HomeMy WebLinkAboutMINUTES - 09271994 - 1.44 TO: BOARD OF SUPERVISORS
Contra
FROM: Mari Finucane, Health Services Director t11%
By: Elizabeth A. Spooner, Contracts Administra Costa
DATE: September 15, 1994 County
SUBJECT: Approval of Standard Agreement #28-523-3 with the State Department
of Health Services for the HIV CARE Consortium
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 #28-523-3 (State #94-
19872) , with the State Department of Health Services, for the
period from July 1, 1994 through June 30, 1997 , for the HI_V CARE
Consortium. This Standard Agreement provides a maximum reimburs-
able amount of $192 , 529 per fiscal year, not to exceed a total of
$577, 587 during the term of the Agreement.
II. FINANCIAL IMPACT:
Approval of this Agreement will result in a maximum reimbursable
amount of $192, 529 from the State (through the Ryan White. CARE Act,
Title 2) , for the first year of the three-year term of this
contract. Funding beyond fiscal year 1994-95 is contingent upon
the availability of appropriated funds by the Legislature for the
HIV CARE Consortium. No County funds are required.
III. REASONS FOR RECOMMENDATION/BACKGROUND:
On September 14 , 1993 , the Board of Supervisors approved Standard
Agreement #28-523-2 with the State Department of Health Services,
for the County's local HIV CARE Consortium, to improve the quality,
availability and organization of health care and support services
for individuals with HIV Disease and their families.
Approval of Standard Agreement #28-523-3 will allow the Department
to continue these services through June 30, 1997 .
The Board Chair should sign nine copies of the agreement, including
the Certification Regarding Lobbying. Eight signed copies of the
agreement and three certified and sealed copies of this Board Order
should be returned to the Contracts and Grants Unit for submission
to the State Department of Health Services.
I
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMM ATI N OF BOARD C MITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON SEP Z 7 UP APPROVED AS RECOMMENDED _ OTHER
VOTE OF SUPERVISORS
X UNANIMOUS (ABSENT Z ) 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 7199 _
CC: Health Services ( Contracts ) ATTESTED
State Dept . of Health Services
Phil Batchelor, Clerk of the Board of
Supeai�rsaudCountyAdlnininra�
M382/7-63 BY �� DEPUTY
ST;(T'G OF GALIFCHNLA
APPROVED BY THE �J Z?�Q� o 4'
S� A- NDARD AGREEMENT a7ToRNEYCENE AL !� `avaER A`I.NSTO.2(RE`J.d•90) ���• �{I � �. CCPY 872
-X CONT ^h CTCSS r'_D_RAL 1.0,NU!AS_R
THIS AGREEMENT,made and entered L-tto this I -qt day of - .Ti11 y 1924_, '94-6000509
in the State of California,by and between State of Califozrua,through its duly Elected or a000inted,qualified and acting
TITLE OF OFFECER ACTING FOR STATE_ I AGENCY
Chief, Program Support Branch Demrbrertt of Health Services 'rereafc--clledtheState, acrd
CCNTRACTCA'S NAME A ^ ` �A �
Contra Costa, County of •�iJ� �}Jd ^eeaiter called the Contrsctor.
WITNESSETH: That the Cona-aetor for and in considerration of the covenants,conditions,agreements,and stipulations of.he State hereinafter, expresscd,
does hereby agree to furnish to the State services and mate::ais as follows: (Set forth service to be rendered by Contractor,amount to be paid Contractor,
time for performance or completion,and c:rcch plans and specifications,if any)
1. DEFINITION OF TERMS
A. HIV Care Consortium - is an association of one or more public, and one or more nonprofit private, health care and
support service providers and community based organizations operating within areas determined by the State to be most
affected by HIV disease. A consortium must include agencies and community-based organizations with a record of
service to populations and subpopulations with HIV disease requiring care within the community to be served.
B. Fiscal Agent- the fiscal agent of the consortium who is authorized to received funds from the State and distribute them
according to the service priorities established by the consortium. The fiscal agent shall fund the activities and services
in accordance with the consortium's HIV Care plan and/or any amendment thereto.
C. Fiscal Year - the fiscal years, for the purposes of this agreement, are defined as follows:
1) Fiscal year 1994/95: July 1, 1994 -June 30, 1995.
2) Fiscal year 1995/96: July 1, 1995 - March 31, 1996.
3) Fiscal year 1996/97: April 1, 1996 -June 30, 1997.
i
D. The parties to this contract shall be the County of Contra Costa (hereafter "Contractor"), fiscal agent for the Contra
Costa HIV/AIDS Consortium, and the California Department of Health Services, Office of AIDS (hereafter "State").
CONTINUED ON 9 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
Lel N ITNESS WHEREOF,this agmemem has becz executed by the parties hereto,upon the date First above written.
STATE OF CALIFORNIA CONTRACTOR
AGENCY CCNTRACTCA tll aNer Jun an indiv ua4.s:a:e wi:et::V -'rruirn.pareersnip,e!:.;
Health Services Contra Costa Count of
3Y(AUT-,.0 D SICNA T l R=) JA
(AUTnCR - S:GNA t nE)
Supervisor
PRL 4TEO NAME OF PERSCN S:GNLNG Pfd T NAME ECF r'EnGN'sCN S: G
Edward E_ Stahlberct Tom mss• fir• Board of &Vmviscrs
,ITL's ACCnESS
Chief, Program Support Branch 651 Pine Street, Martinez, CA 94553
AMOUNT ENCUMSERED SY-,HIS I FRCGnA!-L1CAT=_S0AY:CCC'ANO TITLE) � FUNC 1 LE �I
CCC::MENT Deoar;,-;enr of General Services
Clearincr account General I Use Only
S 192,529 (CP T1CNAL t:SE;
PRICR AMOUNT ENCt:Me_RCD FOR F *ral C`r1t�31C]C7 9 _91 7
TriIS CCNTFIACT — Ii'
S ITEM f CAF`cR STAiU7__ i FISCALYSAA This contract exempt from
—0- 4260-111-890 �(
TOTALAMOUNT ENCUMBEREDTO - ( 1994 194/95 D17G approval per
0A c C5:_CT CF EXP_NCI LAE(C^CE ANO TI L_', Caitingent W1 the ]994/95
192,529 94 51353 4491 702 03 95370L 94 met Act Chapter 1 lStats of 1*1
I hereby certify upon my own personal knowledge that budgeted funds T.S._No. i BA NC. �' d96Q-���_QQ� ' (AIDS
are available for the period and purpose of the excenditure stated above.
