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HomeMy WebLinkAboutMINUTES - 09211993 - 1.29 TO: BOARD OF SUPERVISORS , Mark Finucane Health Services Director r� ContraFROM. By: Elizabeth A. Spooner, Contracts Administrato Costa DATE: September 10, 1993 County SUBJECT: Approve Standard Agreement #28-537-1 with the State Department of Health Services for the Childhood Lead Poisoning Case Management Project 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 #28-537-1 (State #92-16245) with the State Department of Health Services, in the amount of $21, 831, for the period from January 1, 1993 through June 30, 1993 , for the Childhood Lead Poisoning Case Management Project. II. FINANCIAL IMPACT: This Agreement provides $21, 831 of State funding for the first year of a three year project for the County' s Childhood Lead Poisoning Case Management Project. No County funds are required. III. REASONS FOR RECOMMENDATIONS/BACKGROUND: The goal of the Childhood Lead Poisoning Case Management Project is to decrease children ' s health problems, including neurological, developmental and learning deficits due to lead poisoning, by providing timely identification and comprehensive interventions. The project also seeks to determine the extent of lead poisoning in Contra Costa County and to identify high-risk populations for targeted outreach and community education. Seven signed copies of the Standard Agreement and three certified copies of the Board Order should be returned to the Contracts and Grants Unit for submission to the State Department of Health Services. CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMEN ATI N OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S) ACTION OF BOARD ON REP z 17993 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) SEP 2 1 1993 cc: Health Services (Contracts) ATTESTED_ Auditor-Controller (Claims) Phil Batchelor, Clerk of the Board of State Dept. of Health Services $ypeiYlSDi$ 1Atltlli[l1St[ [ M382/7•83 BY DEPUTY STAT:GF CALIFORNIA R - APPROVED BY THE STANDARD AGREEMENT- ATTORNEY GENERAL CONTRACT NUMBER AM.NO. STD.2(REV.5.91) 92-16245 TAXPAYERS FEDERAL EMPLOYER IDENTIFICATION NUMBER THIS AGREEMENT,made and entered into this First day of January . 19 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 Health Services ,hereafter called the State,and CONTRACTOR'S NAME k-8-- �/3 7 - I Contra Costa County ivy ,hereafter called the Contractor. WITNESSETH: 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 State 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.) This Agreement is entered into pursuant to the provisions of the Childhood Lead Poisoning Prevention Act of 1991. The definition of terms used in this Agreement shall be determined under Article 4.6, Section 372.1, Chapter 2, Part I, Division I of the Health and Safety Code and are repeated in Exhibit B for reference. I. Term of Contract The term of this agreement shall be from January 1, 1993 through June 30, 1995, subject to the provisions of Articles II and M. II. Limitation of State Liabbilitv 1. The maximum amount payable for the 1992-93 Fiscal Year ending June 30,1993,shall not exceed twenty one thousand eight hundred thirty one dollars ($21,831). 2. The maximum amount payable under this contract in the 1993-94 Fiscal Year ending June 30,1994,shall not exceed forty three thousand six hundred sixty one dollars ($43,661), subject to the availability of funds. 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 first above written. STATE OF CALIFORNIA CONTRACTOR AGENCY CONTRACTOR(if other than an individual state whether a corporation,partnership,etc.) Health Services Contra Costa Count BY(AUTHORIZED SIGNATURE) B yAUTHORIZED SIGN�JRE{� D PRINTED NAME OF PERSON SIGNING PRWrED NAME AND TITLE OF PERSON SIGNING Edward Stahlberg Chair, Board of Supervisors. TITLE ADDRESS Chief, Program Support Branch 651 Pine Street, Mar�,:inez, CA 94553 AMOUNT ENCUMBERED BY THIS PROGRAM4ATEGORY(CODE AND TITLE) FUND TITLE Department of General Services DOCUMENT Support CLPPF (080) Use Only $ 21,831 (OPTIONAL USE) PRIOR AMOUNT ENCUMBERED FOR THIS CONTRACT $ 0 ITEM 260-001-080 (b) °H sT� T' FICpLXF.AR TOTAL AMOUNT ENCUMBERED TO -T FI" L - DATE OBJECT OF EXPENDITURE(CODE AND TITLE) $ 21,831 4539-418-02-13238 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 CONTRACTOR ❑ STATE AGENCY DEPT.OF GEN.SER. CONTROLLER Contra Costa County Contract Number 92-16245 II. Limitation of State Liability (Continued) 3. The maximum amount payable under this contract in the 1994-95 Fiscal Year ending June 30, 1995 shall not exceed forty three thousand six hundred sixty one dollars ($43,661), subject to the availability of funds. 4. The maximum amount payable under this contract shall not exceed one hundred nine thousand one hundred fifty three dollars ($109,153). III. Funding or funding Reduction in Subsequent Fiscal Years 1. Funds are presently not available for performance under this agreement beyond June 30, 1993. The State's obligation for performance of this agreement beyond that date is contingent upon the availability of funds in the Childhood Lead Poisoning Prevention Fund and the availability of appropriated funds by the Legislature from which payment for contract purposes can be made. No legal liability on the part of the State for any payment may arise for performance under this agreement beyond June 30, 1993 until funds are made available to the State for performance and-until the Contractor receives notice of availability, to be confirmed in writing by the State. 2. If funding for any subsequent fiscal year after 1992-93 is reduced or deleted by the Legislature for purposes of this program, or if sufficient funds are not available in the Childhood Lead Poisoning Prevention Fund, the State shall have the option to either: a. Cancel this agreement. b. Offer a contract amendment to the Contractor to reflect the reduced funding for this agreement. IV. Exhibits 1. The attached Exhibit A entitled"Scope of Work",consisting of one (1) page,is incorporated herein and made a part hereof by this reference. 2. The attached Exhibit A(S) entitled "Additional Provisions, consisting of ten (10) pages, is incorporated herein and made a part hereof by this reference. 3. The attached Exhibit B entitled"Definition of Terms",consisting of one(1)page,is incorporated herein and made a part hereof by this reference. 4. The attached Exhibit C entitled "Budget", consisting of one (1) page, is incorporated herein and made a part hereof by this reference. 5. The attached Exhibit D entitled "Follow-up Activities", consisting of three (3) pages, is incorporated herein and made a part hereof by this reference. This exhibit is excerpted from the CDC publication, "Preventing Lead Poisoning in Young Children"; a complete copy of this document is available on request from Childhood Lead Poisoning Prevention Branch,California Department of Health Services, 5801 Christie Avenue, Suite 600, Emeryville, CA 94608-2008. 6. The attached Exhibit E entitled "Lead Poisoning Followup Form", consisting of eleven (11) pages, is incorporated herein and made a part hereof by this reference. Page 2 Contra Costa County Contract Number 92-16245 IV. Exhibits (continued) 7. The attached Exhibit F, entitled "Contract Time Accounting Report", consisting of two (2) pages, is incorporated herein and made a part hereof by this reference. 8. The attached Exhibit G entitled"Furnishing of Property by the State or purchase of Property with State or Federal Funds", consisting of one (1) page is incorporated herein and made a part hereof by this reference. 