HomeMy WebLinkAboutDepartment of HealthDOH Contract GVL28360-0 Page 1 of 13
Revision March 2021
CONTRACT NUMBER:
GVL28360-0
SUBRECIPIENT *
YES NO
FFATA FORM REQUIRED
YES NO
INTERAGENCY AGREEMENT
Between
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
And
Mason County Public Health
THIS AGREEMENT is made by and between the State of Washington Department of Health, hereinafter
referred to as DOH, and Mason County Public Health, hereinafter referred to as Contractor pursuant to the
authority granted by Chapter 39.34 RCW.
PURPOSE: The purpose of this agreement is to add funds in the FFY23 USDA WIC Client Services
Contracts category to complete staff training in preparation for this agency to provide WIC Nutrition
Program services
THEREFORE, IT IS MUTUALLY AGREED THAT:
STATEMENT OF WORK AND BUDGET: The Contractor shall furnish the necessary personnel,
equipment, material and/or services and otherwise do all things necessary for or incidental to the
performance of the work set forth in Exhibit A, attached hereto and incorporated herein.
PERIOD OF PERFORMANCE: Subject to its other provisions, the period of performance of this
Agreement shall commence on Date of Execution and be completed on September 30, 2023, unless
terminated sooner as provided herein. Any work done outside of the period of performance shall be
provided at no cost to DOH.
FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA): If checked
above, this Agreement 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 federal funds are spent.
To comply with the act and be eligible to enter into this Agreement, your organization must have a Data
Universal Numbering System (DUNS®) number. A DUNS® number provides a method to verify data
about your organization. If you do not already have one, you may receive a DUNS® number free of charge
by contacting Dun and Bradstreet at www.dnb.com.
Information about your organization and this Agreement will be made available on
www.USASpending.gov by DOH as required by P.L. 109-282. DOH’s form, Federal Funding
Accountability and Transparency Act Data Collection Form, is considered part of this Agreement and must
be completed and returned along with the Agreement.
DOH Contract GVL28360-0 Page 2 of 13
Revision March 2021
PAYMENT: Compensation for the work provided in accordance with this Agreement has been established
under the terms of RCW 39.34.130. The parties have estimated that the cost of accomplishing the work
herein will not exceed $92,600.00 in accordance with Exhibit A, attached hereto and incorporated herein.
Compensation incudes but is not limited to all taxes, fees, surcharges, etc. Payment will not exceed this
amount without a prior written amendment. DOH will authorize payment only upon satisfactory completion
and acceptance of deliverables and for allowable costs as outlined in the statement of work and/or budget.
Source of Funds:
Federal: $92,600.00 State: $-0- Other: $-0- TOTAL: $92,600.00
Contractor agrees to comply with applicable rules and regulations associated with these funds.
BILLING PROCEDURE: Payment to the Contractor for approved and completed work will be made by
warrant or account transfer by DOH within 30 days of receipt of the invoice. Upon expiration of the
Agreement, any claim for payment not already made shall be submitted within 60 days after the expiration
date or the end of the fiscal year, whichever is earlier.
AGREEMENT ALTERATIONS AND AMENDMENTS: This Agreement may be amended by mutual
agreement of the parties. Such amendments shall not be binding unless they are in writing and signed by
personnel authorized to bind each of the parties.
ASSIGNMENT: The work to be provided under this Agreement, and any claim arising thereunder, is not
assignable or delegable by either party in whole or in part, without the express prior written consent of the
other party, which consent shall not be unreasonably withheld.
CONFIDENTIALITY/SAFEGUARDING OF INFORMATION: The use or disclosure by any party of
any information concerning a client obtained in providing service under this Agreement shall be subject to
Chapter 42.56 RCW and Chapter 70.02 RCW, as well as any other applicable Federal and State statutes
and regulations.
Any unauthorized access or use of confidential information must be reported to the DOH Chief Information
Security Officer at security@doh.wa.gov. The notification must be made in the most expedient time
possible (usually within one business day) and without unreasonable delay, consistent with the legitimate
needs of law enforcement, or any measures necessary to determine the scope of the breach and restore the
reasonable integrity of the data system.
CONTRACT MANAGEMENT: The contract manager for each of the parties shall be responsible for and
shall be the contact person for all communications and billings regarding the performance of this agreement.