SIGNAT REO COUN7 FFICER � j /� '
O 1 OAT.- L i97Y
l b
n CCNTRACTCR rI STA--E AGENCY F-1 0SPT.CF GEN.SE.q. n CCNT'nCLLER n
M
STATE OF CALZFORUNIA p Y
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STANDARD AGREEMENT
STD. 2(REV. 5-91) (REVERS^s)
1. The Contractor agrees to indemnify, defend and save harmless the State, its officers,
4.'
agents and employ," ftCm�.any and all claims and losses accruing or resulting to any
and all contractors, subcontractors, materialmen, laborers and any other person, firm
or corporation furnishing or supplying work services, materials or supplies in
connection with the performance of this. contract, and from any and all claims and
losses accruing or resulting to any person, firm or corporation who =ay- be injured or
damaged by the Contractor in the performance of this contract.
2 . The Contractor, and the agents and employees of Contractor, in the performance of the
agreement, shall act in an independent capacity and not as officers or employees or
agents of State of California.
3 . The State may terminate this agreement and be relieved of the payment of any
consideration to Contractor should Contractor fail to perform the covenants herein
contained at the time and in the manner herein provided. in the event of such
termination the State may proceed with the work in any manner deemed proper by the
State. The cost to. the State shall be deducted from any sum due the Contractor under
this agreement, and the balance, if any, shall be paid the Contractor upon demand.
4 . Without the written consent of the State, this agreement is not assignable by
Contractor either in whole or in part.
5 . Time is of the essence in this agreement.
6. - No alteration or variation of the terms of this contract shall be valid unless made in
writing and signed by the parties hereto, and no oral understanding or agreement not
incorporated herein, shall be binding on any of the parties hereto.
7 . The consideration to be paid Contractor, as provided herein, shall be in compensation
=for all of Contractor' s expenses incurred in the performance hereof, _zcluding travel
and per diem, unless otherwise expressly so provided.
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!1 61014
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Contract No:94-19872
Contractor: County of Contra Costa
Page 2 of 10
2. PURPOSE OF FUNDS
A. HIV Care Consortium receiving Ryan White Comprehensive AIDS Resources Emergency (CARE) Act
funds agrees to use these funds for planning, development, and delivery of comprehensive outpatient
health and support services to meet the identified needs of individuals and families with HIV disease
within the geographic area identified by the consortium.
B. HIV Care Consortium receiving Housing Opportunities for People with AIDS (HOPWA) funds agree
to use these funds for the planning and development of housing, rental assistance or related housing
support services to people with HIV/AIDS in the geographic area identified by the consortium.
3. TERM OF AGREENILNT
The term of this contract shall be from July 1, 1994 through June 30, 1997, subject to the provisions of
Paragraph 4. This contract is of no force and effect until it is approved by State and Contractor.
4. LMTATION OF STATE LIABILITY
A. The maximum amount payable for the 1994/95 Fiscal Year ending June 30, 1995, shall not exceed
$192,529. Any requirement of performance by State and Contractor for the period of the contract
subsequent to June 30, 1995 is dependent upon the availability of subsequent state and federal
appropriations.
B. If funds become available for purposes of this contract from future state and federal appropriations,
the maximum amount payable for the 1995/96 Fiscal Year beginning July 1, 1995 and ending March
31, 1996 shall not exceed $192,529 and the maximum amount payable for the 1996/97 Fiscal Year
beginning April 1, 1996 and ending June 30, 1997 shall not exceed $192,529.
C. The total maximum amount payable under this contract shall not exceed $577,587.
D. Contractor agrees that if during the term of this contract State determines that if the maximum amount
specified in Paragraph 4C of this contract will not be expended the State reserves the right to reduce
the contract amount. State may exercise these reduction rights at any time if in the sole judgement of
State it is determined-by a review of Contractor's invoices and progress reports that Contractor is under
utilizing these funds. Reductions will be made in accordance with the provisions outlined in Paragraph
9 entitled "Contract Amendment", or Paragraph 10 entitled "Contract Termination".
5. FUNDING OR FUNDLNiG REDUCTION IN SUBSEQUENT FISCAL YEARS
A. Funds are presently not available for performance under this agreement beyond June 30, 1995. State's
obligation for performance under this agreement beyond that date is contingent upon the availability of
appropriated state and federal funds from which payment for contract purposes can be made. No
liability on the part of State for,any payment may arise for performance of this agreement beyond June
30, 1995 until funds are made available to State and Contractor has been given notice of availability and
availability is confirmed in writing by State.
� 1
Contract No: 94-19872
Contractor: County of Contra Costa
Page 3 of 10
B. If funding for this contract after fiscal year 1994/95 is reduced or deleted by the federal government
or the state legislature, State shall have the option to either:
1. Cancel this agreement pursuant to Paragraph 10; or
2. Offer a contract amendment pursuant to Paragraph 9.
C. In the event that State elects option 5.B.2 above, it shall be mutually understood by both parties that
State reserves the right to determine which contracts, if any, under this program shall be reduced and
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that some contracts may be reduced by a greater amount than others, and that State shall determine at
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its sole discretion the amount that any or all of the contracts shall be reduced for the fiscal year.
6. ADDITIONAL PROVISIONS
The attached Exhibit "A(F)", entitled "Additional Provisions", consisting of twenty-seven pages is
incorporated and made a part hereof by this reference.
7. BUDGET
The attached Exhibit "C" entitled "Budget", consisting of three pages, is incorporated and made a part hereof
by this reference.
8. PAYTIENT PROCEDURES
In consideration of the services performed in a manner acceptable to the State, the State shall reimburse the
Contractor no more frequently than monthly in arrears. Payment shall be made upon submission of a
completed Consortium Invoice. A sample Consortium Invoice is attached and marked "Exhibit "L".
Invoices shall be submitted to State no later than 30 days after the end of each billing period, except for the
final billing period at the end of the fiscal year. The final invoice for each fiscal yearshall be submitted no
later than 90 days after the end of the last billing period. Late invoices will not be paid unless Contractor
has obtained prior written approval from State. The attached Exhibit L, consisting of one page, is
incorporated and made a part hereof by this reference.
9. CONTRACT ANVIENDMENT
One contract amendment by each parry will be allowed each fiscal year. Requests for amendments must be
received before the last 150 days of the fiscal year and must include a justification for the amendment and
a revised HIV Care Plan. Within 30 calendar days of receipt of the request, State will accept or reject the
proposed changes in writing. Once accepted the contract shall be amended to provide the change mutually
agreed to.
