HomeMy WebLinkAboutWashington State Department of Health Amendment # 14 Page 1 of 39
MASON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH31019 AMENDMENT NUMBER: 14
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, lereinafter referred to as"LHJ", pursuant to the
Modifications/Waivers clause, and to make necessary clianges 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:
https:HstateoRva.sliaret)oint.conn/sites/doh-ofsfunditipresources/sitepaQes/lionie.aspx?=e 1:9a94688da2d94d3ea80ac7fbc32e4d7c
® Adds Statements of Work for the following programs:
Executive Office of Resiliency&Health Security-PHEP -Effective July 1,2023
Executive Office of Resiliency&Health Security-WFD LHJ-Effective July 1,2023
® Amends Statements of Work for the following programs:
Foundational Public Health Services(FPI-IS) -Effective July 1, 2023
Maternal and Child Health Block Grant-Effective January 1,2022
Office of Drinking Water Group A Program -Effective January 1,2022
Office of Immunization-Perinatal Hepatitis B -Effective July 1,2023
Office of Immunization-Promotion of Immunizations to Improve Vaccination Rates-Effective July 1, 2023
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-14 Allocations,attached and incorporated by this reference, amends and replaces Exhibit B-13 Allocations as follows:
® Increase of$960,605 for a revised maximum consideration of$6,301,797.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maxinnum 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/leer signature in execution thereof.
MASON COUNTY PUBLIC HEALTH STATE OF WASHINGTON
DEPARTMENT OF HEALTH
Signature: Signature:
8rmd al Henri sVwl
Date: Date:
09/14/2023
APPROVED AS TO FORM ONLY
Assistant Attorney General
Page I of I
EXHIBIT B-14 Page 2 of 39
Mason County Public Health ALLOCATIONS Contract Number: CLH31019
Contract Term:2022-2024 Date: August 1,2023
Indirect Rate January 1,2022 through December 31,2022:17.26%
Indirect Rate January 1,2023 through December 31,2023:18.44% 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
FFY23 PHEP 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 $1339143
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 PHEP BP3 LHJ Funding NU90TP922043 Amd 2 93.069 333.93.06 01/01/22 06/30/22 07/01/21 06/30/22 $34,459 $34,459
FFY22 Overdose Data to Action Prev NU17CE925007 Amd 10 93.136 333.93.13 09/01/22 08/31/23 09/01/22 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 09/01/22 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 NTJ17CE925007 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 $550 $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 $69160 $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 $354,803
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 NU50CK000515 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 NGA Not Received Amd 12 93.323 333.93.32 08/01/23 09/30/23 08/01/23 09/30/23 $1,200 $1,200 $8,500
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
FFY24 HRSA MCHBG LHJ Contracts NGA Not Received Amd 14 93.994 333.93.99 10/01/23 09/30/24 10/01/23 09/30/24 $679694 $679694 $1229553
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 07/01/23 09/30/23 10/01/22 09/30/23 $22,194 $22,194 $22,194
Pagel of 3
EXHIBIT B-14 Page 3 of 39
Mason County Public Health ALLOCATIONS Contract Number: CLH31019
Contract Term:2022-2024 Date: August 1,2023
Indirect Rate January 1,2022 through December 31,2022:17.26%
Indirect Rate January 1,2023 through December 31,2023:18.44% 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
FFY22 MCHBG LHJ Contracts B04MC45251 Arad 1 93.994 333.93.99 01/01/22 09/30/22 10/01/21 09/30/22 $50,770 $50,770 $50,770
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 $12,938
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
SFY24 Drug User Health Program Amd 13 N/A 334.04.91 07/01/23 12/31/23 07/01/23 12/31/23 $2,500 $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 S500
Rec ShellfishBiotoxin 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 13 N/A 334.04.93 07/01/24 12/31/24 07/01/23 06/30/25 $53,636 $53,636 $98,636
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 $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 $75,000
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) Amd6 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
FPHS-LHJ-Proviso(YRl) Amd 9 N/A 336.04.25 01/01/22 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
FPHS-Local Health Jurisdiction Amd 14 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $832,000 $29098,000 $2,098,000
FPHS-Local Health Jurisdiction Amd 13 N/A 336.04.25 07/01/23 06/30/24 07/01/23 06/30/25 $1,266,000
YR 25 SRF-Local Asst(15%)(FO-SW)SS Amd 14 N/A 346.26.64 01/01/23 12/31/23 01/01/23 12/31/23 $800 $11,600 $24,000
YR 25 SRF-Local Asst(15%)(FO-SW)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(FO-SW)SS-State Amd 14 N/A 346.26.65 01/01/22 12/31/23 07/01/21 12/31/23 $800 $24,000 $24,000
Sanitary Survey Fees(FO-SW)SS-State Amd 11 N/A 346.26.65 01/01/22 12/31/23 07/01/21 12/31/23 $10,800
Sanitary Survey Fees(FO-SW)SS-State Amd 7,11 N/A 346.26.65 01/01/22 12/31/23 07/01/21 12/31/23 $1,400
Sanitary Survey Fees(FO-SW)SS-State Amd 1,11 N/A 346.26.65 01/01/22 12/31/23 07/01/21 12/31/23 $11,000
YR 25 SRF-Local Asst(15%)(FO-SW)TA Amd 11 N/A 346.26.66 01/01/23 12/31/23 01/01/23 12/31/23 $1,000 $1,000 $2,000
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
Page 2 of 3
EXHIBIT B-14 Page 4 of 39
Mason County Public Health ALLOCATIONS Contract Number: CLH31019
Contract Term:2022-2024 Date: August 1,2023
Indirect Rate January 1,2022 through December 31,2022:17.26%
Indirect Rate January 1,2023 through December 31,2023:18.44% 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
TOTAL $6,301,797 $69301,797
Total consideration: $5,341,192 GRAND TOTAL $6,301,797
$960,605
GRAND TOTAL $6,301,797 Total Fed $2,345,607
Total State $39956,190
*Catalog of Federal Domestic Assistance
**Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Page 5 of 39
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Executive Office of Resiliency&Health Security- Local Health Jurisdiction Name: Mason County Public Health
PHEP-Effective July 1,2023
Contract Number: CLH31019
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ❑ Reimbursement
❑ (Transparency Period of Performance: July 1,2023 through June 30,2024 Other State ® FFATA( p y Act)
❑ Fixed Price
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to establish funding and tasks to support and sustain LHJ public health emergency preparedness as part of
statewide public health emergency preparedness(PHEP),resilience and response.
Notes: Regional Emergency Response Coordinator LHJs(RERCs): Benton-Franklin,Chelan-Douglas,Clark,Kitsap, Seattle-King, Snohomish, Spokane,Tacoma-Pierce,and
Thurston
Local Emergency Response Coordinator LHJs(LERCs):Adams,Asotin,Clallam,Columbia,Cowlitz,Garfield,Grant,Grays Harbor, Island,Jefferson,Kittitas,Klickitat,Lewis,
Lincoln,Mason,NE Tri-County, Okanogan,Pacific, San Juan, Skagit,Skamania,Wahkiakum,Walla Walla,Whatcom,Whitman,and Yakima
Revision Purpose: NA
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY23 PHEP BP5 LHJ Funding 31602231 93.069 333.93.06 07/01/23 06/30/24 0 49,342 49,342
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 49,342 49,342
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
PHEP BP5 LHJ Funding Reimbursement for actual
costs not to exceed total
1 Across Domains and Capabilities Mid-and end-of-year reports on template December 31,2023 funding allocation amount.
provided by DOH. June 30,2024
All LHJs Complete reporting templates as requested by DOH to
comply with program and federal grant requirements, Additional reporting may be required if
including mid-year and end-of-year reports. federal requirements change.
