HomeMy WebLinkAboutWashington State Department of Health Amendment # 18 - Amendment Page 1 of 15
MASON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH31019 AMENDMENT NUMBER: 18
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as
"DOH", and MASON COUNTY PUBLIC HEALTH, a Local Health Jurisdiction, 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, includes the following statements of work, which are incorporated by this reference
and located on the DOH Finance SharePoint site in the Upload Center at the following URL:
h!Ws:Hstateofwa.sharepoint.com/sites/doh-ofsfundinjzresources/sitepaizes/home.aspx?=e 1:9a94688da2d94d3ea8Oac7fbc32e4d7c
❑ Adds Statements of Work for the following programs:
® Amends Statements of Work for the following programs:
Office of Drinking Water Group A Program-Effective January 1, 2022
WIC Nutrition Program-Effective March 1,2024
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-18 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-17 Allocations
as follows:
® Increase of$20,666 for a revised maximum consideration of$6,901,977.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of
Exhibit B Allocations are attached only for informational purposes.
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
Signature: Signature:
D-id Wmd..np o,mzaiass or) ereaaa—n—IMar 1,202101:11 111�
Date: Date:
Apr 30,2024 May 1,2024
APPROVED AS TO FORM ONLY
Assistant Attorney General
Page 1 of 1
EXHIBIT B-18 Page 2 of 15
Mason County Public Health ALLOCATIONS Contract Number: CLH31019
Contract Term:2022-2024 Date: April 1,2024
Indirect Rate January 1,2022 through December 31,2022:17.26%
Indirect Rate January 1,2023 through December 31,2023:18.44%
Indirect Rate January 1,2024 through December 31,2024:18.95% DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY25 USDA WIC Client Svs Contracts NGA Not Received Amd 18 10.557 333.10.55 10/O1/24 12/31/24 10/O1/24 09/30/25 $5,000 $23,075 $76,916
FFY25 USDA WIC Client Svs Contracts NGA Not Received Amd 17 10.557 333.10.55 10/01/24 12/31/24 10/01/24 09/30/25 $189075
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 18 10.557 333.10.55 03/O1/24 09/30/24 10/O1/23 09/30/24 $11,666 $53,841
FFY24 USDA WIC Client Svs Contracts 7WA700WA7 Amd 17 10.557 333.10.55 03/01/24 09/30/24 10/01/23 09/30/24 $42,175
FFY23 PREP BP5 LHJ Funding NU90TP922043 Amd 14 93.069 333.93.06 07/01/23 06/30/24 07/01/23 06/30/24 $49,342 $49,342 $133,143
FFY22 PHEP BP4 LHJ Funding NU90TP922043 Amd 7 93.069 333.93.06 07/01/22 06/30/23 07/01/22 06/30/23 $49,342 $49,342
FFY21 PREP BP3 LHJ Funding NU90TP922043 Amd 2 93.069 333.93.06 01/01/22 06/30/22 07/01/21 06/30/22 $349459 $34,459
FFY22 Overdose Data to Action Prev NU17CE925007 Amd 10 93.136 333.93.13 09/01/22 08/31/23 09/O1/22 08/31/23 $56,938 $106,938 $144,746
FFY22 Overdose Data to Action Prev NU17CE925007 Amd 7 93.136 333.93.13 09/01/22 08/31/23 09/O1/22 08/31/23 $50,000
FFY21 Overdose Data to Action Prev NU17CE925007 Amd 4 93.136 333.93.13 01/01/22 08/31/22 09/01/21 08/31/22 $2,696 $37,808
FFY21 Overdose Data to Action Prev NU17CE925007 Amd 3 93.136 333.93.13 01/01/22 08/31/22 09/01/21 08/31/22 $35,112
FFY24 CDC PPHF Ops NH231P922619 Amd 14 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $50 S550 $550
FFY24 CDC PPHF Ops NH231P922619 Amd 13 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $500
