HomeMy WebLinkAboutWashington State Department of Health Amendment # 10 MASON COUNTY PUBLIC HEALTH
2018—2020 CONSOLIDATED CONTRACT MC Contract#19-090
CONTRACT NUMBER: CLH18253 AMENDMENT NUMBER: 10
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as"DOH",and
MASON COUNTY PUBLIC HEALTH hereinafter referred to as"LHJ",pursuant to the Modifications/Waivers clause,and to make
necessary changes within the scope of this contract and any subsequent amendments thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work,attached and incorporated by this reference,are amended as follows:
® Adds Statements of Work for the following programs:
• Childhood Lead Poisoning Prevention Program-Effective July 1,2019
• Foundational Public Health Services(FPHS)-Effective July 1,2019
• Office of Emergency Preparedness&Response-Effective July 1,2019
® Amends Statements of Work for the following programs:
• Maternal&Child Health Block Grant-Effective January 1,2018
• Office of Drinking Water Group A Program-Effective January 1,2018
Office of Drinking Water Group B Program-Effective January 1,2018
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-10 Allocations,attached and incorporated by this reference,amends and replaces Exhibit B-9 Allocations as follows:
® Increase ofS205,406 for a revised maximum consideration of$1,011,177.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations are attached only for informational purposes.
3. Exhibit C-9 Schedule of Federal Awards,attached and incorporated_by this reference,amends and replaces Exhibit C-8.
Unless designated otherwise herein,the effective date of this amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force and effect.
IN WITNESS WHEREOF,the undersigned has affixed his/her signature in execution thereof.
MASON COUNTY PUBLIC HEALTH STATE OF WASHINGTON
DEPARTMENT OF HEALTH
Date Date
APPROVED AS TO FORM ONLY
Assistant Attorney General
I
Page 1 of 26
AMENDMENT#10
201E-2020 CONSOLIDATIED CONTRACT -
EX$IBIT A
STATEMENTS OF WORK
TABLE OF CONTENTS
DOH Program Name or Title: Childhood Lead Poisoning Prevention Program-Effective July 1,2019..........................................................................................3
DOH Program Name or Title: Foundational Public Health Services(FPHS)-Effective July 1,2019..............................................................................................6
DOH Program Name or Title: Matemal &Child Health Block Grant-Effective January 1,2018..................................................................................................10
DOH Program Name or Title: Office of Drinking Water Group A Program-Effective January 1,2018 ....................................................................................... is
20
DOH Program Name or Title: Office of Drinking Water Group B Program-Effective January 1,2018........................................................................................
DOH Program Name or Title: Office of Emergency Preparedness&Response-Effective July 1,2019............................................-..........................................22
Exhibit A,Statements of Work Page 2 of 26 Contract Number CLH18253-10
Revised as of July 15.2019
AMENDMENT#10
Exhibit A -
Statement of Work
Contract Term: 201$-2020
DOH Program Name or Title: Childhood Lead Poisoning Prevention Program- Local Health Jurisdiction Name: Mason Countv Public Health
Effective July 1,2019
Contract Number: CLH18253
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
❑Federal<Select One> (check if applicable) Z Reimbursement
23 sute ❑FFATA(Transparency Act) Ell Fixed Price
Period of Performance: July 1.2019 through June 30.2020
j_]Other L]Research&Development
Statement of Work Purpose: The purpose of this statement of work is to support local interventions with the case management of elevated blood lead levels in children 14 years
of age and younger.The focus of this program is to build local capacity statewide to provide case management services to all children with elevated blood Iead levels.
Revision Purpose: N/A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
Healthy Communities 'QUA 334.04.91 25611100 07/01/19 il(W30/20 0 1,370 1,370
TOTALS 0 1,370 1,370
Task Task/Activity/Description "May Support PHAS Deliverables/Outcomes Due Date/Time Payment Information
Number Standards/Measures Frame and/or Amount
l Horne Visit 1 Submit the information collected Submit as needed Reimbursement of up
a) Contact the provider to gather complete during the home visit via the within 60 days after to$500 maximum per
information on the assigned elevated blood lead applicable fields of the completion. home visit,per child.
level case. Washington Disease Reporting Up to two(2)home
b) Contact the family to schedule the visit. System(WDRS). visits per child not to
c) Visit the child's residence(or other sites where exceed total funding
the child spends significant amounts of time). Submit,as attachment(s)via consideration.
d) Interview the caregivers using the Child Blood WDRS the documentation of the
Lead Investigation Form and conduct an Plan of Care prepared for the Note:this excludes
environmental assessment to identify factors family(DOH will provide a indirect costs.
that may impact the child's blood lead level. template)including a summary
e) Determine if the family lives in Section S or of the environmental assessment
HUD housing,and if the child is Medicaid and suggestions for reducing or
enrolled. climinating exposure. Provide a
f) Provide educational material to the child's copy ofthis document or
caregivers in the family's primary language. documents to the child's
caregivers and provider.
Exhibit A,Statements of Work Page 3 of 26 Contract Number CLH 19253-10
Revised as of July 15,2019
AMENDMENT#10
Task Task/Activity/Description "May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information-
Number Standards/Measures Frame and/or Amount
g) Arrange with family and provider to have the
child retested following the Pediatric
Environmental Health Specialty Unit(PEHSU)
medical management guidelines:
httPs:/1www.pehsu.net/ LibraiVfacts/medical-
m nt-childh d- -ex osure-June-2013: f
2 Home Visit 2(optional) Submit a new or updated Plan of Submit as needed Reimbursement of up
a) The purpose of the optional second home visit Care to DOH via WDRS and within 60 days of to$500 maximum per
is to connect the family to other service provide a copy to the child's completion home visit,per child.
providers,explain recommendations,answer caregivers and provider that Up to two(2)home
questions,and provide any further needed includes: visits per child not to
assistance for the family in implementing a) A summary of the results exceed total funding
recommendations. of any assessments consideration.
b) Facilitate the completion of a developmental conducted by LHJ staff Note:this excludes
screening to be conducted by LHJ staff via the and/or information on all indirect costs.
online WithinReach Developmental Screening referrals made.
Questionnaire hjV://www.parenthely I 23 oral b) The names of any at-risk
or other methodology,or by referral to the family members referred
child's physician or another entity trained to for blood lead testing.
administer developmental screening tests. c) The names of all
c) Encourage blood lead testing of other children professionals who have
less than 72 months of age and pregnant or been part of the Plan of
nursing persons in the home. Care or to which the family
d) If appropriate,refer the family to the Women, has been referred for
Infants,and Children(WIC)program or a services.
Registered Dietitian Nutritionist for a
nutritional assessment and to other service
providers as appropriate.
e) Coordinate services and communicate with
other involved professionals.
3 DOH will reimburse LHJ for costs incurred for field Submit vendor invoices to DOH As needed. Total reimbursements
investigation sample laboratory testing,as well as to document the reimbursement may not exceed total
costs incurred for interpretation and/or translation request. funding consideration.
services needed as part of case management.
(See Special Billing
Requirements below.
*For Information On1v:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board(PHAB)Standards/Measures that may apply can be found at:
hn://www.phaboard.orii/wi)-content/mloadsIP14AB-Standards-and-Measures-Version-I Apdf
Exhibit A,Statements of Work Page 4 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT #10
Program Specific Requirements/Niarrative
Program Manual,Handbook,Policy References
Guide for Public Health Case Management of Children with Elevated Blood Lead Levels
Jos://ww%v.doh,w4.gov!?ortals/l iDDocuments/4000/334-414.pdf
A Targeted Approach to Blood Lead Screening in Children,Washington State
2015 Expert Panel Recommendations
https:"uwvw.doh.wa,gov/Portals`1 tDocumentsfPubs/334-383.ndf
Special References(RCWs,WACs,etc)
Laboratories are required to report to the Department of Health all Blood Lead test results(WAC 246-101-201).Elevated results(greater than or equal to 5 mcg/dL)must be
reported within two(2)days;non-elevated results need to be reported within one(1)month.
Monitoring Visits(frequency,type)
Telephone calls and/or in person meetings with contract manager on as as-needed basis.
Definitions
BLL—Blood Lead Level
EBLL—Elevated Blood Lead Level
PEHSU—Pediatric Environmental Health Specialty Units
Special Billing Requirements
The average total amount expended for Iaboratory, interpreter,and translation services is suggested to be approximately$185 per home visit,per child.It is recognized that more
complex cases may require a higher level of services,while simpler cases may require fewer services.Total reimbursements may not exceed total funding consideration.
