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HomeMy WebLinkAboutC13-127 Department of Publich Health (13-FLA 48290)DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PSD - STEPP DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 14 -55276 AMENDMENT FOR TASK ORDERS #1 This Amendment is made this 16TH day of April, 2013, 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 24, 2012, with contract encumbrance number PO FLA PPG1348290, and contract routing number 13 FLA 48290, collectively referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: To provide 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 Thirty Eight Thousand Five Hundred Fifty Six Dollars, ($138.556.00) for the renewal term of twelve (12) months, ending on June 30, 2014, 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, 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. 2013, through and including June 30. 2014. The maximum amount payable by the State for the Page 1 of 5 Rev 3/16/2010 work to be performed by the Contractor during this renewal term is One Hundred Thirty Eight Thousand Five Hundred Fifty Six Dollars, J$138,556.001 for an amended total financial obligation of the State of TWO HUNDRED FORTY TWO THOUSAND EIGHT HUNDRED THIRTY TWO DOLLARS, ($242,832.00). This is an increase of One Hundred Thirty Eight Thousand Five Hundred Fifty Six Dollars, ($138,556.00) of the amount payable from the previous term. The revised specifications to the Additional Provisions are incorporated herein by this reference and identified as "Exhibit D ". The revised Statement of Work is incorporated herein by this reference and identified as "Exhibit E ". The revised Budget is incorporated herein by this reference and identified as "Exhibit F ". 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, 2013, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. 5.Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6.FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 2 of 5 Rev 3/16/2010 This page left intentionally blank. Page 3 of 5 Rev 3/16/2010 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 1 EAGLE COUNTY John W. Hickenlooper, Governor a political subdivision of the ,ate of Colorado) for the e and benefit of the , . . G E COUNTY PUB TH AGENC `` Ii4 AL 46 By: Si natur of Authorized1fficer For the Executive Director DEPARTMENT OF PUBLIC HEALTH 51-WA ENVIRONMENT Print Name of Authoriz d Officer 9Mi Print Title of Authorized Officer PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24 -30 -202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and /or services provided hereunder. STATE CONTROLLER David J. McDermott, CPA By: Date: Page 4 of 5 Rev 3/16/2010 This page left intentionally blank. Page 5 of 5 Rev 3/16/2010 EXHIBIT D ADDITIONAL PROVISIONS To Task Order Contract Dated 08/31/2012 - Contract Routing Number 13 FLA 48290 — Contract Amendment Routing Number 14 FLA 55276 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 D -1 may be referenced to in Exhibit D, Exhibit E, and all and any attachments thereof in this Task Order Contract. 2.This Task Order Contract contains state 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.colorado.gov /cs/ Satellite /CDPHE- Main/CBON/1251 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 E and incorporated herein and the associated Budget attached hereto as Exhibit F and incorporated herein. All other expenditures shall not be reimbursed without prior written consent of the State. All expenditures must be reasonable and necessary for the performance of this Contract, and must comply with The State of Colorado, specifically the Colorado Department of Public Health and Environment, fiscal guidelines and rules. Submit completed CDPHE Reimbursement Invoice Form to: Colorado Department of Public Health and Environment Tobacco Program Generalist PSD - STEPP - 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. Unless otherwise provided for in this 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. 4.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. To be attached to CDPHE Page 1 of 3 Revised: 12/19/06 Task Order v1.0 (3/12) contract template EXHIBIT D 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. 5.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. 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 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 Section 5 of this Task Order Contract. 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 To be attached to CDPHE Page 2 of 3 Revised: 12/19/06 Task Order v1.0 (3/12) contract template EXHIBIT D 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. 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. 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. 11. 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. 12. 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. 13. 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). 14. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding Letter substantially equivalent to Attachment D -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 D -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 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 D -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 Cunent 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 D -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.ka. 