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Home My WebLink AboutC24-252 CDPHE_grant - overdose preventionModification Submittal Checklist Version 08.24.23 1 CONTRACT MODIFICATION SUBMITTAL CHECKLIST Contractor/Subrecipient Name Board of County Commissioners of Eagle County ☐ All Contractor name occurrences and Secretary of State Status Summary Page match exactly Modification Routing # 2023-11 EAGL Option Letter#2 Original Routing # 2023-11 EAGL CORE # Enter # or ☒ NO ENCUMBRANCE Modification Start Date 7/1/2024 Modification End Date 6/30/2025 SOW Modification Pre-Approval or Regents Pre-Review (AMD) - OnBase Approval # Enter # (if applicable) Division Acronym STI/HIV/VH Unit Acronym FTS Submitter Name Shruti Pandey Email Shruti.pandey@state.co.us SOW Delegate Name Chad Jones Email chad.jones@state.co.us Purpose(s) of Modification (Select all that apply) ☐ Scope of Work ☐ Budget ☒ Renewal ☒ No Cost ☐ Assignment ☐ Other If ‘Other’ Describe Modification DOCUMENT TYPE Select Only One A B C A. Amendment ☐ B. Option Letter ☒ C. Assignment ☐ Modification – DocuSign Backup Documents Include requested backup documents (as required) and contract in DocuSign envelope in order from 1-11. Mark all that apply for the selected Document Type. A B C 1. Contract Modification Quality Assurance Checklist ☐ ☐ ☐ 2. Contract Modification Submittal Checklist ☐ ☒ ☐ 3. Cover Page of original contract document and cover page of most recent assignment, if applicable ☐ ☒ ☐ 4. If Subrecipient, Pre-Award Financial Risk Assessment # (See Internal Audit Site) Enter # (Renewal required each year) ☐ ☐ 5. Insurance Certificate(s) *** Insurance Policy Dates must be current on effective date of contract *** If Assignment, Certificate of Insurance (COI) for Assignee only. NOT required for Interagency Agreement or Intergovernmental Contract. Waiver - OnBase Approval ID# Enter # Insurance Waiver Type: Enter Type of Waiver Granted ☐ ☐ ☐ 6. ☐ Sole Source REVISION (Modification required when increased amount, change in SOW, or date change) New PCS Sole Source Request # Enter PCU Request # New PCS Sole Source Term Select SS Term Start Date to Select SS Term End Date New NPSS1 # Enter NPPSS1 # ☐ ☐ 7. Secretary of State Status Summary Page (Amendment or Option Letter for a new term) (Must state the entity is in ‘good standing’) (If Assignment, SOS for Assignee only; NOT required for Interagency Agreement, Intergovernmental Contract) ☐ ☐ ☐ If ‘Doing Business As’ (dba), Secretary of State Status Summary Page for dba ☐ ☐ ☐ 8. Signature Authority Letter or Corporate Documentation (If contract signed by other than apparent authority) (See OSC Policy Signature Authority Delegation) ☐ ☐ 9. SAM Exclusion Summary Page (Record verified and no exclusions/restrictions) (See SAM Verification Guidance) (If Assignment, SAM for Assignee only; NOT required for Interagency Agreement Contract or LPHA) ☐ ☒ ☐ 10. Contract Modification (cover page, signature page, main body) ☐ ☒ ☐ 11. Contract Modification Exhibits (as shown on cover page of modification being submitted) ☐ ☐ ☐ DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 Modification Submittal Checklist Version 08.24.23 2 CMS RECORD Required for contracts $100,000 over the life of the contract (X) = Completed 1. Record Type – Record type chosen is ‘Modification’. ☐ 2. Linked Record – Record is linked to the Master Record ONLY. ☐ 3. Record Title – Title follows the naming convention for a Modification to a Master Record. ☐ 4. Data Field: Vendor Name – Has been selected in the ‘Contractor/Vendor’ field. ☐ 5. Data Fields: If this Modification is to renew or extend a contract, has the contractor’s work to date been certified as complying with the terms of the contract AND the Master CMS contract record updated? Choose ‘Yes’ when renewing or extending the expiration date and enter ‘Yes’ in the corresponding field in the Master Record. If the Modification is not to renew or extend, choose ‘N/A’ and do not make any changes in the corresponding field in the Master Record. ☐ 6. Data Field: Certification – If applicable, enter date of MOST RECENT annual certification of contractor work – If contract has been renewed or extended, enter expiration date of the contract. We are using the expiration date of the contract to represent the last contractor performance evaluation of the contract period (quarterly or 3x per year). If the Modification is not to renew or extend, leave blank. If the corresponding field in the Master Record is set to ‘Yes’ as a result of