HomeMy WebLinkAboutWashington State Department of Health Amendment # 12 MASON COUNTY PUBLIC HEALTH.
• '2018—2020 CONSOLIDATED CONTRACT `
MC Contract#20-01.3
CONTRACT.NUMBER: CLH182S3 AMENDMEN.1 NUMBER.: 12
PURPOSE OF:CHANGE: Toamend this contract between the.DEPARTMENI'.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 andany subsequent.
amendments thereto.
iT._LS MUTUALLY AGREED: That the contract is hereby ainended 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:
• Amends'Statements,af Work for the following programs:
O Childhood Lead Poisoning-Prevention Program -Effective July'1,2019'
a Office of Drinking Water Group A Progratii - Effective January 1,201:8
o Office of Emergency Preparedness&Response-Effective July 1,2019
❑ Deletes Statements of Work forthe;'following programs:
2. Exhibit B12 Allocations,attached and incorporated by this reference,ai lends and replaces Exhibit 13-11:Allocutions
as follows:
• Increase of$24,400 for revised maximum consideration of$1,085,577.
❑ Decrease of .for.a revised maximum consideration of .
❑ No change in themaximum consideration of
Exhibit:13 Allocations are attached only for informational purposes_
Unless designated otherwise herein,the effective date of this amendment is the(late of execution.
AlL.OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments teinain iit full force
and effect.
IN WITNESS WHEREOF,the undersigned has affixed his/her signature 10 execution thereof.
MASON COUNTY PUBLIC HEALTH STATE OF-WASHINGTON
DEPARTMENT OF,HI3ALTH
e:› 02/q/e -O.
Date to
APPROVED AS TO FORM ONLY
• Assistant Attorney General
•
Page 1.of 16
AMENDMENT#12
2018-2020 CONSOLIDATED CONTRACT
EXED3IT A
STATEMENTS OF WORK
TABLE OF CONTENTS
DOH Program Name or Title: Childhood Lead Poi'soning Prevention Program-Effective July 1,2019 3
DOH Program Name or Title: Office of Drinking Water Group A Program-Effective January 1,2018 6
DOH Program Name or Title: Office of Emergency Preparedness&Response-Effective July 1,2019 11
Exhibit A,Statements of Work Page 2 of 16 Contract Number CLH1S'253-12
Revised as of November 15,2019
AMENDMENT#12 ,.
Exhibit A
Statement,of Work
Contract Term: 2018-2020 -
DOH Program Name or Title: Childhood Lead Poisoning Prevention Program- LocaI Health Jurisdiction Name: Mason County Public Health
Effective July 1.2019
Contract Number: CLHI 8253
SOW Type: Original Revision•#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
❑Federal <Select One> (check if applicable) EI Reimbursement
Period of Performance: July 1.2019 through June 30.2020 ®State 0 FFATA(Transparency Act) 0 Fixed Price
0 Other ❑Research&•Development
Statement of Work Purpose: The purpose of tbis 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:, The purpose of this revision is to move the funding from Healthy Communities(MI 25611100)to FPH Lead Case Mgmt-FP1I(MI 25619702)for funding
period 07/01/19-06/30/20: The SOW and total consideration remains the same.
Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change, Total
Revenue Index (LHJ Use Only) Consideration None Consideration
Code Code Start Date End Date.
Healthy.Communities N/A 334.04.91 25611I00 07/01/19 06/30/20 1,370 -1,370 0
FPI-Lead Case Mgmt-FPH . . N/A 334.04:93 1 256.19702: 07/01/19 . 06/30/20 0 1,37.0 1,370
TOTALS 1,370 0 1,370
Task *May Support PHAB Due Date/Time Payment Information
Task/Activity/Description Deliverables/Outcomes
Number Standards/Measures Frame and/or Amount
1 Home Visit I 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 S5(10 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 3 or of the.environmental'assessment
HUD housing,and if the child is Medicaid and.suggestions for reducing or
enrolled. eliminating exposure. Provide a
copy of this document or
Exhibit A.Statements of Work Page 3 of 16 Contract Number CLH18253.12
Revised as of November 15,2019
AMENDMENT#12
Task Task/Activity/Description "May Support PHAB Deliverables/Qufcomes. Due Date/Time Payment Information
Number Standards/Measures Frame and/or Amount
f) Provide educational material to the child's documents to the child's
caregivers in the family's primary language. caregivers and provider.
g) Arrange with family and provider to have the
child retested following the Pediatric
Environmental Health Specialty Unit(PEHSU)
medical management guidelines:
httns://www.pehsu.net/ Library/facts/medical
mgmnt-childhood-lead=exposure-June 2013.pdf
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 S500 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 http:Ihy w.parenthelp123.oral b) The names of any at-risk
or otherr 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.)