10. CONTRACT TERMINATION
A. This contract may be terminated in whole or in part without cause by either party upon 30 days advance
written notice to the other party. Such notification shall state the effective date of termination. In the
event of such termination, in full or in part, Contractor shall take immediate steps to cease the
1 1
Contract No: 94-19872
Contractor: County of Contra Costa
Page 4 of 10
incurrence of costs. Contractor shall be entitled to payment of all costs and uncancellable obligations
allowable under the terms of this contract incurred prior to the date of termination in an amount not to
exceed the maximum allowable under Paragraph 4C.
B. State may immediately, upon notice, terminate this contract in whole or in part for cause should the
Contractor fail to materially perform the services promised in this contract. In the event of such
termination, State shall be relieved of the payment of any consideration to Contractor for the terminated
portion of the agreement. State may proceed with the terminated work in any manner deemed proper
by State. The cost of the terminated work shall be deducted from any sum due to Contractor under this
agreement, and the balance, if any, shall be paid to Contractor upon demand.
11. CONDITIONS OF AWARD
A. Ryan White CARE Act, Title II Funds
1. Eligible Beneficiaries: Contractor shall use at least 20 percent of all funds to provide health and
support services to women, infants, children, and families with HIV disease. Services should be
targeted to populations that have been underserved with special emphasis on populations with
emerging HIV incidence.
3. Contractor may use no more than 10 percent of the CARE Act, Title II allocation for all non-direct
service functions,such as: administration,oversight,planning,evaluation,accounting, and reports.
These costs are contained in Exhibit "C", entitled "Budget" as line items A. Personnel Expenses,
B. Operating Expenses, C. Capital Expenditures, and E. Indirect Costs. A minimum of 90 percent
of the CARE Act, Title 1I allocation must be used for subcontracts/direct services in the amount
contained in Exhibit "C", entitled "Budget" as line item D. Other Costs.
4. No funds can be used to purchase or improve (other than minor remodeling) any building or other
facility.
5. No funds can be used to make cash payments to intended recipients of services.
6. Funds from this contract must not comprise more than 60 percent of any subcontracting applicant
organization's total budget.
7. Contractor and consortium must adhere to the requirements and guidelines contained in the State
Office of AIDS Application and Program Guidance, dated March, 1994 and any subsequent
additions or amendments issued by the federal government or State during the term of this contract.
B. Housing Opportunities for Persons With AIDS (HOPWA) Funds
1. Eligible Beneficiaries: Eligible beneficiaries are low-income individuals with HIV disease or
AIDS. The intent of HOPWA is to prevent low-income persons with HIV disease or AIDS from
becoming homeless. 'Low income individual' is defined as any individual or family whose
1.
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Contract No: 94-19872
Contractor: County of Contra Costa
Page 5 of 10
income does not exceed 80 percent of the median income for the area, as determined by the federal
Department of Housing and Urban Development (HUD), with adjustments for smaller and larger
families.
2. A maximum of seven percent of a consortium's HOPWA allocation may be used for non-direct
service functions such as administration, oversight, planning, evaluation, accounting, and reporting
functions, including costs of staff necessary to carry out eligible activities. These costs are
contained in Exhibit "C", entitled "Budget" as line items A. Personnel Expenses, B. Operating
Expenses, C. Capital Expenditures, and E. Indirect Costs. A minimum of 93 percent of the total
HOPWA allocation must be used for subcontracts/direct services in the amount contained in Exhibit
"C", entitled "Budget" as line item D. Other Costs.
3. Of the remaining balance, a maximum of 25 percent may be used for supportive services, defined
in I I.B.5.vi., associated with housing.
4. The balance of funds must be used for direct housing assistance activities listed in Sections
11.B.5.i. through 11.B.5.v.. Ifa consortium cannot use their allocation within these parameters,
a waiver may be submitted to the Office of AIDS for review and subsequent action.
5. The following activities may be carried out with HOPWA funds:
i. Short-term rent, mortgage and utility payments and short-term tenant- or project-based rental
assistance. Rental assistance for a short-term housing facility (such as a room in a hotel) may
not be provided for more than 60 days during any six-month period. Short-term rental or
mortgage assistance and project- or tenant-based rental assistance may not be provided for
more than 21 weeks in any 52-week period;
ii. Housing information services including, but not limited to, counseling, information and
referral services to assist an eligible person to locate, acquire, finance and maintain housing.
This may also include fair housing counseling for eligible persons who may encounter
discrimination on the basis of race, color, religion, sex, age, national origin, familial status,
or handicap;
iii. Resource identification to establish, coordinate and develop housing assistance resources for
eligible persons (including conducting preliminary research and making expenditures necessary
to determine the feasibility of specific housing-related initiatives);
iv. Operating costs for housing, including maintenance, security, operation, insurance, utilities,
furnishings, equipment, supplies, staff training and recruitment, and other incidental costs;
v. Technical assistance in establishing and operating a community residence, including planning
and other pre-development or pre-construction expenses and including, but not limited to,
costs relating to community outreach and educational activities regarding AIDS or related
diseases for persons residing in proximity to the community residence; and
Contract No: 94-19872
Contractor: County of Contra Costa
Page 6 of 10
vi. Supportive services associated with housing which include, but are not limited to: case
management; health and mental health assessment; permanent housing placement; drug and
alcohol abuse treatment and counseling; day care; nutritional services; intensive care when
required (related to keeping the person in their residence, but not related to "intensive care"
for health emergencies); and assistance in gaining access to local, state, and federal
government benefits and services. Health services may only be provided to individuals with
HIV/AIDS and not to family members of these individuals. For any individual with
HIV/AIDS who requires more intensive care than can be provided in housing assisted with
HOPWA resources, the grantee shall assist with locating a care provider who can
appropriately care for the individual and refer the individual to the care provider. Appropriate
supportive services must be provided as part of any HOPWA assisted housing and may be
provided independently of any housing assistance.
6. The following activities allowed under federal HOPWA regulations are NOT ALLOWABLE
activities for state HOPWA-funded consortia. Consortia may, however, submit to the Office of
AIDS a request for waiver and a proposal for HOPWA funds to be used for these activities. The
proposal must specify the need and detail the planned use of funds.
i. Acquisition, rehabilitation, conversion, or lease and repair of facilities to provide housing and
services;
ii. New construction (for single room occupancy [SRO] dwellings and community residences
only); and
iii. Project- or tenant-based rental assistance in excess of 21 weeks in any 52-week period.
7. The consortium must adhere to the requirements and guidelines contained in the State Office of
AIDS Application and Program Guidance, dated March, 1994 and any subsequent additions or
amendments issued by the federal government or State during the term of this contract.