Please note WDRS event number(s)on invoice to allow DOH review of deliverables via WDRS. Payment to completely expend the"Total Consideration"for a specific funding
period will not be processed until all deliverables are accepted and approved by DOH. Invoices may be submitted as needed within 60 days after home visit completion and must
be based on actual direct program costs. Billing for services on a monthly fraction of the"Total Consideration"will not be accepted or approved.If needed,additional funding
may be requested and upon DOH approval may be added if funds are available.
Note: Blood Lead Case Management reimbursement excludes indirect costs.
DOH Program Contact DOH Fiscal Contact
Amy Bertrand,Health Services Consultant/Case Management Coordinator Victoria Reyes,Management Analyst
Office of Environmental Health Sciences Assistant Secretary's Office
Washington State Department of Health Telephone:360-236-3071
Street Address:310 Israel Rd SE,Tumwater WA 98501
Telephone:360-236-3392/Fax 360-236-3059
Email:amy.bertrandT(1&doh.wa.gov
Exhibit A,Statements of Work Page 5 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Exhibit A -
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Foundational Public Health Services Local Health Jurisdiction Name: Mason Countv Public Health
(FPHS)-Effective Julv 1.2019
Contract Number: CLI4 18253
SOW Type: Original Revision#(for this SOW) Fumding Source Federal Compliance Type of Payment
❑ Federal<Select Ones (check if applicable) ❑Reimbursement
Period of Performance: Julv 1.2019 through December 31,2020 ® State Q FFATA(Transparency Act) ®Periodic
Q Other Q Research&Develo rrant Distribution
Statement of Work Purpose: The purpose of this statement of work is to specify how state fuinds for Foundational Public Health Services(FPHS)will be used for the period of
July 1,2019 through June 30,2021,
Note: The total consideration is for the period of July],2019 through June 30,2021. 2019-2021 biennial funding allocations will be divided into four six-month lump
sum amounts that will be disbursed at the beginning of each six month period as follows: July,1,2019;January 1,2020;July 1,2020;January 1,2021.
The final disbursement of funds scheduled for January 1,2021 and deliverables due dates after December 31,2020 are included in this statement of work for
informational purposes only and will be carried forward into a new statement of work in the new consolidated contract term be21
ginning January 1,2021.
FPHS funds must be spent in the state fiscal year(SFY)in which they are disbursed: SFV20 07/01/19-06/3020 and SFY21 07/01/-10-06/30;21.
2019-2021 Biennial Allocation: $84,000
Annual Allocation: $42,000
Six Month Disbursement: 521,000
Revision Purpose: N/A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
FPHS FUNDING FOR LHJS N/A 336.04,25 TBD 07/01/19 06/3020 0 42,000 42,000
FPHS FUNDING FOR LHJS N/A 336.04.25 TBD 07/0120 12/3120 0 42,000 42,000
TOTALS 01 84,000 1 84,000
Task Task/Activity/Description Deliverables/Outcomes Due Date/Time payment Information and/or Amount
Number Frame
1 These funds are for delivering ANY or all of the FPHS Annual Report(template By 08/1520 Funds are available beginning July 1,2019.
communicable disease,environmental public health or provided by DOH)for SFY20 Half of the wnual allocation will be
assessment service and can also be used for any of the other (07/01119—06/3020) disbursed each July upon receipt of the
FPHS capabilities that support these FPHS as defined in the Annual Report and the second half will be
most current version of FPHS Definitions, disbursed ea::h:anu
Exhibit A,Statements of Work Page 6 of 216 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Task Task/Activity/Description Deliverabltes/Outcomes Due Date/Time payment Information and/or Amount
Number Frame
Annual Report(template By 08/15/21
provided by DOH)for SFY21 Note: Funds must be spent in the state
(07/01/20—06/30/21) fiscal year(SFY)in which they are
disbursed.
Tasks/Activities/Description Impact Measures
Control of Communicable Disease and Other Notifiable Conditions Percent of toddlers and school age children that have
1. Provide timely,statewide,locally relevant and accurate information statewide and to communities on completed the standard series of recommended vaccinations.
prevention and control of communicable disease and other notifiable conditions.
2. Identify statewide and local community assets for the control of communicable diseases and other Percent of new positive Hepatitis C lab reports that are
notifiable conditions,develop and implement a prioritized control plan addressing communicable received electronically which 1•ave a completed case report.
diseases and other notifiable conditions and seek resources and advocate for high priority prevention and
control policies and initiatives regarding communicable diseases and other notifiable conditions. Percent of new positive Hepatitis C case reports with
3. Promote immunization through evidence-based strategies and collaboration with schools,health care completed investigations.
providers and other community partners to increase immunization rates.
4. Ensure disease surveillance,investigation and control for communicable disease and notifiable Percent of Gonorrhea cases investigated.
conditions in accordance with local,state and federal mandates and guidelines.
5. Ensure availability of public health laboratory services for disease investigations and response,and Percent of Gonorrhea cases investigated that are receiving
reference and confirmatory testing related to communicable diseases and notifiable conditions. dual treatment(treatment for bath Gonorrhea and Chlamydia
6. When Additional Important Services(AIS)are delivered regarding prevention and control of at the same time)
communicable disease and other notifiable conditions,ensure that they are well coordinated with
foundational services. Percent of newly diagnosed syphilis cases that receive partner
services interview.
Environmental Public Health TBD
1. Provide timely,state and locally relevant and accurate information statewide and to communities on
environmental public health issues and health impacts from common environmental or toxic exposures.
2. Identify statewide and local community environmental public health assets and partners, and develop and
implement a prioritized prevention plan to protect the public's health by preventing and reducing
exposures to health hazards in the environment,seek resources and advocate for high priority policy
initiatives.
3. Conduct environmental public health investigations,inspections,sampling,laboratory analysis and
oversight to protect food,recreational water.drinking water and liquid waste and solid waste systems in
accordance with local,state and federal laws and regulations.
4. Identify and address priority notifiable zoonotic conditions(e.g.those transmitted by birds,insects,
rodents,etc.),air-bome conditions and other public health threats related to environmental hazards.
5. Protect the population from unnecessary radiation exposure in accordance with local,state and federal
laws and regulations.
6. Participate in broad land use planning and sustainable development to encourage decisions that promote
positive public health outcomes
7. When Additional Important Services(AIS)are delivered regarding environmental public health,assure �
that they are well coordinated with foundational services.
Exhibit A.Statements of Work Page 7 of 2.6 Contract Number CLH 18253-10
Revised as of July 15,2019
AMENDMENT#10
Tasks/Activities/Description Impact Measures
Assessment(Surveillance and Epidemiology) TBD
1. Ability to collect sufficient,statewide and community level data and develop and maintain electronic
information systems to guide public health planning and decision making at the state,regional and local
level.
2. Abili to access,analyze,use and interpret data.
3. Ability to conduct a comprehensive community or statewide health assessment and identify health
priorities arising from that assessment,including analysis of health disparities and the social determinants
of health.
Emergency Preparedness(All Hazards). TBD
1. Ability to develop emergency response plans for natural and man-made public health hazards;train public
health staff for emergency response roles and routinely exercise response plans.
2. Ability to lead the Emergency Support Function 8—Public Health&Medical and/or a public health
response for the county,region,jurisdiction and state.
3. Ability to activate and mobilize public health personnel and response teams;request and deploy resources;
coordinate with public sector,private sector and non-profit response partners and manage public health
and medical emergencies utilizing the incident command system.
4. Ability to communicate with diverse communities across different media,with emphasis on populations
that are disproportionately challenged during disasters,to promote resilience in advance of disasters and
protect public health during and following disasters.
Communication.
1. Ability to engage and maintain ongoing relations with local and statewide media.
2. Ability to develop and implement a communication strategy, in accordance with Public Health
Accreditation Standards,to increase visibility of public health issues. This includes the ability to provide
information on health risks,healthy behaviors,and disease prevention in culturally and linguistically
appropriate formats for the various communities served.
Policy Development and Support
1. Ability to develop basic public health policy recommendations.These policies must be evidence-based,
or, if innovative/promising,must include evaluation plans.
2. Ability to work with partners and policy makers to enact policies that are evidence-based(or are
innovative or promising and include evaluation plans)and that address the social determinants of health
and health equity.
3. Ability to utilize cost-benefit information to develop an efficient and cost-effective action plan to respond
to the priorities identified in a community and/or statewide health assessment.
Community Partnership Development
1. Ability to create and maintain relationships with diverse partners, including health-related national,
statewide and community-based organizations;community groups or organizations representing
populations experiencing health inequity;private businesses and health care organizations;Tribal Nations,
and local,state and federal government agencies and leaders.
2. Ability to select and articulate governmental public health roles in programmatic and policy activities and
coordinate with these partners.