Exhibit A, Statement of Work Page 1 of 11 Contract Number CLH31019-Amendment 14
Page 6 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
2 Across Domains and Capabilities Submit information by September 1, September 1,2023
2023,and any changes within 30 days of
All LHJs Submit names,position titles,email addresses and phone the change. Within 30 days of the
numbers of key LHJ staff responsible for this statement of change.
work,including management,Emergency Response Mid-and end-of-year reports on template
Coordinator(s),and accounting and/or financial staff. provided by DOH.Note any changes or December 31,2023
no changes. June 30,2024
3 Across Domains and Capabilities Mid-and end-of-year reports on December 31,2023
templates provided by DOH. June 30,2024
All LHJs Review and provide input to DOH on public health
emergency preparedness plans developed by DOH,upon Input provided to DOH upon request
request from DOH. from DOH.
4 Across Domains and Capabilities Participation in site visit discussion. Upon request from
DOH
All LHJs Participate with DOH in site visit(virtual or in person)to Preparation and follow-up activities as
discuss LHJ's performance measure data and readiness to requested by DOH.
respond.
Reviewed and returned discussion notes
Complete preparation and follow-up activities as requested (sent to you for review by DOH).
by DOH.
DOH will take notes during the discussion and send them to
you for review.
5 Domain 1 Community Resilience Mid-and end-of-year reports on December 31,2023
Capability 1 Community Preparedness templates provided by DOH. June 30,2024
All LHJs
Participate in emergency preparedness events(for example,
trainings,meetings,conference calls,and conferences)to
advance LHJ,regional,or statewide public health
preparedness.
Note: For Seattle-King County and Tacoma-Pierce County,
the LHJ is the region.
6 Domain 1 Community Resilience Mid-and end-of-year reports on December 31,2023
Capability 1 Community Preparedness templates provided by DOH. June 30,2024
All LHJs
Assist DOH and the University of Washington in developing
a tool to complete a public health disaster risk assessment
tailored to the needs of LHJs and our state.
Exhibit A, Statement of Work Page 2 of 11 Contract Number CLH31019-Amendment 14
Page 7 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
LHJ participation in one or more 90-minute engagement
sessions/focus groups is planned for this statement of work
period.
7 Domain 1 Community Resilience Mid-and end-of-year reports on December 31,2023
Capability 1 Community Preparedness templates provided by DOH. June 30,2024
All LHJs
DOH/Executive Office of Resiliency and Health Security
(ORHS)anticipates many changes in the next months to
years as we incorporate lessons learned from the COVID-19
response. In preparation for these changes,the LHJ may use
PHEP funding to participate in training and/or learning
discussions in the following areas:
• Adaptive Leadership
• Change Management
• Trauma-Informed Change Management
• Trauma-Informed Systems
• Trauma-Informed Practice
• Outward Mindset
• Growth Mindset
• Racial Equity and/or Social Justice
• Community Resilience
• Climate Change and Health Equity
• Related topics—prior approval from ORHS
required for training topics other than those listed
above.
Note: Prior approval from DOH/ORHS is required for any
out-of-state travel.
8 Domain 1 Community Resilience Mid-and end-of-year reports on December 31,2023
Capability 1 Community Preparedness templates provided by DOH. June 30,2024
All LHJs
Connect with new and/or existing partners to develop
Note for working relationships that promote capabilities,capacity,and
RERCs community resilience,including,but not limited to:
• Local and/or regional Emergency Manager(s).
• Local and/or regional hospitals.
• Local and/or regional elected officials.
• Local and/or regional Community Health Workers
(CHWs).
• Local and/or regional organizations that work with
groups disproportionately impacted by public health
Exhibit A, Statement of Work Page 3 of 11 Contract Number CLH31019-Amendment 14
Page 8 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
emergencies or incidents. (For RERCs,this may
include some or all the groups identified in#21.)
9 Domain 2 Incident Management Mid-and end-of-year reports on December 31,2023
Capability 3 Emergency Operations Coordination-Training templates provided by DOH,including June 30,2024
All LHJs &Exercise title,date(s),sponsor of the training or
conference,and summary of what you
Participate in at least one public health emergency learned.
preparedness,response,or recovery training provided or
approved by DOH.Participation in a conference related to
public health emergency preparedness,response,or recovery
may be used to meet this requirement.
Notes:
• Prior approval from DOH is required for any out-of-state
travel.
• Participation in an activation,exercise or real-world event
may be considered additional training,but does not take
the place of the requirement to participate in at least one
training as described above.
• Participation in the optional trainings listed in#7 and/or
the communication drill(#15) does not meet the
requirement for this activity.
10 Domain 2 Incident Management
Capability 3 Emergency Operations Coordination-Training
All LHJs &Exercise
10.1 Review LHJ public health preparedness and response
capabilities and identify gaps,priorities,and training needs.
10.2 Complete Integrated Preparedness Planning Workshop 10.2 IPPW Workbook 10.2 December 31,2023
(IPPW)Workbook.
10.3 Participation in IPPW. 10.3 As requested by
10.3 Participate in Integrated Preparedness Planning DOH.
Workshop(IPPW).The Workshop is planned for February End-of-year report on template provided
2024. by DOH. June 30,2024
Exhibit A, Statement of Work Page 4 of 11 Contract Number CLH31019-Amendment 14
Page 9 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
11 Domain 2 Incident Management Mid-and end-of-year reports on template December 31,2023
Capability 3 Emergency Operations Coordination provided by DOH. June 30,2024
All LHJs
• Provide immediate notification to DOH Duty Officer at
360-888-0838 or hanalertkdoh.wa.gov for all response
incidents involving use of emergency response plans
and/or incident command structures.
• Produce and provide situation reports(sitreps)
documenting LHJ activity during all incidents. Sitrep may
be developed by the LHJ or another jurisdiction that
includes input from LHJ.
12 Domain 2 Incident Management Mid-and end-of-year reports on template December 31,2023
Capability 3 Emergency Operations Coordination provided by DOH.
All LHJs June 30,2024
After a locally affected Emergency Support Function(ESF)-
8 related incident or ESF-8 related exercise,participate in After Action Report(s)/Improvement
After Action Review and an After Action Report,including Plan(s)
an Improvement Plan.
Notes:
• Follow Homeland Security Exercise and Evaluation
Program(HSEEP)guidelines for process and
documentation.
• Include list of organizations that participated in the After
Action Review.
13 Domain 2 Incident Management Mid-year report on template provided by December 31,2023
Capability 3 Emergency Operations Coordination DOH.
All LHJs,
unless If not, completed and submitted in previous reporting period, County COVID-19 Improvement Plan,
completed develop and/or update a county COVID-19 Improvement unless submitted previously.
previously. Plan,including progress tracking and estimated dates of
completion.
County ESF-8 AAR for COVID-19,
If not, completed and submitted in previous reporting period, unless submitted previously.
coordinate or participate in a county Emergency Support
Function(ESF)8 AAR for COVID-19.Participants include,
but not limited to:
• Local Health Officer
• Public Health Official(s)
• Emergency Manager
Exhibit A, Statement of Work Page 5 of 11 Contract Number CLH31019-Amendment 14
Page 10 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
• Regional Health Care Coalition
• Local and regional hospitals,if in your county
• Federally Qualified Health Center(s),if in your
county
• Accountable Community of Health
• Emergency Medical Services Medical Program
Director
• County Coroner or Medical Examiner
Notes:
• Follow Homeland Security Exercise and Evaluation
Program(HSEEP)guidelines for process and
documentation.
• Include name,title,and organization of each
participant in documentation(AAR).
• Outreach may need to be conducted to gather input
from entities not able to participate in an AAR
meeting.
14 Domain 3 Information Management Mid-and end-of-year reports on December 31,2023
Capability 4 Emergency Public Information and Warning- templates provided by DOH. June 30,2024
All LHJs Communication
Participate in Monthly Public Health Communicator
Call/Webinar by joining call/webinar and/or following
information on the public health communicator online
collaborative workspace(for example,Basecamp).
15 Domain 3 Information Management Hot wash December 31,2023
Capability 4 Emergency Public Information and Warning- June 30,2024
All LHJs Communication If you participated in a real-world
incident,submit hotwash or AAR.