The Contract Manager for DOH is: The Contract Manager for the Contractor is:
Name: Michael Schweizer Name: {Field1_es_:signer1}}
Office: PCH/ONS Title: {{Field2_es_:signer1}}
Agency: Department of Health Agency: Mason County Public Health
Address: PO Box 47886 Address: 411 North 5th Street
City, State,
Zip: Olympia, WA 98504-7886
City, State,
Zip: Shelton, WA 98584
Phone: (360)236-3714 Phone: (360)427-9670
# - * ) - . &
Commissioner
DOH Contract GVL28360-0 Page 3 of 13
Revision March 2021
DISPUTES: In the event that a dispute arises under this Agreement, it shall be determined by a Dispute
Board in the following manner: Each party to this agreement shall appoint one member to the Dispute
Board. The members so appointed shall jointly appoint an additional member to the Dispute Board. The
Dispute Board shall review the facts, Agreement terms and applicable statutes and rules and make a
determination of the dispute. The determination of the Dispute Board shall be final and binding on the
parties hereto. As an alternative to this process, either of the parties may request intervention by the
Governor, as provided by RCW 43.17.330, in which event the Governor's process will control.
GOVERNANCE: This Agreement is entered into pursuant to and under the authority granted by the laws
of the State of Washington and any applicable federal laws. The provisions of this Agreement shall be
construed to conform to those laws.
In the event of an inconsistency in the terms of this Agreement, or between its terms and any applicable
statute or rule, the inconsistency shall be resolved by giving precedence in the following order:
A. Federal statutes and regulations
B. State statutes and regulations
C. Agreement amendments
D. The Agreement (in this order)
1. Primary document (document that includes the signature page)
2. Statement of Work (Exhibit A)
INDEPENDENT CAPACITY: The employees or agents of each party who are engaged in the
performance of this Agreement shall continue to be employees or agents of that party and shall not be
considered for any purpose to be employees or agents of the other party.
PRIVACY: Personal information collected, used or acquired in connection with this Agreement shall be
used solely for the purposes of this Agreement. Contractor and its subcontractors agree not to release,
divulge, publish, transfer, sell or otherwise make known to unauthorized persons personal information
without the express written consent of the agency or as provided by law. Contractor agrees to implement
physical, electronic and managerial safeguards to prevent unauthorized access to personal information.
DOH reserves the right to monitor, audit or investigate the use of personal information collected, used or
acquired by the Contractor through this Agreement. The monitoring, auditing, or investigating may include
but is not limited to "salting" by DOH. Contractor shall certify the return or destruction of all personal
information upon expiration of this Agreement. Salting is the act of placing a record containing unique but
false information in a database that can be used later to identify inappropriate disclosure of data contained
in the database.
Any breach of this provision may result in termination of the Agreement and the demand for return of all
personal information. The contractor agrees to indemnify and hold harmless DOH for any damages related
to the Contractor's unauthorized use of personal information.
RECORDS MAINTENANCE: The parties to this Agreement shall each maintain books, records,
documents and other evidence which sufficiently and properly reflect all direct and indirect costs expended
by either party in the performance of the services described herein. These records shall be subject to
inspection, review or audit by personnel of both parties, other personnel duly authorized by either party,
the Office of the State Auditor, and federal officials so authorized by law. All books, records, documents,
and other material relevant to this Agreement will be retained for six years after expiration and the Office
DOH Contract GVL28360-0 Page 4 of 13
Revision March 2021
of the State Auditor, federal auditors, and any persons duly authorized by the parties shall have full access
and the right to examine any of these materials during this period.
Records and other documents, in any medium, furnished by one party to this Agreement to the other party,
will remain the property of the furnishing party, unless otherwise agreed. The receiving party will not
disclose or make available this material to any third parties without first giving notice to the furnishing
party and giving it a reasonable opportunity to respond. Each party will utilize reasonable security
procedures and protections to assure that records and documents provided by the other party are not
erroneously disclosed to third parties.
RIGHTS IN DATA: Unless otherwise provided, data, which originates from this Agreement shall be
"works for hire" as defined by the U.S. Copyright Act of 1976 and shall be owned by DOH. Data shall
include, but not be limited to, reports, documents, pamphlets, advertisements, books magazines, surveys,
studies, computer programs, films, tapes, and/or sound reproductions. Ownership includes the right to
copyright, patent, register, and the ability to transfer these rights.