9. The attached Exhibit H entitled "Equipment Purchased With State Funds", consisting of one (1) page is incorporated herein and made a part hereof by this reference. 10. The attached Exhibit I entitled "Inventory of State Furnished Property", consisting of one (1) page is incorporated herein and made a part hereof by this reference. 11. The attached Exhibit J entitled"Nondiscrimination Clause", consisting of one (1) page, is incorporated herein and made apart hereof by this reference. V.. Primark+ Parties 1. The primary parties of this-contract shall be the County of Contra Costa and the California State Department of Health Services. 2. For purposes of this agreement, Vee Ainars,RMMPH, shall be designated as Contract Officer for the Contractor. 3. For purposes of this agreement,Charles G.Belknap,Program Administrator,Childhood Lead Poisoning Prevention Branch, shall be designated as Contract Officer for the State. 4. Either Contract Officer may be changed by written notice to the other party, without contract amendment. VI. Scope of Work The contractor shall perform all of the services described in Exhibit A,"Scope of Work",in accordance with the applicable criteria in Exhibit D, "Follow-up Activities". VII. Invoicing and Payment of Funds 1. In consideration of the services described in Exhibit A, "Scope of Work", performed in a manner acceptable to the State,the State shall reimburse the contractor,quarterly,in arrears, upon receipt and acceptance of a detailed invoice showing actual expenditures in accordance with the budget attached hereto and shown as Exhibit C. Page 3 Contra Costa County Contract Number 92-16245 VII. Invoicing and Payment of Funds (Cont'd) 2. Invoices shall be submitted in triplicate and shall show the Contractor's name and address, the contract number, and the time period covered by the invoice. Invoices shall be mailed to: Charles G. Belknap, Childhood Lead Poisoning Prevention Branch, California State Department of Health Services, 5801 Christie Avenue, Suite 600, Emeryville, CA 94608-2008. VIII. Advance Payments 1. Pursuant to the Health and Safety Code, Section 104.5, the State may, to the extent that funds are available, provide a single advance payment yearly for the services performed under this contract. No advance payment made pursuant to this section shall exceed 25 percent of the annual contract amount. 2. Requests for advance payment shall be made on the Contractor's letterhead and shall bear the contract number, the time period for which advance payment is requested, and shall be mailed to: Charles G. Belknap,Childhood Lead Poisoning Prevention Branch,California State Department of Health Services, 5801 Christie Avenue, Suite 600, Emeryville, CA 94608-2008. 3. All advanced funds paid to the Contractor pursuant to this Section shall be maintained in and payments made from a separate, interest-bearing bank account. No part of the funds, in the separate bank account,shall be mingled with other funds of the Contractor,prior to withdrawal from the account. The State shall be notified, in writing, within ninety days of the establishment of such an account, the name of the bank and the account number. 4. Any interest accruing from money advanced through this agreement shall be identified and returned to the State by September 1 following the end of the fiscal year in which it accrued. Payments of this interest shall made payable to the Department of Health Services and mailed to Department of Health Services, 714 P Street, Room 1109, Sacramento, CA 95814. Each check or warrant returning such interest earned must have the following information clearly written on the face of the check or warrant: Contract #92-16245, INTEREST EARNED ON ADVANCE PAYMENT ACCOUNT. 5. The State shall recover any funds provided from the Childhood Lead Poisoning Prevention Fund which are not expended in accordance with this Agreement. Recovery of funds will be accomplished through reduction of the final quarters (April-May-June, 1995) payment to the Contractor from the Childhood Lead Poisoning Prevention Fund under this agreement. The recovery of any excess funds advanced shall be limited to the amount not expended in accordance with this agreement. 6. As required by the Health and Safety Code,Section 104.5,should the total annual dollar amount of this agreement be increased by contract amendment to exceed two hundred thousand dollars ($200,000), advance payments will no longer be permitted. IX. Fiscal Assurances The Contractor agrees that State funds provided from the Childhood Lead Poisoning Prevention Funds, under this agreement, will be used for no other purpose than financing the services described in Exhibit A, "Scope of Work". Page 4 Contra Costa County Contract Number 92-16245 X. Equipment 1. All equipment purchased from funds advanced, reimbursed, or furnished by the State under the terms of this agreement shall be in accordance with the provisions of Exhibit G, "Furnishing of Property by the State or Purchase of Property with State or Federal Funds", paragraph 2 and 4 of Exhibit A(S), Additional Provisions. The form, "Equipment Purchased with State Funds", which is Exhibit H, shall be completed and submitted to the State prior to the purchase of such equipment. 2. During the final month of each fiscal year during the term of this contract, the Contractor shall submit an inventory of equipment furnished or purchased during the fiscal year under the terms of this contract. Such inventory shall be on the form identified as Exhibit I, "Inventory of State Furnished Property". XI. Fiscal Control 1. Payments are not permitted for construction,renovation,alteration,improvement,or repair of privately- owned property which would enhance the value to such property to the benefit of the owner. . 2. Contract funds not expended in any fiscal year may be spent anytime within the subsequent two fiscal years, provided the funds are encumbered by the State within the fiscal year for which they are budgeted. However, no funds may be obligated under this contract beyond June 30, 1995 unless the term of this contract is extended by-contract amendment. 3. Reasonable direct, indirect, and overhead costs, including employee fringe benefits, may be expended under this contract. 4. Invoices for any rental costs for which reimbursement is requested must specify the unit rate, such as the rate per square foot. 5. The Contractor may make changes, without contract 'amendment, m an individual line item in the Budget (Exhibit C) provided.that: A. such changes as to any one line item shall not exceed$10,000 or 10%of the total budget,whichever is greater; B. the Contractor receives prior approval in writing from the State for such changes; and C. in no event shall the maximum amount payable under this agreement exceed the maximum amount specified in Article II of this agreement. D. The State reserves the right to deny any request for approval of such line item budget changes. XII. Audits 1. The State may audit the records of the Contractor and subcontracts let under this agreement pursuant to the provisions of Exhibit A(S), "Additional Provisions". Page 5 Contra Costa County Contract Number 92-16245 XII. Audits (Cont'd) 2. In the event that the Contractor requests an appeal of all or a portion of any audit findings concerning the program governed under this Agreement, the Department will conduct an informal hearing and render a final decision on the appeal and audit findings. In order to initiate an appeal, the Contractor must submit a written notice of disagreement to the State's Program Administrator within sixty calendar days from the date of the Contractor's receipt of the Department's audit report. XIII. Reports 1. The Contractor agrees that the following reports will be submitted to the State in the form and according to procedures established by the Department: a. Submit a report of personnel time spent on each element of this agreement. This report shall be submitted quarterly, by the fifteenth of the month following the end of the quarter, for the preceding quarter, and shall be in the format shown on Exhibit F, "Contract Time Accounting Report", and shall include all of the information shown on that exhibit. This report shall be mailed to Childhood Lead Poisoning Prevention Branch, California Department of Health Services, Attn: C. Belknap, 5801 Christie Avenue,•Suite 600, Emeryville, CA 94608-2008. b. Submit a Lead Poisoning Follow-up Form. This follow-up form shall be sent as described in Exhibit A, "Scope of Work". A copy of the form is attached to this Agreement as Exhibit E and shall be mailed to Childhood Lead Poisoning Prevention Branch,California Department of Health Services, Attn: J. Flattery, 5801 Christie Avenue, Suite 600, Emeryville, CA 94608-2008. 