Exhibit A.Statements of Work Page 4 of 16 Contract'Number CLH18253-12
Revised as of November 15.2019
AMENDMENT 412
*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.oraIwp-content/uploads1PHAB-Standards-and-Measures-Version-1.0.ndf
Program Specific:Requirements/Narrative
Program Manual,Handbook,Policy References
Guide for Public Health Case Management of Children with Elevated Blood Lead Levels
httos://www.doh.wa.cov/Portals/liDocuments/4000/334-414.pdf
A'Targeted Approach to.Blood Lead Screening in Children,Washington State
2015 Expert Panel Recommendations
httpsiliwww.doh.Wa.gov/Portals/l/Documents/Pubs/334-385.pdf
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 laboratory,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 maybe 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:amv.bertrand(adoh.wa_gov,
Exhibit A,Statements,of Work Page 5 of:]6, Contract Number CLH 18253-12•'
Revised as of November 15,2019
AMENDMENT#12
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: .CLHI 5253
SOW Type: Revision Revision#(for this SOW) 5 Funding Source Federal Compliance Type of Payment
®Federal Contractor (check`if applicable) ❑Reimbursement
Period of Performance: January 1.2018 through December 3 L.2020 State 0 FFATA(Transparency Act) El Fixed Price
Other 0 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_ofthis revision is to extend funding periods from 12/31/19 to 12/31/20 for Yr22 SRF SS,TA and SS-State,increase Total Consideration to
incorporate 2020 SS and TA,and revise Special Billing Requirements and Special Instructions:
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
Yr 20 SRF-Local Asst(I5%o)(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 12/31/20 24,800 11,200 36;000
Yr20 SRF-Local Asst(15%)'(FS) TA N/A 346.26.66 24139220 01/01/18 12/31/1S 0 0 0
Yr 21 SRF-Local Asst.(15%)(FS) SS N/A 346.26.64 24139221 01/01/18. 06/30/19 11,200 0 11,200
Yr 21 SRF-Local Asst(15%)(FS) TA N/A 346.26.66 24139221 01/01/18 06/30/19 I 0 0 0
Yr 22 SRF-Local Asst(15%)(FO-SW)SS N/A 346.26.64 .24239222 01/01/19 I2/31/20 I 13,600 11,200 24,800
Yr.22 SRF-LocaI Asst(15%)(FO-SW)TA N/A 346.26.66 24239222 01/01/19 12/31/20 2,000 2,000 4,000
TOTALS 51,600 24,400 76,000
Task Task/Activity/Description *May Support PHA13 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 •• • :, •r 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 6 of 16 Contract Number CLHI$253-12
Revised as of November 15,.2019
AMENDMENT#12.
Task Task/Activity/Description 'May Support.PHAS 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,aIll 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 staffwill 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$800 for each
of small community and non- documents and photos to received by the SPI.
community Group A water systems ODW Regional Office. ODW Regional
identified by the.ODW`Regional - Office within 2 Payment is inclusive of all associated costs
Office. working days of the such as travel,lodging,per diem.
service request:
See Special Instructions for task Payment is authorized upon•receipt and
activity. acceptance of completed SPI Report within
the 2 working day deadline.
•
Late or incomplete reports may not be
accepted for payment.
Exhibit A.Statements of Work Page 7 of 16 Contract Number CLH 18253-12
Revised as of November 15,2019
•
AMENDMENT#12
Task Task/Activity/Description *May Support PHAB' Deliverables/Outcomes Due Date/Time Payment Information and/or Amount •
Number Standards/Measures Brame
3 Trained LHJ staff will provide direct Provide completed TA Completed TA Upon acceptance of the completed TA
technical assistance(TA)to small Report and any supporting Report must be Report,the LHJ shall be paid for each
community and non-community documents and photos to received by the technical assistance activity as follows:
Group A water systems identified by ODW Regional Office. ODW Regional • Up to 3 hours of work:$'250
the ODW Regional Office. Office within 30 0 3-6 hours of work:S500
calendar days of e. More than 6 hours of work:S750
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.govlresourcesltravel.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:I/www:phaboard.org/up-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf
Program.Specific Requirements/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 8 of 16 Contract Number CLH 1 S253-12
Revised as of November I5,2019
AMENDMENT#12.
