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Home My WebLink AboutWashington State Department of Health Amendment # 03C MASON COUNTY PUBLIC HEALTH 2018 - 2020 CONSOLIDATED CONTRACT NTRACT NUMBER: CLH18253 AMENDMENT NUMBER: 3 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: 0 FPHS Communicable Disease & Support Capabilities - Effective January 1, 2018 Office of Immunization & Child Profile-Perinatal Hepatitis B - Effective July 1, 2018 OICP-Promotion of Immunizations to Improve Vaccination Rates - Effective July 1, 2018 Amends Statements of Work for the following programs: 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-3 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-2 Allocations as follows: x rei Increase of $53,100 for a revised maximum consideration of $480,036. 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-3 Schedule of Federal Awards, attached and incorporated by this reference, amends and replaces Exhibit C-2. 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 y Dk-1 Date Date APPROVED AS TO FORM ONLY Assistant Attorney General Page 1 of 15 AMENDMENT #3 DOH Program Name or Title: DOH Program Name or Title: DOH Program Name or Title: DOH Program Name or Title: DOH Program Name or Title: 2018-2020 CONSOLIDATED CONTRACT EXHIBIT A STATEMENTS OF WORK TABLE OF CONTENTS FPHS Communicable Disease & Support Capabilities - Effective January 1, 2018 3 Office of Drinking Water Group A Program - Effective January 1, 2018 6 Office of Drinking Water Group B Program - Effective January 1, 2018 10 Office of Immunization & Child Profile-Perinatal Hepatitis B - Effective July 1, 2018 12 OICP-Promotion of Immunizations to Improve Vaccination Rates - Effective July 1, 2018 14 Exhibit A, Statements of Work Page 2 of 15 Contract Number CLH18253-3 Revised as of May 15, 2018 AMENDMENT #3 Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or Title: FPHS Communicable Disease & Support Capabilities - Effective January 1, 2018 SOW Type: Original Revision # (for this SOW) Period of Performance: January 1, 2018 through August 15, 2019 Local Health Jurisdiction Name: Mason County Public Health Contract Number: CLH18253 Funding Source ❑ Federal <Select One> ® State ❑ Other Federal Compliance (check if applicable) ❑ FFATA (Transparency Act) ❑ Research & Development Type of Payment ❑ Reimbursement ® One -Time Distribution Statement of Work Purpose: The purpose of this statement of work is to specify how Foundational Public Health Services (FPHS) state funds will be used. Note: The total lump sum payment for SFY18 (07/01/17-06/30/18) was distributed to LHJs in their 2015-2017 Consolidated Contracts that ended 12/31/17. This statement of work is to include tasks and deliverables for the remainder of SFY18 (01/01/18-06/30/18) and SFY19 (07/01/18-06/30/19) in the 2018-2020 Consolidated Contracts. Revision Purpose: N/A Chart of Accounts Program Name or Title CFDA # BARS Revenue Code Master Index Code Funding Period (LHJ Use Only) Start Date End Date Current Consideration Change Increase (+) Total Consideration FPHS FUNDING FOR LHJS DIR (Funding for SFY18 was distributed to LHJs in 2015-2017 Consolidated Contracts. The funding amount shown as Current Consideration in this Statement of Work is for Informational Purposes Only.) N/A 336.04.25 91106102 01/01/18 06/30/18 42,000 0 42,000 FPHS FUNDING FOR LHJS DIR N/A 336.04.25 91106102 07/01/18 06/30/19 0 42,000 42,000 TOTALS 42,000 42,000 84,000 Task Number Task/Activity/Description Impact Measures Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount 1 These funds are for delivering ANY or all of the Percent of toddlers and SFY18 (07/01/17-06/30/18) By 08/15/18 SFY19 (07/01/18-06/30/19) FPHS communicable disease service and can also school age children that Report: Actual Activities funds are available be used for the FPHS capabilities that support FPHS communicable disease services as defined have completed the standard series of and Estimated Expenditures beginning July 1, 2018 and the full year allocation will in the most current version of FPHS Definitions — recommended vaccinations. SFY19 (07/01/18-06/30/19) Work Plan: Planned By 08/15/18 be dispersed upon receipt of the SFY18 Report and Version 1.3 (November 2017) Percent of new positive Activities and Projected SFY19 Work Plan. Control of Communicable Disease and Other Notifiable Conditions Hepatitis C lab reports that are received electronically which have a completed case report. Spending Exhibit A, Statements of Work Revised as of May 15, 2018 Page 3 of 15 Contract Number CLH18253-3 AMENDMENT #3 Task Number Task/Activity/Description 1-1. Provide timely, statewide, locally relevant and accurate information statewide and to communities on prevention and control of communicable disease and other notifiable conditions. 