a previous renewal/exte nsion, do not change it. ☐ 7. Data Fields: All other relevant data fields are completed per CDPHE protocol. ☐ 8. Update Master Record – Cumulative Dollar Amount, Latest Performance End Date, and Recertification data fields have been updated as applicable. ☐ NOTES: Click here to enter text DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 Task Order Number: 2023-11 EAGL Page 1 of 3 Version 02.24.2022 TASK ORDER - HB22-1326 CONTRACTS ONLY State Agency State of Colorado for the use & benefit of the Department of Public Health and Environment 4300 Cherry Creek Drive South Denver CO 80246 Contractor Board of County Commissioners of Eagle County (a political subdivision of the state of Colorado) 500 Broadway Eagle CO 81631-0850 for the use and benefit of the Eagle County Public Health Agency 551 Broadway Eagle CO 81631 Master Task Order Contract Number 23 FAA 00016 Task Order Number 2023-11 EAGL Task Order Performance Beginning Date The later of the Task Order Effective Date or January 17, 2023 Task Order Maximum Amount Initial Term 1/17/2023 – 6/30/2023 $0.00 Extension Terms Year 20xx $0.00 Year 20xx $0.00 Year 20xx $0.00 Year 20xx $0.00 Total for All Years $0.00 Task Order Expiration Date June 30, 2023 Except as stated in §2.D., the total duration of this Contract, including the exercise of any options to extend, shall not exceed 5 years from its Performance Beginning Date. Pricing/Funding Price Structure: N/A Contractor Shall Invoice: N/A Funding Source: N/A Miscellaneous: Authority to enter into this Contract exists in: C.R.S. 25-1.5-101 – C.R.S. 25-1.5-113 Law Specified Vendor Statute (if any): 25-20.5-1101 Procurement Method: N/A Solicitation Number (if any): N/A State Representative Sophie Feffer, Drug User Health Coordinator, STI/HIV/VH Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80246 sophie.feffer@state.co.us Contractor Representative Megan Vilece Eagle County Public Health Agency 551 Broadway Eagle CO 81631 Megan.vilece@eaglecounty.us Exhibits and Order of Precedence The following Exhibits and attachments are included with this Contract: Exhibit A Additional Provisions Exhibit B Statement of Work Contract Purpose: This project serves to increase the availability of overdose prevention tools, specifically synthetic opiate detection tools, across the state of Colorado as part of a fentanyl education and prevention campaign. DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 EAGLE COUNTY GOVERNMENT Unique Entity ID HWBNNGAR6QH6 CAGE / NCAGE 4DB18 Purpose of Registration All Awards Registration Status Active Registration Expiration Date Nov 6, 2024 Physical Address 217 Eldon Wilson RD Gypsum, Colorado 81637-9753 United States Mailing Address 500 Broadway ST P.O. Box 850 Eagle, Colorado 81631-0850 United States Business Information Doing Business as Eagle County Air Terminal Corp Division Name (blank) Division Number (blank) Congressional District Colorado 02 State / Country of Incorporation (blank) / (blank) URL (blank) Registration Dates Activation Date Nov 13, 2023 Submission Date Nov 7, 2023 Initial Registration Date Apr 12, 2006 Entity Dates Entity Start Date Apr 23, 1996 Fiscal Year End Close Date Dec 31 Immediate Owner CAGE 343S0 Legal Business Name COUNTY OF EAGLE Highest Level Owner CAGE (blank) Legal Business Name (blank) Executive Compensation Registrants in the System for Award Management (SAM) respond to the Executive Compensation questions in accordance with Section 6202 of P.L. 110-252, amending the Federal Funding Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is sent to USAspending.gov for display in association with an eligible award. Maintaining an active registration in SAM demonstrates the registrant responded to the questions. Proceedings Questions Registrants in the System for Award Management (SAM.gov) respond to proceedings questions in accordance with FAR 52.209-7, FAR 52.209-9, or 2. C.F.R. 200 Appendix XII. Their responses are displayed in the responsibility/qualification section of SAM.gov. Maintaining an active registration in SAM.gov demonstrates the registrant responded to the proceedings questions. Exclusion Summary Active Exclusions Records? No SAM Search Authorization I authorize my entity's non-sensitive information to be displayed in SAM public search results: Yes Entity Types Business Types Entity Structure U.S. Government Entity Entity Type US Local Government Organization Factors (blank) Profit Structure (blank) Last updated by Anna Earl on Nov 07, 2023 at 02:23 