'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 invoke the quarter and year being billed for.
Payment cannot exceed a maximum accumulative fee of S49,600 S72,000 for Task 1,and 2 00 S4,0000 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 O.TA Date and.description of TA work performed,and Amount Billed.
Wheninvoicing for Task 4,submit receipts and thesignedpre-authorization form for non-employee travel to the ODW Program Contact below and a signed A19-IA 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 Technicalassistance(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.
o No more than 0 surveys of non=community systems with three or fewer connections to be completed between January 1,2018 arid December 31,2018.
o No more than 28 surveys of non-community systems with four or more connections and all community systems to be completed between January I_,2018 and
December 31,2018.
o No more than 10 surveys of non-community systems with three or fewer connections to be completed between January 1,20I9 and December 31,2019.
o 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.
4 No snore than 14 surveys of nor7-communiiysystems with three or-fewer connections to be completed between:lanrtar : 1.2020 and December 31.2020.
• No more t an.21 surreys of non-conrrr.rtnh; systems with.four or more connections and all community*vents to be completed between:lanuaty 1.2020 and
December 31.2020.
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;I,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 9 of 16 Contract Number CLH 18253-12
Revised as of November 15.2019
AMENDMENT#12
If required trainings,workshops or meetings are not available;notscheduled.or ifthe LHJstaff person is unable to attend these activities prior to.conducting assigned"tasks,the
LHJ staff person may,with ODW approval,substitute othertraining activities to be determined by ODW.Such substituteactivities 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 Mannal,Handbook,.Policy
http://ww*.doh.wa.gov/PoitalS/1/DoctimentS/Pubs/331-486:ndf
DOH Prograni Contact DOH Fiscal Contact
Denise Miles Karena McGovern
DOH Office of Drinking Water DOH"Office of Drinking Water
243"Israel Rd SE- 243 Tsrael Rd SE.
Tumwater,WA 95501 Tumwater,WA 98501
Denise.Miles@doh.wa.gov- Karena_McGovern{'?a doh.wa.gov
(360)236-3028 (360)236-3094
Exhibit A.Statements of Work Page 10 of 16 ' 2
Revised as"of November 15.2019 Contract Number CLH 1 S_2o� L
AMENDMENT#12
Exhibit A
Statement of Work
Contract Term:3018-2020 •
DOH Program Name or Title:. Office of Emergency Preparedness&Response.- Local Health Jurisdiction Name: Mason County Public Health
Effective July.I.2019
Contract Number CLHI 8253`
SOW Type: Revision. Revision#(for this SOW):I Funding Source Federal Compliance Type.of Payment
®Federal Subrecipient (check if applicable) ®Reimbursement
Period of Performance: July L 2019 through 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: The purpose of this revision is to add regional or statewide to scope of emergency preparedness events to be attended,spell out acronyms,update several
deliverables and due dates to match activities,clarify health•care coalition participation and deliverable,;and update DOH contact;information.
Chart of Accounts Program Name or Title CFDA f BARS Master Funding Period Current. Change .Total
Revenue Index (LHJ Use Only) Consideration None Consideration
Code Code Start Date End Date
FFYI9 PREP BP1.LHJ FUNDING 93.069 333.93,06 31102190 07/01/19. -06/30/20 49,342 0 49,342
TOTALS .. 49,342 0 . 49.342.. .
Task *May Support PHAB Due Date/Time Pa ment"
y
Task/Activity/Description Deliverables/Outcomes Frame Information and/or
Number Standards/Measures Amount
I 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)to advance LHJ regional or'ctctteiaicle : exceed total funding
preparedness or complete the deliverables in this consideration amount
statement of
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 3 1,,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.,
Exhibit A.Statements of Work Page 11 of 16 Contract Number CLH18253-12
Revised as of November 15.2019
•
AMENDMENT#12
Task *May Support PHAB Due Date/TimePayment
Tasl/Activity/Description Deliverables/Outcomes Information and/or
Number Standards/Nteasures Frame
Amount
Submit documentation of
participation in trainines. If
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.Tole in the
LHJ for receiving alerts from DOH,;and.include all emergency response plan.
critical LI-U 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 3I,:2019
progress reports. and June 30,2020
6.1)'Participate in at least,one risk communications
webiinar 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 ofthe'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.