1-2. Identify statewide and local community assets for the control of communicable diseases and other notifiable conditions, develop and implement a prioritized control plan addressing communicable diseases and other notifiable conditions, seek resources and advocate for high priority prevention and control policies and initiatives regarding communicable diseases and other notifiable conditions. 1-3. Promote immunization through evidence based strategies and collaboration with schools, health care providers and other community partners to Increase immunization rates. 1-4. Ensure disease surveillance, investigation and control for communicable disease and notifiable conditions in accordance with local, state and federal mandates and guidelines. See activities in the definitions. Impact Measures Deliverables/ tutco m es Percent of new positive Hepatitis C case reports with completed investigations. Percent of Gonorrhea cases investigated. Percent of Gonorrhea cases investigated that are receiving dual treatment (treatment for both Gonorrhea and Chlamydia. at the same time) Percent of newly diagnosed syphilis cases that receive partner services interview. Due Date/Tine Frame SFY l 9 (07/01/18-06/30/19) Report: Actual Activities and Estimated Expenditures (Note: Use OH. online tool for reports and work plans. See Special Instructions below.) Payment Information and/or Amount By 08/15/19 Program Specific equirements/Narrative Special References (RCWs, WACs, etc) • Immunizations — http://www.doh.wa.gov/YouandYourFamily/Immunization • Notifiable Conditions - http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/NotifiableConditions ® Sexually Transmitted Diseases (STD) — http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/SexuallyTransmittedDisease ® Human Immunodeficiency Virus (HIV) — http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/HIVAIDS Tuberculosis (TB) — http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/Tuberculosis Hepatitis C (HCV) - https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/NotifiableConditions/HepatitisC G Definitions ® FPHS Definitions, Version 1.3, November 2017 Exhibit A, Statements of Work Page 4 of 15 Revised as of May 15, 2018 Contract Number CLH18253-3 AMENDMENT #3 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 E J ealth 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 — Version 1.3, November 2017 SAO's BARS Manual — http://www.sao.wa.gov/local/pages/BARSManual.aspx Deliverables are to be submitted via the DOH online reporting tool at: https://www.surveymonkey.com/r/FPHS_2018 Note: This online tool replaces previously provided Word document reporting templates. DOH Program Contact Marie Flake, Special Projects, Foundational Public Health Services Washington State Department of Health PO Box 47890, Olympia, WA 98504-7890 Phone 360-236-4063 / Mobile 360-951-7566 Fax 360.236.4024 / marie.flake@doh.wa.gov DOH Program Contact Jaimie Hayes, Health Services Consultant Health Systems Transformation and Innovation Washington State Department of Health PO Box 47890, Olympia, WA 98504-7890 Phone 360-236-4262 / jaimie.hayes@doh.wa.gov Exhibit A, Statements of Work Revised as of May 15, 2018 Page 5 of 15 Contract Number C 1118253-3 AMENDMENT #3 Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or 'Title: Office of Drinking Water Group A Program - Effective January 1, 2018 SOW Type: Revision Revision # (for this SOW) 1 Period of Performance: January 1, 2018 through December 31, 2020 Local Health Jurisdiction Name: Mason County Public Health Contract Number: CLH 18253 Funding Source EXI Federal Contractor State IOther Federal Compliance (check if applicable) ❑ FFATA (Transparency Act) ❑ Research & Development Type of Payment ❑ Reimbursement Z