SECURITY OF INFORMATION – Unless otherwise specifically authorized by the DOH Chief
Information Security Officer, Contractor receiving confidential information under this contract assures that:
Encryption is selected and applied using industry standard algorithms validated by the National
Institute of Standards and Technology (NIST) Cryptographic Algorithm Validation Program against
all information stored locally and off-site. Information must be encrypted both in-transit and at rest
and applied in such a way that it renders data unusable to anyone but authorized personnel, and the
confidential process, encryption key or other means to decipher the information is protected from
unauthorized access.
It is compliant with the applicable provisions of the Washington State Office of the Chief Information
Officer (OCIO) policy 141, Securing Information Technology Assets, available at:
https://ocio.wa.gov/policy/securing-information-technology-assets.
It will provide DOH copies of its IT security policies, practices and procedures upon the request of the
DOH Chief Information Security Officer.
DOH may at any time conduct an audit of the Contractor’s security practices and/or infrastructure to
assure compliance with the security requirements of this contract.
It has implemented physical, electronic and administrative safeguards that are consistent with OCIO
security standard 141.10 and ISB IT guidelines to prevent unauthorized access, use, modification or
disclosure of DOH Confidential Information in any form. This includes, but is not limited to, restricting
access to specifically authorized individuals and services through the use of:
o Documented access authorization and change control procedures;
o Card key systems that restrict, monitor and log access;
o Locked racks for the storage of servers that contain Confidential Information or use AES encryption
(key lengths of 256 bits or greater) to protect confidential data at rest, standard algorithms validated
by the National Institute of Standards and Technology (NIST) Cryptographic Algorithm Validation
Program (CMVP);
o Documented patch management practices that assure all network systems are running critical
security updates within 6 days of release when the exploit is in the wild, and within 30 days of
release for all others;
o Documented anti-virus strategies that assure all systems are running the most current anti-virus
signatures within 1 day of release;
o Complex passwords that are systematically enforced and password expiration not to exceed 120
days, dependent user authentication types as defined in OCIO security standards;
DOH Contract GVL28360-0 Page 5 of 13
Revision March 2021
o Strong multi-factor authentication mechanisms that assure the identity of individuals who access
Confidential Information;
o Account lock-out after 5 failed authentication attempts for a minimum of 15 minutes, or for
Confidential Information, until administrator reset;
o AES encryption (using key lengths 128 bits or greater) session for all data transmissions, standard
algorithms validated by NIST CMVP;
o Firewall rules and network address translation that isolate database servers from web servers and
public networks;
o Regular review of firewall rules and configurations to assure compliance with authorization and
change control procedures;
o Log management and intrusion detection/prevention systems;
o A documented and tested incident response plan
Any breach of this clause may result in termination of the contract and the demand for return of all personal
information.
SEVERABILITY: If any provision of this Agreement or any provision of any document incorporated by
reference shall be held invalid, such invalidity shall not affect the other provisions of this Agreement which
can be given effect without the invalid provision, if such remainder conforms to the requirements of
applicable law and the fundamental purpose of this Agreement, and to this end the provisions of this
Agreement are declared to be severable.
SUBCONTRACTING: Neither the Contractor, nor any subcontractors, shall enter into subcontracts for
any of the work contemplated under this agreement without prior written approval of DOH. In no event
shall the existence of the sub operate to release or reduce the liability of the Contractor to DOH for any
breach in the performance of the contractor’s duties. This clause does not include contracts of employment
between the contractor and personnel assigned to work under this Agreement.
Additionally, the Contractor is responsible for ensuring that all terms, conditions, assurances and
certifications set forth in this Agreement are carried forward to any subcontracts. Contractor and its
subcontractors agree not to release, divulge, publish, transfer, sell or otherwise make known to unauthorized
persons personal information without the express written consent of DOH or as provided by law.
If, at any time during the progress of the work, DOH determines in its sole judgment that any subcontractor
is incompetent, DOH shall notify the Contractor, and the Contractor shall take immediate steps to terminate
the subcontractor's involvement in the work. The rejection or approval by DOH of any subcontractor or
the termination of a subcontractor shall not relieve the Contractor of any of its responsibilities under the
Agreement, nor be the basis for additional charges to DOH.
