013
Exhibit
" Colorado Department of Public Health and Environment
t' 9
4 } PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
R7ti" Contract Routing# 15 FLA 67517
Colorado Department
of Public Heath
and Environment
Program Contact Name,Title, Karen Koenemann,Project Director 970-328-2610,
Contractor Name Eagle County Government Phone and Email karen.koenemann @eaglecounty.us
Fiscal Contact Name,Title, Wendi Gill,Fiscal Lead Specialist,970-328-8804,
Budget Period 7/1/14-6/30/15 Phone and Email Wendi.gill @eaglecounty.us
Project Name West Mountain Tobacco Program
•
Ms.Carey is a public health nurse who will provide
Techincal Assistance to Eagle County Public Health
programs to ensure that all staff are following
consistent intake procedures and referals.She will
continue to work with health care providers to insure
Theresa Carey All
y they have the resources and knowledge to implement $56,135.00 $26,738.37 5% $4,143.67
their models. Fringe Detail-
FICA:$3,480.37 Medicare:5813.96 County Retirement: '
3,368.10 Workers Comp:419.95 County Wellness:
$450.00 County Insurance:$18,206.00
The fringe percentage rates will vary based on the
General Fringe Detail employee marital status for health insurance and the
wellness benefit.It may also vary depending on the
employee selected retirement%.
Personal Services
Hourly Employees
List SOW
deliverable/ Total#of Match or
primary task In-Kind(If Total Amount Requested
Position Title/Employee Name Description of Work Hourly Wage Hourly Fringe Hours on
number(s) Required from CDPHE
this budget Project by RFA)
$0
Total Personal Services
(including fringe benefits) ;0 $95,143
Supplies&Operating Expenses
List SOW
deliverable/ Match or
primary task In-Kind(If Total Amount Requested
Item Description of Item Rate Quantity
numbers) Required from CDPHE
this budget by RFA)
item supports
Conduct a tobacco use and attitudes post-survey among students on
the Aspen,Spring Valley,Rifle and Edwards Colorado Mountain
Incentives College campuses.Incentives include$5.00 starbucks gift cards and 3 $ 5.00 200 $1,000
will total 200 cards.The gift cards will be admistered eletronically to
students who have completed the electronic survey
Refreshments for Tobacco Education Groups($3 person x 10
Meeting Expenses 4 $ 30.00 8
participants x 8 meetings(4/eagle,4/pitkin)=$240.00 $240
Advertising for Colorado Quitline-1.newspaper(3 papers x 4 ads x
Media Marketin $250.00/ad=3,000 2.local buses(1 buses at$3,100=53,100)3.Radio 2 .
/ 8 ads($6.00/spot x 165 times=$990.00).Average monthly spend is $ 590.83 12 $7,090
anticiapted to equal$590.83 per month.
Page 2 of 5
V.1 Jan 2013
Exhibit 1
4';',,°` °` y, , Colorado Department of Public Health and Environment
. . : ; PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
%' ti Contract Routing# 15 FLA 67517
Colorado Department
of Public Heath
and Environment
Program Contact Name,Title, Karen Koenemann,Project Director 970-328-2610,
Contractor Name Eagle County Government
Phone and Email karen.koenemann @eaglecounty.us
Fiscal Contact Name,Title, Wendt Gill,Fiscal Lead Specialist,970-328-8804,
Budget Period 7/1/14-6/30/15 Phone and Email Wendi.gill @eaglecounty.us
Project Name West Mountain Tobacco Program
Outreach material for recruitment and education on CMC and County
Printing/Copying Human Service campuses(6 campuses x 160 copies x.10/copy). 2,4 $ 0.10 960 $96
Estimate based on historical consumption - -
Total Supplies $0
&Operating Expenses $8,426
Travel
List SOW
deliverable/ Match or
primary task In-Kind(If Total Amount Requested
Item Description of Item Rate Quantity
number(s) Required from CDPHE
this budget by RFA)
item supports
Coordinator will attend two mandatory trainings in Denver. Round
• trip is approximately 250 miles a 2 trips=(500 miles x.5lmile=
$255.00) Reimbursement at$.51/mile.Coordinator will be driving
Mileage 1,2,5 $ 0.51 5,300
400 miles/month to support activities with Health Care Providers, $2,703
Colorado Mountain College Campuses and County Public Health
organizations(400 x.51/mile x 12 months=$2,448)TOTAL:$2,703.00
•
Coordinator will attend two mandatory trainings in Denver.Meal
estimate is based on current government per diem rate for Denver
Travel day per diem reimbursement at$49.50 and full day
Meals 1,2,3,4,5 $ 231.00 2 $462
reimbursement at$66.00.Meals are not being provided during the
trainings.(We are anticipating two days of travel per diem and two
days of full per diem for each training.($231/trip x 2=$462)
Overnight stay for coordinator to attend two mandatory meetings in
o ging Denver.$149/night x 3 nights x 2 trainings 5 $ 149.00 6
$894
Parking downtown Denver for two mandatory meetings-$10/day x 6
Parking days. - 5 $ 10.00 6 $60
Total Travel $0 $4,119
Contractual
list SOW
deliverable/ Match or
primary task In-Kind(If Total Amount Requested
Subcontractor Name Description of Item Rate Quantity
number(s) Required from CDPHE
this budget by RFA)
item supports
Page 3 of
V.1 1an 2013
Exhibit
oc co.