C. Subcontractor Budget Detail
By the dates noted below, Contractor shall submit to State a list identifying the name(s) of all the
subcontractor(s) and total funds available to each subcontractor (Exhibit "N"). Attach to this list a copy
of the approved subcontractor budget(Exhibit"0") and budget justification. The attached Exhibit "N",
entitled "Subcontractor Listing", consisting of one page, and Exhibit "0", entitled "Subcontractor
Information & Budget", consisting of two pages are incorporated and made a part hereof by this
reference.
1. Fiscal year 94/95: July 1, 1994.
2. Fiscal Year 95/96: July 1, 1995.
3. Fiscal Year 96/97: April 1, 1996.
Contract No: 94-19872
Contractor: County of Contra Costa
Page 7 of 10
1-1. MID YEAR AND YEAR END REPORTING REQUIRUNIENTS
A. Contractor shall submit a mid-year report to the State Office of AIDS by the dates listed below:
1. Fiscal Year 94/95: February 15, 1995.
2. Fiscal Year 95/96: February 15, 1996.
3. Fiscal Year 96/97: February 15, 1997.
B. Each mid-year report will contain the following information:
1. A Financial Status Report (FSR) identifying all service providers (subcontractors), the total amount
of funds obligated to each provider, and the total expended to date by each service provider. The
FSR is attached and marked Exhibit "M". Exhibit "M", consisting of two pages is incorporated
and made a part hereof by this reference; and
2. A Progress Report describing the consortium's progress in implementing funded programs and
services and a summary of issues and/or problems which may have impeded implementation of
services and strategies for resolving them. A copy of a Progress report is attached and marked
Exhibit "E". Exhibit "E", consisting of three pages is incorporated and made a part hereof by this
reference.
C. Contractor shall submit a year-end report to the State Office of AIDS by the dates listed below:
1. Fiscal Year 94/95: September 30, 1995.
2. Fiscal year 95196: June 30, 1996.
3. Fiscal year 96/97: September 30, 1997.
D. Each year-end report will contain the following information:
1. A Financial Status Report (FSR) identifying all service providers, the total amount of funds
obligated to each provider, and the total expended by each service provider, and
2. A Progress Report describing the consortium's progress in implementing funded programs and
services and a summary of issues and/or problems which may have impeded implementation of
services and strategies for resolving them.
�. DATA COLLECTION AND REPORTING REQUIREMENTS
The Contractor must comply with the following data requirements for use of Ryan White, Title II funds:
A. Data Elements
Beginning July 1, 1994, Contractor shall collect and submit the following data elements from
subcontractors: subcontractor characteristics, an unduplicated count of clients receiving services eligible
for Ryan White funding, race/ethnicity of clients served, age, gender, HIV exposure category (medical
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Contract No: 94-19872
Contractor: County of Contra Costa
Page 8of10
care providers only), percent of clients with HIV, percent of clients with AIDS diagnosis, number of
office based health services by type of service, number of case management encounters, number of
home health care visits, number of HIV/AIDS clients that received certain other services, HIV/AIDS
funding by source, HIV/AIDS expenditures by category, full time equivalent HIV/AIDS paid staff, full
time equivalent HIV/AIDS volunteers, and additions to paid HIV/AIDS staff.
B. Client and Service Data Reporting
Data collected pursuant to Section 13.A. shall be submitted to the state office of AIDS as follows: Two
reports per year consisting of a summary of client and service data by subcontractor, shall be submitted
by Contractor. The first is a calendar year report, which will be due at the State Office of AIDS on
February 15 following the end of the calendar year. For the first year only, the report will consist of
data collected during a six-month period from July 1, 1994 through December 31, 1994. In subsequent
years, the report will consist of data collected during a 12-month period from January 1 through
December 31. The second report is a fiscal year report, which is due at the State Office of AIDS
following the end of each fiscal year. For the first year(94/95), the report will consist of data collected
from July 1, 1994 through June 30,1995 and is due on September 30, 1995. For fiscal years 95/96 and
96/97, the reports are due on June 30, 1996 and September 30, 1997 respectively.
C. Subcontractor Characteristics Data Reporting
Contractor shall submit subcontractor characteristics data to the State Office of AIDS as part of the
annual application for Ryan White Title IJ funds and whenever changes occur.
D. Subcontractor Funding, Expenditure, and Staffing Data Reporting
Contractor shall submit subcontractor funding, expenditure, and staffing data to the State Office of
AIDS in an annual survey, which will be distributed by the State Office of AIDS by December 31 and
due to the State Office of AIDS on February 15 following the end of the calendar year. These data will
be based on a calendar year from January through December.
E. Format
Contractor shall submit data in a format designated by the State Office of AIDS, either electronically
on a 3 1/2" or 5 1/4" diskette or on a standard paper form.
F. Future Data Requirements
Acceptance of this award indicates the Contractor's agreement to comply with future data requirements
developed by Federal program staff and the State Office of AIDS.
14-:.- MONITORLNG ACTIVITIES
Contractor shall provide any necessary assistance to State in carrying out its monitoring activities and
inspection rights as provided in this contract. Contractor shall make available all records, materials, data
Contract No: 94-19872
Contractor: County of Contra Costa
Page 9 of 10
information, and appropriate staff to authorized State and/or Federal representatives, and shall cooperate fully
_in the monitoring and audit processes.
15...:NONDISCRIMINATION CLAUSE
The attached Exhibit "D", entitled "Nondiscrimination Clause", consisting of one page is incorporated and
made a part hereof by this reference.
16. .=PRIOR TO JULY 1, 1994 LANGUAGE
-The attached Exhibit "G", entitled "Prior to July 1, 1994 Language", consisting of one page is incorporated
__and made a part hereof by this reference.
17. .__PUBLICITY
Contractor agrees to submit to State, prior to release, copies of any proposed publicity pertaining to this
contract. State reserves the right to modify or withdraw said publicity.
18. . ACKNOWLEDGEMENT OF FUNDING SOURCE
Contractor agrees that all written materials including, but not limited to, newsletters, brochures, pictorials,
_and like materials funded by this contract shall acknowledge the funding source as outlined in the State Office
of AIDS Program and Application Guidance dated March 1994. Contractor agrees to submit a copy of said
-materials to the State Office of AIDS.
19. CONTRACT GENERATED REVENUES
Contractor shall place any income generated by activities conducted under this contract, accruing to or
-received by the Contractor, into a separate, identifiable account. Revenue generated by Contractor as a
result of this contract must be utilized to meet identified, agreed upon, program-related needs of Contractor,
or must be returned to State. Any revenues accruing to Contractor, based on services supported in whole
or in part by State pursuant to this contract, shall only be used to defray costs incurred to measurably expand
_the program or improve the quality of services detailed in this contract, and must be approved in writing by
_State. Contractor shall maintain adequate documentation of the receipt and use of such funds and shall
-provide this documentation to State upon request.
