HomeMy WebLinkAboutMINUTES - 07271993 - 1.42 TO: Y BOARD OF SUPERVISORS 1 -.-. 4 2
FROM: Mark Finucane, Health Services Director k - �,� Contra
By: Elizabeth A. Spooner, Contracts Administrator Costa
DATE: July 15, 1993 40 County
SUBJECT: Approve Standard Agreement #29-208-45 with the State Department of Health
Services for the Immunization Assistance Program
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Chair, Board of Supervisors, to execute on behalf of the
County, Standard Agreement #29-208-45 with the State Department of Health Services,
in the amount of $204,761, for the period from July 1, 1993 through June 30, 1994,
for continuation of the Immunization Assistance Program.
II. FINANCIAL IMPACT:
Approval of this agreement by the State Department of Health Services will result
in $204,761, for the period from July 1, 1993 through June 30, 1994, for
continuation of the Immunization Assistance Program. Sources of funding are as
follows:
$ 50,687 State Funds
154.074 Federal Subvention Funds (via the State)
$204,761 TOTAL FUNDS
No County funds are required.
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
On June 15, 1993, the Board of Supervisors approved submission of Funding
Application #29-208-44, to the State Department of Health Services, for continuation
of the long-standing Immunization Assistance Program. Standard Agreement #29-208-45
is the result of that application and provides funding to continue services through
June 30, 1994.
The County's Immunization Program makes immunizations available to all persons in
need of such service in order to prevent the occurrence and transmission of
childhood diseases; and under the terms of this Contract, the State provides free
vaccine to the County. The Program monitors the compliance of preschools,
elementary schools, and secondary schools in meeting State-mandated immunization
requirements through inservice programs and limited technical assistance. An
adverse reaction monitoring system and outbreak control team are also included in
the Program.
The Board Chair should sign eight copies of this agreement, seven of which should
then be returned to the Contracts and Grants Unit for submission to the State.
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMEN ATIO OF BOARD COMMITTEE +•c•-�
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS
UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
OF SUPERVISORS ON THE DATE SHOWN.
Contact: Wendel Brunner, M.D. (313-6712)
C C: Health Services (Contracts) ATTESTED D.� 2
Auditor-Controller (Claims) Phil iatcheloryclerk of Ae Board of
State Department of Health Services supery' � 11�yAdm1i91st(etQ[
M382/7-83 BY DEPUTY
STATE OF CA!'1,^RNLA 9 4 2
STANDARD AGREEMENT— APPROVED BY THE CONTRACT NUMBER AM.No.
STD.2(REv.5-91) ATTORNEY GENERAL 93-17657 00
TAXPAYER'S FEDERAL EMPLOYER IDENTIFICATION NUMaER
THIS AGREEMENT,made and entered into this 1St day of June l9 93
94-6000509
in the State of California,by and between State of California,through its duly elected or appointed,qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services ,hereafter called the State,and
CONTRACTOR'S NAME � � 0 QQ _
COUNTY OF CONTRA COSTA (Health Services) ,hereafter called the Contractor.
WPTNESSETH: That the Contractor for and in consideration of the covenants,conditions,agreements,and stipulations of the State hereinafter expressed,
does hereby agree to furnish to the Sfate services and materials as follows: (Set forth service to be rendered by Contractor,amount to be paid Contractor,
time for performance or completion,and attach plans and specifications,if any.)
1. The Contractor shall complete the objectives as stipulated in the attached Exhibit "A" entitled 'Terms" consisting of sox
pages and made a part of this agreementby this reference.
2. The attached Exhibit"B"entitled"Budget"consisting of four pages is made a part of this agreement by this reference.
3. The attached Exhibit"C"entitled"Project Summary and Budget Justification"consisting of three pages is made a part of this
agreement by this reference.
4. The attached Exhibit"D"entitled"Prior to July 1,1993 Language"consisting of one page,is incorporated herein and made
a part hereof by this reference in recognition of both parties that the validity and effectiveness of this contract are conditioned
upon the availability of funds in the Budget Act of 1993.
5. The attached Exhibit"A(F)"entitled"Additional Provisions"consisting of twenty-seven pages is made a part hereof by this
reference.
6. The attached Exhibit"A1"entitled"Equipment Purchased with State Funds"consisting of one page is made a part of this
agreement by this reference.
7. The attached Standard Form 17A entitled "Nondiscrimination Clause"consisting of one page is incorporated herein and
made a part hereof by this reference.
1
CONTINUED ON SHEETS,EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF,this agreement has been executed by the parties hereto,upon the date fust above written.
STATE OF CALIFORNIA CONTRACTOR
AGENCY coN � NY � N FgllePetc)of Health Services 9rvlces)
44
BY(AUTHORI IGNATURE) BY(AUTHORIZF,DSIG:mmReT_�
syr / ✓,
PRINTED NAY PE ON SIGNINGSUPPORT 'PRINTED NAME AND TITLE OF PERSON SIGNING
PkOfitAM
f:01W E. SIAHLBERG CNIEF Chair, Board of Supervisors
TITLE ADDRESS 651 Pine Street
Chief, Program Support Branch
Martinez, CA 94553
AMOUNT ENCUMBERED BY THIS PROGRAM ATEGORY CODE AND TITLE) FUND TITLE Department of General Services
DOCUMENT Local Assistance /Clearing Account General use only
$ 204,761.00 (OPTIONAL USE
PRIOR AMOUNT ENCUMBERED FOR FFP 175.2% Federal Catalog#93.268
THIS CONTRACT
$ 0 ITEM 4260-111-001 CHAPTER I STATUTEF{SCAL YEAR
4260-001-001 1993 1993/94
TOTAL AMOUNT ENCUMBERED TO
DATE 1[76W—CCTr3!Xgy91
9I$ 204,761.00 �/ 35651581-93-$154,074.00
93-51343-4470-70 - $9;0 SATAQ
I hereby certify upon my own personal knowledge that budgeted funds T.B.A.NO. B.R.NO.
are available for the period and purpose of the expenditure stated above.
SIGNATURE OF ACCOUNTING OFFICER ;:DATE
El CONTRACTOR STATE AGENCY DEPT.OF GEN.SER. CONTROLLER
Contractor: County of Contra Costa Contract No.: 93-17657
(Health Services) Page 2
8. The period of this contract shall be from July 1, 1993 through June 30, 1994.
9. Limitation of State Funding.
a. Under the terms of this contract for Fiscal Year 1993/94 ending June 30, 1994,the maximum amount payable shall not
exceed$50,687.
10. Limitation of Federal Funding.
a. Under the terms of this contract for the period July 1, 1993 through June 30, 1994,the maximum amount payable shall
not exceed$154,074.
11. Underthe terms of this contract,the combined maximum amount of state and federal funds payable through June 30,1994
shall not exceed$204,761.
12. In accordance with Public Law 98-502 and OMB Circular A-128, it is stipulated between the parties hereto that:
1. The cost of the single audit will be charged to the federal assistance program providing funds for this agreement.
2. The Contractor shall include a clause in any contract the Contractor enters into with the audit firm doing the single audit
to provide access by the State or Federal Government to the working papers of the independent auditor who prepares
the single audit for the Contractor.
13. Contractor agrees that this contract is subject to examination and audit by the State,including the Auditor General,for a period
of three years after final payment under said contract.
e '
EXHIBIT A(Pediatric-IAP Continued)
FY 1993-94 Page 2
e.) Assure that the importance of completing the recommended schedule of immunizations is
discussed with all patients(or parents of patients) receiving immunizations at the public clinics.
f.) Assure that the date the next vaccine dose(s) are due is given in writing to the patient or
parent. The appropriate space on the CIR may be used for this purpose.
g.) Within the health jurisdiction, the Contractor will strive to implement and maintain public
immunization clinic reminder/recall systems among all medical providers, who receive state-
supplied vaccines,to improve age-appropriate immunizations of preschool-age children.
h.) In accordance with current Immunization Branch guidelines, which were furnished to the
contractor by the State,the Contractor must participate in the national Vaccine Adverse Events
Reporting System (VAERS)for adverse events following immunization.
2.) Immunization Assessment Levels
a.) In accordance with the guidelines and timetables provided by the Immunization Branch, the
Contractor must coordinate the assessment of the immunization levels of child care centers,
Head Start Centers, and kindergarten entrants.
b.) Through coordination with Immunization Branch Representatives, county health authorities
and local child care center and school authorities,the Contractor must make efforts to ensure
that all (100%) child care centers, Head Start centers and schools fully enforce existing
regulations pertaining to the immunization of children admitted to such institutions.
c.) Annually,within the health jurisdiction,the Contractor shall select at least a 20%representative
random sample of public clinics who receive state-supplied vaccine. Of the public clinics
selected, the Contractor shall conduct immunization record audits of children (24 months - 35
months old) who are served by the clinics. The sampling technique and immunization clinic
record methodology must be compatible with the methodology of the Immunization Branch
(formerly Immunization Unit)of the Caldomia Department of Health Services. The record audit
specifications (with additional detailed guidelines), if requested, will be provided to the
Contractor by the CDHS Immunization Branch.