SUSPENSION OF PERFORMANCE AND RESUMPTION OF PERFORMANCE: In the event
contract funding from State, Federal, or other sources is withdrawn, reduced, or limited in any way after
the effective date of this Agreement and prior to normal completion, DOH may give notice to Contractor
to suspend performance as an alternative to termination. DOH may elect to give written notice to Contractor
to suspend performance when DOH determines that there is a reasonable likelihood that the funding
insufficiency may be resolved in a timeframe that would allow performance to be resumed prior to the end
date of this Agreement. Notice may include notice by facsimile or email to Contractor’s representative.
Contractor shall suspend performance on the date stated in the written notice to suspend. During the period
of suspension of performance each party may inform the other of any conditions that may reasonably affect
the potential for resumption of performance.
DOH Contract GVL28360-0 Page 6 of 13
Revision March 2021
When DOH determines that the funding insufficiency is resolved, DOH may give Co ntractor written notice
to resume performance and a proposed date to resume performance. Upon receipt of written notice to
resume performance, Contractor will give written notice to DOH as to whether it can resume performance,
and, if so, the date upon which it agrees to resume performance. If Contractor gives notice to DOH that it
cannot resume performance, the parties agree that the Agreement will be terminated retroactive to the
original date of termination. If the date Contractor gives notice it can resume performance is not acceptable
to DOH, the parties agree to discuss an alternative acceptable date. If an alternative date is not acceptable
to DOH, the parties agree that the Agreement will be terminated retroactive to the original date of
termination.
TERMINATION: Either party may terminate this Agreement upon 30 days prior written notification to
the other party. If this Agreement is so terminated, the parties shall be liable only for performance rendered
or costs incurred in accordance with the terms of this Agreement prior to the effective date of termination.
TERMINATION FOR CAUSE: If for any cause, either party does not fulfill in a timely and proper
manner its obligations under this Agreement, or if either party violates any of these terms and conditions,
the aggrieved party will give the other party written notice of such failure or violation. The responsible
party will be given the opportunity to correct the violation or failure within 15 working days. If the failure
or violation is not corrected, this Agreement may be terminated immediately by written notice of the
aggrieved party to the other.
WAIVER: A failure by either party to exercise its rights under this Agreement shall not preclude that party
from subsequent exercise of such rights and shall not constitute a waiver of any other rights under this
Agreement unless stated to be such in a writing signed by an authorized representative of the party and
attached to the original Agreement.
ALL WRITINGS CONTAINED HEREIN: This Agreement contains all the terms and conditions agreed
upon by the parties. No other understandings, oral or otherwise, regarding the subject matter of this
Agreement shall be deemed to exist or to bind any of the parties hereto.
IN WITNESS WHEREOF, the parties have executed this Agreement.
This contract has been approved as to form by the attorney general.
CONTRACTOR SIGNATURE
{{Sig_es_:signer1:signature}}
DATE
{{Dte_es_:signer1:date}}
PRINT OR TYPE NAME
TITLE
{{*Ttl_es_:signer1:title}}
DOH CONTRACTING OFFICER SIGNATURE
{{Sig_es_:signer2:signature}}
DATE
{{Dte_es_:signer2:date}}
# - * ) - . & — 4 A v A ? A B ? G w C A ˜
9 K D U R Q : U D V N May 2, 2023
CommissionerSharon Trask
May 2, 2023
EXHIBIT A
STATEMENT OF WORK
DOH Contract Number GVL28360-0
Mason County Public Health
DOH Contract GVL28360-0 Page 7 of 13
Revision March 2021
Period of Performance: Date of Execution through September 30, 2023
Statement of Work Purpose: Complete staff training in preparation to provide WIC Nutrition Program services by
following WIC federal regulations, WIC State office policies and procedures, WIC directives, staff training
guidance, and other rules. Refer to the Program Specific Requirements section of this document.
Funding Period: DOE – 9/30/2023
Total Funding: $92,600
Task
# Activity Deliverables/Outcomes Due Date/Time
Frame
Payment
Information
and/or
Amount
1 WIC Nutrition Program
See “Billing
Requirements”
below.
1.1 Hire and train staff:
Competent Professional
Authority staff, as defined by
WIC policy, to determine
participant eligibility,
prescribe an appropriate food
package and offer nutrition
education based on the
participants’ needs.