Exhibit A, Statements of Work Page 8 of 26 Contract Number CLHI 8253-10
Revised as of July 15,2019
AMENDMENT#10
Tasks/Activities/Description Impact Measures
Business Competencies—Leadership Capabilities; Accountability and Quality Assurance Capabilities;Quality TBD
Improvement Information;Technology Capabilities;Human Resources Capabilities;Fiscal Management,
Contract and Procurement Capabilities;Facilities and Operations;Legal Capabilities.
Program Specific Reg uirem ents/Narrative
Special References(RCWs,WACs,etc)
Link to 2SHB 1497—http://lawfilesext.leg.wa.govibiennium/2019-20/Pdf/Bills/House%2OPassed%2OLegislature/1497-S2.PL.pdf
FPHS Definitions
www.doli.wa.p,ov/fphsresources
Special Instructions
There are two different BARS Revenue Codes for"state flexible funds"to be tracked separately and reported separately on your annual BARS report. These two BARS Revenue
Codes and definitions from the State Auditor's Office(SAO's)are listed below along with a link to the BARS Manual. 336.04.25 is the new BARS Revenue Code to use for the
Foundational Public Health Services(FPHS)funds included in this statement of work.
336.04.24—County Public Health Assistance
Use this account for the state distribution authorized by the 2013 2ESSB 5034,section 710.The local health jurisdictions are required to provide reports regarding expenditures
to the legislature from this revenue source.
336.04.25—Foundational Public Health Services
Use this account for the funding designated for the local health jurisdictions to provide a set of core services that government is responsible for in all communities in the WA
state. This set of core services provides the foundation to support the work of the broader public health system and community partners. At this time the funding from this
account is for delivering ANY or all of the FPHS communicable disease services(listed above)and can also be used for the FPHS capabilities that support FPHS communicable
disease services as defined in the most current version of FPHS Definitions.
SAO's BARS Manual
Deliverables are to be submitted to Marie Flake at marie.tlake(&doh.wa.eov
DOH Program Contact
Marie Flake,Special Projects,Foundational Public Health Services
Washington State Department of Health
PO Box 47890,Olympia,WA 98504-7890
Phone 360-2364063/Mobile 360-951-7566
Fax 360.236.4024/marie.flake a.doh.wa.gov
Exhibit A, Statements of Work Page 9 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT #10
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Maternal&Child Health Block Grant- Local Health Jurisdiction Name: Mason County Public Health
Effective January 1,2018
Contract Number: CLH18253
SOW Type: Revision Revision#(for this SOW) 4 Funding Source Federal Compliance T pe of Payment
®Federal Subrecipient (check if applicable) Reimbursement
Period of Performance: January 1,2018 through September 30,2020 ❑ State ®FFATA(Transparency Act) ❑Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work is to support local interventions that impact the target population of the Maternal and Child Health Block
Grant.
Revision Purpose: The purpose of this revision is to provide additional funding,add activities and deliverable due dates,and extend the period of performance and funding from
September 30,2019 to September 30,2020 for continuation of MCHBG-related activities.
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
FFY18 MCHBG!LHJ CONTRACTS 93.994 333.93.99 78120281 01/01/18 09/30/18 56,115 0 56,115
FFY19 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120291 10/01/18 09/30/19 67,694 0 67,694
FFY20 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120292 10/01/19 09/30/20 0 67,694 67,694
TOTALS 123,809 67 694 191,503
Task *May Support PHAB Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Maternal and Child Health Block Grant(MCHBG)Administration
]a Participate in calls,at a minimum of every Designated LHJ staff will participate September 30,2018 Reimbursement for
quarter,with DOH contract manager. Dates and in contract management calls. September 30,2019 actual costs, not to
time for calls are mutually agreed upon between September 30, 2020 exceed total funding
DOH and LHJ consideration.
lb Report actual expenditures for October 1,2017 Submit actual expenditures using the May 26,2018 Action Plan and
through March 31,2018 MCHBG Budget Workbook to DOH Progress Reports
contract manager must only reflect
1 c Develop 2018-2019 MCHBG Budget Workbook Submit MCHBG Budget Workbook September 5,2018 activities paid for
for October 1,2018 through September 30,2019 to DOH contract manager with funds provided
using DOH provided template. in this statement of
Exhibit A, Statements of Work Page 10 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Task *May Support PHAB Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Id Report actual expenditures for October 1,2018 Submit actual expenditures using the May 24,2019 work for the
through March 31,2019 MCHBG Budget Workbook to DOH specified funding
contract manager. period.
I e Develop 2019-2020 MCHBG Budget Workbook Submit MCHBG Budget Workbook September 5,2019
for October 1,2019 through September 30,2020 to DOH contract manager See Program
using DOH provided template. Specific
I f Report actual expenditures for October 1,2017 Submit actual expenditures using the November 30,2018 Requirements and
through September 30,2018 MCHBG Budget Workbook to DOH Special Billing
contract manager. Requirements.
1 g Participate in DOH sponsored MCHBG fall Designated LHJ staff will attend September 30, 2020
regional meeting, regional meeting,
1 h Report actual expenditures for October 1, 2018 Submit actual expenditures using the December 6, 2019
through September 30, 2019 MCHBG Budget Workbook to DOH
contract manager.
I i Develop 2020-2021 MCHBG Budget Workbook Submit MCHBG Budget Workbook September 6, 2020
for October 1, 2020 through September 30, 2021 to DOHconh•act manager
usin DOH provided template.
lj Report actual expenditures for the six month Submit actual expenditures using the May 22, 2020
period from October 1, 20/9 through March 31, UCHBG Budget Workbook to DOH
2020 contract manager.
MCHBG Assessment and Evaluation
2a Participate in project evaluation activities Documentation using report September 30,2018 Reimbursement for
developed and coordinated by DOH,as template provided by DOH September 30,2019 actual costs,not to
re uested. September 30, 2020 exceed total funding
2b Report program level strategy measure data Documentation using report January 15,2018 consideration.
(CSHCN,UDS,ACES). template provided by DOH April 15,2018
July 15,2018 See Program
October 15,2018 Specific
2c Conduct a Maternal and Child Health(MCH) Submit Needs Assessment May 24,2019 Requirements and
Needs Assessment. documentation to DOH contract Special Billing
manager using templates provided Requirements.
by DOH
2d Explore health equity approaches to maternal Include health equity plan in 2020- Draft Augusl 16, 2020
and child health and develop implementation 2021 MCHBG Action Plan using Final September 6, 2020
plan DOH-provided template.
Exhibit A, Statements of Work Page 1 I of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Task *May Support PHAB Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
MCHBG Implementation
3a Develop 2018-2019 MCHBG Action Plan for Submit MCHBG Action Plan to Draft August 17,2018 Reimbursement for
October 1,2018 through September 30,2019 DOH contract manager Final-September 5, actual costs,not to
using DOH-provided template. 2018 exceed total funding
3b Report activities and outcomes of 2017-2018 Submit Action Plan monthly reports Monthly,on or before consideration.
MCHBG Action Plan using DOH-provided to DOH contract manager the 151 of the following Action Plan and
template. month Progress Reports
3c Develop 2019-2020 MCHBG Action Plan for Submit MCHBG Action Plan to Draft August 17,2019 must only reflect
October 1,2019 through September 30,2020 DOH contract manager Final-September 5, activities paid for
using DOH-provided template. 2019 with funds provided
3d Report activities and outcomes of 2018-2019 Submit Action Plan monthly reports Monthly,on or before in this statement of
MCHBG Action Plan using DOH-provided to DOH contract manager the 151 of the following work for the
template. month specified funding
3(2 Develop 2020-2021 MCHBG Action Plan for Submit MCHBG Action Plan to Draft August 16, 2020 period.
October 1, 2020 through September 30, 2021 DOH contract manager Final September 6, 2020
using DOH-provided template. See Program
3f Report activities and outcomes of 2019-2020 Submit Action Plan monthly reports Monthly, on or before Specific
AICHBG Action Plan using DOH-provided to DOH contract manager the 15'h of the following Requirements and
template. month Special Billing
Requirements.
Children and Youth with Special Health Care Needs(C YSHCN)
4a Complete Child Health Intake Form(CHIF) Submit CHIF data into Secure File January 15,2018 Reimbursement for
using the CHIF Automated System on all infants Transport(SFT)website: April 15,2018 actual costs,not to
and children served by the C YSHCN Program as https://sft.wa.ggv July 15,2018 exceed total funding
referenced in CSHCN Program Manual. October 15,2018 consideration.
Ensure client data is collected on all children January 15,2019 Action Plan and
served by C YSHCN contractors,including April 15,2019 Progress Reports
neurodevelopmental centers,regional July 15,2019 must only reflect
maxillofacial coordinators,and the DOH October 15. 2019 activities paid for
Newborn Screening Program. January 15, 2020 with funds provided
April 15, 2020 in this statement of
July 15, 2020 work for the
4b Administer requested DOH Diagnostic and Submit completed Health Services 30 days after forms are specified funding
Treatment funds for infants and children per Authorization forms and Central completed. period.