6.3)Participate in at least one risk communications
drill conducted by DOH.Drill will occur via
webinar,conference call,and email.. Drill will test
Lars 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:12"of`16 Contract Number CLH 18253-12
Revised as of November 15.2019
AMENDMENT#12
Task *May Support PHAB" Due Date/Time Payment
Task/Activity/Description (Deliverables/Outcomes Information and/or
Number Standards/Measures Frame Amount
6.4)Conduct a hot wash evaluating LHJ Submit Ddocumentation of items Within 90 days of the.
participation in the drill. - identified in,hot wash in midyear rah'-1a-= ter-than
and end glycol*reports- :f:ne 300.202
December'34, 2019
and.June 30, 2020 •
6.5)Participation in a real-world incident will Submit documentation of Within 90 days of the
satisfy the need to participate in a communications participation in incident including end of the incident,
drill. communication methods and tools but no later than
used.Submit After'etia'?Review June 30,2020
(AAR).
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 41 LHJs are not required to maintain a Hub;
LHJs may partner with other organizations to
centralize distribution.
Note#2:.DOH will provide technicalassistance 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-S8S-0838 or hanalert(a doh:wa.t ov 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)
Exhibit A.Statements of Work Page 13 of 16 Contract Number CLHI S253-12,
Revised as:of November 1.5.2019
AMENDMENT 412
Task XM[ay'Support PRAB Due::Date/Tiine Payment
Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or .
Amonnt _
'9 Produce and provide situation reports documenting Submit mid-year.and end of year December 31,2019
.LHJ activityto 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 maybe 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,
HANALERT( doh.wa aov. 2020
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 duringan incident. .
? .iltcntircgiol7a!1-lealth C^r-2Ccaliti5'n-ditti4e- ETr` a: a :d snd o, yca1- e.r71?^:•21. 200'9
tN A li o A. 1$ r?et`` : progrest7 r 1 ores fi) ;1FFfRF?f;7: r _ .2 -i
Re j-A9PME-C-9P i-Fd : ptiV i icipr7Eret7 ii:meeting: and�C-A.
i1.7.71'(%lis.`P/C:tFi l-i scan be 7ter:7ded:'r: ti ei in-c
we'�/ncr or in person),as requested'.LT WCC Lead
e:ri dz.‘einal.pprc prick:7.i•LII]. . . .
: Partieif eas-i iw! lealt/7 Car:C-aalitfetr. Submit laid tear c d et7 eir Deeem&r 31,2019
{JrCCJ in t r:,c infoia1ctioll s?ea-ing p ros cs 11.7-rng, f � r is ice i met ti:n •an-iii:s,301, 2220
inc:dents ai _ p.,7-ricipl,;icin xis'i,7rarmHa:S?n
,:.\ercice candu 'eilc ill,' - ' '1 ;ki .. e-a.- .. -
t sp ns-lb.ilities-f,f—giubli-health, f.lanning-p#eeessfes2-ate'.4.
exercise1 i). .
;, •Participate in d elopr +rt-ef$isas:'4r Clim al . Subi,iir and 3--2ar cih crd of y;:aF em 31.2010
.l it'isen Ca:nF-diet:'-(- - -to"ctin s as -s-- ee deenni:nrrn ti:i i.Jvn:. lry.2020
appropriate.opriate. .M4May 117::It ilenti 1#1 JO l-aliTh'e l parttcipa a
per-ffcip-xf7isS, atte1 ing inccrttlgs i'tc u e I car and
re:le-wing planning'efThra..
44. Pat.'t ip ote in-11 C plcnning:proeess io update Submi,4-mid year and end f ye a' ee r= -40/-9
pans&r rein: "in ,:oagtiot plans--or alignmetrz pt-.o re s-f•epot'tx- rntd.Iaae 30. 0..-0
wilt 1:cal Ent.:t 7 ' rii.T.ePt-F-tenetian S:Public
. !' ; r 2ces(ESI4.3'-61-ans:.
11 Regional healthcare coalition" Submit:mid tear and end ofyear December 31,:2019
Participate in: progress-reports documenting and June 30.2020
- health Cat-e coalition(!/CC)district activities.meeting and/or inform RERC of
. jurisdictional-input fdis'tricrmeetirigs can be
Exhibit A.Statements.of Work Page 14 of 16 Contract Number CLH15253-12
Revised as of November 15.2019
..... .
,.
. . . A.MENDMENT#12
. "
. .. . ...,.
. . Task . .-- -TaSklAdtivitY/Destription eliVerables/OutcomeS
*May Support PHAB-... Due Date/Time, ' Inforniation aild/or •
Number :.IStandards/Measures" -D . Frame. . Amnt
, .