Registered Dietitian (RD) or
other qualified nutritionist to
provide nutrition services to
high-risk participants, to
include development of a
high-risk care plan. The RD is
also responsible for quality
assurance of WIC nutrition
services. See WIC Policy for
qualifications for a Registered
Dietitian and other qualified
nutritionists.
Breastfeeding Coordinator to
organize and direct local
agency efforts to meet federal
and state policies regarding
breastfeeding promotion and
support. The Breastfeeding
Coordinator must be an
International Board-Certified
Lactation Consultant or attend
an intensive lactation
Certifier Competency
Training Documentation
form and Certifier
Competency Observation
Tool
Nutritionist Orientation
Checklist
IBCLC or intensive
lactation management
course completion
documents.
End of contract
period $85,350
EXHIBIT A
STATEMENT OF WORK
DOH Contract Number GVL28360-0
Mason County Public Health
DOH Contract GVL28360-0 Page 8 of 13
Revision March 2021
Task
# Activity Deliverables/Outcomes Due Date/Time
Frame
Payment
Information
and/or
Amount
management course, or other
state approved training.
1.2 Develop required local agency’s
policies and procedures.
Develop written agreements with other
health care agencies in preparation to
refer participants to these services.
Submit local agency’s
policies and procedures to
LPC for approval.
Submit DSAs to LPC for
approval prior to
execution.
End of contract
period
1.3 Complete and submit entire WIC
Budget Workbook with monthly data
on Rev-Exp Report spreadsheet from
the WIC Budget Workbook monthly
with A-19 monthly.
Budget Workbook and A-
19
End of contract
period
1.4
Complete procurement of office
supplies and furniture for preparation
of delivery of services.
A-19 and back up
documentation
End of contract
period $7,250
Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal grant awards.)
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 p urpose 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 local agency must
have a UEI number.
Information about the local agency and this statement of work will be made available on USASpending.gov by
DOH as required by P.L. 109-282.
Program Specific Requirements
This section is for program specific information not included elsewhere. In SOWs where more than one project is
listed, each requirement must be identified by MI Code.
Program Manual, Handbook, Policy References:
The local agency shall be responsible for providing services according to rules, regulations and other information
contained in the following:
WIC Federal Regulations, USDA, and FNS 7CFR Part 246.
Washington State WIC Nutrition Program Policy and Procedure Manual
Office of Management and Budget, Uniform Administrative Requirements, Cost Principles, and Audit
Requirements for Federal Awards, 2 CFR 200
Farmers Market Nutrition Program Federal Regulations, USDA, FNS 7CFR Part 248
Other directives issued during the term of the contract
Staffing Requirements:
The local agency shall:
EXHIBIT A
STATEMENT OF WORK
DOH Contract Number GVL28360-0
Mason County Public Health
DOH Contract GVL28360-0 Page 9 of 13
Revision March 2021
Use Competent Professional Authority staff, as defined by WIC policy, to determine participant eligibility,
prescribe an appropriate food package and offer nutrition education based on the participants’ needs.
Use a Registered Dietitian (RD) or other qualified nutritionist to provide nutrition services to high risk
participants, to include development of a high-risk care plan. The RD is also responsible for quality
assurance of WIC nutrition services. See WIC Policy for qualifications for a Reg istered Dietitian and other
qualified nutritionist.
Assign a qualified person to be the Breastfeeding Coordinator to organize and direct local agency efforts to
meet federal and state policies regarding breastfeeding promotion and support. The Breastfeed ing
Coordinator must be an International Board Certified Lactation Consultant or attend an intensive lactation
management course, or other state approved training.
Restrictions on Funds (i.e., disallowed expenses or activities, indirect costs, etc.):
The local agency shall follow the instructions found in the Policy and Procedure Manual under WIC Allowable
Costs and 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards.
Special References (i.e., RCWs, WACs, etc.):
What is the WIC program?
1. The WIC program in the state of Washington is administered by the Department of Health.
2. The WIC program is a federally funded program established in 1972 by an amendment to the Child Nutrition
Act of 1966. The purpose of the program is to provide nutrition and health assessment; nutrition education;
nutritious food; breastfeeding counseling; and referral services to pregnant, breastfeeding, and postpartum
women, infants, and young children in specific risk categories.