Participate in at least one risk communication drill offered by
DOH between July 1,2023,and June 30,2024. If the real-world event is ongoing,submit
hotwash or AAR,or brief summary of
Conduct a hot wash evaluating LHJ participation in the drill. communication activities and one sample
of communication with report.
Notes:
• DOH will offer one July 1 —December 31,2023,and one
drill between January 31 —June 30,2024.
• Drill will occur via webinar,phone,and email.
• Identifying and implementing communication strategies in
real-world incidents will satisfy need to participate in drill.
Exhibit A, Statement of Work Page 6 of 11 Contract Number CLH31019-Amendment 14
Page 11 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
Conduct a hot wash or After-Action Review(AAR)
evaluating LHJ participation in communication strategies
during the incident.
• If the real-world incident response is ongoing,LHJ may
conduct a hot wash or AAR evaluating communication
strategies to date or include a summary of communication
activities and one sample of communication in mid-year or
end-of year report.
16 Domain 3 Information Management Mid-and end-of-year reports on template December 31,2023
Capability 6 Information Sharing provided by DOH. June 30,2024
All LHJs
Maintain Washington Secure Electronic Communications,
Urgent Response and Exchange System(WASECURES)as
primary notification system.
Participate in DOH-led notification drills.
Conduct at least one LHJ drill using LHJ-preferred staff
notification system.
Notes:
• Registered users must log in(or respond to an alert)
quarterly at a minimum.
• DOH will provide technical assistance to LHJs on using
WASECURES.
• LHJ may choose to use another notification system in
addition to WASECURES to alert staff during incidents.
17 Domain 3 Information Management Mid-and end-of-year reports on template December 31,2023
Capability 6 Information Sharing provided by DOH. June 30,2024
All LHJs
Provide Essential Elements of Information(EEIs)during
incident response upon request from DOH.
Note: DOH will request specific data elements from the LHJ
during an incident response,as needed to inform decision
making by DOH and state leaders,as well as federal partners
when requested.
Exhibit A, Statement of Work Page 7 of 11 Contract Number CLH31019-Amendment 14
Page 12 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
18 Domain 4 Countermeasures and Mitigation Mid-and end-of-year reports on template December 31,2023
Capability 8 Medical Countermeasures Dispensing provided by DOH. June 30,2024
All LHJs Capability 9 Medical Countermeasures Management and
RERCs Distribution Updated MCM plan. June 30,2024
additional Update and maintain Medical Countermeasure(MCM)Plans
activity for LHJ and/or PHEP Region.
Note for RERCs—Gather input and provide technical assistance to
CRI LHJs LERCs in PHEP region,as needed.
MCM plans include:
• Number of local points of dispensing(PODS).
• Number of local PODS for which a point-to-point
distribution plan from local distribution site to dispensing
site has been jointly confirmed by LHJ and POD operator
(for example,nursing home,local agency,public POD,
and independent pharmacy).
Notes:
• DOH will provide technical assistance to LHJs on core
elements of an MCM plan,including hosting MCM
planning sessions.
• LHJs are not required to maintain a hub.LHJs may
partner with other organizations to centralize distribution.
If LHJs opt to maintain a hub,this should be included in
the MCM plan.
• CRI LHJs—See also CRI Task#3.
19 Domain 4 Countermeasures and Mitigation Mid-and end-of-year reports on template December 31,2023
Capability 11 Non-Pharmaceutical Interventions provided by DOH,including progress on June 30,2024
All LHJs updating plan(meetings,draft,etc.).
Update public health emergency preparedness plan to include
capability to isolate or quarantine people suspected of,or
confirmed to have an infectious disease,who cannot isolate
or quarantine safely within the confines of their current
living arrangements.
Note: This can be accomplished with Memorandums of
Understanding(MOUs)or agreements with neighboring
jurisdictions for a regionalized approach to ease potential
funding and/or staffing constraints.
Exhibit A, Statement of Work Page 8 of 11 Contract Number CLH31019-Amendment 14
Page 13 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
20 Domain 5 Surge Management Briefly describe engagement in December 31,2023
Capability 10 Medical Surge mid-and end-of-year reports on template June 30,2024
All LHJs provided by DOH.
Engagement with regional Health Care Coalition(HCC)or
Healthcare Alliance:
• Northwest Healthcare Response Network(Network)
• Regional Emergency and Disaster(REDi)Healthcare
Coalition
• Healthcare Alliance(Alliance)
During each reporting period(see notes below),participate in
one or more of the following activities:
• Meetings-Communication
o Regional meeting,in person or virtually.
o Subgroup(catchment area,committee,district,
etc. (meeting in person or virtually)
o Discussions pertaining to ESF8 and HCC or
Alliance roles and responsibilities.
o Development of Disaster Clinical Advisory
Committee(DCAC)meetings.May include
identifying local clinical participants,attending
meetings via webinar and reviewing planning
efforts.
• Planning
o Planning process to inform on the roles and
responsibilities of public health,including
reviewing HCC or Alliance plans for alignment
with local ESF8 plans.
• Drills and Exercises
o Drill or exercise,including redundant
communications,WATrac,Medical Response
Surge Exercise(MRSE),or other drills and
exercises to support planning and response
efforts.
• Response
o Information sharing process during incidents.
o Coordination with HCC or Alliance during
responses involving healthcare organizations
within your jurisdiction.
Notes:
• Reporting periods are July 1 —December 31,2023,and
January 1 —June 30,2024
Exhibit A, Statement of Work Page 9 of 11 Contract Number CLH31019-Amendment 14
Page 14 of 39
Task# Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
and/or Amount
• LHJs in HCC or Alliance regions:
o Alliance: Clark,Cowlitz,Klickitat,Skamania and
Wahkiakum.
o Network: Clallam,Grays Harbor,Island,
Jefferson,Kitsap,Lewis,Mason,Pacific, San
Juan, Seattle-King, Skagit,Snohomish,Tacoma-
Pierce,Thurston,and Whatcom.
o REDi:Adams,Asotin,Benton-Franklin, Chelan-
Douglas, Columbia,Garfield,Grant,Kittitas,
Lincoln,NE Tri,Okanogan,Spokane,Walla
Walla,Whitman,and Yakima.
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
Follow all Federal requirements for use of Federal funds:
Code of Federal Regulations(CFR),Title 2, Subtitle A,Chapter II,Part 200
Uniform Administrative Requirements,Cost Principle,and Audit Requirements for Federal Awards
eCFR::2 CFR Part 200--Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards
The following expenses are not allowable with these funds:
• Clothing(except for vests to be worn during exercises or responses.
• Food or beverages.
• Incentives.
• Items to be given to community members(members of the public).
• Salaries at a rate more than Executive Level II(Federal Pay Scale).
• Vehicles(with preapproval,funds may be used to lease vehicles).
Preapproval from DOH is required to use these funds for:
• Contracting.
• Purchasing equipment. (Equipment is a tangible item with an original per-unit cost of$5,000 or more.)
• Disposition of equipment with a current value of$5,000 or more.
Exhibit A, Statement of Work Page 10 of 11 Contract Number CLH31019-Amendment 14
Page 15 of 39
(Equipment is a tangible item with an original per-unit cost of$5,000 or more.)
• Leasing vehicles.
• Out of state travel.
Note: Preapproval is no longer required for paying overtime.
See also DOH A19 Documentation Matrix for additional expenses that may require preapproval.
BILLING
All expenses on invoices must be related to statement of work tasks.
Submit invoices monthly on a signed A19 with backup documentation appropriate for risk level.DOH will provide A19 and risk level.
• If your invoice includes indirect costs,you must have an indirect rate cost agreement approved by DOH.
• If you have no expenses related to this contract for a month,let your DOH Primary Point of Contact know via email.
• Submit final billing within 60 days of the end of the contract period.