Fixed Price 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 change end date in Funding Period from 12/31/20 to 12/31/18 and change chart of accounts title and MI for SS and TA. Chart of Accounts Program Name or 'Title CFDA # BARS Master index Code Funding Period Current Change Total Revenue (L:'J Start Date Use Only) End Date Consideration None Consideration Code Yr 20 SRF - Local Asst (15%) (FS) SS N/A 346.26.64 24139220 01/01/18 12/31/18 12,000 -12,000 0 Sanitary Survey Fees (FO-SW) SS -State N/A 346.26.65 24232522 01/01/18 12/31/18 12,000 0 12,000 Yr 20 SRF - Local Asst (15%) (FS) TA N/A 346.26.66 24139220 01/01/18 12/31/18 2,000 -2,000 0 Yr 21 SRF - Local Asst (15%) (FS) SS N/A 346.26.64 24139221 01/01/18 12/31/18 0 12,000 12,000 Yr 21 SRF - Local Asst (15%) (FS) TA N/A 346.26.66 24139221 01/01/18 12/31/18 0 2,000 2,000 TOTALS 26,000 0 26,000 Number Task Task/Activity/Description xMay Standards/Measures Support PHA Deliverables/Outcomes Due Date/TimePayment Frame information and/or Amount 1 sanitary and systems of Trained Drinking non -community LHJ surveys identified staff Water of will by (ODW) small Group the conduct community DOH A Regional water Office Provide Survey Regional Sanitary shall 1. significant significant recommendations, Cover observations, include: Reports Final* Survey Office. letter Sanitary to deficiencies, findings, identifying Complete Reports ODW and Final Survey must the Office calendar conducting sanitary ODW be Sanitary within Reports received survey. days Regional the 30 of by Upon ODW acceptance of the Final be Sanitary paid community connections. Upon Sanitary paid community connections Payment such $400 $800 as ODW travel, Survey Survey is for for inclusive system system acceptance and each each lodging, Report, Report, each sanitary sanitary with with of community all per the three of the four the survey associated survey diem. LHJ LHJ or or Final fewer more shall shall system. of of a a costs be non non - - See activity. Office. Special Instructions for task 2. refen-als ODW Completed follow-up. for further Small Water System checklist. Exhibit A, Statements of Work Revised as of May 15, 2018 Page 6of15 Contract Number CLH18253-3 AMENDMENT #3 Task Number TaskJActivity/Description *May Support PHAB Standards/Measures DOH will provide a tablet and GPS unit for the LHJ to gather source data during a routine sanitary survey. DOH expects the LHJ to commit to using the tablet and GPS for a five-year period. 2 Trained LHJ staff will conduct Special Purpose Investigations (SPI) of small community and non - community Group A water systems identified by the ODW Regional Office. See Special Instructions for task activity. 3 Trained LHJ staff will provide direct technical assistance (TA) to small community and non -community Group A water systems identified by the ODW Regional Office. See Special Instructions for task activity. Deliverables/Outcomes 3. Updated Water Facilities Inventory (WFI). 4. Photos of water system with text identifying features 5. Any other supporting documents. *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. Provide completed SPI Report and any supporting documents and photos to ODW Regional Office. Provide completed TA Report and any supporting documents and photos to ODW Regional Office. ue Date/'T'ime Frame Payment Information and/or Amount Payment is authorized upon receipt and acceptance of the Final Sanitary Survey Report within the 30-day deadline. Late or incomplete reports may not be accepted for payment. Completed SPI Reports must be received by the ODW Regional Office within 2 working days of the service request. Completed TA Report must be received by the ODW Regional Office within 30 calendar days of providing technical assistance. Upon acceptance of the completed SPI Report, the LHJ shall be paid $800 for each SPI. Payment is inclusive of all associated costs such as travel, lodging, per diem. Payment is authorized upon receipt and acceptance of completed SPI Report within the 2 working day deadline. Late or incomplete reports may not be accepted for payment. Upon acceptance of the completed TA Report, the LHJ shall be paid for each technical assistance activity as follows: • Up to 3 hours of work: $250 • 3-6 hours of work: $500 o More than 