3. Federal regulations governing the WIC program (7 CFR Part 246) require implementation of standards and
procedures to guide the state's administration of the WIC program. These regulations define the rights,
responsibilities, and legal procedures of WIC employees, participants, persons acting on behalf of a participant,
and retailers. They are designed to promote:
a. High quality nutrition services;
b. Consistent application of policies and procedures for eligibility determination;
c. Consistent application of policies and procedures for food benefit issuance and delivery; and
d. WIC program compliance.
4. The WIC program implements policies and procedures stated in program manuals, handbooks, contracts, forms,
and other program documents approved by the USDA Food and Nutrition Service.
5. The WIC program may impose sanctions against WIC participants for not following WIC program rules stated
on the WIC rights and responsibilities.
6. The WIC program may impose monetary penalties against persons who misuse WIC benefits or WIC food but
who are not WIC participants.
Monitoring Visits (i.e., frequency, type, etc.):
Program and fiscal monitoring are done on a biennial (every two years) basis and are conducted onsite.
The local agency must maintain on file and have a vailable for review, audit and evaluation:
All criteria used for certification, including information on income, nutrition risk eligibility and referrals
Program requirements
EXHIBIT A
STATEMENT OF WORK
DOH Contract Number GVL28360-0
Mason County Public Health
DOH Contract GVL28360-0 Page 10 of 13
Revision March 2021
Nutrition education
All financial records
Assurances/Certifications:
1. Computer Equipment Loaned by the Department of Health WIC Nutrition Program
In order to perform WIC program activities, the Department requires computer equipment, such as computers,
signature pads, document scanners, card readers and printers to be in local WIC cli nics or to be transported to
mobile clinics. This equipment (“Loaned Equipment”) is owned by the Department and loaned to the local
agency (Contractor). The Loaned Equipment is supported by the Department. This equipment shall be used for
WIC business only or according to WIC Policy and Procedures.
An inventory of Loaned Equipment is kept by the Department. Each time Loaned Equipment is changed, the
parties shall complete the Equipment Transfer Form and the Department updates the inventory. A copy of the
Transfer Form will be provided to the contractor. Copies of the updated inventory list may be requested at any
time.
The local agency agrees to:
a. Defend, protect and hold harmless the Department or any of its employees from any claims, suits or actions
arising from the use of this Loaned Equipment.
b. Assume responsibility for any loss or damage from abnormal wear or use, or from inappropriate storage or
transportation. The Department may enforce this by:
1) Requiring reimbursement from the local agency of the value of the Loaned Equipment at the time of
the loss or damage.
2) Requiring the local agency to replace the Loaned Equipment with equipment of the same type,
manufacturer, and capabilities (as pre-approved by the Department), or
3) Assertion of a lien against the Contractor's property.
c. Notify the Department immediately of any damage to Loaned Equipment.
d. Notify the Department prior to moving or replacing any Loaned Equipment.
The Department recommends Contractors carry insurance against possible loss or theft.
2. Civil Rights Assurance
a. The local agency shall perform all services and duties necessary to comply with federal law in accordance
with the following Civil Rights Assurance.
b. “The Program applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964 (42
U.S.C. 2000d et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), Section
504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), Age Discrimination Act of 1975 (42 U.S.C. 6101 et
seq.); all provisions required by the implementing regula tions of the Department of Agriculture;
Department of Justice Enforcement Guidelines, 28 CFR 50.3 and 42; and FNS directives and guidelines, to
the effect that, no person shall, on the ground of race, color, national origin, sex, age or handicap, be
excluded from participation in, be denied benefits of, or otherwise be subject to discrimination under any
program or activity for which the Program applicant receives Federal financial assistance from FNS; and
hereby gives assurance that it will immediately take measures necessary to effectuate this agreement.
EXHIBIT A
STATEMENT OF WORK
DOH Contract Number GVL28360-0
Mason County Public Health
DOH Contract GVL28360-0 Page 11 of 13
Revision March 2021
c. “By accepting this assurance, the Program applicant agrees to compile data, maintain records and submit
reports as required, to permit effective enforcement of the nondiscrimination laws and permit a uthorized
USDA personnel during normal working hours to review such records, books and accounts as needed to
ascertain compliance with the nondiscrimination laws. If there are any violations of this assurance, the
Department of Agriculture, Food and Nutrition Service, shall have the right to seek judicial enforcement of
this assurance. This assurance is binding on the Program applicant, its successors, transferees, and
assignees, as long as it receives assistance or retains possession of any assistance from the Department. The
person or persons whose signatures appear on the contract are authorized to sign this assurance on behalf of
the Program applicant.”