Exhibit A, Statement of Work Page 11 of 11 Contract Number CLH31019-Amendment 14
Page 16 of 39
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Executive Office of Resiliency&Health Security- Local Health Jurisdiction Name: Mason County Public Health
WFD LHJ-Effective July 1,2023
Contract Number: CLH31019
SOW Type: Original Revision#(for this SOW) Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ❑ Reimbursement
❑ (Transparency Period of Performance: July 1,2023 through July 31,2024 State ® FFATA Other ( p y Act)
El Fixed Price
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work is to provide funding to establish,expand,train,and sustain the LHJ public health workforce to support
jurisdictional COVID-19 prevention,preparedness,response,and recovery initiatives,in accordance with the CDC Crisis Response Cooperative Agreement: COVID-19 Public
Health Workforce Development(WFD).
Note: Program does not expect to be able to extend funding beyond June 30,2024.LHJs will not be provided a fund allocation. Program will review invoices and
manage use of funds across all LHJs who want to access these funds.Timely invoicing of costs by LHJs to DOH is essential.The program also asks LHJs to inform DOH
as soon as possible if they do not plan to invoice for any of these funds.
Revision Purpose: NA
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None Allocation
FFY21 CDC COVID-19 PHWFD-LHJ 319062IG 93.354 333.93.35 07/01/23 06/30/24 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 0 0 0
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Submit names,position titles,email addresses and phone Submit information by September 15,2023, September 15,2023 Reimbursement for actual
numbers of key LHJ staff responsible for this statement of and any changes within 30 days of the costs not to exceed total
work,including management,program staff,and accounting change. Within 30 days of the funding allocation amount.
and/or financial staff. change.
2 Develop a plan to use these funds for one or more of the Implementation Plan December 31,2023,or
allowable costs listed below. sooner.
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH31019-Amendment 14
Page 17 of 39
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Submit plan to the DOH Program Contact for review and
prior approval as soon as possible. We want to be sure your
planned activities are allowable,and we will be able to
reimburse you for the expenses.
3 Funding is intended to establish,expand,train,and sustain Implementation Plan December 31,2023,or
public health staff to support LHJ COVID-19 prevention, sooner.
preparedness,response,and recovery initiatives.
Funding can be used for permanent full-time and part-time
staff,temporary or term-limited staff,fellows,interns, Data on form provided by DOH. January 10,2024
contractors,and contracted employees. July 10,2024
Allowable costs include:
• Costs including,wages and benefits,related to
recruiting,hiring, and training of new or existing
public health staff.
• Purchase of supplies and equipment to support the
expanded and/or current workforce and any training
related to the use of supplies and equipment.
• Training and education(and related travel)for new
and existing staff on topics such as incident
management training,health equity issues,working
with underserved populations,cultural competency,
disease investigations,informatics or data
management,or other needs identified by the LHJ.
• Costs of contractors and contracted staff.
Notes:
• Preapproval from DOH is required to contract with
these funds.
• Preapproval is required for the purchase of
equipment. (Equipment is a tangible item with an
original per-unit cost of$5,000 or more.)
4 Data collection, as applicable,based on activities LHJ has Data on form provided by DOH. January 10,2024
completed during the reporting period. July 10,2024
Data collection includes:
• Total new hires
• Describe challenges or experiences that have
impacted progress toward achieving set hiring goals.
Exhibit A, Statement of Work Page 2 of 4 Contract Number CLH31019-Amendment 14
Page 18 of 39
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Describe promising practices or activities that should
be considered for sustained funding.
• Explain your approach and mitigation plans to
address challenges in meeting these hiring goals.
• Health Equity—Identify metrics to address
Diversity,Equity,and Inclusion(DEI)in hiring.
• Administrative Support Staff—New Hires
• Professional or Clinical Staff—New Hires
• Disease Investigation Staff—New Hires
• Program Management Staff—New Hires
• Existing Staff budget for this funding.
Note:Reporting periods are July 1 —December 31,2023, and
January 1 —June 30,2024.
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
Follow all Federal requirements for use of Federal funds:
Code of Federal Regulations(CFR),Title 2, Subtitle A,Chapter II,Part 200
Uniform Administrative Requirements,Cost Principle,and Audit Requirements for Federal Awards
eCFR:: 2 CFR Part 200--Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards
The following expenses are not allowable with these funds:
• Clothing(except for vests to be worn during exercises or responses).
• Food or beverages.
• Incentives.
• Items to be given to community members(members of the public).
• Salaries at a rate more than Executive Level II(Federal Pay Scale).
• Vehicles(with preapproval,funds may be used to lease vehicles).
Exhibit A, Statement of Work Page 3 of 4 Contract Number CLH31019-Amendment 14
Page 19 of 39
Preapproval from DOH is required to use these funds for:
• Contracting.
• Purchasing equipment. (Equipment is a tangible item with an original per-unit cost of$5,000 or more.)
• Disposition of equipment with a current value of$5,000 or more.
(Equipment is a tangible item with an original per-unit cost of$5,000 or more.)
• Leasing vehicles.
• Out of state travel.
Note: Preapproval is no longer required for paying overtime.
See also DOH A19 Documentation Matrix for additional expenses that may require preapproval.
BILLING
All expenses on invoices must be related to statement of work tasks.
Submit invoices monthly on a signed A19 with backup documentation appropriate for risk level.DOH will provide A19 and risk level.
• If your invoice includes indirect costs,you must have an indirect rate cost agreement approved by DOH.
• If you have no expenses related to this contract for a month,let your DOH Primary Point of Contact know via email.
• Submit final billing within 60 days of the end of the contract period.
Exhibit A, Statement of Work Page 4 of 4 Contract Number CLH31019-Amendment 14
Page 20 of 39
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Foundational Public Health Services(FPHS)- Local Health Jurisdiction Name: Mason County Public Health
Effective July 1,2023
Contract Number: CLH31019
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ❑ Reimbursement
Trans
® State ❑ FFATA(Transparency ® Periodic Distribution
Period of Performance: July 1,2023 through June 30,2024 ❑ Other ( Development
p y Act)
❑ Research&Develo ment
Statement of Work Purpose: Per RCW 43.70.512,Foundational Public Health Services(FPHS)funds are for the governmental public health system: local health jurisdictions,
Department of Health, state Board of Health,sovereign tribal nations and Indian health programs. These funds are to build the system's capacity and increase the availability of
FPHS services statewide.