3.) Immunization of Infants and Preschool Children
In addition to the above stated activities,the Contractor agrees to the following activities intended to
assure the age-appropriate immunization of infants and preschoolers who reside within the
Contractor's jurisdiction.
a.) Make efforts to ensure that the immunization status of infants and children receiving services
through programs such as CHDP, MCH, AFDC, and WIC is assessed and that a system is
established to ensure age-appropriate immunization.
b.) Promote immunization information and education of parents with newborn children through all
hospitals with matemity services within the Contractor's jurisdiction.
4.) Vaccine Preventable Disease Surveillance and Outbreak Control
a.) Establish and maintain an effective system for identification and reporting of suspect, probable
and confirmed cases of vaccine preventable diseases. Sources of surveillance information
should include practicing physicians, outpatient clinics, hospitals, schools, child care centers
and Head Start centers. Active surveillance is only required during outbreaks of measles.
b.) Investigation and Control of Measles
1.) Investigation of all reported suspect, probable and confirmed cases of measles must be
EXHIBIT A
TERMS
SECTION 1. TERMS AND CONDITIONS
The Contractor must agree to the following inclusive objectives and conduct the following activities. Please
note that many of these Terms and Conditions are also objectives and activities required by the Federal
Government and are conditions for funding of the California Immunization Program and/or statutory
requirements of State and local health departments. The level of subvention contract funding to be awarded
is not represented as sufficient for support of all the required activities; a significant amount of local support
and funding is expected. Subvention contract funds must not be used to supplant (i.e., replace) local funds
currently being expended for routine immunization services and activities. Subvention funds can only be
used for the activities outlined in the budget justification.
A. Objectives:
1.) Raise to (or maintain) immunization levels of 98% or greater for each of the legally required
immunizations among all kindergarten entrants and incoming transfer students to schools within the
Contractor's jurisdiction.
2.) Raise age-appropriate immunization levels to 95% or greater among infants and preschool-age
children residing within the Contractor's jurisdiction.
3.) During the twelve-month (12) period of this agreement, the number of fourth doses of DTP
administered in public clinics to children before their second birthday will increase by ten
percentage (10%) points compared to the number administered to children of the identical age
during the preceding twelve-month (12) period.
4.) Through prevention, surveillance and outbreak control, reduce, and if possible eliminate, illness,
disability and death due to vaccine preventable diseases such as polio, diphtheria, tetanus,
pertussis, measles, rubella, mumps, hepatitis B, and Haemophilus Influenzae Type b within the
Contractor's jurisdiction.
B. Specific Pediatric Activities:
1.) Immunization Clinic Services
a.) apt staffing in existing regularly scheduled public immunization clinics and/or expand
clinics in more locations on more days with longer hours which are reasonably accessible to
parents of children who reside within the Contractor's jurisdiction.
b.) Clinic policies must allow for the immunization of all susceptible infants, children, adolescents
and adults who visit within the scheduled hours of operation regardless of their city, county or
state of residence.
c.) Public immunization clinic policies and practices must be in general accordance with the
current recommendations approved by the U.S. Public Health Service and endorsed by the
American Academy of Pediatrics (AAP) as specified in the 'Standards for Pediatric
Immunization Practices. (Note: ' The Standards represent the consensus of the National
Vaccine Advisory Committee (NVAC) and of a broad group of medical and public health experts
about what constitute the most desirable immunization practices. The Standards are expected
to be useful as a means of assisting providers to identify needed changes, to obtain resources
N necessary, and to actually implement the desirable immunization practices.) Accordingly,
appropriate in-service training shall be instituted to assure compliance with the Standards.
d.) Each patient (or patient's parents) receiving"pediatric" immunizations through the Contractor's
public clinics must be provided a new or updated Cal'rfomia Immunization Record (CIR). The
month,day and year of each immunization must be recorded on the CIR.
EXHIBIT A(Pediatric-IAP Continued)
FY 1993-94 Page 4
Contractor submit an explanation of the need for such excess with the claim for reimbursement and
to specifically identify the line item(s) to be reduced in order to increase the excess Rem(s) and
provided further that the State reserves the right to deny any such claim for any excess
reimbursement on any item. It is further understood that in no event shall the maximum amount
payable under this agreement exceed the maximum amount specified in paragraph 11 of the
Standard Agreement.
10.) It is agreed by the Contractor that in the event that a significant portion of the Contract objectives for
the initial four months of the Contract are not met by that time; and in the event that the State
determines from quarterly invoices, performance reports, and other sources of information that the
Contractor will not perform the total quantity of services contracted for; and that therefore,the total
budget allocation will not be depleted; the State and/or Contractor may make an equitable
adjustment in the original Contract budget and Contract objectives in order to decrease the total
quantity of services and commensurate Contract amount. Any adjustment shall be by amendment
only and duly executed by both parties and approved by the Department of General Services (if
applicable).
SECTION It. TERMS AND CONDITIONS FOR RECEIPT OF VACCINE PURCHASED
WITH STATE OF CALIFORNIA OR FEDERAL FUNDS
The local health department receiving vaccine purchased with State of California/Federal funds, herein
called State purchased vaccines, agrees to the following terms and conditions.
1.) Prior to receipt of an immunization,all patients(or their parents or legal guardians) must be:
a.) provided a copy of the current "Important Information" statement and/or "Vaccine
Information Pamphlet"for each vaccine dose to be administered (in the case of hepatitis B
vaccine given to newborn infants this can be provided to the mother during prenatal care or
within 12 hours after delivery);
b.) provided a reasonable opportunity to read the "Important Information" statement(s) and/or
"Vaccine Information Pamphiet(s)";
c.) provided an opportunity to ask questions and have questions answered concerning the
benefits and risks of each immunization;
d.) specifically asked if they understand the information provided to them and if they have any
questions;
e.) given a telephone number to call should the patient become ill and have to visit a physician,
clinic or hospital within the 28 days following the immunization;
Q provided the authorized appropriate translations of the "Important Information"statements
and/or "Vaccine Information Pamphlets" if English is not their first language and their
language is one for which the State has made translations available.
The Immunization Branch will supply to all local health departments camera-ready copies of the
current "Important Information" statements and a supply of the "Vaccine Information Pamphlets" in
English and Spanish. In addition, should a sufficient need exist, the Immunization Branch will
arrange for authorized translations and provide camera-ready copies of the "Important Information"
statements and a supply of"Vaccine Information Pamphlets"in other languages.
2.) If a signature card or clinic log is used in lieu of the bottom portion of the "Important Information"
statement and/or "Vaccine Information Pamphlet",the patient (or parent or legal guardian) must
read the following statement which is required to appear at the top of the signature record card or
i
EXHIBIT A(Pediatric-IAP Continued) .
FY 1993-94 Page 3
initiated within one working day of receipt of a report by the Contractor.
2.) Outbreak control procedures in accordance with the guidelines of the Immunization
Branch must be initiated by the Contractor within two working days of determination of a
probable or confirmed measles case.
C. Required Reports
1.) Reports of Local Program Progress and Activities
In accordance with the guidelines and format provided by the Immunization Branch,the Contractor
shall submit,through his/her Immunlzatlon Branch District Field Representative. to
the Branch identified in paragraph 6 of Section I in this Exhibit, by the 15th of the month following
the end of each quarter, a written quarterly report of progress and activities. In addition to the written
report the Contractor and Project Liaison,or his designee, may meet and discuss the above matters
in person.
2.) Upon completion of the investigation of each probable or confirmed measles case, a completed
investigation form must be submitted to the Immunization Branch.
3.) Contractor agrees that itemized QQrsonnel positions listed in said Exhibit B shall not be subject to
Contractor's personnel policy decisions to refrain from filling vacant positions. The total amount of
the contract will be indicated as either some part, or all, of the total operations budget. If the total
amount of the contract is less than the total operations budget, the Contractor will be responsible
for providing the difference between the total amount of the contract and the total operations
budget. Further, all invoices to the State which request reimbursements for positions included in
Exhibit "B" must include the name and Social Security number of the persons that have performed
in these positions,
4.) The Contractor shall provide for any personnel or operating expenses that are necessary to meet
the provisions included herein but are not provided for in the Budget included as Exhibit "B".
5.) The Contractor shall submit through his/her Immunization Branch District Field
Representative.to the Branch identified in paragraph 6 of Section I in this Exhibit, on or before
the 3rd of the month following the report month, a written Monthly Vaccine Usage Report in the form
prescribed by the State Department of Health Services, Immunization Branch.
6.) All reports, other than those required to be directed to the District Field Representatives, invoices,
and other written communications are to be addressed and delivered to the State Department of
Health Services, Immunization Branch, 2151 Berkeley Way, Berkeley, California 94704.