2. The State shall withhold, in part or in whole, payment of any funds specified in this Agreement if any of the reports requested by this Agreement have not been received from the Contractor by the dates specified herein, unless an extension for submission of such reports is granted, in writing,by the State. Any funds withheld from the Contractor pursuant to this Article shall be released upon receipt of the required reports by the Department. M. Cancellation This contract may be canceled by either party upon thirty (30) days written notice to the other party. Page 6 EXHIBIT A SCOPE OF WORK 1. The County agrees to provide appropriate case management for all identified lead poisoned children as defined in Exhibit D, "Follow-up Activities". 2. These follow-up activities shall be based on blood lead concentrations as described in Exhibit D, "Follow-u p Activities". 3. Children in Class IIB may be referred for home investigation. Children in Classes III,IV,and V must be referred for home investigation. 4. Home investigations,when required as a part of these follow-up activities shall be performed by a Public Health Nurse and an Environmental Health Specialist. Other staff classifications may be used with written authorization from the State. 5. The County will assure that all laboratory reports will be received by the County Project Coordinator. 6. The County will provide coordination of the medical management of lead poisoned children between the health care provider and the County health department The County will notify the health care providers within its jurisdiction of procedures to be followed in the event that lead poisoned child is identified. 7. The County will complete,and submit to the State,a"Lead Poisoning Follow-up Form",Exhibit E, on each identified lead poisoned child as follows: Until case closure, the County shall keep the original, working, form in its files, as information will be entered into it. Once a case investigation is underway and a home visit has been completed, an initial copy of the form will be made and sent to the State. If environmental samples are submitted to the State for analysis,the copy shall accompany the samples. If the County analyses its own samples, the copy will be sent after the environmental results have been obtained and entered onto the form. A second copy of the completed form will be sent to the state upon case closure. This form will be mailed to the State in accordance with the provisions of Article XI. 8. This Scope of Work may only be modified by written mutual consent followed by a formal contract amendment. EXHIBIT A(S) ADDITIONAL PROVISIONS 1. Travel and Per Diem Any reimbursement for necessary traveling and per diem shall be at rates not to exceed those amounts paid to the State's represented employees under collective bargaining agreements currently in effect. No travel outside the State of California shall be reimbursed unless prior written authorization is obtained from the State. 2. Procurement Requirement a. Prior authorization in writing by the State will be required before the Contractor will be reimbursed for any purchase order or subcontract exceeding$2,500 for any articles, supplies, equipment, or services or for any fee, or other payment, for consultation of three hundred fifty dollars ($350) or more per day. The Contractor must provide in its request for authorization all particulars necessary for evaluation of the necessity or desirability of incurring such cost,and as to the reasonableness of the price or cost. For purchases of any said articles, supplies, equipment, services, or for consultant fees exceeding such minimum amount, three competitive quotations must be submitted with the request, or the absence of bidding must be adequately justified. b. If other than the lowest bidder or a sole-source provider is selected, all documents used in contractor selection must be presented in writing to the State for prior approval before awarding any subcontract, and maintained for possible future audit as specified in paragraph 6 below. c. The terms "purchase order" and "subcontract" as used in the above paragraph 2a only, excludes: (a) purchase orders not exceeding$2,500,and (b)subcontracts or purchase orders for public utility services at rates established for uniform applicability to the general public. 3. Standards of Work The Contractor agrees that the performance of work and services pursuant to the requirements of this contract shall conform to high professional standards. 4. Furnishing of Property by the State or Purchase of Property 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. Final 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. Exhibit A(S) Page 2 (3) Motor Vehicles (a) If, under the provisions of paragraph a 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 motor 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. The certificate of insurance must include provisions (i) and (ii), stating that: (i) The insurer will not cancel the insured's coverage without 30 days prior written notice to the State. (ii) The State of California, its officers, agents, employees, and servants are included as additional insureds, but only insofar as the operations under this contract are concerned. Contractor agrees that bodily injury liability insurance herein provided for shall be in effect at all times during the term of this contract. In the event said insurance coverage expires at any time or times during the term of this contract, Contractor agrees to provide at least thirty (30) days prior to said expiration date a new certificate of insurance evidencing insurance coverage as provided for herein for not less than the remainder of the term of the contract, or for a period of not less than one (1) year. New certificates of insurance are subject to the approval of said Department of General Services, and Contractor agrees that no work or services shall be performed prior to the giving of such approval. In the event Contractor fails to keep in effect at all times insurance coverage as herein provided, State may, in addition to any other remedies it may have, terminate this contract upon the occurrence of such event. b. If the Equipment line item budget in this contract is$10,000 or more, the State shall purchase said equipment through its Office of Procurement. The cost of procurement of equipment will be deducted from contract amount. Contractor shall submit to State a separate list of the equipment specifications. State