Revision Purpose: Adding SFY24 funds and additional activities
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
FPHS-LOCAL HEALTH JURISDICTION 99210840 N/A 336.04.25 07/01/23 06/30/24 1,266,000 832,000 2,098,000
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 1,266,000 832,000 2,098,000
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
I FPHS funds to each LHJ—See below in Program Specific See below in Program Specific See below in Program Specific $625;000
Requirements—Activity pecial Instructions for details Requirements-Deliverables Requirements-Deliverables $629,000
2 Assessment Reinforcing Capacity—See below in Program Specific See below in Program Specific See below in Program Specific $60,000
Requirements—ActivitSpecial Instructions for details Requirements-Deliverables Requirements-Deliverables
3 Assessment—CHA/CHIP—See below in Program Specific See below in Program Specific See below in Pro rg am Specific $30,000
Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
Lifeeourse infrastructure Wo 1 folr r ity Coo bolo Coo below in Pr-eg Spee:fie Coo below i D.-,,.,...af Cpee: e-
4 rra=acrue i-�Tvi-�uvrcc-c�Tpfl•• ••• „ ,•� $,,Ln nnn
'f; D f A ♦iyity C 1 T �r,,..tions for detailsD D li b D Deliverables �
I'r9g "ccrcxczccgi-iiiciricniS ztCcrvzsy-r�pcciuriii3craccronsrvr ic€�Uri€i�i�3tS zc@E11irrEi�i€i�t�
Exhibit A, Statement of Work Page 1 of 6 Contract Number CLH31019-Amendment 14
Page 21 of 39
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
Lifecourse-NEW SFY 24 Full Lifecourse Workforce Capacity—See See below in Pro rg am Specific See below in Program Specific
5 below in Program Specific Requirements—Activity Special Instructions Requirements-Deliverables Requirements-Deliverables $384,000
or details
CD-NEWSFY24Immunization Outreach,Education &Response— See below in Program Specific See below in Program Specific
6 See below in Program Specific Requirements—Activity Special $75,000
Instructions or details Requirements-Deliverables Requirements-Deliverables
EPH-NEW SFY 24 Fully fund Environmental Public Health Policy& See below in Program Specific See below in Program Specific
7 Leadership Capacity—See below in Pro rg am Specific Requirements— Requirements-Deliverables Requirements-Deliverables $125,000
Activi S ecial Instructions or details
FC-NEW SFY 24 Strengthening Local Finance Capacity—See below See below in Program Specific See below in Program Specific
8 in Program Specific Requirements—Activity Special Instructions for $62,000
details Requirements-Deliverables Requirements-Deliverables
9 FC-NEW SFY 24 Public Health Communications—See below in See below in Program Specific See below in Program Specific $200,000
Program Specific Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
Lifecourse-NEW SFY 24 Illicit Substance Use and Overdose See below in Program Specific See below in Program Specific
10 Response—See below in Program Specific Requirements—ActivitX Requirements-Deliverables Requirements-Deliverables $150,000
S ecial Instructions or details
EPR-NEW SFY 24 Emergency Preparedness&Response—Capacity See below in Program Specific See below in Program Specific
11 and Capability—See below in Program or details Specific Requirements—ActivitX Requirements-Deliverables Requirements-Deliverables $195,000
S ecial Instructions
12 CD—Hepatitis C—See below in Program Specific Requirements— See below in Pro rg am Specific See below in Pro rg am Specific $103,000
ActivitySpecial Instructions for details Requirements-Deliverables Requirements-Deliverables
13 CD—Case Investigation Capacity—See below in Program Specific See below in Program Specific See below in Program Specific $85,000
Requirements—Activity Special Instructions for details Requirements-Deliverables Requirements-Deliverables
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 financekdoh.wa.gov.
FPHS staff from DOH and the Washington State Association of Local Public Health Officials(WSALPHO)will coordinate and communicate together to build and assure common
systemwide approaches per FPHS Steering Committee direction and the FPHS framework intent.
• For LHJ questions about the use of funds:
o Chris Goodwin,FPHS Policy Advisor,WSALPHO—ceoodwinkwsac.org,564-200-3166
o Brianna Steere,FPHS Policy Advisor,WSALPHO—bsteere e wsac.org, 564-200-3171
The intent of FPHS funding is outlined in RCW 43.70.512.
Foundational Public Health Services Definitions and related information can be found here: www.doh.wa.gov/fphs.
Stable funding and an iterative decision-making process—The FPHS Steering Committee's roles and responsibilities are outlined in the FPHS Committee&Workgroup
Charter The Steering Committee is the decision making body for FPHS and operates under a consensus-based decision making model,outlined here.The Steering Committee use
Exhibit A, Statement of Work Page 2 of 6 Contract Number CLH31019-Amendment 14
Page 22 of 39
an iterative approach to decision making meaning additional tasks and/or funds may be added to a local health jurisdiction's(LHJ)FPHS Statement of Work(SOW)as funding
decisions are made.
Spending of FPHS funds—FPHS funds do not require pre-approval or pre-authorization to spend.FPHS funds are to assure FPHS services are available in each jurisdiction based
on the FPHS Definitions(link)and as reflected in the SOW.Assurance includes providing FPHS as part of your jurisdiction's program operations,contracting with another
governmental public health system partner to provide the service,or receiving the service through a new service delivery model such as cross jurisdictional sharing or regional
staff.FPHS funds are eligible starting at the beginning of each state fiscal year(July 1)regardless of when funds are received by the LHJ,even if the expenditure
occurred before the LHJ's contract was signed.
These funds are not intended for fee-based services such as select environmental public health services.As state funding for FPHS increases,other funds sources(local revenue,
grants, federal block grants)should be directed to the implementation of additional important services and local/state priorities as determined by each agency/jurisdiction.
Annual Allocations—The legislature appropriates FPHS funding on an annual basis and the FPHS Steering Committee allocates funds annually through the FPHS Concurrence
Process for the State Fiscal Year(SFY):July-June.
The Legislature appropriates FPHS funding amounts for each fiscal year of the biennium. This means that funds must be spent within that fiscal year and cannot be carried
forward. Any funds not spent by June 30'i'each year must be returned to the State Treasury. Funding allocations reset and begin again at the start of the next fiscal year(July 1).
This Statement of Work is for the period of July 1,2023-June 30,2024 and may be included in multiple Consolidated Contracts(ConCons)which are based on the calendar year
and renewed every three years.
Disbursement of FPHS funds to LHJs—Unlike other ConCon grants,FPHS bill-back to DOH is NOT required. Half of the annual FPHS funds allocated by the Steering
Committee to each LHJ are disbursed each July and January. The July payments to LHJs and access to FPHS allocation for all other parts of the governmental public health
system occur upon completion of the FPHS Annual Assessment.
Deliverables—FPHS funds are to be used to assure FPHS services statewide. The FPHS accountability process measures how funds are spent, along with changes in system
capacity through the FPHS Annual Assessment, system performance indicators,and other data. DOH, SBOH and local health jurisdictions have agreed to complete:
1. Reporting of spending and spending projections. Process timelines and reporting template are provided by the FPHS Steering Committee via FPHS Support Staff.
2. FPHS Annual Assessment is due each July to report on the previous state fiscal year. Process and reporting template are provided by the FPHS Steering Committee via
FPHS Support Staff. System results are published in the annual FPHS Investment Report available at www.doh.wa.gov/fphs.
BARS Revenue Code: 336.04.25
BARS Expenditure Coding—provided for your reference.
562.xx BARS Expenditure Codes for FPHS activities: see below
10 FPHS Epidemiology&Surveillance
1 I FPHS Community Health Assessment
12 FPHS Emergency Preparedness&Response
13 FPHS Communication
14 FPHS Policy Development
15 FPHS Community Partnership Development
16 FPHS Business Competencies
17 FPHS Technology
Exhibit A, Statement of Work Page 3 of 6 Contract Number CLH31019-Amendment 14
Page 23 of 39
20 FPHS CD Data&Planning
21 FPHS Promote Immunizations
23 FPHS Disease Investigation—Tuberculosis(TB)
24 FPHS Disease Investigation—Hepatitis C
25 FPHS Disease Investigation—Syphilis,Gonorrhea&HIV
26 FPHS Disease Investigation—STD(other)
27 FPHS Disease Investigation—VPD
28 FPHS Disease Investigation—Enteric
29 FPHS Disease Investigation—General CD
40 FPHS EPH Data&Planning
41 FPHS Food
42 FPHS Recreational Water
43 FPHS Drinking Water Quality
44 FPHS On-site Wastewater
45 FPHS Solid&Hazardous Waste
46 FPHS Schools
47 FPHS Temporary Worker Housing
48 FPHS Transient Accommodations
49 FPHS Smoking in Public Places
50 FPHS Other EPH Outbreak Investigations
51 FPHS Zoonotics(includes vectors)
52 FPHS Radiation
53 FPHS Land Use Planning
60 FPHS MCH Data&Planning
70 FPHS Chronic Disease,Injury&Violence Prevention Data&Planning
80 FPHS Access/Linkage with Medical,Oral and Behavioral Health Care Services Data&Planning
90 FPHS Vital Records
91 FPHS Laboratory—Centralized(PHSKC Only)
92 FPHS Laboratory
Special References(i.e.,RCWs,WACs,etc.):
FPHS Intent-RCW 43.70.512
FPHS Funding—RCW 43.70.515
FPHS Committee&Workgroup Charter
FPHS Steering Committee Consensus Decision Making Model
Activity Special Instructions:
Investments to Each LHJ:
1. FPHS Funds to Each LHJ
These funds are allocated to be used to provide any programs and services within all of the FPHS Definitions.Each LHJ is empowered to prioritize where and how to use
these funds to maximize equitable,effective and efficient delivery of FPHS to every community in Washington.