C YSHCN Program Manual when funds are used. Treatment Fund requests directly to
the C)SHCN Program as needed. See Program
Specific
Requirements and
Exhibit A, Statements of Work Page 12 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Task *May Support PHAB Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Special Billing
Requirements.
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board(PHAB)Standards/Measures that may apply can be found at:
Iittp://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.O.pdf
Program Specific Requirements/Narrative
Special Requirements
Federal Fundine Accountability and Transparency Act(FFATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Data Universal Numbering System(DUNS®)number.
Information about the LHJ and this statement of work will be made available on USASpendina.gov by DOH as required by P.L. 109-282.
Program Manual,Handbook,Policy References
Children and Youth with Special Health Care Needs Manual-
httns•//wN,w doh wn gov/Fol-PublicHealthandHealtlicareProvideis/PublicHc,althSi,steniResoitrcesatidServic•e,s/LocalHealthResourcesandTools/MaternalaticiCIiildHealthBlockGt.a
nt/Childrenand]'ozdhWitltSpecialHealthCareNeeds
Health Services Authorization(HSA)Form
http://www.doh.wa.gov/Portals/1/Documents/Pubs/910-002-ApprovedHSA.docx
Restrictions on Funds(what funds can be used for which activities,not direct payments,etc.)
1. At least 30%of federal Title V funds must be used for preventive and primary care services for children and at least 30%must be used services for children with
special health care needs. [Social Security Law,Sec.505(a)(3)].
2. Funds may not be used for:
a. Inpatient services,other than inpatient services for children with special health care needs or high risk pregnant women and infants,and other patient services approved by
Health Resources and Services Administration(HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land,the purchase,construction,or permanent improvement of any building or other facility, or the purchase of major medical
equipment.
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. payment for any services furnished by a provider or entity who has been excluded under Title XVIII(Medicare),Title XIX(Medicaid),or Title XX(social services block
grant).[Social Security Law,Sec 504(b)].
Exhibit A,Statements of Work Page 13 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
3. If any charges are imposed for the provision of health services using Title V(MCH Block Grant)funds,such charges will be pursuant to a public schedule of charges;will not
be imposed with respect to services provided to low income mothers or children;and will be adjusted to reflect the income,resources,and family size of the individual
provided the services. [Social Security Law, Sec. 505 (1)(D)].
Monitoring Visits(frequency,type)
Telephone calls with contract manager at least one every quarter, and annual site visit.
Special Billing Requirements
Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable A l 9-1 A invoice voucher. Payment to completely expend the"Total Consideration"
for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly by the 30th of each month
following the month in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a monthly fraction of the"Total
Consideration"will not be accepted or approved.
Special Instructions
Contact DOH contract manager below for approval of expenses not reflected in approved budget workbook.
DOH Program Contact
Mary Dussol,Community Consultant
Office of Family and Community Health Improvement
Washington State Department of Health
Street Address: 310 Israel Rd SE,Tumwater,WA 98501
Mailing Address: PO Box 47848,Olympia,WA 98504
Telephone: 360-236-3781 /Fax: 360-236 3646
Email: Mary.Dussol(c-)doh.wa.gov
Exhibit A, Statements of Work Page 14 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Office of Drinking Water Group A Program- Local Health Jurisdiction Name: Mason County Public Health
Effective January 1,2018
Contract Number: CLH18253
SOW Type: Revision Revision#(for this SOW) 4 Funding Source Federal Compliance T pe of Payment
®Federal Contractor (check if applicable) Reimbursement
Period of Performance: January 1,2018 through December 31,2020 ® State ❑FFATA(Transparency Act) ®Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non-community Group A water systems.
Revision Purpose: The purpose of this revision is to decrease Total Consideration, revise Special Billing Requirements, and move remaining SS and TA federal funds from Yr 21
SRF to Yr 22 SRF.
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Decrease(—) Consideration
Code Code Start Date End Date
Yr 20 SRF-Local Asst 15% (FS) SS N/A 346.26.64 24139220 01/01/18 12/31/18 0 0 0
Sanitary Survey Fees FO-SW) SS-State N/A 346.26.65 24232522 01/01/18 12/31/19 24,800 0 24,800
Yr 20 SRF-Local Asst 15%)(FS) TA N/A 346.26.66 24139220 01/01/18 12/31/18 0 0 0
Yr 21 SRF-Local Asst 15% FS SS N/A 346.26.64 24139221 01/01/18 06/30/19 24,800 -13,600 11,200
Yr 21 SRF-Local Asst 15% S TA N/A 346.26.66 24139221 01/01/18 06/30/19 4,000 -4,000 0
Yr 22 SRF-Local Asst 15% O-SW)SS N/A 346.26.64 24239222 01/01/19 12/31/19 0 13,600 13,600
Yr 22 SRF-Local Asst 15% O-SW)TA N/A 346.26.66 1 24239222 1 01/01/19 1 12/31/19 0 2,000 2,000
TOTALS 53,600 -2,000 51,600
Task Task/Activity/Description *May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information and/or Amount
Number Standards/Measures Frame
1 Trained LHJ staff will conduct Provide Final* Sanitary Final Sanitary Upon ODW acceptance of the Final
sanitary surveys of small community Survey Reports to ODW Survey Reports Sanitary Survey Report,the LHJ shall be
and non-community Group A water Regional Office. Complete must be received by paid$400 for each sanitary survey of a non-
systems identified by the DOH Office Sanitary Survey Reports the ODW Regional community system with three or fewer
of Drinking Water(ODW)Regional shall include: Office within 30 connections.
Office. 1. Cover letter identifying calendar days of
significant deficiencies, conducting the Upon ODW acceptance of the Final
See Special Instructions for task significant findings, sanitary survey. Sanitary Survey Report,the LHJ shall be
activity. observations, paid$800 for each sanitary survey of a non-
recommendations,and
Exhibit A, Statements of Work Page 15 of26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Task Task/Activity/Description *May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information and/or Amount
Number Standards/Measures Frame
referrals for further community system with four or more
ODW follow-up. connections and each community system.
2. Completed Small Water
DOH will provide a tablet and GPS System checklist. Payment is inclusive of all associated costs
unit for the LHJ to gather source data 3. Updated Water such as travel, lodging,per diem.
during a routine sanitary survey.DOH Facilities Inventory
expects the LHJ to commit to using (WFI). Payment is authorized upon receipt and
the tablet and GPS for a five-year 4. Photos of water system acceptance of the Final Sanitary Survey
period. with text identifying Report within the 30-day deadline.
features
5. Any other supporting Late or incomplete reports may not be
documents. accepted for payment.
*Final Reports reviewed
and accepted by the ODW
Regional Office.
The LHJ surveyor will
record at least two(2)GPS
data points,for each source,
into the preloaded Excel
template on the tablet and
submit that data file with the
associated sanitary survey.
2 Trained LHJ staff will conduct Provide completed SPI Completed SPI Upon acceptance of the completed SPI
Special Purpose Investigations(SPI) Report and any supporting Reports must be Report,the LHJ shall be paid$800 for each
of small community and non- documents and photos to received by the SPI.
community Group A water systems ODW Regional Office. ODW Regional
identified by the ODW Regional Office within 2 Payment is inclusive of all associated costs
Office. working days of the such as travel, lodging,per diem.
service request.
See Special Instructions for task Payment is authorized upon receipt and
activity. acceptance of completed SPI Report within
the 2 working day deadline.
Late or incomplete reports may not be
accepted for payment.
Exhibit A, Statements of Work Page 16 of 26 Contract Number CLH 18253-10
Revised as of July 15,2019
AMENDMENT#10
Task Task/Activity/Description *May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information and/or Amount
Number Standards/Measures Frame
3 Trained LHJ staff will provide direct Provide completed TA Completed TA Upon acceptance of the completed TA
technical assistance(TA)to small Report and any supporting Report must be Report,the LHJ shall be paid for each
community and non-community documents and photos to received by the technical assistance activity as follows:
Group A water systems identified by ODW Regional Office. ODW Regional • Up to 3 hours of work: $250
the ODW Regional Office. Office within 30 a 3-6 hours of work: $500
calendar days of . More than 6 hours of work: $750
See Special Instructions for task providing technical
activity. assistance. Payment is inclusive of all associated costs
such as consulting fee,travel, lodging,per
diem.
Payment is authorized upon receipt and
acceptance of completed TA Report within
the 30-day deadline.
Late or incomplete reports may not be
accepted for payment.