will pay vendor directly for equipment purchases,and title to the equipment will remain with the State. The equipment will be delivered to the Contractor's address as stated in the contract unless notified by Contractor in writing. Exhibit A(S) Page 3 c. (1) Title to state property shall not be affected by the incorporation or attachment thereof to any property not owned by the State, nor shall such state property,or any part thereof,be or become a fixture or lose its identity as personality by reason of affixation to any realty. (2) State property shall be used only for the performance of this contract. (3) Unless otherwise provided herein, the State shall not be under any duty or obligation to restore or rehabilitate, or to pay the cost of the restoration or rehabilitation of the Contractor's facility or any portion thereof which is affected by removal of any state property. (4) The Contractor shall maintain and administer, in accordance with sound business practice, a program for the utilization, maintenance, repair, protection, and preservation of state property so to assure its full availability and usefulness for the performance of this contract. The Contractor shall take all reasonable steps to comply with all appropriate directions and instructions which the State may prescribe as reasonably necessary for the protection of state property. d. For nonexpendable equipment only. Before equipment purchases made by the Contractor are reimbursed by the State,the Contractor must submit paid vendor receipts identifying the purchase price, description of the item,serial number,model number,and location where equipment will be used during the term of this agreement. Said paid receipts will be attached to Contractor's invoices submitted to the State. S. 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. 6. Examination of Accounts, Audit, Records, and Subcontract Language 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 purposes 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. 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. Exhibit A(S) Page 4 (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, to have access to and to examine and audit any pertinent books, documents,papers, and records of(name of subcontractor or vendor) related to this(purchase order or subcontract)." 7. Inspection The State, through any authorized representatives, has the right at all reasonable times to inspect or otherwise evaluate the work performed or being performed hereunder including subcontract supported activities and the premises in which it is being performed. If any inspection or evaluation is made by the State of the premises of the Contractor or a subcontractor, the Contractor shall provide and shall require his subcontractors to provide all reasonable facilities and assistance for the safety and convenience of the state representatives in the performance of their duties. All inspections and evaluations shall be performed in such a manner as will not unduly delay the work. 8. Nondiscrimination in Services, Benefits, and Facilities a. The Contractor will not discriminate in the provision of services because of race, color, creed, national origin, sex, age, or physical or mental handicap as provided by state and federal law. b. For the purpose of this contract, distinctions on the grounds of race, color, creed, national origin, sex, age, or physical or mental handicap include, but are not limited to, the following. denying a participant any service or benefit to a participant which is different, or is provided in a different manner or at a different time from that provided to other participants under this contract; subjecting a participant to segregation or separate treatment in any matter related to his receipt of any service; restricting a participant in any way in the enjoyment of any advantage or privilege enjoyed by others receiving any service or benefit; treating a participant differently from others in determining whether he satisfied any admission,enrollment quota,eligibility,membership,or other requirement or condition which individuals must meet in order to be provided any service or benefit; the assignment of times or places for the provision of services on the basis of the race, color, creed, or national origin of the participants to be served. c. The Contractor will take affirmative action to ensure that intended beneficiaries are provided services without regard to race, color, creed, national origin, sex, age, or physical or mental handicap. d. The Contractor agrees that complaints alleging discrimination in the delivery of services by the Contractor or his or her subcontractor because of race,color, national origin, creed,sex, age,or physical or mental handicap will be resolved by the State through the Department of Health Services' Affirmative Action/Discrimination Complaint Process. Exhibit A(S) Page 5 e. The Contractor shall,subject to the approval of the Department of Health Services,establish procedures under which participants of service are informed of their rights to file a complaint alleging discrimination or a violation of their civil rights with the Department of Health Services. f. The Contractor shall operate the program or activity in such a manner that it is readily accessible to and usable by mentally or physically handicapped persons pursuant to 45 Code of Federal Regulations, Part 84, Sections 84.21 and 84.22- g. The Contractor shall keep records, submit required compliance reports, and permit state access to records in order that the State can determine compliance with the nondiscrimination requirements pursuant to 45 Code of Federal Regulations, Part 80, 84, and 90, Sections 80.6,84.61, and 90.41 9. 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. 10. 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 the 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. 11. Utilization of Small Business and Minority and Women Owned Business Enterprises a. It is a federal policy to award a fair share of contracts to small, minority, and women owned business firms. The State Legislature has declared that a fair proportion of the total purchases and contracts or subcontracts for property and services for the State be placed with small minority and women owned business enterprises. b. A firm shall qualify as a small business if it meets the requirements specified in Government Code, Section 14837. Exhibit A(S) Page 6 c. The Contractor hereby agrees to carry out this policy in the awarding of subcontracts to the fullest extent consistent with efficient contract performance. As used in this contract, the term "minority business enterprise" means a business concern (a) which is at least 51 percent owned by one or more minority group members or women, or in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more minority group members or women; and (b) whose management and daily business operations are controlled by one or more such individuals. A minority group member is a person who is Black, Asian, Hispanic, Filipino, Polynesian, American Indian, or Alaskan Native. "Control," as used in this clause, means exercising the power to make policy decisions. d. Contractors acting in good faith may rely on written representations by their subcontractors regarding their status as minority business enterprises in lieu of an independent investigation. 