�ti y,°�7g, Colorado Department of Public Health and Environment
PREVENTION SERVICES DIVISION-BUDGET WITH JUSTIFICATION FORM
l8?5` #
Contract Routing 15 FLA 67517
Colorado Department
of Public Heath
and Environment
Program Contact Name,Title, Karen Koenemann,Project Director 970-328-2610,
Contractor Name Eagle County Government Phone and Email karen.koenemann @eaglecounty.us
Fiscal Contact Name,Title, Wendi Gill,Fiscal Lead Specialist,970-328-8804,
Budget Period 711/14-6130/15 Phone and Email Wendi.gill @eaglecounty.us
Project Name West Mountain Tobacco Program
Garfield County Public Health will continue to monitor the
implementation of the 5A's and AAR model through check-ins with
- Garfield County Public Health clinics.Distribute quitline materials to clinics on an as need basis. 1,2 $ 30.00 96 $2 880
8hrs/month x$30.00 a 12months=$2880.00
Page 4 of 5
V.1 Jan 2013
, r
Exhibit I
---.-61:'-,C9,-<-6-
yam , Colorado Department of Public Health and Environment
�C �� • PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
`;R'?6=�' Contract Routing# 15 FLA 67517
Colorado Dopararent
of Public Health
and 1'nironrtncnt
Program Contact Name,Title, Karen Koenemann,Project Director 970-328-2610,
Contractor Name Eagle County Government
Phone and Email karen.koenemann @eaglecounty.us
Fiscal Contact Name,Title, Wendi Gill,Fiscal Lead Specialist,970-328-8804,
Budget Period 7/1/14-6/30/15 Phone and Email Wendi.gill @eaglecounty.us
•
Project Name West Mountain Tobacco Program
NASPA provide technical assistance to the tobacco coordinator.
National Association of Student Personnel
Technical Assistance&development time 6.66 hrs x$150.00= 2 $ 150.00 6,666 $1,000
Administrators(NASPA) $1,000
Pitkin Community Health Services staff will hold meetings once a
month to mobilize Pitkin County Health and Human Services to
Pitkin Community Health Services 4 $ 30.00 40 $1,200
strengthen current tobacco policies and promote quitline($30.00/hr
@ 40 hrs)
Aspen to Parachute Dental Alliance will reach out to 6 dental
providers in the community to conduct baseline analysis of current
tobacco protocols and practices and discuss the importance of
Aspen to Parachute Dental Alliance tobacco cessation and Quitline resources and referal.65 hours x 1 $ 2,310.00 1 $2,310
$31.20=$2,028 staff time 504.46 miles x.56/mile=
$282.50 TOTAL=$2,310.50
Total Contractual $0 $7,390
SUB-TOTAL BEFORE INDIRECT $115,078
Indirect
Match or
Item Description of Item In-Kind Of Total Amount Requested from
Required CDPHE
by RFA)
Negotiated Indirect cost rate(Federal, Eagle is In the process of securing a negotiated rate with COPHE.The rate of 24.20%of personnel/fringe has been
State,or CDPHE( provisionally approved by the FO,Deborah Borek. $23,025
Indirect rate(other):
Indirect(modified or additional base) 2%of contractual costs per RFA. $148
Total Indirect $23,173
TOTAL MATCH OR IN KIND $0
TOTAL $138,250
•
Page 5 of 5
V.1 Jan 201.3
•