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 Virus 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 D -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 ATTACHMENT D -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 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 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 D -2 GRANT FUNDING CHANGE LETTER Date:1 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 $insert new cumulative total> for the following reason:Section is hereby modified accordingly. This Grant Funding Change Letter does not constitute an order for services under this Grant. The effective date of hereof is upon approval of the State Controller or whichever is later. STATE OF COLORADO John W. Hickenlooper, GOVERNOR Department of Public Health and Environment PROGRAM APPROVAL: By: Lisa Ellis, Purchasing & Contracts Unit Director By: Date: ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER CRS §24 -30 -202 requires the State Controller to approve all State Grants. This Grant is not valid until signed and dated below by the State Controller or delegate. Grantee is not authorized to begin performance until such time. If Grantee begins performing prior thereto, the State of Colorado is not obligated to pay Grantee for such performance or for any goods and /or services provided hereunder. STATE CONTROLLER David J. 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Mt 7) > \ a) § - S ; a 2 § V kSEA ^ a b 7 - \ 2 5 0 § 00 - 4 ƒ \ ( e, ° 6. jyes / o x J = ,© 2 p., g E- 5 o 0 f , , E0 c — o - a o V e a a V = acc © a = e .2 ©, c _ a) 0 ® - r:3 q: cocr B \ § 2 r o t c d ac).2 I. t. a 333u2 _ k0. § 2 —2. % © f i § U ° § E o k \ k• 2 ez §, ƒS f$ $2 0 a et 4 a o z 2 © © ^ 0au.e a k 4) / @ VI cia 2 c =f E • -° S / / . § 7 0f/ 0 EXHIBIT F Colorado Department of Public Health and Environment h .PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM 41,I s •To Task Order Dated 8/31/2012 - Contract Routing Number 13 FLA 48290 - Contract Amendment Routing Number 14 FLA 55276 Colorado Department of Public Health and Emironmrnt Program Contact Name, Title, Phone Carly Rietmann, Project Coordinator, 970-328 - Contractor Name Eagle County Government and Email 8896, carly.rietmann @eaglecounty.us Fiscal Contact Name, Title, Phone and Wendi Gill, Fiscal Specialist,970- 328 -8804, Budget Period July 1, 2013 -June 30, 2014 Email wendi.gill @eaglecounty.us Project Name West Mountain Region Tobacco Program Total Match or In- Amount Expenditure Categories Kind (If Applicable) RequestedfromCDPHE Percent of Gross or Annual Personal Services Fringe FTE on Salary Project List 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 # of months budgetted.supports Ms. Rietmann will be housed in the Eagle office and facilitate programming east of Garfield County Eagle River side of the region). She will act as lead, ensuring deliverables are met and reports are submitted in a timely, professional manner. She will work directly with Doctor's On -Call, Eagle Care, and Colorado Mountain College in Eagle County. Duties will include buildingnetworks, coordinating with BACCHUS, identifying a champion and lead contact at CMC, providing education to health care providers, coordinating with public health programs, collecting and analyzing data, and conducting Carly Rietmann research.Deliverable 1 -4 50,469.00 13,124.00 50.00%531,797 Ms. Koenemann provides oversight of staff, programming, and ensures fiscal responsibility of Karen Koenemann the budget including subcontracts.Deliverable 1 -4 70,040.00 23,928.00 20.00%18,794 Ms. Carey is a public health nurse who will provide tobacco education and quitline material distribution when she makes her community rounds to providers, and will assist with the health systems Theresa Carey change model.Deliverable 1, 2 56,135.00 521,993.00 5.00%3,906 Total Personal Services including fringe benefits)1 0.00 54,497 Supplies & Operating Expenses List objective /activity number(s) this Match or In Total Amount budget item kind (if Requested from Item Description of Item supports Rate Quantity applicable) CDPHE Printing /Copying Outreach material for recruitment and education on CMC campuses Deliverable 3 1,250 pieces per campus)50.10 2,500 250 Paper for in -house printing and use at coalition meetings. ($200) General office supplies General office supplies (pens, notebook paper, printer cartridges, folder, Deliverable 3 etc.) estimated at $15 per month $15x12= $180).380.00 1 380 Meeting Expenses-Snacks for college campus meetings and focus groups - $25 /meeting x 6 Deliverable 3 Refreshments meetings at each of 4 campuses 25.00 24 600 Page 1 of 3 EXHIBIT F Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Dated 8/31/2012 - Contract Routing Number 13 FLA 48290 - Contract Amendment Routing Number 14 FLA 55276 Colorado Department of Public Healtb and Environment Program Contact Name, Title, Phone Carly Rietmann, Project Coordinator, 970-328 - Contractor Name