FFY24 CDC VFC Ops NH231P922619 Amd 14 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $560 $6,160 $6,160
FFY24 CDC VFC Ops NH231P922619 Amd 13 93.268 333.93.26 07/01/23 06/30/24 07/01/23 06/30/24 $5,600
COVID19 Vaccines NH231P922619 Amd 4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803 $354,803 S3549803
COVID19 Vaccines R4 NH231P922619 Amd 1 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803 $354,803 $354,803
FFY23 PPHF Ops NH231P922619 Amd 7 93.268 333.93.26 07/01/22 06/30/23 07/01/22 06/30/23 $500 $500 $1,000
FFY22 PPHF Ops NH231P922619 Amd 3 93.268 333.93.26 01/01/22 06/30/22 07/01/21 06/30/22 $500 $500
FFY19 COVID CARES NU50CK000515 Amd 2,3 93.323 333.93.32 01/01/22 06/30/22 04/23/20 07/31/24 $65,595 $65,595 $65,595
FFY19 ELC COVID Ed LHJ Allocation NTJ50CK000515 Amd 3,11 93.323 333.93.32 01/01/22 01/31/23 05/19/20 01/31/23 ($29,966) $213,061 $213,061
FFY19 ELC COVID Ed LHJ Allocation NU50CK000515 Amd 2,11 93.323 333.93.32 01/01/22 01/31/23 05/19/20 01/31/23 $243,027
FFY20 ELC EDE LHJ Allocation NU50CK000515 Amd 7,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 ($27,095) $867,729 $867,729
FFY20 ELC EDE LHJ Allocation NU50CK000515 Amd 3,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 ($30)
FFY20 ELC EDE LHJ Allocation NU50CK000515 Amd 2,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 $894,854
FFY23 Vector-borne T2&3 Epi ELC FPH NU50CK000515 Amd.16 93.323 333.93.32 08/01/23 09/30/23 08/01/23 09/30/23 $195 $1,395 $8,695
FFY23 Vector-borne T2&3 Epi ELC FPH NU50CK000515 Amd 12 93.323 333.93.32 08/01/23 09/30/23 08/01/23 09/30/23 $1,200
FFY22 Vector-borne T2&3 Epi ELC FPH NU50CK000515 Amd 12 93.323 333.93.32 08/01/22 07/31/23 08/01/22 07/31/23 $1,800 $4,550
FFY22 Vector-borne T2&3 Epi ELC FPH NU50CK000515 Amd 5,12 93.323 333.93.32 08/01/22 07/31/23 08/01/22 07/31/23 $2,750
FFY21 Vector-borne T2&3 Epi ELC FPH NU50CK000515 Amd 5 93.323 333.93.32 06/01/22 07/31/22 08/01/21 07/31/22 $2,750 $2,750
Pagel of 3
EXHIBIT B-18 Page 3 of 15
Mason County Public Health ALLOCATIONS Contract Number: CLH31019
Contract Term:2022-2024 Date: April 1,2024
Indirect Rate January 1,2022 through December 31,2022:17.26%
Indirect Rate January 1,2023 through December 31,2023:18.44%
Indirect Rate January 1,2024 through December 31,2024:18.95% DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY21 CDC COVID-19 PHWFD-LHJ NU90TP922181 Amd 15 93.354 333.93.35 07/01/23 06/30/24 07/01/23 06/30/24 $100,000 $100,000 $100,000
FFY22 PH Infrastructure Comp Al-LHJ NEI IOE000053 Amd 16 93.967 333.93.96 01/01/24 12/31/24 12/01/22 06/30/25 $200,000 $200,000 $200,000
FFY24 HRSA MCHBG LHJ Contracts B04MC52960 Amd 14 93.994 333.93.99 10/01/23 09/30/24 10/01/23 09/30/24 $67,694 $67,694 $122,553
FFY23 HRSA MCHBG LHJ Contracts B04MC47453 Amd 14 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 ($12,835) $54,859
FFY23 HRSA MCHBG LHJ Contracts B04MC47453 Amd 7 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 $67,694
FFY22 HRSA MCHBG Special Proj B04MC45251 Amd 14 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 $22,194 $22,194 $22,194
FFY22 MCHBG LHJ Contracts B04MC45251 Amd 1 93.994 333.93.99 01/01/22 09/30/22 10/01/21 09/30/22 $50,770 $50,770 $50,770
SFYI GFS-Group B Amd 17 N/A 334.04.90 01/01/24 06/30/24 07/01/23 06/30/25 $6,469 $6,469 $19,407
GFS-Group B(FO-SW) Amd 10 N/A 334.04.90 01/01/23 06/30/23 07/01/22 06/30/23 $6,469 $6,469