4 LHJ staff performing the activities Prior to attending the Annually LHJ shall be paid mileage,per diem,
under tasks 1,2 and 3 must have training,submit an lodging,and registration costs as approved
completed the mandatory Sanitary "Authorization for Travel on the pre-authorization form in accordance
Survey Training. (Non-Employee)"DOH with the current rates listed on the OFM
Form 710-013 to the ODW Website
See Special Instructions for task Program Contact below for http://www.ofm.wa.gov/resources/travel.asp
activity. approval(to ensure that
enough funds are available).
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board(PHAB)Standards/Measures that may apply can be found at:
http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.O.pdf
Proaram Specific Reauirements/Narrative
Special References(RCWs,WACs,etc)
Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work,ODW contracts with the LHJ to conduct sanitary surveys(and SPIs,and
provide technical assistance)for small community and non-community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys(and
SPIs,and provide technical assistance)for small community and non-community water systems with surface water sources, large water systems,and systems with complex
treatment.
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4,below.
Exhibit A, Statements of Work Page 17 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Special Billing Requirements
The LHJ shall submit quarterly invoices within 30 days following the end of the quarter in which work was completed, noting on the invoice the quarter and year being billed for.
Payment cannot exceed a maximum accumulative fee of$49,600 for Task 1,and $4,000$2,000 for Task 2,Task 3 and Task 4 combined during the contracting period,to be
paid at the rates specified in the Payment Method/Amount section above. When invoicing for sanitary surveys,bill half to BARS Revenue Code 346.26.64 and half to BARS
Revenue Code 346.26.65.
When invoicing for Task 1,submit the list of WS Name, ID#,Amount Billed, Survey Date and Letter Date that you are requesting payment.
When invoicing for Task 2-3,submit the list of WS Name, ID#,TA Date and description of TA work performed,and Amount Billed.
When invoicing for Task 4,submit receipts and the signed pre-authorization form for non-employee travel to the ODW Program Contact below and a signed A 19-1 A Invoice
Voucher to the DOH Grants Management,billing to BARS Revenue Code 346.26.66 under Technical Assistance(TA).
Special Instructions
Task 1
Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW.Detailed
guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance(Field Guide). The sanitary survey will include an
evaluation of the following eight elements: source;treatment;distribution system;finished water storage;pumps,pump facilities and controls;monitoring,reporting and data
verification;system management and operation;and certified operator compliance. If a system is more complex than anticipated or other significant issues arise,the LHJ may
request ODW assistance.
• No more than 0 surveys of non-community systems with three or fewer connections to be completed between January 1,2018 and December 31,2018.
• No more than 28 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2018 and
December 31,2018.
• No more than 10 surveys of non-community systems with three or fewer connections to be completed between January 1,2019 and December 31,2019.
• No more than 29 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2019 and
December 31,2019.
The process for assignment of surveys to the LHJ,notification of the water system,and ODW follow-up with unresponsive water systems;and other roles and responsibilities of
the LHJ are described in the Field Guide.
Task 2
Trained LHJ staff will perform Special Purpose Investigations(SPIs)as assigned by ODW. SPIs are inspections to determine the cause of positive coliform samples or the cause of
other emergency conditions. SPIs may also include sanitary surveys of newly discovered Group A water systems.Additional detail about conducting SPIs is described in the Field
Guide.The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staff will conduct Technical assistance as assigned by ODW.Technical Assistance includes assisting water system personnel in completing work or verifying work
has been addressed as required,requested,or advised by the ODW to meet applicable drinking water regulations. Examples of technical assistance activities are described in the
Field Guide. The ODW Regional Office must authorize in advance any technical assistance provided by the LHJ to a water system.
Task 4
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work.LHJ staff performing the activities under tasks 1,
2 and 3 must have completed,with a passing score,the ODW Online Sanitary Survey Training and the ODW Sanitary Survey Field Training.LHJ staff performing activities under
tasks 1,2,and 3 must attend the Annual ODW Sanitary Survey Workshop,and are expected to attend the Regional ODW LHJ Drinking Water Meetings.
Exhibit A, Statements of Work Page 18 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
If required trainings,workshops or meetings are not available,not scheduled,or if the LHJ staff person is unable to attend these activities prior to conducting assigned tasks,the
LHJ staff person may,with ODW approval,substitute other training activities to be determined by ODW. Such substitute activities may include one-on-one training with ODW
staff,co-surveys with ODW staff,or other activities as arranged and pre-approved by ODW.LHJ staff may not perform the activities under tasks 1,2,and 3 without completing
the training that has been arranged and approved by ODW.
Program Manual,Handbook,Policy References
htty://www.doh.wa.eov/Portals/1/Documen ts/Pubs/331-486.adf
DOH Program Contact DOH Fiscal Contact
Denise Miles Karena McGovern
DOH Office of Drinking Water DOH Office of Drinking Water
243 Israel Rd SE 243 Israel Rd SE
Tumwater,WA 98501 Tumwater,WA 98501
Den ise.M ilesAdoh.wa.gov Karena.McGovern a,doh.wa.gov
(360)236-3028 (360)236-3094
Exhibit A, Statements of Work Page 19 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT #10
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Office of Drinkinp-Water Group B Program. - Local Health Jurisdiction Name: Mason County Public Health
Effective January 1.2018
Contract Number: CLH18253
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance T pe of Payment
ElFederal<Select One> (check if applicable) Reimbursement
Period of Performance: January 1,2018 through December 31,2020 ® State ❑FFATA(Transparency Act) ®Fixed Price
❑Other ❑Research&Development
Statement of Work Purpose: The purpose of this statement of work is to provide financial support to LHJs implementing local Group B water system programs.
Revision Purpose: The purpose of this revision is to extend the Period of Performance end date from June 30,2019 to December 31,2020,increase Current Consideration,revise
Special Billing Requirements,and change the DOH Program Contact.
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
GFS-Group B FO-SW) N/A 334.04.90 24230103 01/01/18 06/30/18 2,500 0 2,500
FY2 Group B Programs for DW FO-SW N/A 334.04.90 24230105 07/01/18 06/30/19 5,000 0 5,000
GFS-Group B FO-S N/A 334.04.90 24230103 07/01/19 06/30/20 0 2,500 2,500
GFS-Group B(FO-SW) N/A 334.04.90 24230103 1 07/01/20 12/31/20 0 2,500 2,500
TOTALS 7,500 5,000 12,500
Task *May Support PHAB Memorandum of Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Agreement Number Information and/or
Amount
I Implement a partial Group B water system An executed joint plan of Reference DOH JPR# Lump sum payment
program. responsibility(JPR)with DOH CLH2O495 (See Special Billing
identifying responsibilities of a Requirements)
partial Group B program.
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board(PHAB)Standards/Measures that may apply can be found at:
http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf
Exhibit A, Statements of Work Page 20 of 26 Contract Number CLH18253-10
Revised as of July 15,2019
AMENDMENT#10
Program Specific Requirements/Narrative
Special Billing Requirements
For Januat), 1, 2018—June 30, 2019, the LHJ shall submit three semi-annual invoices as follows: $2,500 in the first half of each calendar year(no later than May 15)and$2,500
in the second half of each calendar year(no later than November 15). Payment cannot exceed a maximum cumulative fee of$5,000 per year.
For AN 1, 2019—December 31, 2020, the LHJshall submit two invoices as follows: $2,500 between July 1, 2019—June 30, 2020(no later than Mav 15, 2020) and$2,500
between July /, 2020—December 31, 2020. Payment cannot exceed the amounts indicated during the time periods above.
DOH Program Contact DOH Fiscal Contact
. Denise Miles Karena McGovern
Southwest Regional Afanager Office DOH Office of Drinking Water
DOH Office of Drinking Water 243 Israel Rd SE
243 Israel Rd SE Tumwater,WA 98501
Tumwater,WA 98501 Karena.Mcgovern a,doh.wa.gov
Bennie _ (360)236-3094
Denise.Milesna,doh.wa.gov
(360)236-3023 3028
Exhibit A,Statements of Work Page 21 of 26 Contract Number CLH 18253-10
Revised as of July 15,2019
AMENDMENT#10
Exhibit A
Statement of Work
Contract Term: 2018-2020
DOH Program Name or Title: Office of Emergency__Preparedness&Response- Local Health Jurisdiction Name: Mason County Public Health
Effective July 1,2019
Contract Number: CLH18253
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance T pe of Payment
®Federal Subrecipient (check if applicable) Reimbursement
Period of Performance: July 1,2019 though June 30,2020 ❑ State ® FFATA(Transparency Act) ❑Fixed Price
❑Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to establish the funding and tasks for the Public Health Emergency Preparedness and Response program
for the 2019 grant period.