6 hours of work: $750 Exhibit A, Statements of Work Revised as of May 15, 2018 Page 7ofl5 Contract Number CLH 18253-3 AMENDMEI\ T #3 Number Task Task/Activity/Description *May Standards/Measures Support PHABDeliverabues/tautcomes Due Date/TimePayment information and/or Amount Frame Payment such diem. Payment acceptance the Late accepted 30-day as or consulting incomplete is is for inclusive authorized of deadline. payment. completed fee, reports of upon travel, all TA associated may receipt lodging, Report not and be within costs per Prior to the be diem, Annually LHJ lodging, on with http://www.ofm.wa.gov/resources/travel.asp Website the shall the pre and current -authorization paid registration rates mileage, listed costs form per on in as the accordance approved OFM 4 LHJ under completed staff tasks performing the 1, 2 mandatory and the 3 must activities Sanitary have training, "Authorization attending submit for an Travel Survey Training. (Non -Employee)" DOH Form 710-013 to the ODW See activity. Special Instructions for task Program approval enough funds Contact (to ensure are below available). that for 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 Program Specific Requirements/Narrative Special "': eferences (RCWs, 'PACs, 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. 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 $24,000 for Task 1, and $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 Exhibit A, Statements of Work Revised as of May 15, 2018 Page 8 of 15 Contract Number CLH18253-3 AMENDMENT #3 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 30 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. 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. e 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. 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 http://www.doh.wa.gov/Portals/1/Documents/Pubs/331-486.pdf DOH Program Contact Denise Miles DOH Office of Drinking Water 243 Israel Rd SE Tumwater, WA 98501 Denise.Miles@doh.wa.gov (360) 236-3028 DOH Fiscal Contact Karena McGovern DOH Office of Drinking Water 243 Israel Rd SE Tumwater, WA 98501 Karena.McGovern@doh.wa.gov (360) 236-3094 Exhibit A, Statements of Work Revised as of May 15, 2018 Page 9 of 15 Contract Number CL1-118253-3 AMENDMEt T #3 Exhibit A Statement of Work Contract Term: 2018-2020 OH Program Name or Title: Office of Drinking Water Group B Program - Effective January 1, 2018 SOW Type: Revision Revision # (for this SOW) 1 Period of Performance: January 1, 2018 through June 30, 2019 Local Health Jurisdiction Name: Mason County Public Health Contract Number: CLH18253 Funding Source Federal <Select One> State Other Federal Compliance (check if applicable) ❑ FFATA (Transparency Act) ❑ Research & Development Type of Payment ❑ Reimbursement Fixed Price 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 from June 30, 2018 to June 30, 2019, Increase Current Consideration, and revise Special Billing Requirements. BARS '; evenue Master Index Code Current Total Change Increase ( + ) Funding Period CFDA # Chart of Accounts Program Name or Title (LIU Use Only) Consideration Consideration Code Start Date End Tate 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 0 5,000 5,000 TOTALS 2,500 5,000 7,500 Task/Activity/Description *May Standards/Measures Support Su ort PHAB Deliverables/Outcomes Agreement Memorandum Number of Information Payment Amount and/or Number Task 1 Implement program. a partial Group B water system An executed joint plan of Reference #N20495 DOH JPR Lump (See Requirements) Special sum payment Billing responsibility identifying partial Group responsibilities (JPR) B program. with DOH of a *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 Program Specific Requirements/Narrative Special Billing Requirements The tiff shall submit a $ 2, 500 invoice before May 15, 2018. The all shall submit three semi-annual invoices as follows: $2, 500 in the first half of each calendar year (no later than May 15) and S2,500 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. Exhibit A, Statements of Work Revised as of May 15, 2018 Page 10 of 15 Contract Number CLH18253-3 AMENDMENT #3 DOH Program Contact Bonnie Waybright, P.E. Southwest Regional Manager DOH Office of Drinking Water 243 Israel Rd SE