GFS-Group B(FO-SW) Amd 1 N/A 334.04.90 01/01/22 06/30/22 07/01/21 06/30/22 $6,469 $6,469
SFY25 Drug User Health Program Amd 16 N/A 334.04.91 07/01/24 12/31/24 07/01/24 06/30/25 $92,500 $92,500 $187,500
SFY24 Drug User Health Program Amd 16 N/A 334.04.91 01/01/24 06/30/24 07/01/23 06/30/24 $92,500 $92,500
SFY24 Drug User Health Program Amd 13 N/A 334.04.91 07/01/23 12/31/23 07/01/23 06/30/24 $2,500 $2,500
State Drug User Health Program Amd 12 N/A 334.04.91 02/01/23 06/30/23 07/01/23 12/31/23 $5,000 $5,000 $5,000
State TB Control-FPH Amd 9 N/A 334.04.91 10/01/22 06/30/23 07/01/21 06/30/23 $500 $500 $500
Rec Shellfish/Biotoxin Amd 13 N/A 334.04.93 07/01/23 12/31/24 07/01/23 06/30/25 $5,250 $5,250 $10,500
Rec Shellfish/Biotoxin Amd 1 N/A 334.04.93 01/01/22 06/30/23 07/01/21 06/30/23 $5,250 $5,250
Small Onsite Management(GFS) Amd 15 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 ($53,636) $0 $0
Small Onsite Management(GFS) Amd 13 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 $53,636
Small Onsite Management(GFS) Amd 15 N/A 334.04.93 07/01/23 06/30/24 07/01/23 06/30/25 ($45,000) $0
Small Onsite Management(GFS) Amd 13 N/A 334.04.93 07/01/23 06/30/24 07/01/23 06/30/25 $45,000
SFY25 Wastewater Management-GFS Amd 15 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 $53,636 $53,636 $173,636
SFY24 Wastewater Management-GFS Amd 15 N/A 334.04.93 07/01/23 06/30/24 07/01/23 06/30/25 $45,000 $45,000
Wastewater Management-GFS Amd 1 N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $60,000 $60,000
Wastewater Management-GFS Amd 1 N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $15,000 $15,000
FPHS-LHJ-Proviso(YR2) Amd 6 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 $1,266,000 $1,266,000 $1,603,116
FPHS-LHJ-Proviso(YR2) Amd 7 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 ($761,000) $0
FPHS-LHJ-Proviso(YR2) Amd 1 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 $761,000
Page 2 of 3
EXHIBIT B-18 Page 4 of 15
Mason County Public Health ALLOCATIONS Contract Number: CLH31019
Contract Term:2022-2024 Date: April 1,2024
Indirect Rate January 1,2022 through December 31,2022:17.26%
Indirect Rate January 1,2023 through December 31,2023:18.44%
Indirect Rate January 1,2024 through December 31,2024:18.95% DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FPHS-LHJ-Proviso(YRl) Amd 9 N/A 336.04.25 01/O1/22 06/30/22 07/01/21 06/30/23 ($423,884) $337,116
FPHS-LHJ-Proviso(YRl) Amd 1 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 $761,000
SFY24 FPHS-LHJ-Funds-GFS Amd 14 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $832,000 $2,098,000 $2,098,000
SFY24 FPHS-LHJ-Funds-GFS Amd 13 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $1,266,000
YR26 SRF-Local Asst(15%)SS Amd 18 N/A 346.26.64 01/O1/24 12/31/24 07/O1/23 06/30/25 $2,000 $15,800 $39,800
YR26 SRF-Local Asst(15%)SS Amd 15 N/A 346.26.64 01/01/24 12/31/24 07/01/23 06/30/25 $139800
YR25 SRF-Local Asst(15%)SS Amd 14 N/A 346.26.64 01/01/23 12/31/23 01/01/23 12/31/23 $800 $11,600
YR25 SRF-Local Asst(15%)SS Amd 11 N/A 346.26.64 01/01/23 12/31/23 01/01/23 12/31/23 $10,800
YR24 SRF-Local Asst(15%)(FO-SW)SS Amd 7 N/A 346.26.64 01/01/22 12/31/22 07/01/21 06/30/23 $1,400 $12,400
YR24 SRF-Local Asst(15%)(FO-SW)SS Amd 1 N/A 346.26.64 01/01/22 12/31/22 07/01/21 06/30/23 $11,000
Sanitary Survey Fees SS-State Amd 18 N/A 346.26.65 01/O1/22 12/31/24 07/O1/21 12/31/24 $29000 $39,800 $39,800