Revision Purpose: N/A
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total
Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration
Code Code Start Date End Date
FFY19 PHEP BPI LHJ FUNDING 93.069 333.93.06 31102190 07/01/19 06/30/20 0 49,342 49,342
TOTALS 1 0 49,342 49,342
Task *May Support PHAB Due Date/Time Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
1 Attend emergency preparedness events,(e.g. Submit summary on the mid-year December 31,2019 Reimbursement for
trainings,meetings,conference calls,and and end of year progress report. and June 30,2020 actual costs not to
conferences)as necessary to advance LHJ exceed total funding
preparedness or complete the deliverables in this consideration amount
statement of work.
2 Complete reporting templates as requested by Submit completed templates to Upon request
DOH to comply with program and federal grant DOH.
requirements such as: gap analysis,mid-year report
and end-of-year report,etc.
3 Complete all performance measure reporting Submit completed performance Upon request
requirements as requested by DOH. measure data.
4 Participate in at least one emergency preparedness Submit mid-year and end of year December 31,2019
training provided to LHJ staff by DOH or a DOH- progress reports. and June 30,2020
contracted partner. Training may be conducted in-
person or via webinar. Submit documentation of
participation in trainin s. If
Exhibit A, Statements of Work Page 22 of 26 Contract Number CLH 18253-10
Revised as of July 15,2019
AMENDMENT#10
Task *May Support PHAB Due Date/Time Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
training is conducted by a partner,
provide a sign in sheet with
participants' contact information.
5 Washington Secure Electronic Communication, Submit mid-year and end of year December 31,2019
Urgent Response and Exchange System progress reports. and June 30,2020
(WASECURES):
5.1)Maintain WASECURES program as the A list of registered users to include December 31,2019
primary emergency notification system within the their title and role in the
LHJ for receiving alerts from DOH,and include all emergency response plan.
critical LHJ positions as registered users. Within one week of
Submit results of notification drills the drill,but no later
5.2)Participate in DOH-led WASECURES conducted or participated in. than June 30,2020
notification drills.
5.3)Conduct a notification drill using LHJ's
preferred staff notification system.
Notes: Registered users must log in quarterly at a
minimum. DOH will provide on-site technical
assistance to LHJs,as needed,on using
WASECURES.LHJs may choose to use other
notification systems in addition to WASECURES
to alert staff during incidents.
6 Communications: Submit mid-year and end of year December 31,2019
progress reports. and June 30,2020
6.1)Participate in at least one risk communications
webinar hosted by DOH.Webinars will be offered
twice;one in the first half of the budget period and Submit messaging used to inform Within 90 days of
one in the second half of the budget period. the public during drills, including a drill,but no later than
summary of how communication June 30,2020
6.2)Participate in DOH Public Information Officer tools were used.
Workgroup.
Documentation of items identified Within 90 days of the
6.3)Participate in at least one risk communications in hot wash. end of the incident,
drill conducted by DOH.Drill will occur via but no later than
webinar,conference call,and email. Drill will test June 30,2020
LHJ's ability to develop and disseminate key
messages via social media,email to community
partners,phone trees,newsletters,and other means
preferred by the LHJ.
Exhibit A, Statements of Work Page 23 of 26 Contract Number CLH 18253-10
Revised as of July 15,2019
AMENDMENT#10
Task *May Support PHAB Due Date/Time Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
6.4)Conduct a hot wash evaluating LHJ Submit documentation of Within 90 days of the
participation in the drill. participation in incident including end of the incident,
communication methods and tools but no later than
6.5)Participation in a real-world incident will used. Submit AAR. June 30,2020
satisfy the need to participate in a communications
drill.
7 Update plans to request,receive,and dispense Submit mid-year and end of year December 31,2019
Medical Countermeasures(MCM).Plans should progress reports. and June 30,2020
include the addresses of all local public Points of
Dispensing(PODs)(not including pharmacies or
healthcare facilities),sources of public POD Updated Medical Countermeasures June 30,2020
staffing, local receiving and pickup sites(Hubs) Plan.
identified by the LHJ,and whether the LHJ intends
to pick up countermeasures from DOH.
Note#1:LHJs are not required to maintain a Hub;
LHJs may partner with other organizations to
centralize distribution.
Note#2: DOH will provide technical assistance to
LHJs on core elements of an MCM plan.
8 Provide immediate notification to the DOH Duty Submit mid-year and end of year December 31,2019
Officer at 360-888-0838 or hanalert(a)doh.wa.gov progress reports including and June 30,2020
for all response incidents involving utilization of documentation that notification to
emergency response plans and structures. DOH was provided;or statement
that no incident response occurred.
Notification to DOH duty officer. As soon as possible
(performance measure
target is within 60
minutes
9 Produce and provide situation reports documenting Submit mid-year and end of year December 31,2019
LHJ activity to DOH during all incidents involving progress reports to include and June 30,2020
an emergency response or activation by the LHJ. situation reports demonstrating
Situation reports may be developed by the LHJ,or DOH was notified of incident
may be jurisdictional situation reports that include response,or statement that no
input from the LHJ. incident response occurred.
Submit situation reports to DOH Upon completion,but
Duty Officer by email to no later than June 30,
I I AN ALERT@doh.wa.gov. 2020
Exhibit A,Statements of Work Page 24 of 26 Contract Number CLH 18253-10
Revised as of July 15,2019
AMENDMENT#10
Task *May Support PHAB Due Date/Time Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or
Amount
10 Provide Essential Elements of Information(EEIs) Provide essential elements of Upon request
during incident response upon request by DOH. information upon request.
Note: DOH will convey requests for specific data
elements EEIs to the LHJ during an incident.
11 Attend regional Health Care Coalition district Submit mid-year and end of year December 31,2019
meetings and/or inform RERC of jurisdictional progress reports documenting and June 30,2020
input(district meetings can be attended via participation in meetings and/or
webinar or in person),as requested by HCC Lead webinars.
and deemed appropriate by LHJ.
12 Participate with regional Health Care Coalition Submit mid-year and end of year December 31,2019
(HCC)in the information sharing process during progress reports documenting and June 30,2020
incidents and at least one planning process or participation and information
exercise conducted to inform on the roles and sharing during incident(s),
responsibilities of public health. planning process(es),and/or
exercises .
13 Participate in development of Disaster Clinical Submit mid-year and end of year December 31,2019
Advisory Committee(DCAC)meetings as progress reports documenting and June 30,2020
appropriate.May include identifying local clinical participation in DCAC.
participants,attending meetings via webinar and
reviewing planning efforts.
14 Participate in HCC planning process to update Submit mid-year and end of year December 31,2019
plans by reviewing coalition plans for alignment progress reports. and June 30,2020
with local ESF8 plans.
15 Complete an evaluation of your response Document evaluation participation December 31,2019
capabilities based on a standard evaluation tool in the mid-year and end of year and June 30,2020
provided by DOH. progress reports.
16 Produce a budget plan including a detailed 12- Submit budget plan using DOH- August 1,2019
month spending plan demonstrating how the LHJ provided template.
plans to spend the funds during this period of
performance,using a budget template provided by
DOH.
Note:20%of LHJ's annual allocation will be
withheld until this requirement is met.Failure to
meet this requirement may result in DOH
redirecting funds from the LHJ.
Exhibit A,Statements of Work Page 25 of 26 Contract Number CLH 18253-10
Revised as of July 15,2019
AMENDMENT#10
*For Information Only:
Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a
Standard/Measure. More detail on these and/or other Public Health Accreditation Board(PHAB)Standards/Measures that may apply can be found at:
littp://www.phaboard.orp/wp-content/uploads/PH AB-Standards-and-Measures-Version-1.O.pdf
Program Specific Reauircments/Narrative
Any subcontract/s must be approved by DOH prior to executing the contracts.
Deliverables are to be submitted to the ConCon deliverables mailbox at concondeliverablesaa,doh.wa. og_v
Special Requirements
Federal Fundin¢Accountability and Transparency Act(FFATA)
This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act(FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Data Universal Numbering System(DUNS®)number.
Information about the LHJ and this statement of work will be made available on USASyending_gov by DOH as required by P.L. 109-282.