12. Printing If printing or other reproduction work of more than an incidental and minor dollar amount is a reimbursable item in this contract,it shall be printed or produced by the State Printer. The State Printer may, at his sole option, elect to forego said work and delegate the work to the private sector. If the State Printer prints or produces said work, or the State obtains the printing or other work through the Office of State Procurement, the cost will be deducted from said contract amount. This requirement does not apply to normal in-house copying necessary for routine business matters of the Contractor. 13. Prior Approval of Training Seminars,Workshops, or Conferences Contractor shall obtain prior State approval over the location, costs, dates,agenda,instructors,instructional materials, and attendees at any reimbursable training seminar, workshop or conference, and over any reimbursable publicity,or educational materials to be made available for distribution. The Contractor shall acknowledge the support of the State whenever publicizing the work under the contract in any media. This paragraph does not apply to necessary staff meetings to conduct routine business matters. 14. Confidentiality 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, svrnbol, or other identifying particular assigned to the individual. such as finger or voice print or a photoeraph. Exhibit A(S) Page 7 15. Documents and Written Reports 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. 16. Financial and Compliance Audit of Nonprofit Entities (Applicable only if Contractor is a nonprofit entity) a. Defuzidons within this paragraph are defined in Section 38040 of the Health and Safety Code,which, by this reference, is made a part hereof. b. Contractor agrees to obtain an annual single, organization-wide financial and compliance audit. The audit shall be conducted in accordance with the requirements specified in the Federal Office of Management and the Budget (OMB) Circular A-133, "Audits of Institutions of Higher Education and Other Nonprofit Organizations." c. References to "Federal" in OMB Circular A-133 shall be considered to mean "Federal and/or State" in contracts where State funds are present either alone or in conjunction with Federal funds. d. The audit shall be completed by the 15th day of the fifth month following the end of the Contractor's fiscal year. Two copies of the audit report shall be delivered at the State program funding this contract. The report shall be due within 30 days after the completion of the audit. e. If the Contractor receives less than $25,000 per year from the State, the audit shall be conducted biennially,unless there is evidence of fraud or other violation of state law in connection with this contract. This requirement takes precedence over the OMB A-133 section which exempts from Federal audit requirements any nonprofit institution receiving less than $25,000 per year. L The cost of such audit may be included in the funding for this contract up to the proportionate amount this contract represents of the Contractor's total revenue. g. The State,or its authorized designee including the Auditor-General,is responsible for conducting contract performance audits which are not financial and compliance audits. h. Nothing in this contract limits the State's responsibility or authority to enforce State law or regulations, procedures, or reporting requirements arising pursuant thereto. i. Nothing in this paragraph limits the authority of the State to make audits of this contract, provided, however, that if independent audits arranged for by Contractor meet generally accepted governmental auditing standards, the State shall rely on those audits and any additional audit work shall build upon the work already done. j. The State may, at its option, direct its own auditors to perform the single audit described in OMB Circular A-133. The State's auditors shall meet the independence standards specified in Government Auditing Standards. The audit shall be conducted in accordance with OMB Circular A-133 so as to satisfy all State and Federal requirements for a single organization-wide audit. Exhibit A(S) Page 8 17. Contract Amendments a. This contract may be amended by mutual agreement between the parties and,if required by Government Code, Section 11010.5, or Public Contract Code, Section 10366, the amendment shall be subject to the approval of the Department of General Services, unless otherwise exempted. 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. 18. 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 limitation,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. (7) Occasional or one-time reimbursement of a state employee's travel expenses is not acceptable. (Citation: Public Contract Code Section 10410) Exhibit A(S) Page 9 b. Former State Otticers and Employees (1) Contractor shall not utilize in the performance of this contract any formerly employed person of any state agency or department that was employed under the state civil service, or otherwise appointed to serve in the state government, if that person was engaged in any negotiations, transactions, planning, arrangement, or any part of the decision-making process relevant to the contract while employed in any capacity by any state agency or department. This prohibition shall apply for a two- year period beginning on the date the person left state employment. (2) Contractor shall not utilize within 12 months from the date of separation of services, a former employee of the contracting state agency or department if that former employee was employed in a policy making position in the same general subject area as the proposed contract within the 12- month period prior to the employee leaving state service. (Citation: Public Contract Code, Section 10411) c. Failure to Comply with Subparts (a) or (b) If Contractor violates any provision of subparts a or b above, such action by Contractor shall render this contract void, unless the violation is technical or nonsubstantive. (Citation: Public Contract Code, Section 10420) 19. 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 organization 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. Exhibit A(S) Page 10 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 fake certification. (2) The Contractor violates the certification by failing to carry out the requirements of subdivisions a through c above. EXHIBIT B DEFINITION OF TERMS The definition of terms used in this Agreement shall be determined under Article 4.6, Section 372.1, Chapter 2, Part 1, Division I of the Health and Safety Code and are as follows: 1. "Appropriate case management" means health care referrals, environmental assessments, and educational activities performed by the appropriate person,professional,or entity,necessary to reduce a child's exposure to lead and the consequences of the exposure, as determined by the United States Centers for Disease Control, or as determined by the Department pursuant to Section 372.6 of the Childhood Lead Poisoning Prevention Act of 1991. 2. "Lead poisoning" means the disease present when the concentration of lead in whole venous blood reaches or exceeds levels constituting a health risk,as specified in the most recent United States Centers for Disease Control guidelines for lead poisoning as determined by the Department,or when the concentration in whole venous blood reaches or exceeds levels constituting a health risk as determined by the Department pursuant to Section 372.6 of the Childhood Lead Poisoning Prevention Act of 1991. 3. "Department" means the State Department of Health Services. 4. "Screen" means the medical procedure by which the concentration of lead in whole venous blood is measured. 5. "Health care" means the identification, through evaluation and screening, if indicated, of lead poisoning, as well as any follow-up medical treatment necessary to reduce the elevated blood lead levels. 