Sanitary Survey Fees SS-State Amd 15 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $139800
Sanitary Survey Fees SS-State Amd 14,15 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $800
Sanitary Survey Fees SS-State Amd 11,15 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $10,800
Sanitary Survey Fees SS-State Amd7,11,15 N/A 346.26.65 01/01/22 12/31/24 07/01/21 12/31/24 $1,400
Sanitary Survey Fees SS-State Amd 1,11,15 N/A 346.26.65 01/O1/22 12/31/24 07/01/21 12/31/24 $11,000
YR26 SRF-Local Asst(15%)TA Amd 18 N/A 346.26.66 01/O1/24 12/31/24 07/O1/23 06/30/25 $1,000 $1,000 $2,000
YR25 SRF-Local Asst(15%)TA Amd 18 N/A 346.26.66 01/O1/23 12/31/23 01/O1/23 12/31/23 (51,000) $0
YR25 SRF-Local Asst(15%)TA Amd 11 N/A 346.26.66 01/01/23 12/31/23 01/01/23 12/31/23 $1,000
YR24 SRF-Local Asst(15%)(FO-SW)TA Amd 1 N/A 346.26.66 01/01/22 12/31/22 07/01/21 06/30/23 $1,000 $1,000
TOTAL $6,9019977 $699019977
Total consideration: $6,881,311 GRAND TOTAL $6,901,977
$209666
GRAND TOTAL $6,9019977 Total Fed $297229718
Total State $491799259
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Page 5 of 15
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Drinking Water Group A Program- Local Health Jurisdiction Name: Mason County Public Health
Effective January 1,2022
Contract Number: CLH31019
SOW Type: Revision Revision#(for this SOW) 6 Funding Source Federal Compliance Type of Payment
®Federal Contractor (check if applicable) ❑ Reimbursement
Period of Performance: January 1,2022 through December 31,2024 El Other® State ® FFATA(Transparency Act)
®Fixed Price
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small
community and non-community Group A water systems
Revision Purpose: The purpose of this revision is to finalize activity completed 1/1/2022 through 12/31/2023 for Sanitary Survey, Sanitary Survey State and Technical
Assistance and to update funding provided for Sanitary Survey, Sanitiary Survey State and Technical Assistance activity assigned l/l/2024 through 12/31/2024.
Master Assistance BARS Allocation
Change Index Listing Revenue LHJ Funding Period Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SANITARY SURVEY FEES SS-STATE 24112522 N/A 346.26.65 01/01/22 12/31/24 37,800 2,000 39,800
YR 24 SRF-LOCAL ASST(15%)(FO-SW) SS 24239224 N/A 346.26.64 01/01/22 12/31/22 12,400 0 12,400
YR 24 SRF-LOCAL ASST(15%)(FO-SW)TA 24239224 N/A 346.26.66 01/01/22 12/31/22 1,000 0 1,000
YR 25 SRF-LOCAL ASST(15%)SS 24119226 N/A 346.26.64 01/01/23 12/31/23 11,600 0 11,600
YR 25 SRF-LOCAL ASST 15%)TA 24119226 N/A 346.26.66 01/01/23 12/31/23 1,000 -1,000 0
YR 26 SRF-LOCAL ASST 15% SS 24119226 N/A 346.26.64 01/01/24 12/31/24 13,800 2,000 15,800
YR 26 SRF-LOCAL ASST 15% TA 24119226 N/A 346.26.66 01/01/24 12/31/24 0 1,000 1,000
0 0 0
TOTALS 77,600 4,000 81,600
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
1 Trained LHJ staff will conduct sanitary Provide Final*Sanitary Survey Reports Final Sanitary Survey Upon ODW acceptance of the Final Sanitary
surveys of small community and non- to ODW Regional Office.Complete Reports must be received by Survey Report,the LHJ shall be paid$400 for
community Group A water systems Sanitary Survey Reports shall include: the ODW Regional Office each sanitary survey of a non-community
identified by the DOH Office of Drinking 1. Cover letter identifying significant within 30 calendar days of system with three or fewer connections.