3. 2CFR 200
The local agency shall comply with all the fiscal and operations requirements prescribed by the state agency as
directed by Federal WIC Regulations (7CFR part 246.6), 2CFR part 200, the debarment and suspension
requirements of 2CFR part 200.213, if applicable, the lobbying restrictions of 2CFR part 200.245, and FNS
guidelines and instructions and shall provide on a timely basis to the state agency all required information
regarding fiscal and program information.
Billing Requirements:
1. Definitions
Contract Period: DOE - September 30, 2023
Contract Budget Period: The time period for which the funding is budgeted: DOE -
September 30, 2023.
2. Billing Information:
a. Billings are submitted on an A-19-1A invoice. These invoices are provided by the Department in the WIC
Budget Workbook and include accounting codes for different budget categories.
b. A-19s are submitted monthly and must be received by the Department within 60 days following the close
of each calendar month. Additional A-19s may be submitted at any time, but must be received within 90
days of the close of the federal budget period.
c. Funds are allocated by budget categories and by federal budget periods (refer to the budget spreadsheet).
d. Funds are encumbered or spent only during the budget period; no carry forward from previous time periods
or borrowing from future time periods is allowed.
e. Payments are limited to the amounts allocated for the budget period for each budget category.
f. Billings are based on actual costs for completed activities. Advance payments are not allowed. Back up
documentation must be retained by the local agency and available for inspection by the Department or
other appropriate authorities.
g. Payments will be made only for WIC approved expenditures. Refer to the Washington State WIC Nutrition
Program Policy and Procedure Manual Volume 2, Chapter 4 – Allowable Costs and 2 CFR Part 200
Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards.
h. If billing for indirect costs, a Cost Allocation Plan or Federal Indirect Cost Agreement must be submitted
prior to payment.
EXHIBIT A
STATEMENT OF WORK
DOH Contract Number GVL28360-0
Mason County Public Health
DOH Contract GVL28360-0 Page 12 of 13
Revision March 2021
Special Instructions:
The local agency shall:
1. Maintain complete, accurate, and current accounting of all local, state, and federal program funds received and
expended.
2. Provide, as necessary, a single audit in accordance with the provisions of 2 CFR Part 200 Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. This circular
requires all recipients and sub-recipients of federal funds to have a single audit performed should they spend
$750,000 or more of federal grants or awards from all sources. Contractors spending less than $750,000 in
federal grants or awards may also be subject to audit.
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary
fines or repayment of funds.
Department of Health Program Contact
Michael Schweizer
WIC Nutrition Program
PO Box 47886
Olympia, WA 98504-7886
mike.schweizer@doh.wa.gov 360-236-3714
Department of Health Fiscal Contact
Stephanie Mendez
WIC Nutrition Program
PO Box 47886
Olympia, WA 98504-7886
stephanie.mendez@doh.wa.gov 360-236-3623
EXHIBIT A
STATEMENT OF WORK
DOH Contract Number GVL28360-0
Mason County Public Health
DOH Contract GVL28360-0 Page 13 of 13
Revision March 2021
Mason County Public Health
WIC Nutrition Program Budget - EXHIBIT B
Contract Number:28360
Contract Time Period:2023-2024
Initial Caseload:Funding
Non-caseload/Training Source/Initial
Year Time Period Allocation
WIC Base Funding FFY 23 Jan 23 - Sep 23 92,600
FFY 24 Oct 23 - Sep 24 0
FFY 25 Oct 24 - Dec 24 0
Total Federal Funds $92,600
WIC/USDA FMNP FFY 23 Jan 23 - Sep 23 0
FFY 24 Oct 23 - Sep 24 0
FFY 25 Oct 24 - Dec 24 0
Total Federal Funds $0
WIC/USDA BF Peer FFY 23 Jan 23 - Sep 23 0
Counseling Program FFY 24 Oct 23 - Sep 24 0
FFY 25 Oct 24 - Dec 24 0
Total Federal Funds $0
WIC/USDA TOTALS FFY 23 Jan 23 - Sep 23 92,600
FFY 24 Oct 23 - Sep 24 0
FFY 25 Oct 24 - Dec 24 0
GRAND TOTAL $92,600
Date State Office Created Budget 4/4/2023