7.) The State reserves the right to use and reproduce all reports and data produced and delivered
pursuant to this Contract and reserves the right to authorize others to use or reproduce such
materials, provided that the confidentiality of patient information and records are protected pursuant
to Califomia State laws and regulations.
8.) This Contract may be terminated by either party upon 30 days' written notice to the other party.
Further, this Contract may be terminated or suspended upon written notification by the State at any
time for failure on the part of the Contractor to comply with any of the provisions contained herein.
9.) In consideration of the above services, performed in a manner acceptable to the State, the State
shall reimburse the Contractor quarterly, in arrears, upon submission of a quarterly invoice by
Contractor on Contractor's letterhead, in quadruplicate stating the time period covered, stating the
contract number, for actual expenditures in accordance with the budget (attached hereto and
shown as Exhibit "B"), to: Department of Health Services, Immunization Branch, 2151 Berkeley
Way, Room 712, Berkeley, CA 94704. The Contractor may make changes in any individual line item
in the budget, provided that such changes in the sum total does not exceed $10,000 that the
EXHIBIT A(Pediatric-IAP Continued)
FY 1993-94 Page 5
log sheet and then sign for each antigen administered:
"I have been given a copy and have read, or have had explained to me the
information contained in the Vaccine Information Pamphlet(s) or the appropriate
Important Information Statement(s) about the disease(s) and vaccines(s) indicated
below. I have had a chance to ask questions which were answered to my satisfaction.
I believe I understand the benefits and the risks of vaccine(s) and request that the
vaccine(s) indicated below be given to me or to the person named below for whom I
am authorized to make this request."
The record carni or log sheet must include as a minimum the following information:
a.) patient name
b.) address
c.) date of birth
d.) age at time of immunization
e.) type of vaccine(s) given
I.) clinic identification
g.) date of immunization
h.) site of immunization
I.) name and title of person administering the vaccine(e.g., S. Smith, R.N.)
j.) vaccine manufacturer
k.) vaccine lot number
I.) signature of patient or parent/guardian authorizing immunization
m.) date of signature
n.) date(s) printed on the"Important Information"statement(s) and/or"Vaccine
Information Pamphlets"provided to the patient or parent/guardian
NO ALTERATION, VARIATIONS OR ADDITIONS TO THE IMPORTANT
INFORMATION STATEMENTS, VACCINE INFORMATION PAMPHLETS, OR
VACCINE AGREEMENT MAY BE MADE WITHOUT THE PRIOR WRITTEN
APPROVAL OF THE CHIEF OF THE IMMUNIZATION BRANCH OF THE
CALIFORNIA DEPARTMENT OF HEALTH SERVICES.
3.) The agreemenVsignature portion of the "Important Information" statement and/or "Vaccine
Information Pamphlet" or the authorized signature record card or authorized clinic log sheets
must be stored by the local health department in a retrievable file for a minimum of 10 years
following the end of the calendar year in which the statement/pamphlet was signed. In addition,
if a notice of a claim or lawsuit has been made, the record must be retained until after a final
disposition has been made.
4.) In the case of.a school-based program, or other programs where the "Important Information"
statement(s) and/or"Vaccine Information Pamphlet(s)"are to be read and signed in advance of
the immunization by the patient or parent/guardian or other authorized person who will not be
present at the site where the immunizations are to be given, procedures shall be established and
made known for answering questions by telephone.
5.) Outside non-profit providers of immunization services must sign the State provided "Outside
Provider Agreement for Receipt of State-Supplied Vaccines" terms prepared by the State
Immunization Branch before they may receive State purchased vaccine. Medical providers of
immunization services who sign the agreement must agree to use the "Important Information"
statements and/or"Vaccine Information Pamphlets"and must be provided as many copies of the
statements/pamphlets as vaccine doses distributed, or at least one camera-ready copy of each
vaccine statement. The "Outside Provider Agreement..." and the use of the "Important
Information" statements and/or "Vaccine Information Pamphlets" are required in clinic settings
even if the clinics are supervised by a physician in attendance. The "Outside Provider
EXHIBIT A(Pediatric-IAP Continued) .
FY 1993-94 Page 6
Agreement..." shall be signed annually by non-health department medical providers and
retained by the local health department for a minimum of ten years following the last calendar year
in which the State Immunization Branch purchased vaccine was provided.
6.) Local health departments receiving State-supplied vaccines are required to provide State-
supplied vaccines to Community Health Centers (e.g., Federal and/or State-Funded Community
Health Centers, including Migrant, Rural and Indian Health Centers, etc.) if state vaccine funding
resources are sufficient and if the Community Health Centers maintain compliance with the terms
and conditions listed in the State provided "Outside Provider Agreement for Receipt of State-
Supplied Vaccines".
7.) No charge may be made to the patient, parent, guardian or third party payer for the cost of State
purchased vaccine provided to local health departments by the Immunization Branch. In
addition, outside, non-protit providers of immunization services receiving State purchased
vaccine may not charge patients or parents for the cost of vaccine. Charges made by local health
departments for the direct costs incurred for administration or injection of the vaccine are
discouraged but are not specifically prohibited. Should the health department or outside
medical provider receiving state vaccine establish an administration fee for an injection of
vaccine, information, e.g., sign/poster,M= be prominently displayed which indicates that no
one receiving an immunization in a public clinic may be denied vaccine provided through public .
funds for failure to pay the administration fee or failure to make a donation to the provider.
8.) Local health departments and other private and public providers utilizing State purchased
vaccine and/or hepatitis B immune globulin (HBIG) must report quarterly the vaccine and HBIG
doses administered, by vaccine type and age group of patient, and dose in series (for multiple-
dose vaccines) in a format provided by the Immunization Branch. Reports should be submitted
to the Immunization Branch by the third day of the following month.
9.) Each quarter, the local health department must report a current vaccine inventory including all
sites within the county or local jurisdiction. The Immunization Branch will supply the reporting
forms. All local health departments are to notify their Immunization Branch Field
Representative of any vaccine which is unlikely to be used not later than three months prior to
its date of expiration.
10.) The local health department agrees to ensure that the storage and handling of State purchased
vaccine within its facilities is in accordance with the manufacturers' specifications. The local
health department also agrees to inform other providers who receive Immunization Branch
purchased vaccine of the manufacturers'specifications for vaccine storage and handling.
DHS 8312(9/92) EXHIBIT B
BUDGET
PAGE 4 OF 4 PAGES:
APPUCATION FOR IMMUNIZATION PROJECT SUBVENTION FUNDS
Applicant : County of Contra Costa (Health Services)
Budget Period From: 7/1/93 to 6/30/94
F.Subcontracts
(List the name of the contractor or consultant and the time period of the contract
Also,Indicate the hourty/weekly/monthly rate of reimbursement and total contract amount)
Name of Subcontractor. Pittsburg Preschool Coordinating Council
Address: 1760 Chester Drive
City,State,&Zip Code: Pittsburg, Ca. 94565
Telephone#: 510-439-29061
Dollar Amount
I.Personal Services Rate of Required from
(List positions) Time Period Reimbursement Califomia
Community Outreach 7/1/93-6/30/94 $10/hr. for a $7500
Worker total of 750 houis
Personal Services Subtotal $ 7 500
11. Operating Expenses
Supplies
Health Education Materials
Travel(in-state)
Equipment
Operating Expenses Subtotal $
F.Subcontracts Total = (L Personal Services +11.Operating Expenses) $ 500
(Include amount on Operating Expenses,Exhibit B. Budget,page 2)
Note:
A written justification of the above Contractor service(s) and expected completed
work product(s)must be included in Exhibit C Budget Justification of this agreement.
OHS 8312(9/92) EXHIBIT B
BUDGET
PAGE 3 OF 4 PAGES
APPLICATION FOR IMMUNIZATION PROJECT SUBVENTION FUNDS
Applicant • County of Contra Costa (Health Services)
Budget Period From: to
b/307927-
F.Subcontracts
(List the name of the contractor or consultant and the time period of the contrail
Also,Indicate the hourtytweekly/monthly rate of reimbursement and total contract amount)
Name of Subcontractor. Neighborhood House of North Richmond
Address: 305 Chesley Ave.
City,State, Ili Tip Code: Richmond, Ca. 94801
Telephone#: -510-215-4770
Dollar Amount
I.Personal Services Rate of Required from
(List positions) Time Period Reimbursement California
Community Outreach 7/1/93-6/30/9 $10 per hour $7500
Worker for a total of .
750 hours
Personal Services Subtotal S 7500
11. Operating Expenses
Supplies
Health Education Materials
Travel (in-state)
Equipment
Operating Expenses Subtotal 1 0 —,
F.Subcontracts Total = (l. Personal Services + 11. Operating Expenses) $ 00
(include amount on Operating Expenses, Exhibit B. Budget,page 2)
Note:
A written justification of the above Contractor service(s)and'expected completed
work product(s) must be Included in Exhibit C Budget Justification of this agreement.