Water(ODW)Regional Office. deficiencies, significant findings, conducting the sanitary
observations,recommendations, survey. Upon ODW acceptance of the Final Sanitary
See Special Instructions for task activity. and referrals for further ODW Survey Report,the LHJ shall be paid$800 for
follow-up. each sanitary survey of a non-community
The purpose of this statement of work is to 2. Completed Small Water System system with four or more connections and each
rovide funding to the LHJ for conducting checklist. community system.
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH31019-Amendment 18
Page 6 of 15
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
sanitary surveys and providing technical 3. Updated Water Facilities Inventory
assistance to small community and non- (WFI). Payment is inclusive of all associated costs
community Group A water systems. 4. Photos of water system with text such as travel,lodging,per diem.
identifying features
5. Any other supporting documents. Payment is authorized upon receipt and
acceptance of the Final Sanitary Survey Report
*Final Reports reviewed and accepted within the 30-day deadline.
by the ODW Regional Office.
Late or incomplete reports may not be accepted
for payment.
2 Trained LHJ staff will conduct Special Provide completed SPI Report and any Completed SPI Reports must Upon acceptance of the completed SPI Report,
Purpose Investigations(SPI)of small supporting documents and photos to be received by the ODW the LHJ shall be paid$800 for each SPI.
community and non-community Group A ODW Regional Office. Regional Office within 2
water systems identified by the ODW working days of the service Payment is inclusive of all associated costs
Regional Office. request. such as travel,lodging,per diem.
See Special Instructions for task activity. 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 a ent.
3 Trained LHJ staff will provide direct Provide completed TA Report and any Completed TA Report must Upon acceptance of the completed TA Report,
technical assistance(TA)to small supporting documents and photos to be received by the ODW the LHJ shall be paid for each technical
community and non-community Group A ODW Regional Office. Regional Office within 30 assistance activity as follows:
water systems identified by the ODW calendar days of providing . Up to 3 hours of work: $250
Regional Office. technical assistance. • 3-6 hours of work: $500
• More than 6 hours of work: $750
See Special Instructions for task activity.
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.
Exhibit A, Statement of Work Page 2 of 4 Contract Number CLH31019-Amendment 18
Page 7 of 15
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
4 LHJ staff performing the activities under For training attended in person,prior to Annually For training attended in person,LHJ shall be
tasks 1,2 and 3 attend periodic required attending the training,submit an paid mileage,per diem,lodging,and
survey training as directed by DOH. "Authorization for Travel(Non- registration costs as approved on the pre-
Employee)"DOH Form 710-013 to the authorization form in accordance with the
See Special Instructions for task activity. ODW Program Contact for approval(to current rates listed on the OFM Website
ensure enough funds are available). ht ://www.ofm.wa.gov/resources/travel.asp
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@doh.wa.gov.
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 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 Unique Entity Identifier(UEI)generated by SAM.gov.
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.
Program Specific Requirements
Data Sharing
The Office of Drinking Water will share water system information and files with the local health jurisdiction to support the work identified in this statement of work. To request
water system data please contact the regional office with the name of the water system,water system ID#, specific information being requested and any timeline requirements.If
allowable,please give administrative staff 3 to 5 business days to provide records.
Program Manual,Handbook,Policy References: Field Guide(DOH Publication 331-486).
Special References:
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$48,000$79,600 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 for which 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 A19-IA Invoice
Exhibit A, Statement of Work Page 3 of 4 Contract Number CLH31019-Amendment 18
Page 8 of 15
Voucher to 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 4 surveys of non-community systems with three or fewer connections be completed between January 1,2022 and December 31,2022.
• No more than 29 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2022 and
December 31,2022.
• No more than 0 surveys of non-community systems with three or fewer connections be completed between January 1,2023 and December 31,2023.
• No more than 29 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2023 and
December 31,2023.