..
. . .
. .
• • attendedi!la webinar.or.in person);:as , . . , • . .
., . .
. re4itesteabp:HCC Lead and deetned . . •
,
., . .
' . appropriate by'LTIJ:,
. „
. ..
. :--.. J',itin7inatian.sharingprocess dw-ing'ineidenis":
iihd.:. tle dst one.planning proce.ssr'ar exercise.
., aancincted to.fiffornton the.rates and ,.
•
responsibilitieS,o,fpnblic health.
..
, : •- Development-afIDLiaster.Clinical rtdiiiio
' . .. . , *
Compritt .(ee13cAqineetings'.:as appr opri ate.
Mayhiehtliefident6Ing localClinleal . . .„ .
' -
,—
. .
participantsdttending meetings via webinar
,.
and reig*Iivi plann'ink4forts'.
- Reldemiing HCC Plani for alignment.with
• local Einerency Stipp&t Mena tien:8;.?Oita
,. .
. ... .„ :Health and Iviedical:Sekleeth(ESF8)plaki",
Complete an evaluation of your response' • .': Document evaluation participation • ,,Dec,...vntleile- 4+444-9,,,.
l'Y capabilities based On.a standard evaluation tool ; • , : in the oititi-ywr and end of year : .endRine.30;2020
„. provided by DOH— .. .. .., . . . , , „ . • '..„•• progress report'.
I-4 .Producc.a.budizet plan inelitclitia•a:detailed I.2,,. - :,.. :Subfnithitdoet plan asinu..'D01-14 - A imust 1.2014:-
/.5: :.month,Speading;:p144.dernOnStiatifia how:ihe:LItl41, . ;prosiided4eMplat66 . .
plans to•Spend'ithe'-tandS:dtarinz this period,of:,
. .
)ettOrnianee;i*nikA:hadgetjteMplate provided6ypon
-.. .
. .
. .
l'
NOte:.120°70'ofL111,7slannual:allocation.Wilbe
• Withheld'untiLthis requirement is:Met.',PagtFc:,td
met . :: • " . • .
.•, :. . ,. -;,: ,,,E,,„,;.,,, ,.,••e ...,,,,, ,- .,, —,
this,itegtorpnent mayresplt,m,ppii ,
. . . ... directing,ftnidSlrOinhetai. , .. , -.. ' :-. . . . 1 ", ,. . .. .. .. ,
*For Information Only: • . .. „ ,. , .
Funding is not tiedtolhe revised Standards/Measures listed here. ThiS:inforination'may be helpful in discussions of how prOgrarn•aCtiVities•iniaht•contribute to meetinge
Standard/IVieasure. More detail on these and/Or other Public Health Accreditation Board(PHAB)Standards/Measures that may apPly can be found at;
http://wwW:phaboard.ore.Vp-contenduplOadi/PHAB-StandardS;;and-MeasureS-Version4.0.pdf
Program Specific Requirements/Narrati've: ,,,,,, . • -;,,.1. . - . . . .
',6.nySittiepntfact/s4mSt,be!pitt00:bypOlstririfc:).: 474iiiiii.iii;;; .iiirai 7C',.17.sj;
•
Ple:046,•,1?14,,iithite.6,. 4$ tat*?:tte.:qpiicoo.,,deltir6..riibles mailb6YaticOndoridativerableSta'aiaiOv':
. ,
Exhibit A,,Statements of Work Page 15 of 10, Contract Number.CLH1S253-12
Revised as of NoVember'15.:20T9'
— ,
AMENDMENT#I2
Special Requirement
Federal Funding 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 USASpending.gov by DOH as required by P.L.'109-282.