DHS 8312(9/92) EXHIBIT B
BUDGET
PAGE 2 OF 4 PAGES.
APPLICATION FOR IMMUNIZATION PROJECT SUBVENTION FUNDS
Applicant : County of Contra Costa (Health Services)
Budget Period From: 7/l/93 to 6/30/94
DETAILED LINE ITEM BUDGET FOR THIS PROJECT
Required from
11. Operating Expenses California
A. Supplies
1) Office Mailing, stationary supplies $1000
2) Clinic Syringes, alcohol, needle disposal boxes, etc. $1500
B.Health Education Materials
Printing and reproduction $3000
C. Laboratory Screening (Hepatitis B only)
D.Travel
1) In-State $ 420
2) Out-of-State National Conference $1200
E. Equipment
Computer hardware and software $3617
F.Subcontracts
(description(s)on Exhibit B Budget,Subcontract page(s)
$15,000
TOTAL OPERATING EXPENSES $
$25,737
TOTAL BUDGET= (I. Personal Services + 11. 0 eg_ratina Ex eo nses) $ 204,761
EXHIBIT B
BUDGET
PAGE 1 OF 4 PAGES
APPLICATION FOR IMMUNIZATION PROJECT SUBVENTION FUNDS
Applicant: County of Contra Costa (Health Services)
Budget Period From: 7/1/9 to 6130194
DETAILED LINE rTEM BUDGET FOR THIS PROJECT
% of time and/or Monthly salary rani Dollars required
1. Personal Services hours on project and/or hourly rate fron California
Immunization Coordinator 50.00% 4386-5331 $31,986 (1)
Registered Nurse 100.00% 3689-4962 $59,544
Registered Nurse 20.00% 3689-4962 $11,909
Communicable 50.00% 1925-2340 $14,040
Disease Technician i
Clerk Experienced Level 50.00% 1849-2248 $13,488 (1)
Clerk Experienced Level 25.00% 1849-2248 $6,744
(1) State funds cover al,proximately 50% of I munization
Coordiator and 50% of he Clerk personnel a penses
Total Salaries and Wages $137&1,313
711
Staff Benefits @ 30%TOTAL PERSONAL SERVICES $ 024
(OHS 8312(9/92)
Exhibit C
Project Summary and
Budget Just�ication
Page 2 of Pages
APPLICATION FOR IMMUNIZATION PROJECT SUBVENTION
BUDGET JUSTIFICATION
(Please provide written justifications for all positions and operating expenses requested on Exhibit B Budget pages 1 &2.
ff additional space Is required,attach additional pages.)
I. PERSONNEL SERVICES:
Immunization Coordinator $31,986
Coordinates activities to meet program goals: conducts.immunization assessments and
provides consultation and technical assistance to school and child care facilities to raise
and/or maintain immunization levels of at least 98% in school age children and 95% in
infants and preschool children, participates in newborn and toddler outreach efforts,
provides immunization information to the medical and lay communities, coordinates
programs for continuing education for professionals, works to reduce/eliminate vaccine
preventable disease (ie., measles, mumps, rubella, pertussis, hemophilus influenza type b),
provides the operational link between schools and preschools and the State IAP office,
supervises the computerized record keeping system, manages vaccine and vaccine
accountability,
Registered Nurse $71,453 (1 @ $59,544 and 1 @ $11,909)
WIC clinics operate throughout the county 15-29 times a month. There are an average of
22000-5000 children seen in each area of the county per month. The nurse will provide
immunizations, information on immunizations and health referrals for other needed medical
care. The nurse will also staff the special clinics in targeted areas, assist with health
education information development and assist with evaluation of Day Home assessments.
Clerk-Experienced Level $20,232 (1 @ $13,488 and 1 @ $6,744)
Provides clerical support to accomplish the goals and objectives of the program. The
activities include: typing and filing reports and letters, xeroxing, preparing kindergarten and
preschool registration packets, filling orders, tabulating audit results, mailing materials to
schools, child care facilities, family day homes and health care providers, maintaining the
computerized retrievable immunization record system and manual reminder system, and
providing clerical support to clinic and the Immunization Program Coordinator.
Communicable Disease Technician $14,040
Will provide door to.door outreach and information giving. Will give information classes in
clinics and to community groups in appropriate languages. Will work with migrant workers
to determine needed times for clinics and best access.
Staff Benefits @ 30% $41,313
(DHS 8312(9/92) Exhibit C
Project Summary and
Budget Justification
Page 1 of 3 Pages
APPLICATION FOR IMMUNIZATION PROJECT SUBVENTION
SHORT SUMMARY OF PROJECT (Not to exceed 200 words)
The purpose of the Immunization Program is to prevent the occurrence and transmission of vaccine
preventable diseases through immunizations, surveillance and outbreak control. The program will provide
immunization services, promote immunization awareness, encourage families to keep permanent
immunization records, and assure that schools maintain.a permanent record keeping system. Program
activities will be coordinated with local school officials and community agencies.
These activities will be carried out in an attempt to: (1) raise immunization levels above 98%Q for all school
age children and 95% for all infants and preschool children and (2) increase the number of 4th doses of
DTP administered in public health clinics to children 15 months to 2 years by 10% over the prior fiscal year.
Surveillance and outbreak control measures are incorporated into the program which include measles,
pertussis, rubella, Hepatitis'B, Haemophilus Influenzae Type b and other vaccine preventable disease.
Priority will be given to the: 1) annual kindergarten and preschool immunization assessments and selective
review audits, 2) distribution of immunization materials to all public and private schools and preschools with
inservice/consultation visits maintained, 3) expanded outreach efforts to infants and toddlers 4) on-site clinics
at WIC, State Preschool and Headstart sites, 4) toddler immunization campaign, 5) measles elimination
program, 6) provision of regularly scheduled public immunization clinics with special clinics as needed, 7) a
reminder/recall system for children who attend the monthly immunization clinics, WIC, and State
Preschool/Headstart on site clinics 8) outbreak control measures to contain/stop vaccine preventable disease.
9) increased provider outreach efforts to adopt the 'The No Barriers to Immunization Policy' to reduce
missed opportunities with programs for continuing education units for professionals.
A computerized immunization system with a 386 PC and Green Lira software is updated monthly to
maintain: 1) permanent retrievable record keeping system for persons given immunizations in the
immunization-only clinics and special outreach clinics 2) vaccine usage and inventory activities, and 3)
communi- cations to schools, health care providers, hospitals, and community organizations. Other software
programs will be investigated this year in an effort to establish a computerized immunization link to public
and private immunization providers.
Name of Project Director Name and Address of Applicant Including
Organizational Unit Responsible for
Project Activity
Dottie Langthorn
Immunization Program
597 Center Ave. m200A
Martinez, CA 94553
Exhibit D
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
Prior to July 1, 1993 Language
1. It is mutually understood between the parties that this contract may have
been written and executed prior to July 1, 1993 for the mutual benefit of
both parties in order to avoid program and fiscal delays which could occur
if the contract were executed after July 1, 1993 .
2. This contract is valid and enforceable only if sufficient funds are made
available by the Budget Act of 1993 for the Fiscal Year 1993-94 for the
purposes of this program. In addition, this contract is subject to any
additional restrictions, limitations, or conditions enacted by the Legislature
and contained in the Budget Bill or any statute enacted by the Legislature
which may affect the provisions, terms, or funding of this contract in any
manner.
I It is mutually agreed that if the Budget Act of 1993 does not appropriate
sufficient funds for the program, this contract shall be invalid and of no
further force and effect. In this event, the State shall have no liability to pay
any funds whatsoever to the contractor or to furnish any other
considerations under this contract, and the contractor shall not be
obligated to perform any provisions of this contract.
GMS Wuuenon�suynn No.03(10100)
Project Summary and
Budget Justification
Page 3 of 3 Pages
APPLICATION FOR IMMUNIZATION PROJECT SUBVENTION
II. OPERATIONAL EXPENSES
A. Supplies
1. Office - Pens, paper, envelopes,.postage for mass mailings and
reminder/recall postcards, phone for computer fax/modem. $1,000
2. Clinic- syringes, alcohol, drapes, cotton, bandaids, needle disposal-boxes. $1,500
B. Health Education Materials
Printing reminder/recall postcards to remind parents when their child's next
immunization is due; developing, printing and/or ordering of culturally sensitive
brochures, fliers, posters, videos. $3,000
C. Travel
1. Out-of-State: National Immunization Conference $1,200
Air fare, room and meals for 5 days.
2. In-State: Local program related activities. $420
D. Equipment
Computer software and associated hardware to establish a computer network
system with multi-provider access and reminder/recall. $3,617
F. Subcontract Services $15,000
Will provide community door-to-door outreach workers in high risk neighborhoods
with poor immunization compliance.