• No more than 11 surveys of non-community systems with three or fewer connections be completed between January 1,2024 and December 31,2024.
• No more than 2-934 surveys of non-community systems with four or more connections and all community systems to be completed between January 1,2024 and
December 31,2024.
The process for assignment of surveys to the LHJ,notification of the water system,and ODW follow-up with unresponsive water systems; and other roles and responsibilities of
the LHJ are described in the Field Guide.
Task 2
Trained LHJ staff will perform Special Purpose Investigations(SPIs)as assigned by ODW. SPIs are inspections to determine the cause of positive coliform samples or the cause of
other emergency conditions. SPIs may also include sanitary surveys of newly discovered Group A water systems.Additional detail about conducting SPIs is described in the Field
Guide. The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.
Task 3
Trained LHJ staff will conduct Technical Assistance as assigned by ODW. Technical Assistance includes assisting water system personnel in completing work or verifying work
has been addressed as required,requested,or advised by the ODW to meet applicable drinking water regulations. Examples of technical assistance activities are described in the
Field Guide.The ODW Regional Office must authorize in advance any technical assistance provided by the LHJ to a water system.
Task 4
LHJ staff assigned to perform activities under tasks 1,2,and 3 must be trained and approved by ODW prior to performing work.
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.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH31019-Amendment 18
Page 9 of 15
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: WIC Nutrition Program-Effective March 1,2024 Local Health Jurisdiction Name: Mason County Public Health
Contract Number: CLH31019
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: March 1,2024 through December 31,2024 ❑ State ® FFATA(Transparency Act) ❑ Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose is to provide Women,Infants,and Children(WIC)Nutrition Program services by following WIC federal regulations, WIC state office
policies and procedures,WIC directives,and other rules.Refer to the Program Specific Requirements section of this document.
Revision Purpose: To add FFY24 and FFY25 USDA WIC CLIENT SVS CONTRACTS funds.
Master Assistance BARS Allocation
Change Index Listing Revenue LHJ Funding Period Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY24 USDA WIC CLIENT SVS CONTRACTS 7610124B 10.557 333.10.55 03/01/24 09/30/24 42,175 11,666 53,841
FFY25 USDA WIC CLIENT SVS CONTRACTS 76101251 10.557 333.10.55 10/01/24 12/31/24 18,075 5,000 23,075
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 60,250 16,666 76,916
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
See"Billing
1 WIC Nutrition Program Requirements"below.
1.1 Maintain authorized participating caseload at 100%based on Outcomes based on monthly participation Authorized participating
quarterly average as determined from monthly caseload data from state WIC caseload management caseload for March 2024
management reports generated at state WIC office. reports. through December 2024
The Department of Health(Department)State WIC Nutrition =300
Program has the option of reducing authorized participating
caseload and corresponding funding when:
1. Unanticipated funding situations occur.
2. Reallocations are necessary to redistribute caseload
statewide.
3. Caseload declines.
Exhibit A, Statement of Work Page 1 of 7 Contract Number CLH31019-Amendment 18
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Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1.2 Submit the annual Nutrition Services Plan for each year of the Nutrition Services Plan Due 9/30/24 Payment withheld if not
contract. received by due date.
1.3 Submit the annual Nutrition Services Expenditure Report for Nutrition Services Expenditure Report 11/30/24 Payment withheld if not
each year of the contract. received by due date.
Tell participants about other health services in the agency. If Documentation must be available for
1.4 needed,develop written agreements with other health care review by WIC monitor staff. Biennial WIC Monitor
a encies and refer participants to these services.
Provide nutrition education services to participants and Documentation must be available for
1.5 caregivers in accordance with federal and state requirements. review by WIC monitor staff. Biennial WIC Monitor
Issue WIC benefits while assuring adequate WIC card security Documentation must be available for
1.6 and reconciliation. review by WIC monitor staff. Biennial WIC Monitor
Collect data,maintain records,and submit reports to effectively Documentation must be available for
1.7 enforce the non-discrimination laws(Refer to Civil Rights review by WIC monitor staff. Biennial WIC Monitor
Assurances below).