Use BARS expenditure codes from the list above that most closely align with expenditure made.
Exhibit A, Statement of Work Page 4 of 6 Contract Number CLH31019-Amendment 14
Page 24 of 39
Targeted Investments to Each LHJ:
2. Assessment Reinforcing Capacity(FPHS definition G.2)
Support LHJ assessment capacity with flexible funds to meet locally identified needs.BARS expenditure codes: 562.10 or 11
3. Assessment—CtWCHIP(FPHS definitions G.3)
Support any CHA/CHIP activity or service(e.g.,data analysis, focus groups,report writing,process facilitation)and may be used to contract with other agencies for staff
time or services. Use BARS expenditure codes: 562.11
n. Lifecourse rn&astzu cture& orkforee Capaeity(FPHS definitions DE,F)
Health; e with
Ofal an
e
Disease, and Nliolence Use BARS enditure eodes: .
60 or 70 o
5. Lifecourse-NEW SFY 24 Full Lifecourse Workforce Capacity(FPHS definitions D,E,F)
Infrastructure and workforce investments to each LHJ to meet fundamental needs in three areas:Maternal/Child/Family Health;Access/Linkage with Medical, Oral and
Behavioral Health Services;and Chronic Disease, Injury and Violence Prevention. Use BARS expenditure codes: 562.60, 562.70, and/or 562.80
6. CD-NEW SFY 24 Immunization Outreach,Education &Response(FPHS definition C.3)
Promote immunization education and use of the statewide immunization registry through evidence-based strategies. Funding can also be used to support vaccine-
preventable disease response. BARS expenditure codes: 562.21 and/or 562.27
7. EPH-NE W SFY 24 Fully fund Environmental Public Health Policy&Leadership Capacity(FPHS definitions B.2,A.C,J.1-3,K.1-2,L.1)
These funds are to be used for staffing costs for environmental health responsibilities and functions(that are not directly fee-based)within leadership,policy
development,foundational public health services implementation, evaluation, or administration, including(but not limited to)Environmental Health Directors.Examples
of funded roles include work relating to general policy, statewide and/or system-wide, and/or cross jurisdictional work, legislation, and rulemaking, SBOH engagement,
leadership support and/or development, workforce development, leadership within health equity, climate, and environmental justice. Use BARS expenditure codes:
562.14, 562.40—562.53
8. FC-NEW SFY 24 Strengthening Local Finance Capacity(FPHS definitions L.2-4,L.6,L.8)
Capacity and infrastructure to assure fiscal management and contract and procurement policies and procedures are effectively implemented to support programs and
services. Use BARS expenditure codes: 526.16
9. FC-NEW SFY 24 Public Health Communications(FPHS definitions L 1-2)
Capacity to enhance the frequency, accuracy, and accessibility of public health communications to diverse populations via various media to support programs and
services. Use BARS expenditure codes: 526.13
10. Lifecourse-NE W SFY 24 Illicit Substance Use and Overdose Response(FPHS definitions D.1-2,D.4,RI-3, G.1-3,11-2,J.1-J.3,KI-2)
Capacity and infrastructure related to addressing overdose crisis. This includes but is not limited to:Overdose response trainings, convening stakeholders or
coordination groups, data analysis, and community education. Use BARS expenditure codes:562.13, 562.14, 562.15, 562.60, 562.70, 562.80
11. EPR-NEW SFY 24 Emergency Preparedness&Response—Capacity and Capability(FPHS definitions H. 1-4)
Capacity and infrastructure to support and enhance the local delivery of FPHS Emergency Preparedness and Response services and activities across critical subject
matter areas. Use BARS expenditure codes: 562.12
Exhibit A, Statement of Work Page 5 of 6 Contract Number CLH31019-Amendment 14
Page 25 of 39
Targeted Investments to Select LHJs—Assuring FPHS Available in Own Jurisdiction:
12. CD—Hepatitis C(FPHS definitions C.4.o-p)
Address Hepatitis C cases per guidance developed by the FPHS CD SME Workgroup and DOH's Hepatitis C Prioritization document with particular emphasis on lab
surveillance and investigation of acute cases.Use BARS expenditure codes: 562.24.
13. CD—Case Investigation Capacity(FPHS definitions C.2,C.4)
Support LHJ communicable disease capacity to conduct case investigation and follow up to reduce gaps and meet locally identified needs that address notifiable
conditions responsibilities.Use BARS expenditure codes: 562.23-29.
Exhibit A, Statement of Work Page 6 of 6 Contract Number CLH31019-Amendment 14
Page 26 of 39
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Maternal and Child Health Block Grant- Local Health Jurisdiction Name: Mason County Public Health
Effective January 1,2022
Contract Number: CLH31019
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ❑ Reimbursement
❑ (Transparency Period of Performance: January 1,2022 through September 30,2024 State ® FFATA Other ( p y Act)
El Fixed Price
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to support local interventions that impact the target population of the Maternal and Child Health
Block Grant.
Revision Purpose: The purpose of this revision is to move$12,835 from FFY23 MCHBG LHJ Contracts to FFY22 MCHBG Special Projects and add an addional$9,359 in
funding for the period ending September 30,2023.It is also to provide additional funding,add activities and deliverable due dates, and extend the period of performance and
funding period from September 30,2023 to September 30,2024 for continuation of MCHBG related activities,and update Program Specific Requirements.
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY22 MCHBG LHJ CONTRACTS 78101221 93.994 333.93.99 01/01/22 09/30/22 50,770 0 50,770
FFY23 MCHBG LHJ CONTRACTS 78101231 93.994 333.93.99 10/01/22 09/30/23 67,694 -12,835 54,859
FFY22 MCHBG SPECIAL PROJECTS 7811022A 93.994 333.93.99 10/01/22 09/30/23 0 22,194 22,194
FFY24 MCHBG LHJ CONTRACTS 78101241 93.994 333.93.99 10/01/23 09/30/24 0 67,694 67,694
0 0 0
0 0 0
TOTALS 118,464 77,053 195,517
Task Activity Deliverables/Outcomes Due Date/ Payment Information and/or
# Time Frame Amount
Maternal and Child Health Block Grant(MCHBG)Administration
la Report actual expenditures for the six-month period Submit actual expenditures using the MCHBG May 27,2022 Reimbursement for actual costs,
October 1,2021 through March 31,2022 Budget Workbook to DOH contract manager not to exceed total funding
lb Develop 2022-2023 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 9,2022 consideration.Action D'^^ ^^agas Monthly Reports must
October 1,2022 through September 30,2023 using DOH contract manager provided template. only reflect activities paid for
with funds provided in this
lc Participate in DOH sponsored MCHBG fall regional Designated LHJ staff will attend regional September 30,2023 statement of work for the
meeting. meeting.
specified funding period.
Exhibit A, Statement of Work Page 1 of 6 Contract Number CLH31019-Amendment 14
Page 27 of 39
Task Activity Deliverables/Outcomes Due Date/ Payment Information and/or
# Time Frame Amount
Id Report actual expenditures for October 1,2021 through Submit actual expenditures using the MCHBG December 2,2022 See Program Specific
September 30,2022. Budget Workbook to DOH contract manager. Requirements and Special Billing
le Develop 2022-2023 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 9,2022 Requirements.
October 1,2022 through September 30,2023 using DOH contract manager.
provided template.
if Report actual expenditures for the six-month period from Submit actual expenditures using the MCHBG May 19,2023
October 1,2022 through March 31,2023. Budget Workbook to DOH contract manager.
Ig Report actual expenditures for October 1, 2022 through Submit actual expenditures using the MCHBG December 1, 2023
September 30, 2023. Budget Workbook to DOH contract manager.
1 h Develop 2023-2024 MCHBG Budget Workbook for Submit MCHBG Budget Workbook to DOH September 8, 2023
October 1, 2023 through September 30, 2024 using DOH contract manager.
provided template.