. • . � §
� g �
% � n
-
�
. ■ % � � t � � ' %
-
'
; Ln 7 .
. . . ■ � � o
c f 4
0 % ■ t .
. . / k
.
rt
\
.. � � w
& _ .
M
> # %
a CD
Ul ct \ §
0 »
^ 10 ■
- - - �-0 2 f g
« ® UUl
■
7 t % #
g 2 s
■ s
k
�
_ iL
®
� -
. A w s
�
NONDISCRIMINATION CLAUSE
(OCP - 1)
1 , During the performance of this contract, contractor and its
subcontractors shall not unlawfully discriminate against any
employee or applicant for employment because of race, reli-
gion, color, national origin, ancestry. physical handicap,
medical condition, marital status, age (over 40) or sex.
Contractors and subcontractors shall insure that the evalua-
tion and treatment of their employees and applicants for
employment are free of such discrimination. Contractors and
subcontractors shall comply with the provisions of the Fair
Employment and Housing Act (Government Code, Section 12900
et seq. ) and the applicable regulations promulgated thereunder
(California Administrative Code, Title 2, Section 7285,0 et
seq, ) . The applicable regulations of the Fair Employment and
Housing Commission implementing Government Code, Section 2990,
set forth in Chapter 5 of Division 4 of Title 2 of the Cali-
fornia Administrative Code are incorporated into this contract
by reference and made a part hereof as if set forth in full .
Contractor and its subcontractors shall give written notice of
their obligations under this clause to labor organizations with
which they have a collective bargaining or other agreement .
2. This contractor shall include the nondiscrimination and com-
pliance provisions of this clause in all subcontracts to perform
work under the contract.
STD. 17A (NEW 5-83)
' Exhtbtt A(f)
d. The reports required by paragraph "b" of this clause shall include, but not be limited to,
periodic reports which shall be filed at least quarterly with the appropriate local office
or, where the Contractor has more than one hiring location in a State, with the central
office of that state employment service. Such reports shall indicate for each hiring
location (1) the number of individuals hired during the reporting period, (2) the
number of nondisabled veterans of the Vietnam era hired, (3) the number of disabled
veterans of the Vietnam era hired, and (4) the total number of disabled veterans
hired. The reports should Include covered veterans hired for the on-the-job training
under 39 U.S.C. 1787. The Contractor shall submit a report within 30 days after the end
of each reporting period wherein any performance is made on this contract
identifying data for each hiring location. The Contractor shall maintain at each hiring
location copies of the reports submitted until the expiration of one year after final
payment under the contract, during which time these reports and related
documentation shall be made available, upon request, for examination by any
authorized representatives of the Federal Contracting Officer, the State, or the
Secretary of Labor. Documentation would Include personnel records respecting job
openings, recruitment, and placement.
e. Whenever the Contractor becomes contractually bound to the listing provisions of this
clause, it shall advise the employment service system in each state where it has
establishments of the name and location of each hiring location in the state. As long
as the Contractor Is contractually bound to these provisions and has so advised the
state system, there is no need to advise the state system of subsequent contracts. The
Contractor may advise the state system when it is no longer bound by this contract
clause.
f. This clause does not apply to the listing of employment openings which occur and are
filled outside the 50 states, the District of Columbia, Puerto Rico, Guam, and the
Virgin Islands.
g. The provisions of paragraphs "b", "c", "d", and "e" of this clause do not apply to
openings which the Contractor proposes to fill from within his own organization or to fill
pursuant to a customary and traditional employer-union hiring arrangement. This
exclusion does not apply to a particular opening once an employer decides to
consider applicants outside of his own organization or employer-union arrangement
for that opening.
h. As used in this clause:
(1) "All suitable employment openings" Includes, but is not limited to, openings which
occur In the following job categories: production and nonproduction: plant and
office; laborers and mechanics; supervisory and nonsupervisory; technical and
executive, administrative, and professional openings that are compensated on a
salary basis of less than $25,000 per year. This term includes full-time employment,
temporary employment of more than three days' duration, and part-time
employment. It does not Include openings which the Contractor proposes to fill
from within his own organization or to fill pursuant to a customary and traditional
employer-union hiring arrangement nor openings in an educational Institution
which are restricted to students of that institution. Under the most compelling
circumstances, an employment opening may not be suitable for listing, Including
such situations where the needs of the Federal Government cannot reasonably
be otherwise supplied, where listing would be contrary to national security, or
where the requirement of listing would otherwise not be for the best Interest of
the Federal Government.
-9-
Exhibit A(F)
The Contractor agrees under penalty or perjury (it, he, she) is not subject to cease and
desist order which is not subject to review issued pursuant to Section 13301 of the
Water Code for violation of waste discharge requirements or discharge prohibitions, or
Is not finally determined to be in violation of provisions of federal law relating to air or
water pollution.
b. (Applicable only if the contract or subcontract exceeds $100,000 or the contract is not
otherwise exempt under 40 CFR 15.5.)
The Contractor agrees as follows:
(1) To comply with all the requirements of Section 114 of the Clean Air act as
amended (42 U.S.C. 7401 et seq., as amended by Public Law 95-95), and section
308 of the Federal Water Pollution Control Act (33 U.S.C. 1251 et seq., as
amended by Public Law 92-500),respectively, relating to inspection, monitoring,
entry, reports, and information, as well as all other requirements specified in
Section 114 and Section 308 of the Air Act and the Water Act, respectively, and
all regulations and guidelines issued to implement those Acts before the award of
this contract.
(2) That no portion of the work required by this contract will be performed in a facility
listed on the Environmental Protection Agency List of Violating Facilities on the
date when this contract was awarded unless and until the Environmental
Protection Agency eliminates the name of such facility or facilities from such
listing.
(3) To use his best efforts to comply with clean air standards and clean water
standards at the facility in which the contract is being performed. The terms used
in this paragraph have the following meanings:
(a) The term "clean air standards" means any enforceable rules, regulations,
guidelines standards, limitations, orders, controls, or prohibitions or other
requirements which are contained in, issued under, or adopted pursuant to
the Clean Air Act.
(b) The term "clean water standards" means any enforceable limitation, control,
condition, prohibition, standard, or another requirement which Is
promulgated pursuant to the Clean Water Act or contained in a permit
Issued to a discharger by EPA or by the State under an approved program
as authorized by Section 402 of the Clean Water Act (33 U.S.C. 1342), or by
a local government to ensure compliance with pretreatment regulations as
required by Section 307 of the Clean Water Act (33 U.S.C. 1317), and
regulations Issued pursuant thereto.
(c) in addition to compliance with clean air and water standards, the term
compliance shall also mean.compliance with a schedule or plan ordered or
approved by a court of competent jurisdiction, the Environmental Protection
Agency, or an air or water pollution control agency in accordance with the
requirements of the Clean Air Act and the Federal Water Pollution Control
Act.
(4) As a condition for the award of a contract the applicant or contractor shall notify
the State of the receipt of any communication from the Assistant Administrator
for Enforcement, U.S. EPA indicating that a facility to be utilized for the contract is
under consideration to be listed on the EPA List of Violating Facilities. Prompt
notification shall be required prior to contract award.
-11-
Exhibit A(F)
19. Confidentialb of Information
a. The Contractor and his or her employees agents, or subcontractors shall protect from
unauthorized disclosure names and other identifying information concerning persons
either receiving services pursuant to this contract or persons whose names or
identifying information become available or are disclosed to the Contractor, his/her
employees, agents, or subcontractors as a result of services performed under this
contract, except for statistical information not identifying any such person.
b. The Contractor, his/her employees, agents, or subcontractors shall not use such
Identifying information for any purpose other than carrying out the Contractor's
obligations under this contract.
c. The Contractor, his/her employees, agents, or subcontractors shall promptly transmit
to the State all requests for disclosure of such identifying information not emanating
from the client or person.
d. The Contractor shall not disclose, except as otherwise specifically permitted by this
contract or authorized by the client, any such identifying information to anyone other
than the State without prior written authorization from the State.
e. For purposes of this paragraph, Identity shall include, but not be limited to, name,
identifying number, symbol, or other identifying particular assigned to the Individual,
such as finger or voice print or a photograph.
20. National Labor Relations Board Certification
(not applicable if Contractor is a public entity.)
Contractor, by signing this agreement, does swear under penalty of perjury that no more
than one final unappealable finding of contempt of court by a federal court has been
issued against Contractor within the immediately preceding two-year period because of
the Contractor's failure to comply with an order of a federal court which orders the
Contractor to comply with an order of the National Labor Relations Board.
21. Documents and Written Repo
Any document or written report prepared as a requirement of this agreement shall contain,
in a separate section preceding the main body of the document, the number and dollar
amounts of all contracts and subcontracts relating to the preparation of such document or
report, if the total cost for work by nonemployees of the State exceeds $5.,000.