6. "Environmental lead contamination"means the persistent presence of lead in the environment in quantifiable amounts, that results in ongoing and chronic exposure to children. EXHIBIT C BUDGET Contra Costa County Federal ID #94-6000509 Fiscal Year 1992-93 Fiscal Year 1993-94 Fiscal Year 1994-95 PERSONAL SERVICES (PS) Salaries&Wages (S&W) Total Total Total Total Total Total Classification Salaries FTE's Salaries FTE's Salaries FTE's PH Nurse $9,598 / 0.30 $19,771 / 0.30 $20,363 / 0.30 Occ Hlth Spec 2,088 / 0.08 4,301 / 0.08 4,430 / 0.08 PH Aide (Span Spkng) 0 / 0.00 1,346 / 0.08 2,465 / 0.10 Clerk 0 / 0.00 343 / 0.03 706 / 0.03 Subtotal, S&W 11,686 25,761 27,964 Overtime (PHN) 1,538 3,168 1,632 Temp Help 0 0 0 Net Total (S&W) 13,224 28,929 29,596 Benefits at 31% 4,099 8,968 9,175 TOTAL, PS $17,323 $37,897 $38,771 OPERATING EXPENSE AND EQUIPMENT(O&E) General Expense $0 $3,916 $2,874 Printing 0 0 0 Communications 0 0 0 Postage 0 0 0 Travel, In-State 669 1,848 2,016 Staff Training 0 0 0 Facilities Operations 0 0 0 Equipment # 3,839 .0 0 TOTAL, 0&E $4,508 $5,764 $4,890 Overhead 0 0 0 TOTAL BUDGET $21,831 $43,661 $43,661 EQUIPMENT DETAIL: 1 ea DTR 386 Personal Computer 1,305 1 ea HP Laserjet IV Printer 1,379 1 ea Hayes Ultra-smart Modem 9600 590 Printer and Modem Cables 17 1 ea WordPerfect. 5.1 255 Sales tax 293 Total Equipment 3,839 Ex 11113jT A Iy�TiES FoLLow 0 s ,u.. 54 O W a G lot U. In In C6 0 � J °o Asa � 00) •� S V +' % d "O v r Ey 00 � � � � � � •� � u 8 u a E - o N w r 'C w �N v N c6 u c4'i.—. G N +p' P .► ^ .�+ CR `� � o .un- � N � � c u � rte:► � o °' -.�� � u aoi c ;� c' `y R ba ,c 'O •v :: H :; :G a.... !a J u Q So O's : v © 'v N Zr. o.0 „J. ,?,�.•,i R y � A o0i � O O R u � .5.1 r• O o u -� cv ... '� ,► QCs O a; C 'A �., O bD N u 'U A 1z C J G OAw t1 Z u �' O+ S •O A d d ... 07 O �n 'S3 G .O G >, a1 � c4 'O U �• ,n "x r {� V t/1 Qy O N J in tU/'1 w �' R ¢ "+O O S �' �'• '.• t� SCS u u T p O ami o m w � C1 �. ,r, V .,+ •„ ..� r G N G G Op �". 4Q V w0 G c4 O ✓, v N C w p w R U ti. ,,tj 'Or p a i p w i "' O G 'O � 4 C•✓ G � � � J „ti, +,�,,, � .� u N � o G "fm q G a ^O Cr w +o.+ 4 (.� C p^ c u a oo G ... O�p J T .► O y J�,y G O d GS pp 0 "" `� U ..-- u y F. !u e0u u 6 •p r c E `' J u oC tjoto P ga o d w G N G o 03 d vt •p e ice.• J C O y y r !C O O 7 CA r + J i c U Exhibit D Follow-up Activities Page 2 Screening Schedule The following sections provide a minimum screening schedule for children aged 6 up to 36 and 36 to 72 months. The schedule is not rigid. Rather, it is a guide for pediatric health-care providers and screening programs to use in conjunction with other pertinent information in determining when an individual child should be tested. Children 6 up to 36 months of age: A questionnaire should be used at each routine office visit to assess the potential for high-dose lead exposure and, therefore, the appropriate frequency of screening. • Schedule if the child is at low risk for high dose lead exposure by questionnaire: A child at!ow risk for exposure to high-dose lead sources be questionnaire should have an initial blood lead test at 12 months of age. If the 12-month blood lead result is >10 gg/dL, the child should be retested at 24 months if possible, since that is when blood lead levels peak. If a blood lead test result is 10-14 Ag/dl, the child should be retested every 3 to 4 months. After 2 consecutive measurements are <10 gg/dL or three are <15 gg/dl,., the child should be retested in a year. If any blood lead test result is z 15 gg/dI , the child needs individual case management,which includes retesting the child at least every 3 to 4 months. • Schedule if the child is at high risk for high dose lead exposure by questionnaire: A child at high risk for exposure to high-dose lead sources by questionnaire should have an initial blood lead test at 6 months of age. If the initial blood lead result is <10 gg/dL, the child should be rescreened every 6 months. After 2 subsequent consecutive measurements are <10 gg/dL or three are <15 gg/dL, testing frequency can be decreased to once a year. If a blood lead test result is 10-14 gg/dL, the child should be screened every 3 to 4 months. Once 2 subsequent consecutive measurements are <10 gg/dL or three are <15 gg/dL, testing frequency can be decreased to once a year. If any blood lead test result is z 15 gg/dL, the child needs individual case management which includes retesting the child at least every 3 to 4 months. Children z36 months and <72 months of age: As for younger children, a questionnaire should be used at each routine office visit of children from 36 to 72 months of age. Any child at high risk by questionnaire who has not previously had a blood lead test should be tested. All children who have had venous blood lead tests z 15 gg/dL or who are at high risk by questionnaire should be screened at least once a year until their sixth birthday (age 72 months) or later. if indicated (for example, a developmentally delayed child with pica). Children should also be rescreened any time history suggests exposure has increased. children with blood lead levels z 15 gg/dL should receive followup. Exhibit D Follow-up Activities. Page 3 Follow-up of children with blood lead levels z 15 µg/dL Follow-up of children with blood lead levels 15 µg/dL is briefly summarized below. In general, such children should receive blood lead tests at least every 3 to 4 months. If the blood lead level is 15-19 µg/dL, the child should be screened every 3-4 months, the family should be given education and nutritional counselling as described in the CDC guidelines, and a detailed environmental history should be taken to identify any obvious sources or pathways of lead exposure. When the Venous blood lead level is in this range in two consecutive tests 3-4 months apart„ environmental investigation and abatement should be conducted, if resources permit. If the blood lead level is z20 jug/d1, the child should be given a repeat test for confirmation. If the venous blood lead level is confirmed to be z20 µg/dL, the child should be referred for medical evaluation and follow-up as described in the CDC guidelines. Such children should continue to receive blood lead tests every 34 months or more often if indicated. Children with blood lead levels 2:45 ,ug/dL must receive urgent medical and environmental follow-up, preferably at a clinic with a staff experienced in dealing with this disease. Symptomatic lead poisoning or venous blood lead concentration z70 µg/dL is a medical emergency, requiring immediate inpatient chelation therapy. Exhibit E LEAD POISONING FOLLOW-UP FORM CASE SUMMARY (Complete at case closure) Test at case Blood lead levels(µ(;/dL): Initial test: Confirmatory test: closure: Data: / / Date: / / Date: Source Identified: Check soutce(s)most Irkely to be cause of elevated lead ❑ Paint ❑ Home Remedies ❑ Pottery ❑ Take-home exposure ❑ Other: ❑ Soil ❑ Cosmetics ❑ Dust j] Water Source Remedlated: ❑Y ❑N ❑Don't know Local Health Department investigators: Name T tfe Address Phone Public Health Nurse hours: Environmental Health hours: Other hours: Origin of report: ❑ Laboratory ❑ Provider ❑ DHS-CLPPP ❑ Other. Date of notification: / / ❑ Case dosed Date dosed: This tam is intended to be flejoble,as each lead poisoning case wiN differ. N there is not sul8dant room for writing.attach extra sheetsh e second site is imresagated use the relevant seaww of a sep&gm copY o!the form. PATIENT INFORMATION $OC' Sec'#' I Local IDS: Last name: First name: Middle name: Home phone: Number&street: Census tract