Restrictions on Funds
Please reference the Code of Federal Regulations:
https://www.ecfr.gov/egi-bin/retrieveECFR?�p=l&SIID=S$ffddb53b3a27 6e9d12ccec462549&tv=IiTML&sh=L&ma=truer=PARTRm=pa.1 200#se2.1.200 1.4339
DOH Program Contact
Tort:flenderson, Coniracts& SpecialiIsr
Department of Health
P 0 Box 47960,Olympia,WA 98504-7960
310 236 107'5/karea.let . .r'' • ._
360-236-45961 corn hende,soii(u:doh.wa golf
Exhibit A.Statements of Work Page 16 of 16 Contract Number CLHI82533-12
Revised as of November 15,2019
EXH1BIT•B-12
Mason County Public Health ALLOCATIONS Contract Number: CLH1S2o3
Contract Tcrm:3018-2020 Date: November 15„2019
Indirect Rate as of January 2018:13.71%
Indirect Rate as of January 2019:1453.4 Usc Only
BARS Statement ofWork Chart:of Accounts • Funding Chart of
Federal Award Revenue Funding Period rundrng Period"'. Period Accounts
Chart of Accounts Program Title Identification Amend# CFDAR Code** Start Date End Date StartDateErid:�Datc Amount Sub Total Total
NEP'5=6 Onsite Sewage Management 00JSSSOI Amd 2,S 66.123 333.66.12 01/01/1S 06/30/19 10/01/14 OS/31/19 S10,904 $85.330 $35,330
NEP 5-6 Onsite Sewage Management 00JSSSO1 N/A.Amd S 66:123 333:66.12 01/01/1S 06/30/19 10/01/14' OS/3 1/19 S74.426
PS SST 1-5 OSS Task4 0IJIS001 Amd 2,S. 66.123 333.66.12 '01/01/1S 06/30/19 "07/01/17 •0656/19' (S13,337) $S6,541' $86.541
PS SSI 1-5 OSS Task 4 01J18001 N/A.Amd S 66.123 333.66.12 '01%01/1 S 06/30/19 07/01/17 '06/30/19 "S99.S7S
FFY17 EPR PHEP BPI LHJ Funding NU90TP921839-0I Amd 2 93.069 333.93.06 01/01/1S 06/30/IS 07/01/17 07/02/1S $9.062 $28,979 $28.979
FFYI7 EPR PHEP BPI LHJ Funding NU90TP921SS9-01 N/A 93.069 333,93.06 01/01/IS 06/ 0/1S" 07/01117 07/02/1S $19.917
FFYIS EPR PHEP.BP1 Supp LHJ Funding NU90TP9213S9-01 Amd 5 93.069 333.93.06 07/01/18 .06/30/19 •07/0111S 06/30/19 SSSS S49.341 S49,341
FFYISEPRPEEP BPI Supp LI.1J Funding NU9OTP921SS9-01 Amd4 93.069 333.93.06 07/01/18 06/30/19 07/01/1S 06/30/19 t $48.453
FF'Y19 PREP BP1 LHJ Funding NU90TP922043 •Amd 10 93.069 333.93.06 07/01.119 06/30/26 07/01/19 06/;0P0 i 849.342 S49,342 S49.342
•
FFY19Overdosc Data to Action Prey NU17CE925007 Amd 11 93.136 333.93.13 09/01/19. OS/31/20 09/61/19 • 0S/31/20 S50,000 S50.000 S50.000
FFYI S Prescription Drug OD-Supp NU17CE002734 Amd S 93.136 333.93.13 09/01/1S OS/3 1/19 09/01/1S :OS51/19, S35.000 .$110,000 $173.027
FFYIS Prescription DrugOD-Supp NU17CE002734 Amd4 93.136 333.93.13 09/01/IS -OS/31/19 09/01/18 OS/ 1/19 S75.000
FFYI7 Prescription Drug OD-Supp U17CE002734 Amd2 93.136 333.93.13 .01/01/1S 0S51718 09/0I/I7 0S51/1$ S29.627 S63.027
FFY17 Prescription Drug OD-Supp U17CE002734' N/A 93.136 333.93.13 01/01/1S OS/31/IS 09/01/17 08/31/1S": $33.400
FFY17 Increasing-Immunization Rates NH231P000762> Amd 3.4 93.268 333.9326 07/01/IS 06/30/19 07/01/1S 0650/19: S5,600 S5,600 $5.600
FFY20 PPHF Ops NH231P922619 Amd 9 93268 333.93.26 07/01/19 06/30/20 07/01/19 06/30/20': $500 $500 $1.000
FFYI7PPHFOps NH231P000762 Amd 3.4' 93265 333.9326 07/01/IS 06/30/19 .07/01/18 06/30/i9r', $500 S500