1 i Report actual expenditures for the six-month period from Submit actual expenditures using the MCHBG May 17, 2024
October 1, 2023 through March 31, 2024. Budget Workbook to DOH contract manager.
Implementation
2a Report activities and outcomes of 2022 MCHBG Action Submit quarterly Action Plan reports to DOH January 15,2022 Reimbursement for actual costs,
Plan using DOH-provided template. Contract manager. April 15,2022 not to exceed total funding
July 15,2022 consideration. ^etion Plan and
2b Develop 2022-2023 MCHBG Action Plan for October 1, Submit MCHBG Action Plan to DOH Draft August 19, PTegress-Monthly Reports must
2022 through September 30,2023 using DOH-provided contract manager. 2022 only reflect activities paid for
template. Final-September 9, with funds provided in this
2022 statement of work for the
2c Report activities and outcomes of 2023 MCHBG Action Submit monthly Action Plan reports to DOH July-Sept 2022 specified funding period.
Plan using DOH-provided template. Contract manager. quarterly report due
October 15,2022 See Program Specific
Requirements and Special Billing
November 15,2022 Requirements.
December 15,2022
January 15,2023
February 15,2023
March 15,2023
April 15,2023
May 15,2023
June 15,2023
July 15,2023
August 15,2023
September 15,2023
Exhibit A, Statement of Work Page 2 of 6 Contract Number CLH31019-Amendment 14
Page 28 of 39
Task Activity Deliverables/Outcomes Due Date/ Payment Information and/or
# Time Frame Amount
2d Develop 2023-2024 MCHBG Action Plan for October 1, Submit MCHBG Action Plan to DOH Draft-August 18,
2023 through September 30,2024 using DOH-provided contract manager. 2023
template. Final-September 8,
2023
2e Report activities and outcomes of 2023-24 MCHBG- Submit monthly reports to DOH contract September report due
funded work using DOH-provided reporting template. manager. October 15, 2023
November 15, 2023
December 15, 2023
January 15, 2024
February 15, 2024
March 15, 2024
April 15, 2024
May 15, 2024
June 15, 2024
July 15, 2024
August 15, 2024
September 15, 2024
2f Develop 2024-2025 MCHBG reporting document for Submit MCHBG reporting document to DOH Draft-August 16,
October 1, 2024 through September 30, 2025 using DOH- contract manager. 2024
provided template. Final-September 6,
2024
2g Support statewide roll-out of Universal Developmental Submit updates as part of monthly reporting September 30, 2024
Screening Strong Start system as requested by DOH. document as requested by DOH.
2h Determine howprocesses andprograms can become more Describe in your activities within each November 15, 2023
equitable, as a foundation of your MCHBG work. Domain of the monthly report how you are December 15, 2023
intentionally focused on equity in your work. January 15, 2024
February 15, 2024
March 15, 2024
April 15, 2024
May 15, 2024
June 15, 2024
July 15, 2024
August 15, 2024
September 15, 2024
Children and Youth with Special Health Care Needs(CYSHCN)
3a Complete Child Health Intake Form(CHIF)using the Submit CHIF data into Secure Access January 15,2022 Reimbursement for actual costs,
CHIF Automated System on all infants and children Washington website: April 15,2022 not to exceed total funding
served by the CYSHCN Program as referenced in https:Hsecureaccess.wa.gov July 15,2022 consideration. ^ fie Plan and
CYSHCN Program guidance. thly Reports must
Exhibit A, Statement of Work Page 3 of 6 Contract Number CLH31019-Amendment 14
Page 29 of 39
Task Activity Deliverables/Outcomes Due Date/ Payment Information and/or
# Time Frame Amount
3b Identify unmet needs for CYSHCN on Medicaid and refer Submit completed Health Services 30 days after forms only reflect activities paid for
to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment are completed. with funds provided in this
Diagnostic and Treatment funds to meet the need. Fund requests directly to the CYSHCN statement of work for the
Program as needed. specified funding period.
3c Work with partners to share updated local CYSHCN Review resources for your local area on September 30,2022
resources with Within Reach/Help Me Grow(HMG). ParentHelp123.org annually for accuracy and See Program Specific
submit any updates to Within Reach. Requirements and Special Billing
3d Complete intake and renewal,per reporting guidance Submit data to DOH per CYSHCN Program October 15,2022 Requirements.
supplied by DOH,on all infants and children served by the guidance. January 15,2023
CYSHCN Program as referenced in CYSHCN Program April 15,2023
guidance. July 15,2023
3e Identify unmet needs for CYSHCN on Medicaid and refer Submit completed Health Services 30 days after forms
to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment are completed.
Diagnostic and Treatment funds as needed. Fund requests directly to the CYSHCN
Pro ram as needed.
3f Work with partners to share updated local CYSHCN Review resources for your local area on September 30,2023
resources with Within Reach/Help Me Grow(HMG). ParentHelpl23.org annually for accuracy and
submit an u dates to Within Reach.
3g Complete intake and renewal,per reporting guidance Submit data to DOHper CYSHCN Program October 15, 2023
supplied by DOH, on all infants and children served by guidance. January 15, 2024
the CYSHCN Program as referenced in CYSHCN April 15, 2024
Program guidance. Jul 15, 2024
3h Identify unmet needs for CYSHCN on Medicaid and refer Submit completed Health Services 30 days after forms
to DOH CYSHCN Program for approval to access Authorization forms and Central Treatment. are completed.
Dia nostic and Treatment unds as needed.
3i Review yourprogram's entry on ParentHelp123.org Document in the Administrative box on your September 30, 2024
annually for accuracy. MCHBG report that you have updated
information on your local CYSHCNprogram
with Within Reach/Help Me Grow.
MCHBG Assessment and Evaluation
4a As part of the 5-year MCHBG Needs Assessment, Submit documentation using guidance September 30, 2024 Reimbursement for actual costs,
participate in activities developed and coordinated by provided by DOH. not to exceed total funding
DOH, as requested. consideration. Monthly Reports
must only reflect activities paid
for with funds provided in this
statement of work for the
specified funding period.
See Program Specific
Requirements and Special Billing
Requirements.
Exhibit A, Statement of Work Page 4 of 6 Contract Number CLH31019-Amendment 14
Page 30 of 39
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 e,doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal subrecipient funding.)
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
All training costs and all travel expenses for such training(for example:per diem,hotel,registration fees)must be pre-approved,unless identified in pre-approved Budget
Workbook. Submit a paragraph to your Community Consultant (contract manager) explaining why the training is necessary to implement a strategy in the approved work plan.
Details should also include total cost of the training and a link to or brochure of the training.Retain a copy of the Community Consultant's approval in your records.
Program Manual,Handbook,Policy References:
Children and Youth with Special Health Care Needs Manual-
Children and Youth with Special Health Care Needs Manual(wa.gov)
Health Services Authorization(HSA)Form
http://www.doh.wa.gov/Portals/l/Documents/Pubs/910-002-ApprovedHSA.docx
Restrictions on Funds:
1. At least 30%of federal Title V funds must be used for preventive and primary care services for children and at least 30%must be used for services for children with
special health care needs. [Social Security Law, Sec. 505(a)(3)].
2. Funds may not be used for:
a. Inpatient services,other than inpatient services for children with special health care needs or high-risk pregnant women and infants,and other patient services approved by
Health Resources and Services Administration(HRSA).
b. Cash payments to intended recipients of health services.
c. The purchase or improvement of land,the purchase, construction,or permanent improvement of any building or other facility, or the purchase of major medical
equipment.
d. Meeting other federal matching funds requirements.
e. Providing funds for research or training to any entity other than a public or nonprofit private entity.
f. Payment for any services furnished by a provider or entity who has been excluded under Title XVIII(Medicare),Title XIX(Medicaid),or Title XX(social services block
grant).[Social Security Law, Sec 504(b)].