22. Resolution of Direct Service Contract Disputes
a. If the Contractor believes there is a dispute or grievance between the Contractor and
the State, the procedures set forth In Chapter 2.1, Sections 20201 through 20205, of
Title 22, of the California Code of Regulations, shall be followed.
b. If the Contractor wishes to appeal the decision of the Deputy Director for Public
Health or his/her designee, the Contractor shall follow the procedures set forth in
Division 25.1 (commencing with Section 38050) of the Health and Safety Code and
the regulations adopted thereunder. (Title 1, Subchapter 2.5 commencing with
Section 251, California Code of Regulations.)
-13-
` EmiNt n(F)
b. If any amendment to this contract has the effect of increasing the monetary amount
of the contract or an agreement by the State to Indemnify or save harmless the
Contractor, his agents or employees, the amendment shall be approved by the
Department of General Services, unless otherwise exempted.
25. Evaluation of Contragtors
The Contractor's performance under this contract shall be evaluated at the conclusion of
the term of this contract. The evaluation shall include, but not be limited to:
a. Whether the contracted work or services were completed as specified in the contract
and reasons for and amount of any cost overruns.
b. Whether the contracted work or services met the quality standards specified in the
contract.
C. Whether the Contractor fulfilled all requirements of the contract.
d. Factors outside the control of the Contractor which caused difficulties in Contractor
performance. The evaluation of the Contractor shall not be a public record.
26. Conflict of Interest—Current and Former State Employees
a. Current State Officers and Employees
(1) Contractor shall not utilize in the performance of this contract any state officer or
employee In the state civil service or other appointed state official unless the
employment, activity, or enterprise is required as a condition of the officer or
employee's regular state employment. Employee In the state civil service is
defined to be any person legally holding a permanent or intermittent position in
the state civil service.
(2) If any state officer or employee is utilized or employed in the performance of this
contract, Contractor shall first obtain written verification from the State that the
employment, activity, or enterprise is required as a condition of the officer's,
employee's, or official's regular state employment and shall keep said verification
on file for three years after the termination of this contract.
(3) Contractor may not accept occasional work from any currently employed state
officer, employee, or official.
(4) If Contractor accepts volunteer work from any currently employed State officer,
employee, or official, Contractor may not reimburse, or otherwise pay or
compensate, such person for expenses incurred, Including, without [Imitation,
travel expenses, per diem, or the like, in connection with volunteer work on
behalf of contractor.
(5) Contractor shall not employ any state officers, employees, or officials who are on
paid or unpaid leave of absence from their regular state employment.
(6) Contractor or anyone having a financial Interest in this contract may not
become a state officer, employee, or official during the term of this contract.
Contractor shall notify each of its employees, and any other person having a
financial interest in this contract that it is unlawful under Public Contract Code,
Section 10410 for such person to become a state officer, employee, or official
during the term of this contract unless any relationship with the Contractor giving
rise to a financial Interest, as an employee or otherwise, Is first terminated.
-15-
Attachment 1
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
CERTIFICATION REGARDING LOBBYING
The undersigned certifies,to the best of his or her knowledge and belief,that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned,to any person for Influencing or attempting to Influence an officer or employee of an agency
of the United States Government, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress In connection with the making, awarding or entering Into of this
Federal contract, Federal grant, or cooperative agreement, and the extension, continuation, renewal,
amendment,or modification of this Federal contract,grant,or cooperative agreement.
(2)If any funds other than Federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to Influence an officer or employee of any agency of the United States
Government,a Member of Congress,an officer or employee of Congress,or an employee of a Member of
Congress in connection with this Federal contract,grant,or cooperative agreement,the undersigned shall
complete and submit Standard Form LLL, 'Disclosure of Lobbying Activities' in accordance with Its
Instructions.
(3) The undersigned shall require that the language of this certification be Included In the award
documents for all subawards at all tiers (Including subcontractors,subgrants,and contracts under grants
and cooperative agreements) of $100,000 or more, and that all subrecipients shall certify and disclose
accordingly.
This certification Is a material representation of fact upon which reliance was placed when this transaction
was made or entered Into. Submission of this certification is a prerequisite for making or entering Into this
transaction Imposed by Section 1352, Title 31, U. S. Code. any person who falls to file the required
certification shall be subject to a civil penalty of not less than$10A00 and not more than $100,000 for each
such failure.
None of Contractor Printed Nene of Person Skr"for Contractor
/ern. la�2f�12�
Contract/Grant Number Spahre of Person SlpriV for contractor
Date Title
After execution by or on Behalf of Contractor,please return to:
Department of Health Services
(Name of the DHS program providing the funds)
P.O. Box 942732
714 P Street
Sacramento,CA 94234-7320
CMS hstructiond Metin No.13 00/91) -24-
Attachment 2
DISCLOSURE OF LOBBYING ACTIVITIES Awavedby Oke
0348-0046
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse for publlo burden disclosure)
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
❑ a. contract ❑ a. bid/offer/application ❑ a. Initial filing
b. grant b. Initial award b. material change
c. cooperative agreement c. post-award For Material Change Only:
d. loan
e. loan guarantee Year quarter
f. loan Insurance date of last report
4. Name and Address of Reporting Entity: 5. if Reporting Entity In No.4 Is Subawardee.Enter Name
and Address of Pri
❑ Prime ❑ Subawardee
Tier .If known:
Congressional District.If known: Con ressional District,if known:
6. Federal Department/Agency: 7. Federal Program Name/Description:
CFDA Number,if applicable:
8. Federal Action Number,If known: 9. Award Amount,if known:
10. a. Name and Address of Lobbying Entity b. Name and Address of Lobbying Entity
(if Individual,last name,first name,MD: Of Individual,last name,first name,MI):
(attach Continuation Sheet(s)SF-LLL-A,If necessary)
11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply):
$ ❑ actual ❑ planned ❑ a. retainer
12. Form of Payment(check all that apply): ❑ b. one-time fee
❑ c. commission
❑ a. cash
❑ b. in-kind,specify: Nature ❑ d contingent fee
❑ e. deferred
Value ❑ f. other,specify:
14. Brief Description of Services Performed or to be Performed and Date(s)of Service,Including Officer(s),Employee(s),
or Member(s)Contacted,for Payment Indicated In Item 11:
(Attach Continuation Sheet(s)SF-LLL-A,if necessary)
15. Continuation Sheet(s)SF-LLL-A Attached: ❑ Yes ❑ No
16. Information requested through this form Is authorized by Title 31,
U.S.C.,Section 1352. This disclosure of lobbying activities Is a Sgnat—
material representation of fact upon which reliance was
placed by the tier above when this transaction was made or
entered Into. This disclosure Is required pursuant to Title 31, A"Nme:
U.S.C.,Section 1352. This Information will be reported to the
Congress semiannually and will be available for public Tft:
Inspection. Any person who fails to file the required disclosure
shall be sub)ect to a civil penalty of not less than$10,000 and �� Dare.
not more than$100,000 for each such failure.
;:#>•:•.:::,..::::.::: :::.:::::::.:::::::.:::•:::::.::::::::::::•::.::•::•:•.:r:a:•:::::.:«•:,•::•:::::::.::::.:::::::,<:.::
Authorized for local Reproduction
..f..........................:: ....,.:.
x ..... ... ......:......:.�f...:
::: �•.�:::•:::::::•::::•::::::.�::::::.�:::::::::::::::::::::::::::::>,.::::::::::::::::::::•::•:::f:•:::.:...::..::..........::::;:. Standard Farre—LLL
CMS hgruchonal Metin No.14(10191) -25-
(B) For purposes of paragraph (b)(2)(ii)(A), 'professional and technical
services` shall be limited to advice an analysis directly applying any
professional or technical discipline. For example, drafting of a legal
document accompanying a bid or proposal by a lawyer is allowable.
Similarly, technical advice provided by on engineer on the
performance or operational capability of a piece of equipment
rendered directly in the negotiation of a contract is allowable.
However, communications with the intent to influence made by a
professional (such as a licensed lawyer) or a technical person (such as
a licensed accountant)are not allowable under this section unless they
provide advice and analysis directly applying their professional or
technical expertise and unless the advice or analysis is rendered
directly and solely In the preparation, submission or negotiation of a
covered Federal action. thus, for example, communications with the
intent to influence made by a lawyer that do not provide legal advice
and analysis directly and solely related to the legal aspects of his or her
client's proposal, but generally advocate one proposal over another
are not allowable under this section because the lawyer is not
providing professional legal services. Similarly,communications with the
intent to influence made by on engineer providing an engineering
analysis prior to the preparation or submission of a bid or proposal are
not allowable under this section since the engineer is providing
technical services but not directly in the preparation, submission or
negotiation of a covered Federal action.
(C) Requirements imposed by or pursuant to law as a condition for
receiving a covered Federal award include those required by law or
regulation,or reasonably expected to be required by law or regulation,
and any other requirements in the actual award documents.