20. .CORRESPONDENCE MAILING ADDRESS
All invoices for payment, progress reports, and other official communication shall be mailed to:
Department of Health Services
Office of AIDS
Attn: CARE Section/Lisette Willmarth
P.O. Box 942732
Sacramento, CA 94234-7320
Contract No: 94-19872
Contractor: County of Contra Costa
Page 10 of 10
:21. CONFLICT OF INTEREST
The HIV Care Consortium must have an approved Conflict of Interest Code as required by the Fair Political
Practices Commission. The HIV Care Consortium must also have a Statement of Economic Interests filed
for all members on an annual basis.
:22. FISCAL DOCUMENTATION
A. Adequate documentation of each transaction shall be maintained for a period of five years or until an
audit is completed, whichever comes fust, to permit the determination of the allowability of
expenditures reimbursed by State under this contract.
B. If the allowability of expenditures cannot be determined because records or documentation of the
Contractor are nonexistent or inadequate, according to generally accepted accounting practices, the
questionable cost shall be disallowed by State.
C. In the event of findings of disallowed costs, Contractor has the right to appeal such findings pursuant
to the conditions set forth in the Attached Exhibit A(F).
:23. SUBCONTRACTS
A. Contractor is responsible for ensuring that all subcontracts incorporate the requirements of the prime
contract which are relevant to the services provided by the subcontractor. Contractor shall notify State
immediately of any changes in funding allocations among subcontractors.
B. A subcontractor is not eligible to receive grant funds if listed on the federal Consolidated List of
Debarred, Suspended, and Ineligible Contractors.
24. MEETINGS
Contractor shall make staff available to State for training and meetings which State may find necessary from
time to time.
:25. CONFIDENTIALITY
Public health records relating to any program activity, service, or category executed in reference to this
contract containing personally identifying information which was developed or acquired by local public health
agencies, shall be confidential and shall not be disclosed, except as otherwise provided by law for public
health purposes or pursuant to a written authorization by the person who is the subject of the record or by
his or her guardian or conservator.
:26. FEDERAL CONTRACT FUNDS
The attached Exhibit "B", entitled "Federal Contract Funds", consisting of one page is incorporated and
made a part hereof by this reference.
y bNbit A(F)
STATE OF CALIFORNIA
DEPARTMENT OF HEALTH SERVICES
ADDITIONAL PROVISIONS
(FOR FEDERALLY FUNDED SUBVENTION AID/LOCAL ASSISTANCE
COST REIMBURSEMENT CONTRACTS/GRANTS)
1. E ual Ooportunity 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.
CMS Instructlond Bulletin No.02(11/91)
f. In the event of the Contractor's noncompliance with the requirements of this Equal
Opportunity clause or with any federal rules, regulations, or orders which are
referenced in this clause, this contract may be canceled, terminated, or suspended in
whole or in part and the Contractor may be declared ineligible for further federal or
state contracts in accordance with procedures authorized in Federal Executive Order
No. 11246 as amended and such other sanctions may be imposed and remedies
invoked as provided in Federal Executive Order No. 11246 as amended, or by rule,
regulation, or order of the Secretary of Labor, or as otherwise provided by law.
g. The Contractor will include the provisions of paragraphs [a] through [g] in every
subcontract or purchase order unless exempted by rules, regulations, or orders of the
Secretary of Labor issued pursuant to Federal Executive Order No. 11246 as amended,
or Section 503 of the rehabilitation Act of 1973, so that such provisions will be binding
upon each subcontractor or vendor. The Contractor will take such action with
respect to any subcontract or purchase order as the Director of the Office of Federal
Contract Compliance Programs or the State may direct as a means of enforcing such
provisions including sanctions for noncompliance-provided, however, that in the event
the Contractor becomes involved in, or is threatened with, litigation with a
subcontractor or vendor as a result of such direction by the State, the Contractor may
request in writing to the State, who, in turn, may request the United States to enter into
such litigation to protect the interests of the State and of the United States.
2. 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.
3. 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 contract, and maintained for possible future audit as
specified in paragraph 7 below.
c. The terms "purchase order" and "subcontract" as used in the above paragraph 3a
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.
-2-
Exhbif 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 Progg¢y by the State or Purchase of Progaft 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.
(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 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.
-3-
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 the 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 the
procurement of equipment will be deducted from the contract amount. Contractor
shall submit to the 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 either to the Contractor's address as
stated in the contract unless notified by the Contractor in writing.
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) 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.
(3) 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 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.
-4-
' Exhibit 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. Examination of Accounts. Audit. Records. and Subcontract Langmaae
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 (1) 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 fide
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-
9. 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.
10. 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 providing a benefit to a
participant which is different, or is provided in a different mariner 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
Compliant Process.
e. The Contractor shall, subject to the approval of the Department of Health Services,
establish procedures uhder which service participants 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, Parts 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, Parts 80,
84, and 90, Sections 80.6, 84.61, and 90.42.
-6-
Exhibit A(F)
1 1. . 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
copy6ighted, 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-
g. Deferred Ordering and Delivery of Data. The Federal Government or State shall have
the right to order, at any time during the performance of this contract, or within two
years from either acceptance of all items (other than data) to be delivered under this
contract or termination of this contract, whichever is later, any Subject Data and any
data not called for in the schedule of this contract but generated in performance of
the contract, and the Contractor shall promptly prepare and deliver such data as is
ordered. If the principal investigator is no longer associated with the Contractor, the
Contractor shall exercise its best efforts to prepare and deliver such data as is ordered.
The Federal Government's or State's right to use data delivered pursuant to this
paragraph (g) shall be the same as the rights in Subject Data as provided in "b"
above. The Contractor shall be relieved of obligation to furnish data pertaining to an
item obtained from a subcontractor upon the expiration of two years from the date
he accepts such items. When data, other than Subject Data, is delivered pursuant to
this paragraph (g), payment shall be made, by equitable adjustment or otherwise, for
converting the data into the prescribed form, reproducing it or preparing it for
delivery. The terms of such payment shall be agreed upon in writing by the
Contractor and the State and/or Federal Government, whichever ordered the
production of the data.