FFY17317Ops 5NH231P000762-05-00 N/A 93268 333.9326 01/01/1S 06/30/18 04/6111i 065011S= 81.423 SI423 51.423
FFY17AF11 .5N1-1231P000762-05-00 N/A 93268 333.9326 01/01/IS 06/30/18 '04/01/17 06/30/18 S4.293 S4_293 $4.293
FFY20 VFC Ops NH231P922619 Amd 9 93.268 .333.93 26 07/01/19 06/30/20 07/01/19 06/30/20' 35.600 S5,600 $7,828
FFY17 VFC Ops 5NH23IP000762-05-00 N/A 93.268 333.9326 01/01118 .06/30/18 ,04/01/17 0br0/1`S" S2.228 S�22S
FFY20 MCI-IBG LI-IJ Contracts B04MC3257S Arnd 10 93.994 .333.93.99 )0/01/19 09/30/20 10/01/19 09130/26r. S67,694 S67.694 $1914503
FFYI9MCHBG LHJ Contracts B04MC3257$ -Amd4 93.994 333.93.99 10/01/1S. 09/30/19 10/01/tS 09/30/19 S67,694 S67.694
FFYIS MCHBG LI.1J Contracts B04MC31524 Amd2 '93.994 333.93.99 01/01/18 `:0950/IS 10/01/17 09I 0/1S. S5.344 S56.115
FFYIS.MCHBG LHJ Contracts B04MC31524 N/A 93:994 333.93.99 01/01/1S 09/30/1S 1001/17 09/30/lS S50.771"
FY2 Group BPrograms for DW(FO-SW) Amd 11 N/A 334.04.90" 07/0I/1 S 06/30/19 07/01/17 06/30/19`• ($272) 54,72S $4,725
FY2 Group B Programs for DW(FO-SW) Amd 3 N/A 334.04.90 07/0,1/IS 06/30/19 07/01/17 06/30/19' S5.000
Page 1 of 3
EXHIBIT B-I2
Mason County Public Health ALLOCATIONS Contract Number: CLH1S253
Contract Term:2018-2020 Date: .November 15..2019
Indirect Rate as of January 201S: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# - *. Y' ate End Datc Start Datc End Date - Amount Sub Total Total
.emend.. CFDA Code" Start Da
GFS-Group B(FO-SW) Amd 10 N/A 334.04.90 07/01/20 12/31/20 07/01/19, 06/30/21` 52.500 $2.500 57.500
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 01/01/1S 06/30/1S 07/01/17 06/30/19 $2.500 $2,500
Op Permit Fees(FO-SW) Amd 11 N/A 334.04.90 02/01/19 02/2S/19 07/01/17 .06/30/19'? $272 $272 $272
Healthy Communities Amd'.12 NIA 334.04.91 07/01/19 06/30/20 07/01/19. 06/30/21' (51,370) SO SO
HealthyCommunidcs Amd 10. N/A 334.04.91 07/01/19 06/30/20 07/01/19 0680/21' $1.370
Tt'HI Lead Case M int-FPIE Amd 12 N/A 3334.04.93 07/01/19 06/30/20 7/.1/19 06/30/20;. S1a70 S1570 S1,3370
SFY2LeadEnvironmentsofChildren Amd4 N/A 334.04.93 07/01/1S 06/30/19 07/01/1S 06/30/19 S.1.500 S1500 $4.500
SFY1 Lead Environments of Children Amd 2 N/A 334.04.93 01/01/1S 06/30/1S 07/01/17 06/30/IS' S1,500 53.000
SFYI Lead Environments orChildren Amd1 N/A 334.04.93 .01/01/1S 06/30/1S 07/01/17 06/30/15. 31.500
Res Sheilfish/Biotosin Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 $3,500 $3500 S11.000
RccShellfishBiotoxin N/A N/A 334.04.93 01/01/IS 06/30/19 07/01/17 "06/30/19` S7.500 S7,500
Wastewater Management-GFS Arad N/A 334.04.93 07/01/20 12J3120 07/0I/19' 06/30/21' 330,000 .S30.000 S120.000
Wastewater Management-GFS Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 _06/30/21 S30,000 S30.000
Wastewater Management-GFS Amd 5 N/A 334.04.93 07/01/1S 06/30/19 07/01/17 06/30/19 S43 274 $43 274
Wastewater Management-GFS Amd5 N/A 334.04.93 01/01/1S 06/30/1S 07/01/17 "0650/19 (S43274) SI6.726
Wastewater Management-GFS N/A.Amd 5 N/A 334.04.93. .01/01/18 06/30/1S 07/01/17 06/30/19` 560.000