(D) Only those services expressly authorized by paragraph (b)(2)(ii) are
allowable under paragraph(b)(2)(ii).
(iii) Reporting for Own Employees.
No reporting is required with respect to payments of reasonable
compensation made to regularly employed officers or employees of a
person.
(iv) Professional and technical services by Other than Own Employees.
(A) The prohibition on the use of appropriated funds, in paragraph (b)(1),
does not apply in the case of any reasonable payment to a person,
other than an officer or employee of a person requesting or receiving a
covered Federal action, if the payment Is for professional or technical
services rendered directly In the preparation,submission,or negotiation
of any bid, proposal, or application for that Federal contract or for
meeting requirements imposed by or pursuant to law as a condition for
receiving that Federal contract.
-21-
(2) Each recipient shall file a disclosure (in the form set forth in Attachment 2
consisting of three pages, entitled 'Standard Form-LLL-'Disclosure of Lobbying
Activities') if such recipient has made or has agreed to make any payment using
nonappropriated funds (to include profits from any covered Federal action) in
connection with a contract or grant or any extension or amendment of that
contract or grant,which would be prohibited under paragraph (b) of this Exhibit
if paid for with appropriated funds.
(3) Each recipient shall file a disclosure form at the end of each calendar quarter in
which there occurs any event that requires disclosure or that materially affects
the accuracy of the information contained in any disclosure form previously filed
by such person under paragraph (c)(2). An event that materially affects the
accuracy of the Information reported includes:
() A cumulative increase of $25.000 or more in the amount paid or expected
to be paid for influencing or attempting to influence a covered Federal
action; or
OD A change in the person(s) or Individual(s) influencing or attempting to
influence a covered Federal action; or,
(iii) A change in the officer(s), employee(s), or Member(s) contacted for the
purpose of influencing or attempting to influence a covered Federal action.
(Q) Each person (or recipient) who requests or receives from a person referred to in
paragraph (c)(1) of this section a contract, subcontract, grant, or subgrant
exceeding $100,000 at any tier under a contract or grant shall file a certification,
and a disclosure form,if required,to the next tier above.
(5) All disclosure forms(but not certifications) shall be forwarded from tier to tier until
received by the person referred to in paragraph (1) of this section. That person
shall forward all disclosure forms to the State agency.
(d) Agreement. In accepting any contract,grant,subcontract or subgrant subject to this
Exhibit,the recipient (and any person submitting an offer for such a contract or grant)
agrees not to make any payment prohibited by law or this Exhibit.
(e) Penalties.
(1) Any person who makes an expenditure prohibited under paragraph (b) of this
Exhibit shall be subject to a civil penalty of not less than $10.000 and not more
than $100,000 for each such expenditure.
(2) Any person who fails to file or amend the disclosure form to be filed or amended
K required by this Exhibit,shall be subject to a civil penalty of not less than $10.000
and not more than $100,000 for each such failure.
(3) Recipients may rely without liability on the representations made by their
subcontractors or subgrantees in the certification and disclosure form.
(f) Cost allowability. Nothing in this Exhibit Is to be Interpreted to make allowable or
reasonable any costs which would be unallowable or unreasonable in accordance
with Part 31 of the Federal Acquisition Regulation. Conversely,costs made specifically
unallowable by the requirements in this Exhibit will not be made allowable under any
of the provisions of Part 31 of the Federal Acquisition Regulation.
-23-
Et"A M
The term 'expanded scope auditing' is applied and defined in the U.S. General
Accounting Office (GAO) issued Standards for Audit of Governmental Organizations,
Programs,Activities and Functions,better known as the 'yellow book.'
28. Contractor Name Change
Contractor shall provide written notice to the State at least 30 days prior to any changes to
the Contractor's current legal name.
29. Novation
If the Contractor proposes any novation agreement,the State shall act upon the proposal
within 60 days after receipt of the written proposal. The State may review and consider the
proposal,consult and negotiate with the Contractor,and accept or reject all or part of the
proposal. Acceptance or rejection may be made orally within the 60 day period, and
confirmed In writing within five days.
30. Drug-Free Workplace
Contractor certifies to the State that It will provide a drug-free workplace by doing all of
the following:
a. Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensation, possession, or use of a controlled substance is prohibited in
the person's or organization's workplace and specifying the actions that will be taken
against employees for violations of the prohibition.
b. Establishing a drug-free awareness program to Inform employees about all of the
following:
(1) The dangers of drug abuse in the workplace.
(2) The person's or organization's policy of maintaining a drug-free workplace.
(3) Any available drug counseling, rehabilitation, and employee assistance
programs.
(4) The penalties that may be imposed upon employees for drug abuse violations.
c. Requiring that each employee engaged in the performance of the contract or grant
be given a copy of the statement required by subdivision(a)and that,as a condition
of employment on the contract or grant,the employee agrees to abide by the terms
of the statement.
d. Contractor agrees this contract may be subject to suspension of payments or
termination of this contract,or both,and the contractor may be subject to debarment,
In accordance with the requirements of the Government Code Section 8350,et seq., if
the Department determines that any of the following has occurred:
(1) The contractor or grantee has made a false certification.
(2) The contractor violates the certification by failing to carry out the requirements of
subdivisions(a)through(c)above.
-17-
'Person' means an Individual, corporation, company, association, authority, firm,
partnership, society, State, and local government, regardless of whether such entity is
operated for profit or not for profit. This term excludes an Indian tribe, tribal
organization, or any other Indian organization with respect to expenditures specifically
permitted by other Federal law.
"Reasonable compensation' means, with respect to a regularly employeed officer or
employee of any person, compensation that Is consistent with the normal
compensation for such officer or employee for work that is not furnished to, not
funded by,or not furnished in cooperation with the Federal Government.
"Reasonable payment" means, with respect to professional and other technical
services,a payment in an amount that is consistent with the amount normally paid for
such services in the private sector.
'Recipient' includes the Contractor or Grantee,and all subcontractors or subgrantees
at any tier in connection with a Federal contract, grant, or other Federally funded
activity. The term excludes an Indian tribe, tribal or ganization, or any other Indian
organization with respect to expenditures specifically permitted by other Federal law.
'Regularly employed' means, with respect to an officer or employee of a person
requesting or receiving a Federal contract, an officer or employee who is employed
by such person for at least 130 working days within 1 year immediately preceding the
date of the submission that initiates agency consideration of such person for receipt of
such contract. An officer or employee who is employed by such person for less than
130 working days within 1 year immediately preceding the date of the submission that
initiates agency consideration of such person shall be considered to be regularly
employed as soon as he or she is employed by such person for 130 working days.
"State" means a State of the United States, the District of Columbia, the
Commonwealth of Puerto Rico, a territory or possession of the United States, an
agency or instrumentality of a State, and a multi-State, regional, or interstate entity
having governmental duties and powers.
b Prohibition.
(1) Section 1352 of title 31, U. S. Code provides in part that no appropriated funds
may be expended by the recipient of a Federal contract, grant, loan, or
cooperative agreement to pay any person for influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in
connection with any of the following covered Federal actions: The awarding of
any Federal contract, the making of any Federal grant, the making of any
Federal loan, entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant,loan,or cooperative agreement.
(2) The prohibition does not apply as follows:
(i) Agency and legislative liaison by Own Employees.
(A) The prohibition on the use of appropriated funds, in paragraph (b)(1),
does not apply in the case of a payment of reasonable compensation
made to an officer or employee of a person requesting or receiving a
Federal contract if the payment is for agency and legislative liaison
activities not directly related to a covered Federal action.
-19-
ExfNbH A(F)
6. Income Restrictions
The Contractor agrees that any refunds, rebates, credits, or other amounts (including any
interest thereon) accruing to or received by the Contractor under this contract shall be
paid by the Contractor to the State, to the extent that they are properly allocable to costs
for which the Contractor has been reimbursed by the State under this contract.
7. Fxa ination of Accounts_ Audit. Records.and Subcontract Langur
a. The Contractor shall maintain books, records, documents, and other evidence,
accounting procedures, and practices, sufficient to reflect properly all direct and
Indirect costs of whatever nature claimed to have been incurred in the performance
of this contract, Including any matching costs and expenses. The foregoing
constitutes°records"for the purpose of this clause.
b. The Contractor's facility or office or such part thereof as may be engaged in the
performance of this contract and his records shall be subject at all reasonable times
to Inspection, audit, and reproduction by the State or any of its duly authorized
representatives, Including the Comptroller General of the United States.
c. The Contractor shall preserve and make available his records (i) for a period of three
years from the date of final payment under this contract, and (ii) for such longer
period, If any, as is required by applicable statute, by any other clause of this contract,
or by subparagraphs (1) or(2) below.
(1) If this contract Is completely or partially terminated, the records relating to the
work terminated shall be preserved and made available for a period of three
years from the date of any resulting final settlement.