14. Disabled Ve erans and Veterans of the Vietnam Era
a. The Contractor will not discriminate against any employee or applicant for
employment because he or she is a disabled veteran or veteran of the Vietnam era in
regard to any position for which the employee or applicant for employment is
qualified. The Contractor agrees to take affirmative action to employ, advance in
employment, and otherwise treat qualified disabled veterans and veterans of the
Vietnam era without discrimination based upon their disability or veterans status in all
employment practices such as the following: employment upgrading, demotion or
transfer, recruitment, advertising, layoff or termination, rates of pay or other forms of
compensation, and selection for training, including apprenticeship.
b. The Contractor agrees that all suitable employment openings of the Contractor which
exist at the time of the execution of this contract and those which occur during the
performance of this contract, including those not generated by this contract and
including those occurring at an establishment of the Contractor other than the one
wherein the contract is being performed but excluding those of independently
operated corporate affiliates, shall be listed at an appropriate local office of the state
employment service system wherein the opening occurs. The Contractor further
agrees to provide such reports to such local office regarding employment openings
and hires as may be required.
State and local government agencies holding federal contracts of $10,000 or more
shall also list all their suitable openings with the appropriate office of the state
employment service, but are not required to provide those reports set forth in
paragraphs "d" and "e
c. Listing of employment openings with the employment service system pursuant to this
clause shall be made at least concurrently with the use of any other recruitment
source or effort and shall involve the normal obligations which attach to the placing
of bona fide job order, including the acceptance of referrals of veterans and
nonveterans. The listing of employment openings does not require the hiring of any
particular job applicant or from any particular group of job applicants, and nothing
herein is intended to relieve the Contractor from any requirements in Executive Orders
or regulations regarding nondiscrimination in employment.
-8-
FI • i
Exhibit 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-
(2) "Appropriate office of the state employment service system" means the local
office of the federal/state national system of public employment offices with
assigned responsibility for serving the area where the employment opening is to
be filled, including the District of Columbia, Guam, Puerto Rico, and the
Virgin Islands.
(3) "Openings which the Contractor proposes to fill from within his own organization"
means employment openings for which no consideration will be given to persons
outside the Contractor's organization (including any affiliates, subsidiaries, and
the parent companies) and includes any openings which the Contractor
proposes to fill from regularly established "recall" lists,
(4) "Openings which the Contractor proposes to fill pursuant to a customary and
traditional employer-union hiring arrangement" means employment openings
which the contractor proposes to fill from union halls which is part of the
customary and traditional hiring relationship which exists between the Contractor
and representatives of his employees.
i. The Contractor agrees to comply with the rules, regulations, and relevant orders of the
Federal Secretary of Labor issued pursuant to the Act.
j. In the event of the Contractor's noncompliance with the requirements of this clause,
actions for noncompliance may be taken in accordance with the rules, regulations,
and relevant orders of the Federal Secretary of Labor issued pursuant to the Act.
k. The Contractor agrees to post in conspicuous places available to employees and
applicants for employment notices in a form to be prescribed by the Director of the
Office of Federal Contract Compliance Programs, provided by or through the
contracting Officers or State. Such notices shall state the Contractor's obligation
under the law to take affirmative action to employ and advance in employment
qualified disabled veterans and veterans of the Vietnam era for employment, and the
rights of applicants and employees.
I. The Contractor will notify each labor union or representative of workers with which it
has a collective bargaining agreement or other contract understanding that the
Contractor is bound by terms of the Vietnam Era Veteran's Readjustment Assistance
Act and is committed to take affirmative action to employ and advance in
employment qualified disabled veterans and veterans of the Vietnam era.
m. The Contractor will include the provisions of this clause in every subcontract or
purchase order of $10,000 or more unless exempted by rules, regulations, or orders of
the Federal Secretary of Labor issued pursuant to the Act, so that such provisions will
be binding upon each subcontractor or vendor. The Contractor will take such action
with respect to any subcontract or purchase order as the Director of the Office of
Federal Contract Compliance Programs may direct to enforce such provisions,
including action for noncompliance.
15. Clean Air and Water
a. (Applicable only if the contract is not with a sole source vendor of products or
services, or if it exceeds $5,000.)
The Contractor agrees under penalty of perjury (it,he,she) is not in violation of any
order or resolution which is not subject to review promulgated by the State Air
Resources Board or an air pollution district.
-10-
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.
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(5) To report violations to the State and to the Assistant Administrator for
Enforcement.
(6) To insert the substance of the provisions of paragraph [b] into any nonexempt
subcontract, including this paragraph [b6], and to take such action as the
Federal Government may direct as a means of enforcing such provisions.
16. Utilization of Small Business and Minority and Women Owned Business Enterprise
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.
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 (1) which is
at least 51 percent owned by one or more minority group members or women, or in
the case of publicly owned business, at least 51 percent of the stock of which is
owned by one or more minority group members or women; and (2) 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.
17. P1iiatiaQ
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.
18. Progr 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.
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Exhibit A(F)
19. Confidentioldy 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 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.
22. Resolution of Direct Service Contract Diss
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.)
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c. Disputes arising out of an audit or examination of a contract not covered by subdivision
(a) of Section 20204, of Chapter 2.1,Title 22, of the California Code of Regulations, and
for which no procedures for appeal are provided in statute, regulation or the contract
shall be handled in accordance with the procedures identified in Sections 51016
through 51047,Title 22,California Code of Regulations.
23. Financial and Compliance Audit of Nonprofit Entities
(Applicable only if Contractor is a private, nonprofit entity)
a. Definitions 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 man "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 to 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.
f. 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.
24. 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
10355,the amendment shall be subject to the approval of the Department of General
Services,unless otherwise exempted.
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\ '
, Exhibit A(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 Contractors
The Contractor's performance under this contract shall be evaluated at theconclusion 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 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.
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(7) Occasional or one-time reimbursement of a state employee's travel expenses is
not acceptable.
(Citation: Public Contract Code, Section 10410)
b. Former State Officers 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"
(1) 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)
27. Single Audit Act of 1984 (applicable only if Contractor is a governmental entity)
In accordance with Public Law 98-502 and OMB Circular A-128, it is stipulated between the
parties hereto that:
a. The cost of the single audit will be charged to the federal assistance program
providing funds for this agreement on a "Fair Share" basis. The amount chargeable to
federal assistance programs for the cost of the single audit is calculated based on the
ratio of federal expenditures to total expenditures of the Contractor. The State's share
of the single audit cost under this contract is based upon the ratio of federal funds
received under this agreement to total federal funds received by the Contractor
each fiscal year.
b. 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.
c. Federal or State auditors shall have "expanded scope auditing" authority to conduct
specific program audits during the same period in which a single audit is being
performed, but the audit report has not been issued. The federal or state auditors
shall review and have access to the current audit work being conducted and will not
apply any testing,or review procedures which have not been satisfied by previous
audit work that has been completed.