number. City: County: State: . Zip code: Sex: Date of birth: Age: Race: 1MOther. English speaking? ❑Y ❑N s❑White 3❑Asian n no,what language: ❑F ❑M 1 J `Yrs. twos. 4❑Bladk 2❑Hispanic ❑Dont know Parent or guardian name: Relationship to patient: Day phone: Night phone: Who would know how to contact you if you move? Name: Phone: 3M Itad Poisoning Follow-up Form California OuUhood Lead Poisoning Pr,ewntion Progrant Page 1 Exhibit E 0 CL N v oO � a c m of m ¢ m Q m Q m 2 m Q m Q m I= m Q m 2 no Co Do Da Do Do ❑ o Do ❑ ml m a m m m Sc m o � U m Vf m E � Q a � m 4 ¢ EqD. Z Z z z z z z z z m rn ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 3 � � a o 6 ci � O o0 • � z m N o, a o m -- a, �o 'o m t m a v ` c o � >~ m i5 v i 73� z � O � Q L � C O O t L6 m z 0 E- t z m W t y • O � Exhibit E PATIENT INFORMATION (cont.) Patient Name: List all patient's residences for the past 6 months, including current residence. Number& street: City: County: State: From: To: I Has patient lived outside of the U.S. in the last year? ❑Y ON ❑Dont know Has patient traveled outside of the U.S. in the last month? ❑Y ❑N ❑Dont know Last year? ❑Y ❑N ❑Dont know Where? Where?. Current residence information: Dwelling type: ,[) Single family 2❑ Multiple unit Ownership type: ,❑ Owner occupied 2❑ Rental a❑ Public i❑ Publicly subsidized(Section 8) Owner(if different from occupant): Name: Phone: Address: Note where child spends time when at home(i.e. living room,bedroom,bathroom,backyard). Also note typical activities. Places child spends time, other than home (check all that apply): ❑ None ❑ Preschool/school ❑ Other. ❑ Daycare/baby-sitter ❑ Reiativelriend/neighbor Information regarding above location(s): indkate if site lisiad below is alw kwestoated. Uso.aornoete relevant sections of an addibona/form Name: Address: Phone: Approx.year Time at location: conscueted: HmJWk. Mos.Nr. PROVIDER/PHYSICIAN INFORMATION Last name: First name: Hospital/clinic: Numoer& street: Phone: City: County: State: Zip code: 3192 Und Poisoning FoUow-up Form Page 3 o/I I Exhibit E PROVIDERRHYSICIAN INFORMATION (cont.) Patient Name: Where else does child go for health care? Name of provider/clinic: Address: Phone: MEDICAL INFORMATION Blood test results Date: Laboratory: Method: Pb B,µg/dL: EP,µg/dL: Hematocrit: Ferritin: Iron (Fe): ❑ Venous ❑ Capillary ❑ Venous ❑ Capillary ❑ Venous ❑ Capillary ❑ Venous ❑ Capillary ❑ Venous ❑ Capillary ❑ Venous ❑ Capillary 1 ❑ Venous 0 Capillary Other clinical tests: (Le. Hemoglobin, blood smear, total iron binding capacity, hemoglobin electrophoresis, screen for sickle cell, x-rays, basophilic stippling) How was initial blood lead test paid for? ❑Private insurance 3❑CHOP ❑Dont know i❑Medi-Cal a❑Self s❑Other, Why was test done? Routine screen 47 Anemiariron deficiency ❑Dont know 2E]Known exposure to lead s❑Special screening project 7LjOther: 30 Symptoms of lead poisoning 6❑Parental request 3192 Lead Poisoning FoUow-yep Form Page 4 of 11 Exhibit E MEDICAL INFORMATION (cont.) Patient Name: Symptoms Most children who are lead-burdened show no symptoms. Symptoms, it present.are nonspeceic� which makes diagnosis without a blood lead test unlikely. A child with severe lead poisoning may have some of the following symptoms: Symptom(check if present): Onset: Duration: Symptom(check if present): Onset: Duration: None ❑ Sleeplessness ❑! Abdominal pain + ❑ Weight loss _Ibs_oz ;=J Constipatiorvciarrhea ❑ Loss of appetite !❑ Nausea ❑ Hyperactivity ❑ vomiting ❑ Behavioral changes ❑ Headache ❑ Developmental delays ❑ Lethargy ❑ Seizures ❑ Muscle weakness/soreness ❑ Encephalopathy ❑ Irritability ❑ Other: Remarks&Medical History: Was child hospitalized? ❑Y ❑N ❑Dont know If yes,where hospitalized: Date Admitted: Date Discharged: Blood lead level on discharge: µg/dL gVdL pg/dL Was child chelated? ❑Y ❑N ❑Oont know If yes,with what(check all that apply): ❑EDTA []Succimer(Chemet) ❑Dont know ❑ BAL ❑Penicillamine []Other. Was chelation cnallenge or other lead moo,lizat,on test cone? `;Y r'N ❑Don't know Was patient referred for further neurological or developmental assessment? ❑Y ❑N ❑Dont know 3132 Lead Poisoning Follo u p Form Page 5 of 11 Exbibit E Patient Name: IDtI: SOURCE IDENTIFICATION Address: Date: Behavior Has anyone seen child eat paint? ❑Y O N Soil? O Y ❑N Other nonfood items? 0 ON Specify: Take home Workers with lead exposure can inadvertently bring lead dust home on hair, clothes and shoes. Do any adults in the household wont in a lead industry? O Y ❑N ❑Don't know (Radiator repair shop, battery manufacturer, dismantler, lead or brass smelter or foundry, etc.) Is clothing Is shower Routine How long changed before taken before blood lead Who: What occupation(s): employed there: leaving work: leaving work: test: Mos. Yrs. C ON ❑Y ONJOY ❑N Mos. Yrs. ❑Y ON ❑Y ON ❑Y ❑N Mos. Yrs. 0 ❑N 0 0 ❑Y ❑N Mos. Yrs. ❑Y ❑N ❑Y ❑N ❑Y❑N Home remedies/traditional medicines Some home remedies can contain very high levels of lead. Does your family ever use any of the following horse remedies? 0Y O N O Dont know If yes,where purchased? Given to whom: How often: Date last given: How much: Sampled: Azarcon , I I ❑Y❑N Greta 10YON, O Paytooah ❑Y❑N 71 Other: I JOYON Hobbies Some hobbies use lead and can contaminate a home or work area with lead dust Does anyone in the home have a hobby involving lead? O Y O N O Dont know (Soldering, stained glass,casting bullets or fishing sinkers, ceramics, etc.) For hobbies done outside home: Are clothes Is shower taken How long have changed before before entering Who: What hobby: activities been done: Where done: entering home: the home: Mos. Yrs.I ❑Y ❑N ❑Y ❑N ❑N ❑Y CN Mos. Yrs. ❑Y I Li-Mos. Yrs.1 DY ON I O Y ❑N 3192 Lead Poisoning Follow-up Form Page 6 of i l Exhibit E Patient Narne: SOURCE IDENTIFICATION (cont) Address: Date: Pottery/utensils Some pottery and utensils may contain lead in the glaze. Especially if improperly fired, lead can leach into food and beverages and cause lead poisoning. Imported and handmade items are especially suspicious. Out of what does the patient usually eat and drink? Do you have any imported or handmade ceramics in the household? (]Y ❑N ❑Dont know What: Describe its use: Tested: ❑Y ❑N D ❑N ❑Y ❑N Cosmetics Some cosmetics, especially from India, the Middle East and Asia,may contain high levels of lead. One common use for such cosmetics is as eyeliner. Are any of these cosmetics ever used in the household? ❑Y ❑N ❑Dont know Used by whom: How long used: Sampled- CD Kohl I ❑Y ❑N ❑ Surma + ❑Y ❑N ❑ Ceruse ❑Y ❑N ❑ Other. I ❑Y ❑N Housing environment/characteristics Estimated year constructed: Housing built before and during the 1950's is very likely to contain lead paint. Housing built beween the 60's and the late 70's may contain lead paint.but generally with lesser concentrations of lead. ❑ 1980+ 3❑ 1950-1959 5❑ 1920-1939 ❑ Don't know 2❑ 1960-1979 A❑ 1940-1949 a❑ Pre 1920 Remodelling,painting or renovation in last 6 months? ❑Y ❑N ❑Don't know Disturbing lead paint distnbutes lead dust throughout a home environment. Describe: Close to lead industry? ❑Y ❑N ❑Don't know (Radiator repair shop,battery manufacturer, dismantler, lead or brass smelter or foundry, etc.) Nearby lead industry may contribute lead to soil and housedust Specify: Lead pipes or solder? ❑Y ❑N ❑pont know Water sampled? ❑Y ❑N Lead in water is not often identified as the primary source of childhood lead poisoning in CaMomki 3192 Load Poisoning Follow-up Form Page 7 of I1 Exhibit E Patient Name: ID#: SOURCE IDENTIFICATION (cont) Address: Date: Sampling map . . . . ..: . . . ... . . .. .. . . . .. . . ... .. . . . ._. . . . . .. . . . .. . .. ..... _... . . . ...... . ..:...................._.... . . ..... . . . J192 