FPHS Funding for LHJs Amd 10 N/A 336.04.25 07/01/20 12/31/20 07/01/19 06/30/21 $42.000 S42,000 S126,000
FPHS Funding for LHJs Amd 10 N/A 336.04.25 07/01/19 06/30/20 .07/01/19 06/30/21 542.000 S42.000
FPHS Funding for LHJs Dir Amd 3 N/A 336.04.25 07/01/1S 06/30/19 07/01/17 06/30/19 542,000 S42.000
YR2O`SRF-Local Asst(15%)(FS)-SS Amd3 N/A 34626.64 01/01/1S 12/31/1S 07/01/17 I2/31/1$ (512.000) SO S0
YR 20 SRF-Local Asst(15%)(FS)-SS N/A.Amd 3 N/A 346_26.64 01/01/1 S 12/31/1S 07/01/17 =12/31/IS` S12,000
YR2I SRF-Local Asst(15%)(FS)SS Amd 10 N/A 346.26.64 01/01/IS 06/30/19 .07/01/17-:06/30/19 ($13,600) S1 I200 SI1?00
YR 21 SRF-Local Asst(15%)(FS)SS Amd 7.10 N/A 346 26.64 01/01/IS 06/30/19 07/01/17 ,06/30/I9' SS00
YR 21 SRF-Local Asst(15%)(FS)-SS Amd 6.10 N/A 346.26.64 01/01/1S 06/50/19 07/01/17, 06/30/19 $12,000
YR2ISRF-LocalAsst.(15%)(FS)-SS Amd3.10 N/A 346.26.64 :01/01/1S, 06/30/19 07/01/17 06/30/19 S12.000
YR:22,SRF-Local Asst(15%)(PO-SW)SS hand 12 N/A 344 26.641 01/01/19 12/31/20 07/01/19 06/3021`. S11,200 $24 300 52 .$00
YR 22 SRF-Local Asst(15%)(FO-SW)SS Mid 10. 12 N/A 346.26.64 01/01/19 12/31/20 07/01/19 .06/ 0/31 S 13.600
Page 2 of 3
.............................. .
EXHIBIT B-12
Mason County Public Health ALLOCATIONS Contract Number: CLIIIS2SS
Contract Term:201S-2020 Date: November'15„2019'
Indirect Rate as of January 20 I S:13.71%
Indirect Rate as of January 2019:14.5 3% D.013 Usc'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 R CFDA* Codex* Start Date End Date Start Datc•End'Date Amount Sub Total Total
SanitaryStmc} Fccs(FO=S\\)-S5State Amd 12 NIA 346.26.6S 01/01/1S. 12/31/20 07/01/17 '0,6/30/1V 511;200 S36.000 536.000
San itary Survey Fccs(FO-SW)-SS State Amd 7.12 N/A 346.26.65 :01/01/18 12/31/20 07/01/17 06/a0/21 SSOO
Sanitary Survey Fees(FO-SW)-SS State Amd 6.12 N/A 346:26.65 01/01/1S 12/31/20 07/01/17 06/30/21 S12.000
Sanitary Survey Fees(FO-SW)-SS`Statc N/A.Amd 3.6.12 N/A 346.26.65 01/01/1 S 12/31/2 r 0 07/01/17 .060/21' 512.000
YR'20 SRF-LocalAsst(la%)(FS)-TA Amd3 N/A 34626.66 01/01/18 12131/1S 07/01/17 12/31/151', (S20001 SO SO,
YR20 SRF-Local Asst(15%)(FS)-TA N/A.Amd3 N/A 346.26.66 01/01/IS 12/31/1S :'07/01/17 12/31/1S'' S2.,000
YR 21 SRF-Local Asst(15%)(FS)TA Amd 10 N/A 346 26.66 01/01/1 S 06/30/19 07/01/17 06/.10/19 (S4,000) SO SO
YR 21 SRF-Local Asst(15%)(FS)-TA Amd 6..10 N/A 346.26.66 01/01/18 06/30/19 07/01117 6130119;:. S2.000
YR 21 SRF-.Local Asst(I S%)(FS)-TA Amd3.10 N/A 346 26 66 01/01/1 S 06/30/19 07/01117 06r0/12" S2.000
\'R 22 SRF=Loral Asct(T5%)(FO-SV)TA Amd 12 \/A 346.26-66 :01/01/19 12/31/20 01/01/19 06130/21'' 52 090 5 t:01110 54.000
YR 22 SRF-Local Asst(15%)(FO-SW)TA Amd 10.12 N/A 346.26.66 01/01/19 .12/31/26 01/0011/19 r06130/21:' S2.000
TOTAL S1.085.577 S1,085.577
Total consideration: 51,061.177 GRAND TOTAL 51.085.577
S24.400
GRAND TOTAL 51.0S5.577 Total Fcd S734.207
Total State S351.370
"Catalog of Federal Domestic Assistance:
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of3.