Tumwater, WA 98501 Bonnie.Waybright@doh.wa.gov (360) 236-3025 DOH Fiscal Contact Karena McGovern DOH Office of Drinking Water 243 Israel Rd SE Tumwater, WA 98501 Karena.Mcgovem@doh.wa.gov (360) 236-3094 • Exhibit A, Statements of Work Revised as of May 15, 2018 Page 11 of 15 Contract Number CLI-I18253-3 AMENDMENT #3 Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or Title: Office of Immunization & Child Profile-Perinatal Hepatitis B - Effective July 1, 2018 SOW Type: Original Revision # (for this SOW) Period of Performance: July 1, 2018 through June 30, 2019 Local Health Jurisdiction Name: Mason County Public Health Funding Source Z Federal Subrecipient ❑ State Other Contract Number: CLH18253 Federal Compliance (check if applicable) Z FFATA (Transparency Act) ❑ Research & Development Statement of Work Purpose: The purpose of this statement of work is to define required Perinatal Hepatitis B activities, deliverables, and funding. Revision Purpose: N/A Type of Payment Reimbursement Fixed Price BARS Revenue Master Index (LHJ Start Funding Date Use Period Only) End Date Current Change Total Chart of Accounts Program Name or Title CFDA # Consideration increase (-1-) Consideration Code Code 93.268 333.93.26 74310284 07/01/18 06/30/19 0 500 500 FFY18 PPHF Ops 0 500 500 TOTALS Task *May Standards/Measures Support PHAB Due ate/Time Frame Payment and/or Information Amount Number Task/Activity/Description Deliverables/Outcomes 1 1. In providers, conduct B Hepatitis including ® infection coordination Identification activities B the and in Prevention. following: accordance health with to of hospitals, prevent plans hepatitis Program with (if perinatal applicable), B health the Guidelines, surface Perinatal care hepatitis identified Enter Hepatitis Information Washington information into B module Immunization System the for Perinatal of each the case By each the month last day of Reimbursement actual not funding amount. to costs exceed consideration rncurred, total for antigen women (HBsAG)-positive and pregnant women pregnant with ® unknown Reporting HBsAg of HBsAg-positive status. women and • their Case infants. management for infants born to HBsAg-positive administration of women hepatitis to ensure B immune globulin (HBIG) and hepatitis B vaccine within the 3-dose 12 hours hepatitis of birth, B vaccine the completion series, and of post vaccination serologic testing. Exhibit A, Statements of Work Revised as of May 15, 2018 Page 12 of 15 Contract Number CLI-I18253-3 AMENDMENT #3 Number Task Task/Activity/Description *May Standards/Measures Support PHAB Deliverablles/Outcomes Payment and/or information Amount Due ate/Time Frame 2. 3. Provide hospitals hepatitis hours Committee recommendations. Report including Perinatal System. Washington of all technical to birth, B HBsAg-positive Hepatitis perinatal birth encourage on State in Immunization dose accordance assistance Immunization B hepatitis to Module administration all infants, newborns to B with Practices of birthing investigations, the Information Advisory in the of within (ACIP) the 12 *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 Program Specific Requirements/Narrative Tasks in this statement of work may not be subcontracted without prior written approval from DOH OICP. Special Requirements 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. Staffing Requirements Provide notification via email to oicpcontracts a►,doh.wa.gov within fifteen (15) days of any changes to staffing for those who conduct work outlined in this statement of work. DOH Contract Manager Tawney Harper, MPA Budget and Operations Manager Office of Immunization and Child Profile Department of Health PO Box 47843, Olympia WA 98504-7843 tawney.harper@doh.wa.gov, 360-236-3525 DOH Program Contact Steffen Burney Perinatal Hepatitis B Coordinator Office of Immunization and Child Profile Department of Health PO Box 4784-3, Olympia, WA 98504-7843 steffen.burney@doh.wa.gov, 360-236-3569 DOH Fiscal Contact Vanessa Mojica Special Projects Coordinator Office of Immunization and Child Profile PO Box 47843, Olympia WA 98504-7843 vanessa.moj ica@doh.wa.gov, 3 60-23 6-3 802 Exhibit A, Statements of Work Revised as of May 15, 2018 Page 13 of 15 Contract Number CLI-I18253-3 AMENDMENT #3 Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or Title: OICP-Promotion of Immunizations to Improve Vaccination Rates - Effective July 1, 2018 SOW Type: Original Revision # (for this SOW) Period of Performance: July 1, 2018 through June 30, 2019 Local Health Jurisdiction Name: Mason County Public Health Contract Number: CLH 18253 Funding Source Federal Subrecipient State Other Federal Compliance (check if applicable) FFATA (Transparency Act) Research & Development Type of Payment Reimbursement Fixed Price Statement of Work Purpose: The purpose of this statement of work is to contract with local health to conduct activities to improve immunization coverage rates. Revision Purpose: N/A Chart of Accounts Program Name or Title BARS Revenue Master Index Code Funding Period Current Change Total CFDA # (LHJ Use Only) Consideration Consideration Start Date End Date Increase (+) Code FFY18 Increasing Iininzs Rates ConCon 93.268 333.93.26 74310285 07/01/18 06/30/19 0 5,600 5,600 TOTALS 0 5,600 5,600 Number Task Task/Activity/Description *MaySupport Standards/Measures pp , PHAB Deliverables/Outcomes Due Date/Time Information Payment and/or Frame Amount 1 Develop coverage promotion community a rates proposal activities partners. for a in to target and improve The collaborating population proposal immunization must by with increasing meet shows for Written the starting target proposal population immunization and a report that rates August 1, 2018 Reimbursement actual not funding amount. See Funds to Restrictions costs exceed below. consideration incurred, total for on guidelines outlined the Local Health Jurisdiction Funding Opportunity, Promotion of Immunizations to Iricrease Vaccination Rates announcement. 2 Upon increase target approval population immunization of identified. proposal, coverage implement rates the with plan the to progress milestones Written report made for describing activities on reaching identified the November March 31, 30, 2019 2018 Reimbursement actual not to costs exceed incurred, total for in provided) the plan (template will be funding amount. See Funds Restrictions below consideration on Exhibit A, Statements of Work Revised as of May 15, 2018 Page 14 of 15 Contract Number CLI-I18253-3 AMENDMENT #3 Task Number Task/Activity/Description *May Support PFIAB Standards/Measures Deliverables/Outcomes 3 Conduct an evaluation of the interventions implemented. Final written report, including a report showing ending immunization rates for the target population (template will be provided) Due Date/Tine Frame June 15, 2019 Payment Information and/or Amount Reimbursement for actual costs incurred, not to exceed total funding consideration amount. See Restrictions on Funds below *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 Stan dard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: http://www.pllaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version- l .0.pdf Program Specific Requirements/Narrative Tasks in this statement of work may not be subcontracted without prior written approval from DOH OICP. Special Requirements Federal Funding Accountability and Transparency Act (FFATA) byfederal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act). This statement of work is supported � p The of the Transparency Act is to make information available online so the public can see how the federal funds are spent. purpose To comply with this acteligibleperform and be to 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 (what funds can be used for which activities, not direct payments, etc.) Allowable Uses of Federal Operations Funds document (dated 12/20/2017) is posted on the DOH Consolidated Contract website at this link. These federal funds may not be used for expenses related to travel or attendance at anynon-DOH sponsored conference, training, or event without prior written approval from the DOH- Office of Immunization and p Child Profile. Other be sent electronicallyvia email to oic contracts@a doh.wa.gov, by fax to 360-236-3590, or by mail to PO Box 47843, Olympia WA 98504-7843 Deliverables may P DOH Program Contact Tawney Harper, MPA Budget and Operations Manager Office of Immunization and Child Profile Department of Health PO Box 47843, Olympia WA 98504-7843 tawney.harper@doh.wa.gov / 360-236-3525 Exhibit A, Statements of Work Revised as of May 15, 2018 DOH Fiscal Contact Vanessa Mojica Special Projects Coordinator Office of Immunization and Child Profile Department of Health PO Box 47843, Olympia WA 98504-7843 vanessa.mojica@doh.wa.gov /360-236-3802 Page 15 of 15 Contract Number CLH18253-3 07/16/2018 09:32 CaseyB F O R 2018 06 ACCOUNTS FOR: 300 DEPARTMENT Mason County YEAR-TO-DATE BUDGET REPORT ORIGINAL APPROP Mason County, WA G REVISED BUDGET YTD EXPENDED MTD EXPENDED ENCUMBRANCES nt Financial System p g lytc$hud AVAILABLE PCT BUDGET USED 000 ADMIN/GENERAL OPERATING 150.000000.300.000.321.20.353000.0000.00. 