3. If any charges are imposed for the provision of health services using Title V(MCH Block Grant)funds, such charges will be pursuant to a public schedule of charges;will not
be imposed with respect to services provided to low-income mothers or children;and will be adjusted to reflect the income,resources,and family size of the individual
provided the services. [Social Security Law, Sec. 505 (1)(D)].
Exhibit A, Statement of Work Page 5 of 6 Contract Number CLH31019-Amendment 14
Page 31 of 39
Monitoring Visits:Telephone calls with DOH contract manager as needed.
Billing Requirements: Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable A19-1A invoice voucher. Payment to completely expend the
"Total Consideration"for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly quarteA
by the 30th of each month following the month quafte in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a
monthly fraction of the"Total Consideration"will not be accepted or approved.
Special Instructions: Contact DOH contract manager for approval of expenses not reflected in approved budget workbook.
NICHBG funds may be e"ended on COVID 19 r-espense aefivities that align with matemal and ehild health priorities.Examples may inelude:
• Providing suppeft in edueating the NIC14 pepulatien about COVID 19 threugh paftner-ships with other-leeal ageneies,medieal providers,and health eafe OfgaflizatiOfls.
• Wegdng elosely with state and loeal emergeney preparedness staff to assure that the needs of the NIC14 population are represen
• Funding infrastmetwe that supports the response to COVID 19.For-example,Publie Health�rses who are routinely supported thfough the Title V program may be able
te be mobilized,using Title V ffinds er-separate emer-geney funding,to stippeft a eall eefttef of delivef health sei=viees.
• PaFtner-ing with pafent networks and health eare providers te pfevide aeeur-ate and reliable infOfmatian to all fam
• Engaging eemm-unity leaders,ineluding faith based leaders,to edueate comm-unity members about strategies for preventing illn
Exhibit A, Statement of Work Page 6 of 6 Contract Number CLH31019-Amendment 14
Page 32 of 39
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) 4 Funding Source Federal Compliance Type of Payment
®Federal Contractor (check if applicable) ❑ Reimbursement
Period of Performance: January 1,2022 through December 31,2023 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 add Sanitary Survey Funding.
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SANITARY SURVEY FEES O-SW) SS-STATE 24232522 N/A 346.26.65 01/01/22 12/31/23 23,200 800 24,000
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%)(FO-SW) SS 24239225 N/A 346.26.64 01/01/23 12/31/23 10,800 800 11,600
YR 25 SRF-LOCAL ASST 15%)(FO-SW)TA 24239225 N/A 346.26.66 01/01/23 12/31/23 1,000 0 1,000
0 0 0
0 0 0
TOTALS 48,400 1,600 50,000
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
provide funding to the LHJ for conducting checklist. community system.
sanitary surveys and providing technical 3. Updated Water Facilities Inventory
(WFI).
Exhibit A, Statement of Work Page 1 of 4 Contract Number CLH31019-Amendment 14
Page 33 of 39
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount
assistance to small community and non- 4. Photos of water system with text Payment is inclusive of all associated costs
community Group A water systems. identifying features such as travel,lodging,per diem.
5. Any other supporting documents.
Payment is authorized upon receipt and
*Final Reports reviewed and accepted acceptance of the Final Sanitary Survey Report
by the ODW Regional Office. within the 30-day deadline.
Late or incomplete reports may not be accepted
for a ment.
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 payment.
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 14
Page 34 of 39
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). http://www.ofm.wa.gov/resources/travel.aW
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 financekdoh.wa. og_v.
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$46,400$48,000 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 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 14
Page 35 of 39
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 27-29 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.
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 14
Page 36 of 39
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Immunization-Perinatal Hepatitis B- Local Health Jurisdiction Name: Mason County Public Health
Effective July 1,2023
Contract Number: CLH31019
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ❑ Reimbursement
❑ (Transparency Period of Performance: July 1,2023 through June 30,2024 Other State ® FFATA( p y Act)
❑ Fixed Price
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to define required Perinatal Hepatitis B activities,deliverables,and funding
Revision Purpose: The purpose of this revision is to increase the allocation by 10%
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 CDC PPHF O s 74310246 93.268 333.93.26 07/01/23 06/30/24 500 50 550
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 500 50 550
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 1. In coordination with hospitals,health care providers,and Enter information for each case identified By the last day of each Reimbursement for actual
health plans(if applicable),conduct activities to prevent into the Perinatal Hepatitis B Tracker month costs incurred,not to
perinatal hepatitis B infection in accordance with the exceed total funding
Perinatal Hepatitis B Prevention Program Guidelines, consideration amount.
including the following:
• Identification of hepatitis B surface antigen(HBsAG)-
positive pregnant women and pregnant women with
unknown HBsAg status.
• Reporting of HBsAg-positive women and their infants.
• Case management for infants born to HBsAg-positive
women to ensure administration of hepatitis B immune
globulin(HBIG)and hepatitis B vaccine within 12
hours of birth,the completion of the 3-dose hepatitis B
vaccine series,and post vaccination serologic testing.
Exhibit A, Statement of Work Page 1 of 2 Contract Number CLH31019-Amendment 14
Page 37 of 39
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
2. Provide technical assistance to birthing hospitals to
encourage administration of the hepatitis B birth dose to all
newborns within 12 hours of birth,in accordance with
Advisory Committee on Immunization Practices(ACIP)
recommendations.
3. Report all perinatal hepatitis B investigations,including
HBsAg-positive infants,in the Perinatal Hepatitis B
Module of the Washington State Immunization
Information System.
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(c-r�,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.
Exhibit A, Statement of Work Page 2 of 2 Contract Number CLH31019-Amendment 14
Page 38 of 39
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Immunization-Promotion of Immunizations to Local Health Jurisdiction Name: Mason County Public Health
Improve Vaccination Rates-Effective July 1,2023
Contract Number: CLH31019
SOW Type: Revision Revision#(for this SOW) 1 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ❑ Reimbursement
❑ (Transparency Period of Performance: July 1,2023 through June 30,2024 Other State ® FFATA( p y Act)
❑ Fixed Price
❑ Research&Development
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: The purpose of this revision is to increase the allocation by 10%
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 CDC VFC O s 74310241 93.268 333.93.26 07/01/23 06/30/24 5,600 560 6,160
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 5,600 560 6,160
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Develop a proposal to improve immunization coverage rates for Written proposal summarizing project plan August 1,2023 Reimbursement for actual
a target population by increasing promotion activities and and method of assessing/observing change costs incurred,not to
collaborating with community partners(can use pre and post in target population. exceed total funding
qualitative or quantitative collection methods consideration amount.
Examples of qualitative&quantitative methods/measures: (Template will be provided)
■ Surveys,Questionnaires,Interviews
■ Immunization coverage rates expressed in percentages
■ Observations(i.e.,feedback from surveys/interviews,
social media posts comments)
■ Analytic tools(i.e.,google analytics measuring
website traffic,page views etc.)
Exhibit A, Statement of Work Page 1 of 2 Contract Number CLH31019-Amendment 14
Page 39 of 39
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
2 Upon approval of proposal,implement the plan to increase Written report describing the progress November 30,2023 Reimbursement for actual
immunization coverage rates with the target population made on reaching milestones for activities costs incurred,not to
identified. identified in the plan(template will be March 31,2024 exceed total funding
provided) consideration amount.
3 Develop final report to include comparison of change or Final written report including measured June 15,2024 Reimbursement for actual
improvement of targeted outcome from start of the and/or observed outcomes[what was costs incurred,not to
project/intervention[This can be short-term or intermediate achieved as a result of the exceed total funding
outcomes with overall goal to increase immunization rates] activity/intervention?]. consideration amount.
Examples:
■ Increased partner knowledge on immunization (Template will be provided)
guidelines
■ Change in attitudes about childhood vaccines
■ Increase in school district immunization coverage
rates
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 USASpendinggov by DOH as required by P.L. 109-282.
Exhibit A, Statement of Work Page 2 of 2 Contract Number CLH31019-Amendment 14