Eagle County Government and Email 8896, carly.rietmann @eaglecounty.us Fiscal Contact Name, Title, Phone and Wendi Gill, Fiscal Specialist,970- 328 -8304, Budget Period July 1, 2013 -June 30, 2014 Email wendi.gill @eaglecounty.us Project Name West Mountain Region Tobacco Program The focus group will help us explore barriers to adopting a tobacco free campus policy so that we can respond with appropriate actions in order to change perceptions and build support for a tobacco free policy. Focus Incentives group incentives: $25 Visa Cards for 40 focus group participants. We will Deliverable 3 mark each Visa card with a number and have a corresponding spreadsheet that tracks each card number. At the end of a focus group we will give out cards to participants, record their names in the spreadsheet and obtain signatures acknowledging receipt. Visa cards will be kept in a locked file cabinet when stored.25.00 40 1,000 Advertisement - Newspaper Advertisements for Colorado QuitLine and other tobacco education, Deliverable 1 -4 prevention, and cessation messages in various county newspapers- 3 papers x 4 ads x $250.00 ($3,000)250.00 12 3,000 Advertisement -Buses Deliverable 1-4 Advertisements for Colorado QuitLine on local buses (6 buses at $ 3,100)3,100.00 6 18,600 Advertisement -Radio Advertisement for Colorado QuitLne - 2 weeks of radio ads ($6.00/ per Deliverable 1 -4 30 sec spot x 140 = $830.00 6.00 140 840 Total Supplies Operating Expenses 0.00 24,670 Travel List objective /activity Item number(s) this Match or In Total Amount budget item kind (if Requested from Description of Item supports Rate Quantity applicable) CDPHE Based on 285 miles traveled per month, reimbursed at $0.51 per mile, calculated for 12 months (285 miles x .51 /mile x 12 months = $1,644.20). Miles include 2 required trips to Denver for training 0.51 3420 Mileage Deliverable 1-4 1,744 2 nights lodging for a total of 2 trips to Denver (required trainings). One 150.00 4 TC will attend each training. Nighly lodging amount based on current Lodging government lodging rates. 2x2x$150.00= $600.00 Deliverable 1 -4 600 Based on 2 days for 2 required trainings in Denver; reimbured at the Federal Rate of $66 per day. One tobacco coordinator will attend each 66.00 4 Meals training = 2x2x66= $264.00 Deliverable 1 -4 264 Total Travel 0.00 2,608 Contractual (payments to third parties or entities) List objective /activity Item 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 Contract with BACCHUS Network to provide technical assistance with Objective 3: Tobacco -Free Community Colleges. BACCHUS will provide 655.78 12 7,869 1.)Total TA= $ 6,100 (including conference calls and webinars 24 hrs x 150.00 = $3,600 and 10 calls x $250.00 = $2,500 2) Total Material= $ 1,769.40 a. 1 Tobacco Education Table Kits- 6x $219.00= $1,314.00 b. Stall stories- 6 x 4.40 = $26.40, c. Tobacco Free Policy Guides 6 x 66.00 =$396 d. Annual Collegiate Smokeout Manual 6 x $5.50 =$33) BACCHUS Rate for services is based on BACCHUS' Affiliate State Organization rate. Deliverable 3 Page 2 of 3 EXHIBIT F Colorado Department of Public Health and Environment A,„,:• `PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM r. 8 To Task Order Dated 8/31/2012 - Contract Routing Number 13 FLA 48290 - Contract Amendment Routing Number 14 FLA 55276 Colorado Dcpartm,nt of Public Health and Environment Program Contact Name, Title, Phone Carly Rietmann, Project Coordinator, 970-328 -Contractor Name Eagle County Government and Email 8896, carly.rietmann @eaglecounty.us Fiscal Contact Name, Title, Phone and Wendi Gill, Fiscal Specialist,970- 328 -8804, Budget Period July 1, 2013 -June 30, 2014 Email wendi. gill @eaglecounty.us Project Name West Mountain Region Tobacco Program For Garfield County Public Health staff to provide education to Mountain Family Health Center physicians and staff, provide support and technical 5412.50 12 4,950 assistance to TEPAC coordinators, educate local elected officials, and Garfield County Public assist with data collection and analysis. Staff include public health Health director, public health nurse, and health educator Deliverable 2 Community Health Services, Inc. in Pitkin County will provide program oversight, leadership, guidance, and technical support. One Tobacco coordinator will dedicate half of their time to assist with 2,903.18 12 34,838 implementation of this program initiative .50 FTE $31,800.00 $1644.20 Community Health Services, mileage (285 miles @$0.51 /mile x12 = $1,744.20 ); $600 lodging ($150 x 4 Inc.nights); $264 meals ($66 x 4 days); operating and supplies $530.Deliverable 2 Total Contractual 0.00 47,658 SUB -TOTAL BEFORE INDIRECT 129,432 Indirect Item Description of Item Negotiated Indirect cost rate Indirect (other): please list Eagle County's indirect rate is 21.27% of Salaries and Fringe. 21.27% of $54,495.00 = $11,591.09 ( more than 10% of direct specific indirect costs in costs restriction per RFA). 10% of direct costs approved by CDPHE.8'177 description if no rate exists Indirect (other): Contractual 2% of contractual 947 rate, if applicable Total Indirect 0.00 9,124 TOTAL MATCH OR IN KIND 0.00 TOTAL 138,556 Page 3 of 3