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E#rbit A 0
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. Contr ctor 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.
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31. Debarm nt and Suspension Requirements -
Contractor agrees to comply with the debarment and suspension requirements as found in
7 Code of Federal Regulations,Part 3017,or as amended.
32. LIMITATIONS ON PAYMENTS TO INFLUENCE;
CERTAIN FEDERAL ACTIONS AND RELATED DISCLOSU$F,�
(a) Definitions. As used in this Exhibit,
"Agency," as defined in 5 U.S.C. 552(f), includes Federal executive departments and
agencies as well as independent regulatory commissions and Government
corporations,as defined in 31 U.S.C. 9101(1).
"Covered Federal action" means any of the following Federal actions:
(1) The awarding of any Federal contract;
(2) The making of any Federal grant;
(3) The making of any Federal loan;
(4) The entering into of any cooperative agreement; and
(5) The extension, continuation, renewal, amendment, or modification of any
Federal contract,grant,loan,or cooperative agreement.
Covered Federal action does not include receiving from an agency a commitment
providing for the United States to insure of guarantee a loan.
"Indian tribe" and "tribal organization" have the meaning provided in section 4 of the
Indian Self-Determination and Education Assistance Act (25 U.S.C. 450B). Alaskan
Natives are included under the definitions of Indian tribes in the Act.
"Influencing or attempting to influence" means making, with the intent to influence,
any communication to or appearance before 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 covered Federal action.
"Local government" means a unit of government in a State and, if chartered,
established, or otherwise recognized by a State for the performance of a government
duty, including a local public authority, a special district, an intrastate district, a
council of governments, a sponsor group representative organization, and any other
instrumentality of a local government.
"Officer or employee of an agency" includes the following individuals who are
employed by an agency:
(1) An individual who is appointed to a position in the Government under title 5,
U. S. Code,including a position under a temporary appointment;
(2) A member of the uniformed services as defined in section 101(3), title 37,
U. S. Code;
(3) A special government employee as defined in section 202, title 18, U. S. Code;
and
(4) An individual who is a member of a Federal advisory committee, as defined by
the Federal Advisory Committee Act,title 5,U. S. Code,Appendix 2.
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4
,r "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-
(B) For purposes of paragraph (b)(2)(1)(A), providing any information
specifically requested by an agency or Congress is allowable at any
time.
(C) For purposes of paragraph (b)(2)(1)(A) of this section, the following
agency and legislative liaison activities are allowable at any time only
where they are not related to a specific solicitation for any covered
Federal action:
(i) Discussing with any agency (including individual demonstrations)
the qualities and characteristics of the person's products or
services,conditions or terms of sale,and service capabilities; and,
(ii) Technical discussions and other activities regarding the
application or adaptation of the person's products or services for
an agency's use.
(D) For purposes of paragraph (b)(2)(i)(A) of this section, the following
agency and legislative liaison activities are allowable only where they
are prior to formal solicitation of any covered Federal action:
(i) Providing any information not specifically requested but necessary
for an agency to make an informed decision about initiation of a
covered Federal action;
(ii) Technical discussions regarding the preparation of an unsolicited
proposal prior to its official submission; and,
(Iii) Capability presentations by persons seeking awards from an
agency pursuant to the provisions of the Small Business Act, as
amended by Public Law 95-507 and other subsequent
amendments.
(E) Only those activities expressly authorized by paragraph (b)(2)(i) are
allowable under paragraph (b)(2)(i).
(ii) Professional and technical services by 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 of reasonable
compensation made to an officer or employee of a person requesting
or receiving a Federal contract or an extension, continuation, renewal,
amendment, or modification of a Federal contract if 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.
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Q
.J
(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 an 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 an 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-
(B) For purposes of paragraph (b)(2)(iv)(A), "professional and technical ,
services" shall be limited to advice and 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 an 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
or 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 an 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
negatiation 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) Persons other than officers or employees of a person requesting or
receiving a covered Federal actioii include consultants and trade
associations.
(E) Only those services expressly authorized by paragraph (b)(2)(iv) of this
section are allowable under paragraph(b)(2)(iv).
(v) The prohibition on use of Federal appropriated funds does not apply to
influencing activities not in connection with a specific covered Federal
action. These activities include those related to legislation and regulations
for a program versus a specific covered Federal action.
(55 Fed. Reg. 24542 (June 15, 1990).)
(c) Certification and Disclosure.
(1) Each person (or recipient) who requests or receives a contract, subcontract,
grant,or subgrant,which is subject to section 1352 of title 31, United States Code,
and which exceeds $100,000 at any tier, shall file a certification (in the form set
forth in Attachment 1, consisting of one page, entitled "Certification Regarding
Lobbing") that the recipient has not made, and will not make, any payment
prohibited by paragraph (b) of this Exhibit.
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1.�(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;
(i) 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
(ii) 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.
(4) 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
if 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-
{ 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 fails to file the required
certification shall be subject to a civil penalty of not less than$10,000 and not more than $100,000 for each
such failure.
Name of Contractor Rimej Name of Person signing for Contractor
Contract/Grant Number SignaKze of Persjfn signing for contracts
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 Instructional Bulletin No.13(10/91) -24-
t Attachment 2
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB
034&0046
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse for public 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 Prime;
❑ Rime ❑ Subawardee
Tier ,if known:
Congressional District,if known: Congressional 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,MI): (if 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
Ll b. in-kind.specify: Ll d contingent fee
P ti/� Nature
❑ e. deferred
Value ❑ f. other,specify:
14. Brief Description of Services Performed or to be Performed and Date(s)of Service,Including Offlcer(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 Signature
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, NntName:
U.S.C„Section 1352. This information will be reported to the
Congress semiannually and will be available for public Title:
inspection, Any person who fails to file the required disclosure
shall be subject to a civil penalty of not less than $10,000 and
not more than$100,000 for each such failure. telephone No.: Date:
uthori f
z�� A zed or Loc e s
r a!R oduction
�+I P
:•: Standard Form—LLL
CMS Instructiond Bullefin No.14(10/91) -25-
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity,whether subawardee or prime Federal recipient, at the
initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to Title 31, U.S.C..
Section 1352. The filing of a form Is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Use the
SF-LLL-A Continuation Sheet for additional information if the space on the form Is Inadequate. Complete all Items that
apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of
Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the
outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the
information previously reported,enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered Federal Action.