Restrictions on Funds
Please reference the Code of Federal Regulations:
https://www.ecfr.gov/cgi-bin/retrieveECFR?ep=1&SID=58ffddb5363a27f26e9d l2ccec462549&tv=HTML&h=L&mc=true&r=PART&n=pt2.1.200#se2.1.200 1439
DOH Program Contact
Karen Kenneson,Admin Operations Supervisor
Department of Health
P O Box 47960,Olympia, WA 98504-7960
360-236-4075/karen.kenneson@doh.wa.gov
Exhibit A, Statements of Work Page 26 of 26 Contract Number CLHI 8253-10
Revised as of July 15,2019
EXHIBIT B-10
ALLOCATIONS Contract Number: CLH18253
Mason County Public Ilealth Date: July 15,2019
Contract Term:2018-2020
Indirect Rate as of January 2018: 13.71% DOH Use Only
Indirect Rate as of January 2019:14.53% Funding Chart of
BARS Statement of Work Chart of Accounts g
Revenue Funding Period Funding Period Period Accounts
Federal Award Total
Chart of.Accounts Program Title Identification# Amend# CFDA* Code** Start Date End Date Start Date End Date Amount Sub Total
NEP 5-6 Onsite Sewage Management OOJ88801 Amd 2,8 66.123 333.66.12 01/01/18 06/30/19 10/01/14 08/31/19 $10,904 $85,330 $85,330
NEP 5-6 Onsite Sewage Management OOJ88801 N/A,Amd 8 66.123 333.66.12 01/01/18 06/30/19 10/01/14 08/31/19 $74,426
PS SSI 1-5 OSS Task 4 OIJ18001 Amd 2,8 66.123 333.66.12 01/01/18 06/30/19 07/01/17 06/30/19 ($13,337) $86,541 $86,541
PS SSI 1-5 OSS Task 4 OIJ18001 N/A,Amd 8 66.123 333.66.12 01/01/18 06/30/19 07/01/17 06/30/19 $99,878
FFY17 EPR PHEP BPI LHJ Funding NU90TP921889-01 Amd 2 93.069 333.93.06 07/01/17 07/02/18 1/17 07/02/18 $19,062 $28,979 $28,979
FFY17 EPR PHEP BPI LHJ Funding NU90TP921889-01 N/A 93.069 333.93.06 01/01/18 06/30/18
FFY18 EPR PHEP BPI Supp LHJ Funding NU90TP921889-01 Amd 5 93.069 333.93.06 07/01/18 06/30/19 07/01/18 06/30/19 $888 $49,341 $49,341
FFY18 EPR PHEP BPI Supp LHJ Funding NU90TP921889-01 Amd 4 93.069 333.93.06 07/01/18 06/30/19 07/01/18 06/30/19 $48,453
FFY19 PHEP BPI LHJ Funding NGA Not Received Amd 10 93.069 333.93.06 07/01/19 06/30/20 07/01/19 06/30/20 $49.342 $49,342 $49,342
NU17CE002734 Amd 8 93.136 333.93.13 09/01/18 09/31/19 09/01/18 08/31/19 $35,000 $110,000 $173,027
FFY18 Prescription Drug OD-Supp
FFY18 Prescription Drug OD-Supp NU17CE002734 Amd 4 93.136 333.93.13 09/01/18 O8/31/19 09/Ol/18 08/31/1 $29,
08/31/188 $
627
FFY17 Prescription Drug OD-Supp U17CE002734 Amd 2 93.136 333.93.13 01/O1/18 09/31/18` 09/01/17 , $63,027
08/31/18 $33
FFY17 Prescription Drug OD-Supp U17CE002734 N/A 93.136 333.93.13 01/01/18 08/31/18 09/01/17 ,400
00
FFY17 Increasing Immunization Rates N14231P000762 Amd 3,4 93.268 333.93.26 07/01/18 06/30/19 07/01/18 06/30/19 $5,600 $5,600 $5,600
FFY20 PPHF Ops NH23IP922619 Amd 9 93.268 333.93.26 07/01/19 06/30/20 07/01/19 06/30/20 $500 $500 $1,000
PPHF Ops NE23IP000762 Amd 3,4 93.268 333.93.26 07/01/18 06/30/19 07/01/18 06/30/19 $500 $500
FFY17 5NH231P000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/18 04/01/17 06/30/18 $1,423 $1,423 $1,423
FFY17 PPHFO 317 5NH231P000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/18 04/01/17 06/30/18 $4,293 $4,293 $4,293
FFY17AFC Ops NH23IP922619 Amd9 93.268 333.93.26 07/01/19 06/30/20 07/01/19 06/30/20 $5,600 $5,600 $7,828
FFY20
FFY17 VFC Ops 5NH231P000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/I8 04/01/17 06/30/18 i $2,228 $2,228
FFY20 MCHBG LHJ Contracts NGA Not Received Amd 10 93.994 333.93.99 10/01/19 09/30/20 10/01/19 09/30/20; $67,694 $67,694 $191,503
9 MCHBG LHJ Contracts B04MC32578 Amd 4 93.994 333.93.99 10/01/18 09/30/19 10/01/18 09/30/19� $67,694 $67,694
FFY1
FFY1 MCHBG LHJ Contracts B04MC31524 Amd 2 93.994 333.93.99 01/01/18 09/30/18 10/01/17 09/30/IV $5,344 $56,115
FFY18 MCHBG LHJ Contracts B04MC31524 N/A 93.994 333.93.99 01/01/18 09/30/18 10/01/17 09/30/18 $50,771
Amd 3 N/A 334.04.90 07/01/18 06/30/19 07/01/17 06/30/19 $5,000 $5,000 $5,000
FY2 Group B Programs for DW(FO-SW)
Page I of 3
EXHIBIT B-10
Mason County Public Health ALLOCATIONS Contract Number: CLUIS253
Contract Term:2018-2020 Date: July 15,2019
Indirect Rate as of January 2018:13.71%
Indirect Rate as of January 2019: 14.53% DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Revenue Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# CFDA* Code** Start Date End Date Start Date End Date Amount Sub Total Total
GFS-Group B(FO-SW) Amd 10 N/A 334.04.90 07/01/20 12/31/20 07/01/19 06/30/21 $2,500 $2,500 $7,500
GFS-Group B(FO-SW) Amd 10 N/A 334.04.90 07/01/19 06/30/20 07/01/19 06/30/21 $2,500 $2,500
GFS-Group B(FO-SW) N/A N/A 334.04.90 01/01/18 06/30/18 07/01/17 06/30/19 $2,500 $2,500
Healthy Communities Amd 11) N/A 334.04.91 07/01/19 06/30/20 07/01/19 06/30/21 $1,370 $1,370 $1,370
SFY2 Lead Environments of Children Amd 4 N/A 334.04.93 07/01/18 06/30/19 07/01/18 06/30/19 $1,500 $1,500 $4,500
SFY1 Lead Environments of Children Amd 2 N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/18 $1,500 $3,000
SFYI Lead Environments of Children Amd 1 N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/18 $1,500
Rec Shellfish/Biotoxin Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 $3,500 $3,500 $11,000
Rec Shellfish/Biotoxin N/A N/A 334.04.93 01/01/18 06/30/19 07/01/17 06/30/19 $7,500 $7,500
Wastewater Management-GFS Amd9 N/A 334.04.93 07/01/20 12/31/20 07/01/19 06/30/21 $30,000 $30,000 $120,000
Wastewater Management-GFS Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 $30,000 $30,000
Wastewater Management-GFS Amd5 N/A 334.04.93 07/01/18 06/30/19 07/01/17 06/30/19 $43,274 $43,274
Wastewater Management-GFS Amd 5 N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/19 ($43,274) $16,726
Wastewater Management-GFS N/A,Amd 5 N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/19 $60,000
FPHS Funding for LHJs Amd 11) N/A 336.04.25 07/01/20 12/31/20 07/01/19 06/30/21 $42,000 $42,000 $126,000
FPHS Funding for LHJs Amd 10 N/A 336.04.25 07/01/19 06/30/20 07/01/19 06/30/21 $42,000 $42.000
FPHS Funding for LHJs Dir Amd 3 N/A 336.04.25 07/01/18 06/30/19 07/01/17 06/30/19 $42,000 $42,000
YR 20 SRF-Local Asst(15%)(FS)-SS Amd 3 N/A 346.26.64 01/01/18 12/31/18 07/01/17 12/31/18 ($12,000) $0 $0
YR 20 SRF-Local Asst(15%)(FS)-SS N/A,Amd 3 N/A 346.26.64 01/01/18 12/31/18 07/01/17 12/31/18 $12,000
YR 21 SRF-Local Asst(15%)(FS)SS Amd 10 N/A 346.26.64 01/01/18 06/30/19 07/01/17 06/30/19 ($13,600) $11,200 $11,201)
YR 21 SRF-Local Asst(15%)(FS)SS Amd 7,10 N/A 346.26.64 01/01/18 06/30/19 07/01/17 06/30/19 $800
YR 21 SRF-Local Asst(15%)(FS)-SS Amd 6, 10 N/A 346.26.64 01/01/18 06/30/19 07/01/17 06/30/19 $12,000
YR 21 SRF-Local Asst(15%)(FS)-SS Amd 3,10 N/A 346.26.64 01/01/18 06/30/19 07/01/17 06/30/19 $12,000
YR 22 SRF-Local Asst(15%)(FO-SW)SS Amd 10 N/A 346.26.64 01/01/19 12/31/19 07/01/19 06/30/21 $13,600 $13,600 $13,600
Sanitary Survey Fees(FO-SW)-SS State Amd 7 N/A 346.26.65 01/01/18 12/31/19 07/01/17 12/31/19 $800 $24,800 $24,800