150.000000.300.000.321.20.354000.0000.00. 150.000000.300.000.321.20.356000.0000.00. 150.000000.300.000.321.20.357000.0000.00. 150.000000.300.000.321.20.358000.0000.00. 150.000000.300.000.322.10.352010.0000.00. 150.000000.300.000.322.10.354000.0000.00. 150.000000.300.000.333.66.312010.0000.00. 150.000000.300.000.333.66.312030.0000.00. 150.000000.300.000.333.66.312040.0000.00. 150.000000.300.000.333.66.312300.0000.00. 150.000000.300.000.333.93.310300.0000.00. 150.000000.300.000.334.03.310000.0000.00. 150.000000.300.000.334.04.390010.0000.00. 150.000000.300.000.334.04.393000.0000.00. 150.000000.300.000.334.04.393010.0000.00. 150.000000.300.000.346.20.352000.0000.00. 150.000000.300.000.346.20.353000.0000.00. 150.000000.300.000.346.20.353010.0000.00. 150.000000.300.000.346.20.354000.0000.00. -3,100 -34,000 -102,000 -18,000 -5,000 0 -127, 000 0 -151, 213 - 79,060 0 0 -37,269 -5, 000 - 48,000 0 -49, 000 - 15, 000 - 40,000 -150,000 SOLID WAST - 3,100 LIQUID WST - 34,000 FOOD PERM - 102,000 FOOD HAND -18,000 LIVG ENVIR - 5,000 REVENUE 0 SEPTIC SYS - 127, 000 OYSITE SEW 0 NEP PIC - 151,213 HCPIC - 79, 060 PS SSI 1-5 0 FDA GRANT 0 COOR PREVN - 37,269 GROUP B -5,000 CON CON - 48, 000 WASTE GFS 0 CHGS SRVCS -49,000 CIIGS SRVCS - 15,000 TIPPING FE - 40,000 CHGS SRVCS -150,000 -720.00 - 36,550.00 - 93,249.00 - 8,472.00 - 5,050.00 - 3,750.00 - 93,860.00 - 18,820.00 - 29,206.00 - 32,479.19 - 38,415.00 -964.09 - 31,995.01 -2,500.00 - 1, 048 . 00 - 24,949.00 -44,060.00 - 3,525.00 -27, 171 . 82 - 93,370.87 .00 1,740.00 045.00 -40.00 .00 - 1,350.00 - 17,560.00 -1,400.00 . 00 - 17,287.67 - 8,806.00 . 00 - 31,995.01 - 2,500.00 -208.00 - 2,256.00 - 6,425.00 .00 .00 - 18,295.00 . 00-2,380.00 23.2%* . 00 2,550.00 107.5% . 00-8,751.00 91.4 . 00-9,528.00 47.1%* . 00 50.00 101.0% . 00 3,750.00 100.0% . 00-33,140.00 73.9%* . 00 18,820.00 100.0% . 00-122,007.00 19.3%* .00-46,580.81 41.1%* . 00 38,415.00 100.0% . 00 964.09 100.0% . 00-5,273.99 85.8%* . 00-2,500.00 50.0%* . 00-46,952.00 2.2%* . 00 24,949.00 100.0% . 00-4,940.00 89.9%* . 00-11,475.00 23.5%* . 00-12,828.18 67.9%* .00-56,629.13 62.2%* Mason County, WA Government Financial System 07/16/2018 09:32 CaseyB FOR 2018 06 ACCOUNTS FOR: 300 DEPARTMENT Mason County YEAR-TO-DATE BUDGET REPORT ORIGINAL APPROP REVISED BUDGET YTD EXPENDED MTD EXPENDED ENCUMBRANCES P 2 glytdbud AVAILABLE PCT BUDGET USED 150.000000.300.000.346.20.354010.0000.00. 150.000000.300.000.346.20.354020.0000.00. 150.000000.300.000.346.20.356000.0000.00. 150.000000.300.000.346.26.364000.0000.00. 150.000000.300.000.346.26.365000.0000.00. 150.000000.300.000.346.26.366000.0000.00. 150.000000.300.000.353.70.300000.0000.00. 150.000000.300.000.369.80.300000.0000.00. TOTAL REVENUES -30 - 400 -90 - 13,600 - 13,600 -2, 000 - 100 0 CHRG SVCS -30 OSS FEE - 400 CHGS SRVCS -90 SANSUR-FED -13,600 SANSUR-ST -13,600 DRNKNGWTR -2,000 NTRAFF INF - 100 CASH ADJ 0 -893,462 -893,462 .00 - 550.00 - 424.00 -7,400.00 -7,400.00 .00 - 250.00 8.00 -606,170.98 . 00 . 00 -166.00 - 7,400.00 - 7,400.00 .00 . 00 -2.00 -128,875.68 . 00 . 00 . 00 . 00 . 00 . 00 -30.00 150.00 334.00 - 6,200.00 - 6,200.00 - 2,000.00 . 0%* 0 137.50 471.10 54.4%* 54 . 4%* . 00 . 00 150.00 250.00 . 00 -8.00 100.0%* . 00-287,291.02 • • • e • • • WOOS 4 .t =' :.,►;: • = •y • 1-* r.iT- r.� Mason County, WA Government Financial System 07/16/2018 09:32 CaseyB FOR 2018 06 Mason County YEAR-TO-DATE BUDGET REPORT ORIGINAL REVISED 3 glytdbud AVAILABLE PCT APPROP BUDGET YTD EXPENDED MTD EXPENDED ENCUMBRANCES BUDGET USED GRAND TOTAL -893,462 -893,462 -606,170.98 -128,875.68 END OF REPORT - Generated by Casey Bingham ** .00-287,291.02 67.8% • -. • CI a owes 49. 41 ;_, r t. _.mom• em0. •