load Poisoning Follow-up Form Page 8 of 77 Exhibit E Patient Name: ID#-. SOURCE IDENTIFICATION (cont) Address: Date: Paint When sampling for laboratory analysis(AA), include all layers of paint without adherent substrate. Prioritize samples based on 1)condition of paint and 2)where child spends time. Sample a: Color: Location: Condition: Method: Results(µgig-ppm=mg;kg): O AA ppm XRF ❑ XRF ❑ mg/CM2 ❑ AA ❑ PPM ❑ XRF [) mg/cm2 ❑ AA ❑ ppm ❑ XRF ❑ mg/crn2 ❑ AA ❑ Ppm ❑ XAF ❑ 11119/cM2 ❑ AA ❑ PPM ❑ XAF ❑ MWCM2 ❑ AA ❑ PPM ❑ XRF ❑ mg/0m2 ❑ AA ❑ ppm ❑ XRF ❑ mg/CM2 ❑ AA ❑ PPM ❑ XRF ❑ mg/=2 ❑ AA ❑ PPM ❑ XRF [] mg/cm2 ❑ AA ❑ PPM ❑ XAF ❑ ffV/cm2 ❑ AA ❑ PPM ❑ XRF ❑ 111719/cm2 SON Prioritize based on 1)where child spends time,2)proximity to potential lead source(painted stn=re, roadway, etc), and 3)exposed soil(lack of vegetation). Collect only top 1/2 inch,compositing several points from area into one sample. Location: Ground cover. Results(µgig=ppmuffV*g): I 3192 LAad PoWnmg Follow-up Form Page 9 of 11 Exhibit E Patient Name: ID#: SOURCE IDENTIFICATION (cont) Address: Date: Dust Wipe Sometimes sampAed to supplement paint measurements. Not generally relied upon as primary method of source identification, except in the case of take home exposure. Results: Sarnve a: Location: Surface condition: Area (incites): (ug) (Awsq tt) I Other (Water, Home remedies, Cosmetics, Pottery, Take-home exposure, Hobbies) Type of sample: Location/Description: Results: (Units) I l Other sources & remarks anI Uad Poisoning Follow-up Forst Page 10 of I I Exhibit E Patient Name: ID#: SOURCE REMEDIATION Address: Date: Has there been any legal action involved with this case? OY ON ❑Dont know Were any actions taken to control or reduce the source of the child's lead exposure? O Y ❑N U Don't know Paint To reduce lead exposure from paint in the child's environment: Were the most susoicious lead paint hazards controlled? ❑Y O N O Dont know Were a the lead paint hazards controlled? O Y O N 0 Dont know Was nothing done? OY ON ODon'tknow Was alternative housing provided during paint abatement? OY ON O Dont know Dust To reduce dust and/or take-home exposures,were any of the following actions taken: O Routine wet cleaning/HEPA vacuuming ❑Carpet/furniture removal ❑Other: To remediate take-home exposures due to work or hobbies,do household members working with lead now: shower at work or first thing upon arriving home (i.e.before contact with household members)? O Y [IN O Dont know change clothes at work or first thing upon arriving home (i.e.before household member contact)? ❑Y [IN O Dont know Was there OSHA involvement in case? ❑Y ON ❑Don't know Soil To reduce soil exposure,were any of the following actions taken: Cover soil (i.e.with vegetation. Cwood chips,concrete, other soil) []Removal(i.e.top 3-6'of soil) ❑Nothing done ❑Other. Were any of the following sources disposed of or was their use discontinued? Pottery O Cosmetics O Home remedies O Other: Water Was the source of lead in the water remediated (i.e. removal of lead piping,solder)? ❑Y ON O Don't know Notes Please mail form to: CA Dept. of Health Services,Childhood Lead Poisoning Prevention Program, 5900 Hollis St.,Suite E. Emeryville, CA 94608 Attention:Jennifer Flattery 3192 Load Poisoning Follow-up Form Page 11 of 11 Exhibit F CONTRACT TIME ACCOUNTING REPORT County. Mailing Address: Contract Number: Contact person: Phone: Date of Report: Month: 1. Number of new cases investigated this month 2. Number of continuing cases investigated this month Number Number Highest blood lead level of Cases Highest blood lead level of Cases less than 10 ug/dL less than 10 µg/dL 10 - 14 µg/dL 10- 14µg/dL 15 - 19 ug/dL 15- 19 Mcg/dL 20 - 44 µg/dL 20 -44µg/dL 45 - 69 deg/dL 45 -69µg/dL 70 ug/dL or higher 70µg/dL or higher 3. Number of cases lost to follow-up this month: 4. Number of cases closed this month = cases Number Highest blood lead level of Cases less than 10µg/dL Criteria for case closure: 2 consecutive blood lead tests less than 10 - 14µg/dL 10 µg/dL or 15 - 19 µg/dL 3 consecutive blood lead tests less than 20 -44,cg/dL 15µg/dL 45 - 69 µg/dL 70 µg/dL or higher EXHIBIT F Page 2 5. Staff hours/costs Total # hours in Total # hours in Average annual wage of Staff Classification field on lead office on lead classification, including poisoning cases poisoning cases Total hours benefits Public Health Nurse Environmental Health Specialist Other staff class. (specify) Other staff class. (specify) Other staff class. (specify) Other staff class. (specify) Other staff class. (specify) Other staff class. (specify) Contractor Signature: Date: State of California-Health and Welfare Agency Department of Health Services Contract Management Section EXHIBIT G FURNISHING OF PROPERTY BY THE STATE OR PURCHASE OF PROPERTY WITH STATE OR FEDERAL FUNDS 1. All equipment purchased from funds advanced, reimbursed, or furnished by the State under the terms of this agreement shall be the property of the State and shall be subject to the provisions of this paragraph as well as the following seven provisions below. 2. State property shall be used only for the performance of this contract. 3. If the Equipment line item budget in this contract Is$10,000 or more, the State shall purchase said equipment through it Office of Procurement. The cost of procurement of equipment will be deducted from the contract amount. Contractor shall submit to State a separate list of the equipment specifications. State will pay vendor directly for equipment purchases, and title to the equipment will remain with the State. Said equipment will be delivered either to the Contractor's address as stated in the contract unless notified by Contractor in writing. 4. Title to state property shall not be affected by the incorporation or attachment thereof to any property not owned by the State, nor shall such state property, or any part thereof, be or become a fixture or loose its identity as personality by reason of affixation to any realty. S. Unless otherwise provided herein, the State shall not be under any duty or obligation to restore or rehabilitate, or to pay the cost of the restoration or rehabilitation of the Contractor's facility or any portion thereof which is affected by removal of any state property. 6. The Contractor shall maintain and administer, in accordance with sound business practice, a program for the utilization, maintenance, repair, protection, and preservation of state property so to assure its full availability and usefulness for the performance of this contract. The Contractor shall take all reasonable steps to comply with all appropriate directions and instructions which the State may prescribe as reasonably necessary for the protection of state property. 7. 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. 8. 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. Final 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. 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During the performance of this contract,contractor and its subcontractors shall not unlawfully discriminate against any employee or applicant for employment because of race, religion, color, national origin, ancestry, physical handicap, medical condition,marital status,age(over 40)or sex.Contractors and subcontractors shall insure that the evaluation 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 12990,set forth in Chapter 5 of Division 4 of Title 2 of the California 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 compliance provisions of this clause in all subcontracts to perform work under the contract.