PM EAGLE COUNTY GOVERNMENT Mar 22, 2024 07:28:20 PM GMT https://sam.gov/entity/HWBNNGAR6QH6/coreData?status=null Page 1 of 2 DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 Socio-Economic Types DOT Certified DBE Check the registrant's Reps & Certs, if present, under FAR 52.212-3 or FAR 52.219-1 to determine if the entity is an SBA-certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the SBA supplemental pages during registration. Government Types U.S. Local Government County Other Government Entities Airport Authority Financial Information Accepts Credit Card Payments No Debt Subject To Offset No EFT Indicator 0000 CAGE Code 4DB18 Points of Contact Electronic Business Anna Earl P.O. Box 850 Eagle, Colorado 81631 United States Shauna Huber P.O. Box 850 Eagle, Colorado 81631 United States Government Business Anna Earl P.O. Box 850 Eagle, Colorado 81631 United States Jill Klosterman P.O. Box 850 Eagle, Colorado 81631 United States Service Classifications NAICS Codes Primary Yes NAICS Codes 488119 NAICS Title Other Airport Operations Disaster Response This entity does not appear in the disaster response registry. Last updated by Anna Earl on Nov 07, 2023 at 02:23 PM EAGLE COUNTY GOVERNMENT Mar 22, 2024 07:28:20 PM GMT https://sam.gov/entity/HWBNNGAR6QH6/coreData?status=null Page 2 of 2 DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 Page 1 of 3 Option Letter Contract Number: 2023-11 EAGL option letter#2 Ver. 27.01.20 OPTION LETTER #2 State Agency: Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, Colorado 80246 Original Contract Number: 2023-11 EAGL Option Letter Contract Number: 2023-11 EAGL option letter#2 Contractor: Board of County Commissioners of Eagle County (a political subdivision of the state of Colorado) 500 Broadway Eagle CO 81631-0850 for the use and benefit of the Eagle County Public Health Agency 551 Broadway Eagle CO 81631 Contract Performance Beginning Date: March 14, 2023 Current Contract Expiration Date: June 30, 2025 CONTRACT MAXIMUM AMOUNT TABLE Document Type Contract Number Federal Funding Amount State Funding Amount Other Funding Amount Term (dates) Total Original Contract 2023-11 EAGL $0.00 $0.00 $0.00 3/14/2023- 6/30/2023 $0.00 Option Letter #1 2023-11 Option Letter #1 EAGL $0.00 $0.00 $0.00 7/1/2023- 6/30/2024 $0.00 Option Letter #2 2023-11 EAGL Option Letter #2 $0.00 $0.00 $0.00 7/1/2024- 6/30/2025 $0.00 Current Contract Maximum Cumulative Amount $0.00 1) OPTIONS A. Option to extend for an Extension Term 2) REQUIRED PROVISIONS: A. In accordance with Section 2C of the Original Master Task Order Contract referenced above, the State hereby exercises its option for an additional term, beginning July 1, 2024 and ending on the current contract expiration date shown above, at the rates stated in the Original Task Order Contract, as amended for the following reason: to extend the contract term for an additional year. B. The Contract Maximum Amount table is deleted and replaced with the Current Contract Maximum Amount table shown above. 2) OPTION EFFECTIVE DATE: DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 Page 2 of 3 Option Letter Contract Number: 2023-11 EAGL option letter#2 Ver. 27.01.20 A. The effective date of this Option Letter is upon approval of the State Controller or July 1, 2024, whichever is later. DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 Page 3 of 3 Option Letter Contract Number: 2023-11 EAGL option letter#2 Ver. 27.01.20 SIGNATURE PAGE STATE OF COLORADO Jared S. Polis, Governor Colorado Department of Public Health and Environment Jill Hunsaker Ryan, MPH, Executive Director _____________________________________________ By: Signature ____________________________________________ Name of Executive Director Delegate _____________________________________________ Title of Executive Director Delegate Date: _________________________ In accordance with §24-30-202 C.R.S., this Option is not valid until signed and dated below by the State Controller or an authorized delegate. STATE CONTROLLER Robert Jaros, CPA, MBA, JD ______________________________________________ By: Signature ______________________________________________ Name of State Controller Delegate ______________________________________________ Title of State Controller Delegate Option Effective Date: _________________________ -- Signature Page End -- DocuSign Envelope ID: 12654155-DC9C-4706-BE40-859C54ACA329 2024-04-03 Director of Procurement and Contracts Chelsea Gilbertson Chief Financial Officer Jannette Scarpino 2024-04-04