(2) If any litigation, claim, negotiation, audit, or other action involving the records
has been started before the expiration of the three-year period, the records shall
be retained until completion of the action and resolution of all Issues which arise
from it, or until the end of the regular three-year period, whichever is later.
d. The Contractor further agrees to include in all his subcontracts hereunder a written
agreement with said subcontractor or vendor, the following clause:
"(Name of Vendor or Subcontractor) agrees to maintain and preserve, until three
years after termination of (Contractor's name) agreement or contract with the State
of California, and to permit the State or any of its duly authorized representatives,
Including the Comptroller General of the United States, to have access to and
examine and audit any pertinent books, documents, papers, and records of(name of
subcontractor or vendor) related to this(purchase order or subcontract)."
8. Covenant Against Contingent Fees
The Contractor warrants that no person or selling agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a commission,
percentage, brokerage, or contingent fee, excepting bona fide employees or bona We
established commercial or selling agencies maintained by the Contractor for the purpose
of securing business. For breach or violation of this warranty, the State shall have the right
to annul this contract without liability or in Its discretion to deduct from the contract price or
consideration, or otherwise recover, the full amount of such commission, percentage,
brokerage, or contingent fee.
-5-
` ExhlbH A(F)
11. Final Invoice—Final Report—Retention of Funds
If a final report is required by this contract, 10 percent of the face amount of the contract
or 50 percent of the final invoice, whichever is the larger amount, but not to exceed $3,000,
shall be withheld until after receipt by the State of a report satisfactory to the State.
12. Officials Not to Benefit
No member of or delegate to Congress or the State Legislature shall be admitted to any
share or part of this contract, or to any benefit that may arise therefrom; but this provision
shall not be construed to extend to this contract if made with a corporation for its general
benefit.
13. Rights in Data
a. Subject Data. As used in this clause, the term "Subject Data" means writings, sound
recordings, pictorial reproductions, drawings, designs or graphic representations,
procedural manuals, forms, diagrams, work flow charts, equipment descriptions, data
files and data processing or computer programs, and works of any similar nature
(whether or not copyrighted or copyrightable) which are first produced or developed
under this contract. The term does not include financial reports, cost analyses, and
similar Information Incidental to contract administration.
b. Federal Government and State Rights. Subject only to the provisions of "c" below, the
Federal Government and State may use, duplicate, or disclose in any manner and for
any purpose whatsoever, and have or permit others to do so, all Subject Data
delivered under this contract.
c. License to Copyrighted Data. In addition to the Federal Government and State rights
as provided in [b] above, with respect to any subject data which may be
.copyrighted, the Contractor agrees to and does hereby grant to the Federal
Government and State a royalty-free, nonexclusive and Irrevocable license
throughout the world to use, duplicate, or dispose of such data in any manner for
State or Federal Government purposes and to have or permit others to do so.
Provided, however, that such license shall be only to the extent that Contractor now
has, or prior to completion or final settlement of this contract may acquire, the right to
grant such license without becoming liable to pay compensation to others solely
because of such grant.
d. Relation to Patents. The State reserves a license on patent rights in any contract
Involving research or developmental, experimental, or demonstration work with
respect to any discovery or invention which arises under this contract.
e. Marking and Identification. The Contractor shall mark all Subject Data with the
number of this contract and the name and address of the contractor or
subcontractor who generated the data. The Contractor shall not affix any restrictive
markings upon any Subject Data, and if such markings are affixed, the Federal
Government or State shall have the right at any time to modify, remove, obliterate, or
Ignore any such markings.
f. Subcontractor Data. Whenever any Subject Data is to be obtained from a
subcontractor under this contract, the Contractor shall use this same clause in
subcontract without alteration, and no other clause shall be used to enlarge or
diminish the Federal Government's or State's rights in the subcontractor Subject Data.
-7-
' 6?vbit A 0
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
ADDITIONAL PROVISIONS
(FOR FEDERALLY FUNDED SUBVENTION AID/LOCAL ASSISTANCE
COST REIMBURSEMENT CONTRACTS/GRANTS)
1. Equal Onnortunity Clause
a. The Contractor will not discriminate against any employee or applicant for
employment because of race, color, religion, sex, national origin, physical or mental
handicap, or age. The Contractor will take affirmative action to ensure that qualified
applicants are employed, and that employees are treated during employment
without regard to their race, color religion, sex, national origin, physical or mental
handicap, or age. Such action shall include, but not be limited to, the following:
employment, upgrading, demotion or transfer, recruitment or recruitment advertising;
layoff or termination; rates of pay or other forms of compensation; and career
development opportunities and selection for training, including apprenticeship. The
Contractor agrees to post in conspicuous places, available to employees and
applicants for employment, notices to be provided by the Federal Government or the
State, setting forth the provisions of the Equal Opportunity clause and the
Rehabilitation Act of 1973. Such notices shall state the Contractor's obligation under
the law to take affirmative action to employ and advance in employment qualified
applicants without discrimination based on their race, color, religion, sex, national
origin, physical or mental handicap, or age, and the rights of applicants and
employees.
b. The Contractor will,in all solicitations or advertisements for employees placed by or on
behalf of the Contractor, state that all qualified applicants will receive consideration
for employment without regard to race, color, religion, sex, national origin, physical or
mental handicap,or age.
c. The Contractor will send to each labor union or representative of workers with which
he or she has a collective bargaining agreement or other contract or understanding a
notice, to be provided by the Federal Government or the State, advising the labor
union or worker's representative of the Contractor's commitments under this Equal
Opportunity clause and shall post copies of the notice In conspicuous places
available to employees and applicants for employment.
d. The Contractor will comply with all provisions of the Rehabilitation Act of 1973 and of
the Federal Executive Order No. 11246 as amended,and of the rules, regulations,and
relevant orders of the Secretary of Labor.
e. The Contractor will furnish all information and reports required by Federal Executive
Order No. 11246 as amended and the Rehabilitation Act of 1973, and by the rules,
regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit
access to his books, records, and accounts by the contracting agency and the
Secretary of Labor for purposes of investigation to ascertain compliance with such
rules,regulations and orders.
0A herico nd astir,No.02(11/91)
EXW A(f)
4. Standards of Work
The Contractor agrees that the performance of work and services pursuant to the
requirements of this contract shall confirm to high professional standards.
5. Furnishing of Prog2dy by the State or Purchase of Progeny with State or Federal Funds
a. (1) All equipment, material, supplies, or property of any kind purchased from funds
advanced or reimbursed or furnished by the State under the terms of this
contract and not fully consumed in the performance of the contract shall be the
property of the State and shall be subject to the provisions of this paragraph (a),
as well as paragraphs(b).(c),and(d)below.
If the Equipment Line item in the budget or in any other paragraph of this
contract,exceeds$10,000 or more,the provisions of subparagraph b shall apply.
(2) Inventory and Disposition
(a) .Contractor shall, at the request of the State, submit an inventory of
equipment furnished or purchased under the terms of this contract. Such
inventory will be required not more frequently than annually.
(b) At the termination of this contract, the Contractor shall provide a final
inventory to the State and shall at that time query the State as to the State's
requirements, including the manner and method, in returning said
equipment to the State. Fnal disposition of such equipment shall be at state
expense in accordance with instructions from the State to be issued
immediately after receipt of the final inventory.
(3) Motor Vehicles
(a) If, under the provisions of paragraph (2) above,any part of such property is
motor vehicles, the State Office of Procurement shall purchase said motor
vehicles for and on behalf of the Contractor. The provisions of clause (5b)
below are applicable to this paragraph concerning rotor vehicles.
(b) If, under the provisions of paragraphs (2) or (3) above, any part of such
property is motor vehicles, the State authorizes the Contractor to use said
motor vehicles under the terms and conditions of this contract for purposes
of this contract only, and in accordance with the provisions of
subparagraphs (c) through (f) below.
(c) It is mutually understood that the State of California shall be the legal owner
of said vehicles and the Contractor shall be the registered owner.
(d) Upon return of such motor vehicles to the State, Contractor shall deliver to
State all necessary documents of title to enable proper transfer of
marketable title to the State.
(e) Contractor agrees that all operators of motor vehicles listed in said
agreement shall hold a valid State of California driver's license. In the event
12 or more passengers are to be carried in any one vehicle listed in said
agreement,a Class 2 driver's license will also be required.
(f) Contractor shall furnish to the State a certificate of insurance stating that
there is liability insurance presently in effect for the Contractor of not less
than $500,000 per occurrence for bodily injury and property damage liability
combined.
-3-
DISCLOSURE OF LOBBYING ACTIVITIES
CONTINUATION SHEET
Approved by OMB
-348-0046
ReporWV Enflty: Page of
Au xttod for lata Reproduction
CKG h tnxilonoi&Aotn No.14(10191) -27- Stu K*3d form-LLL-A
I