Sanitary Survey Fees(FO-SW)-SS State Amd 6 N/A 346.26.65 01/01/18 12/31/19 .`07/01/17 12/31/19 $12,000
Sanitary Survey Fees(FO-SW)-SS State N/A,Amd 3,6 N/A 346.26.65 01/01/18 12/31/19 k 07/01/17 12/31/19 $12,000
YR 20 SRF-Local Asst(15%)(FS)-TA Amd 3 N/A 346.26.66 01/01/18 12/31/18 07/01/17 12/31/18 ($2,000) $0 $0
YR 20 SRF-Local Asst(15%)(FS)-TA N/A,Amd 3 N/A 346.26.66 01/01/18 12/31/18 07/01/17 12/31/18 $2,000
Page 2 of 3
EXHIBIT B-10
Mason County Public Health ALLOCATIONS Contract Number: CLI118253
Contract Term:2018-2020 Date: ,July 15,2019
Indirect Rate as of January 2018: 13.71%
Indirect Rate as of January 2019: 14.53% DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Revenue Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# CFDA* Code** Start Date End Date Start Date End Date Amount Sub Total Total
YR 21 SRF-Local Asst(15%)(FS)TA Amd 10 N/A 346.26.66 01/01/18 06/30/19 07/01/17 06/30/19 ($4,000) SO $0
YR 21 SRF-Local Asst(15%)(FS)-TA Amd 6, 10 N/A 346.26.66 01/01/18 06/30/19 07/01/17 06/30/19 $2,000
YR 21 SRF-Local Asst(15%)(FS)-TA Amd 3, 10 N/A 346.26.66 01/01/18 06/30/19 07/01/17 06/30/19 $2,000
YR 22 SRF-Loral Asst(15%)(FO-SW)TA Amd 10 N/A 346.26.66 01/01/19 12/31/19 01/01/19 06/30/21 $2,000 $2,000 $2,000
TOTAL $1,011,177 $1,011,177
Total consideration: $805,771 GRAND TOTAL $1,011,177
$205,406
GRAND TOTAL $1,011,177 Total Fed $684,207
Total State $3269970
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Exhibit C-9 Schedule of Federal Awards AMENDMENT#10
Date:July 16,2019
MASON COUNTY HEALTH SERVICESSWV0001893-04
CONTRACT CLH18253-Mason County Public Health
CONTRACT PERIOD: 01/01/2 01 8-1 2/31120 20
DOH Total Amt Allocation Period
Chart of Accounts Program Title BARS Federal Federal Start End Contract Amt CFDA CFDA Program Title Federal Agency Name Federal Award Federal Grant Award Name
Award Date Award Date Date Identification Number
Puget Sound Action Agenda:
PS SSI 1-5 OSS TASK 4 333.66.12 08/02/16 $5,000,000 01/01/18 06/30/19 $86,541 66.123 Technical Investigations and Environmental Protection Agency 01J18001 PUGET SOUND SHELLFISH
Implementation Assistance Region 10 STRATEGIC INITIATIVE LEAD
Program
Puget Sound Action Agenda:
NEP 5-6 ONSITE SEWAGE MANAGEMENT 333.66.12 01/09/11 $2,490,000 01/01/18 06/30/19 $85,330 66.123 Technical Investigations and Environmental Protection Agency OOJ88801 PUGET SOUND RESTORATION
Implementation Assistance Region 10 PROJECT
Program
NGA Not NGA Not Public Health Emergency Department of Health and Human
FFY19 PHEP BPI LHJ FUNDING 333.93.06 Received Received 07I01/19 06/30I20 $49,342 93.069 Preparedness Services Centers for Disease Control NGA Not Received NGA Not Received
and Prevention
Department of Health and Human HOSPITAL PREPAREDNESS
FFY18 EPR PHEP BPI SUPP LHJ FUNDING 333.93.06 08/O1/18 $11,062,782 07/01/18 06/30/19 $49,341 93.069 Public Health Emergency Services Centers for Disease Control NU90TP921889-01 PROGRAM AND PUBLIC HEALTH
Preparedness EMERGENCY PREPAREDNESS
and Prevention COOPERATIVE AGREEMENT
Public Health Emergency Department of Health and Human HPP AND PHEP COOPERATIVE
FFY17 EPR PHEP BPI LHJ FUNDING 333.93.06 07/18/17 $11,062,782 01/01/18 06/30/18 $28,979 93.069 Preparedness Services Centers for Disease Control NU90TP921889-01 AGREEMENT
and Prevention
Injury Prevention and Control Department of Health and Human PRESCRIPTION DRUG OVERDOSE
FFY18 PRESCRIPTION DRUG OD-SUPP 333.93.13 05/31/17 $6,223,623 09/O1118 08/31/19 $110,000 93.136 Research and Stale and Services Centers for Disease Control U17CE002734 FOR STATES
Community Based Programs and Prevention
Injury Prevention and Control Department of Health and Human PRESCRIPTION DRUG OVERDOSE
FFY17 PRESCRIPTION DRUG OD-SUPP 333.93.13 03/16/16 $4,031,632 01/01/18 08/31/18 $63,027 93.136 Research and State and Services Centers for Disease Control U17CE002734 FOR STATES
Community Based Programs and Prevention
Immunization Cooperative
Department of Health and Human
FFY20 VFC OPS 333.93.26 07/01/19 $9,234,835 07/01/19 06130/20 $5,600 93.268 IMMUNIZATION GRANT AND
Agreements Services Centers far Disease Control NH231P922619 VACCINES FOR CHILDREN PROGRAM
and Prevention
Department of Health and Human
Immunization Cooperative IMMUNIZATION GRANT AND
FFY20 PPHF OPS 333.93.26 07I01/19 $9,234,835 07/01/19 06/30/20 $500 93.268 Agreements Services Centers for Disease Control NH231P922619 VACCINES FOR CHILDREN PROGRAM
and Prevention
Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND
FFY17 VFC OPS 333.93.26 03/03/17 $1,201,605 01/01/18 06/30/16 $2,228 93.268 Agreements Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND
FFY17 PPHF OPS 333.93.26 06/29/18 $3,634,512 07/01I18 06/30/19 $500 93.268 Agreements Services Centers for Disease Control NH231P000762 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND
FFY17 INCREASING IMMUNIZATION RATES 333.93.26 06/29/18 $1,722,443 07/O1/18 06/30/19 $5,600 93.268 Agreements Services Centers for Disease Control NH231P000762 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND
FFY17 AFIX 333.93.26 03/03/17 $1,672,289 01/01/18 O6/30I18 $4,293 93.268 Immunization
Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
Immunization Cooperative Department of Health and Human IMMUNIZATION GRANT AND
FFY17 317 OPS 333.93.26 03/03/17 $575,969 01I01118 06/30118 $1,423 93.268 Agreements Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S
and Prevention PROGRAM
NGA Not NGA Not Maternal and Child Health Services Department of Health and Human
FFY20 MCHBG LHJ CONTRACTS 333.93.99 Received Received 10/01/19 09/30/20 $67,694 93.994 Block Grant to the States Services Health Resources and NGA Not Received NGA Not Received
Services Administration
Maternal and Child Health Services Department of Health and Human MATERNAL AND CHILD HEALTH
FFY79 MCHBG LHJ CONTRACTS 333.93.99 11114118 $2,225,977 10I01/18 09/30119 $fi7,694 93.994 Block Grant to the States Services Health Resources and B04MC32578 SERVICES BLOCK GRANT
Services Administration
Page 1 of 2
Exhibit C-9 Schedule of Federal Awards AMENDMENT#10
Date:July 16,2019
MASON COUNTY HEALTH SERVICES-SWV0001893-04
CONTRACT CLH18253-Mason County Public Health
CONTRACT PERIOD: 01/01/2018-12/31/2020
DOH Total Amt Allocation Period
Chart of Accounts Program Title BARS Federal Federal Start End Contract Amt CFDA CFDA Program Title Federal Agency Name Federal Award Federal Grant Award Name
Award Date Award Date Date Identification Number
Maternal and Child Health Services Department of Health and Human MATERNAL AND CHILD HEALTH
FFY18 MCHBG LHJ CONTRACTS 333.93.99 10/20/17 $1,650,528 01/01/18 09/30/18 $56,115 93.994 Block Grant to the States Services Health Resources and B04MC31524 SERVICES
Services Administration
TOTAL $684,207
Page 2 of 2