Submit entire WIC and Breastfeeding Peer Counseling Budget Budget Workbook Due 2/29/24
1.8a Workbook for each year of the contract
Submit Rev-Exp Report spreadsheet from the WIC Budget Revenue and Expense Report and A-19 Due monthly through
1.8b Workbook monthly with A-19 December 31,2024
2 Breastfeeding Promotion
Provide breastfeeding promotion activities in accordance with Status report of chosen activities in Due 11/30/24
federal and state requirements. Nutrition Services Plan.
2.1
Documentation must be available for Biennial WIC Monitor
review by WIC monitor staff.
Work with community partners to improve practices that affect Status report of chosen activities in Due 8/30/24
breastfeeding. Choose one or more of the following projects: Nutrition Services Plan.
■ Provide staff,health care providers and community
partners virtual breastfeeding training resources. Documentation must be available for Biennial WIC Monitor
■ Work with employers who likely employ low-income review by WIC monitor staff.
people to create worksite environments that support
2.2 breastfeeding.
■ Work with birthing hospitals to improve maternity care
practices that affect WIC participant breastfeeding rates.
■ Provide participants access to lactation consultants.
• Other projects will need pre-approval from the State WIC
Office.
Exhibit A, Statement of Work Page 2 of 7 Contract Number CLH31019-Amendment 18
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Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
See"Billing
3 Farmers Market Nutrition Program(FMNP) Requirements"below.
Distribute all Farmers Market Nutrition Program checks to Send completed readable copy of FMNP Weekly June-Sept.2024
eligible WIC participants between June and September 30 of check registers to State WIC office on a
3.1 current year. weekly basis following FMNP procedures. All sent by Oct. 1,2024
Documentation must be available for Biennial WIC Monitor
review by WIC monitor staff.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance@doh.wa.gov.
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 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 Unique Entity Identifier(UEI)generated by SAM.gov.
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.
Program Specific Requirements
Program Manual,Handbook,Policy References:
The LHJ 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 LHJ shall:
• 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 Registered 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 Breastfeeding Coordinator must be an International Board Certified Lactation Consultant or attend an intensive lactation management course,
or other state approved training.
Exhibit A, Statement of Work Page 3 of 7 Contract Number CLH31019-Amendment 18
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Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
The LHJ 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 LHJ must maintain on file and have available for review,audit and evaluation:
• All criteria used for certification, including information on income,nutrition risk eligibility and referrals
• Program requirements
• 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 clinics 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.
Exhibit A, Statement of Work Page 4 of 7 Contract Number CLH31019-Amendment 18
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An inventory of Loaned Equipment is kept by the Department. Each time Loaned Equipment is changed,the parries 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 LHJ 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 LHJ of the value of the Loaned Equipment at the time of the loss or damage.
2) Requiring the LHJ 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 LHJ 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 regulations of the Department of Agriculture;Department of Justice Enforcement Guidelines,28 CFR 50.3 and 42;and INS 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.
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 authorized 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 LHJ 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 INS guidelines and instructions and
shall provide on a timely basis to the state agency all required information regarding fiscal and program information.
Exhibit A, Statement of Work Page 5 of 7 Contract Number CLH31019-Amendment 18
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Billing Requirements:
1. Definitions
Contract Period: January 1,2022-December 31,2024
Contract Budget Period: The time period for which the funding is budgeted.
• There are four federal budget periods
January 1,2022 through September 30,2022;
October 1,2022 through September 30,2023;
October 1,2023 through September 30,2024;
October 1,2024 through December 31,2024.
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 30 days following the close of each calendar month.Additional A-19s may be submitted at
any time,but must be received within 60 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 LHJ 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.
Special Instructions:
The LHJ 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.
3. Use Breastfeeding Peer Counseling(BFPC)Program funds only to support the peer counseling program. Once the program is established and peer counselors are trained,the
majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs see Volume 2,Chapter 4—Allowable
Costs. The priority use of BFPC funds is to hire and train peer counselors to provide breastfeeding peer counseling services to WIC participants.
Exhibit A, Statement of Work Page 6 of 7 Contract Number CLH31019-Amendment 18
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Special Requirements:
SPECIAL REQUIREMENTS
Contract Funding Period Time Period special requirement Amount Special Requirement Description
funds are available
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
Exhibit A, Statement of Work Page 7 of 7 Contract Number CLH31019-Amendment 18