4. Enter the full name,address,city,state and zip code of the reporting entity. Include Congressional District,if known.
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or
subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier.
Subawards include but are not limited to subcontracts,subgrants and contract awards under grants.
5. If the organization filing the report in Item 4 checks'Subawardee;then enter the full name,address,city,state and zip
code of the prime Federal recipient. Include Congressional District,if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational
level below agency name,If known. For example,Department of Transportation,United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full
Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan
commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action Identified in Item 1
(e.g., Request for Proposal (RFP) number; Invitation.for Bid (IFB) number; grant announcement number,the contract,
grant, or loan award number; the application/proposal control number assigned by the Federal agency). Include
prefixes,e.g,'RFI-DE-90-001.'
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency,enter the
Federal amount of the award/loan commitment for the prime entity Identified in Item 4 or 5.
10. (a) Enter the full name, address, city,state and zip code of the lobbying entity engaged by the reproting entity
identified in Item 4 to influence the covered Federal action.
(b) Enter the full names of the Individual(s)performing services,and include full address if different from 10.(a). Enter
last name,first name,and middle initial(MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4)to the
lobbying entity(Item 10), INdicate whether the payment has been made(actual)or will be made(planned). Check
all boxes that apply. If this is a material change report,enter the cumulative amount of payment made or planned to
be made.
12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution,
specify the nature and value of the in-kind payment.
13. Check the appropriate box(es). Check all box(es)that apply. if other,specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to
perform,and the date(s)of any services rendered. Include all preparatory and related activity,not just time spent in
actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s),
employee(s),or Member(s)of Congress that were contacted.
15. Check wether or not a SF-LLL--A continuation Sheet(s)is attached.
16. The certifying official shall sign and date the form,print his/her name,title,and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response,
including time for reviewing instructions,searching existing data sources,gathering and maintaining the
data needed,and completing and reviewing the collection of information. Send comments regarding
the burden es timate or any other aspect of this collection of information, including suggestions for
reducing this burden,to the Office of Management and Budget. Paperwork Reduction Project
(0348-0046),Washington,D.C.,20503.
-26-
t' DISCLOSURE OF LOBBYING ACTIVITIES
CONTINUATION SHEET
Approved by OMB
-348-0046
Reporting Entity: Page of
Authorized for Local
CMS instructional Bulletin No.14(10/91) -27- Standard form--LLL-A
State of California-Health and Wet/are..gency Department of Health Seruices
Exhibit B
FEDERAL CONTRACT FUNDS
1. It is mutually understood between the parties that this contract may have been
written before ascertaining the availability of congressional appropriation of
funds for the mutual benefit of both parties in order to avoid program and fiscal
delays which would occur if the contract were executed after that determination
was made.
2. This contract is valid and enforceable only if sufficient funds are made available
to the States by the United States Government for the Fiscal Year 1994/95 for the
purposes of this program. In addition, this contract is subject to any additional
restrictions, limitations, or conditions enacted by the Congress or any statute
enacted by the Congress which may affect the provisions, terms, or funding of
this contract in any manner.
3. It is mutually agreed that if the Congress does not appropriate sufficient funds
for the program, this contract shall be amended to reflect any reduction in funds.
4. The Department has the option to void the contract under the 30-day cancellation
clause or to amend the contract to reflect any reduction of funds.
G`1S Instructional Bulletin No.04(01193)
PAGE 1 OF 3
EXHIBIT C
BUDGET
CONTRACTOR: County of Contra Costa
CONTRACT NO.: 94-19872
BUDGET PERIOD: July 1, 1994 - June 30, 1995
CARE ACT
TITLE II HOPWA TOTAL
A. PERSONNEL EXPENSES $ $ $
B. OPERATING EXPENSES $19,253 $ $19,253
C. CAPITAL EXPENDITURES $ $ $
D. OTHER COSTS $173,276 $ $173,276
E. INDIRECT COSTS $ $ $
(Maximum of 15% of
Personnel Expenses)
TOTAL BUDGET 5192,529 $ $192,529
PAGE 2 OF 3
EXHIBIT C
BUDGET
CONTRACTOR: County of Contra Costa
CONTRACT NO.: 94-19872
BUDGET PERIOD: July 1, 1995 - March 31, 1996
CARE ACT
TITLE H HOPWA TOTAL
A. PERSONNEL EXPENSES $ $ $
B. OPERATING EXPENSES $19,253 $ $19,253
C. CAPITAL EXPENDITURES $ $ $
D. OTHER COSTS $173,276 $ $173,276
E. INDIRECT COSTS $ $ $
(Maximum of 15% of
Personnel Expenses)
TOTAL BUDGET $192,529 $ $192,529
PAGE 3 OF 3
EXHIBIT C
BUDGET
CONTRACTOR: County of Contra Costa
CONTRACT NO.: 94-19872
BUDGET PERIOD: April 1, 1996 - June 30, 1997
CARE ACT
TITLE II HOPWA TOTAL
A. PERSONNEL EXPENSES $ $ $
B. OPERATING EXPENSES $19,253 $ $19,253
C. CAPITAL EXPENDITURES $ $ $
D. OTHER COSTS $173,276 $ $173,276
E. INDIRECT COSTS $ $ $
(Maximum of 15% of
Personnel Expenses)
TOTAL BUDGET $192,529 $ $192,529
STATE OF CALIFORNIA
NON-DISCRLML CATION CLAUSE (OCP-1)
STD. 17 A (REV.2-93)
EXHIBIT D
1. During the performance of this contract, contractor and its subcontractors shall not
unlawfully discriminate, harass or allow harassment, against any employee or
applicant for employment because of sex, race, color, ancestry, religious creed,
national origin, physical disability (including HIV and AIDS), mental disability,
medical condition (cancer), age(over 40) or marital status, and denial of family care
leave. Contractors and subcontractors shall insure that the evaluation and treatment
of their employees and applicants for employment are free from such discrimination
and harassment. 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 Code of
Regulations, Title 2, Section 7285.0 et seq.). The applicable regulations of the Fair
Employment and Housing Commission implementing Government Code, Section
12990(a-f), set forth in Chapter 5 of Division 4 of Title 2 of the California Code of
Regulations 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 thev 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.
EXHIBIT "E"
PROGRESS REPORT
Report Periods: Mid-year XX/XX/XX - XX/XX/XX
Year end XX/XX/XX - XX/XX/XX
Contractor Name:
(Fiscal Agent)
Contract Number:
Contract Amount:
Consortium Name and Address: Consortium Representative
Preparing Report
Phone Number:
The Progress Report should be brief but include all relevant information. Answer the following
questions within the space provided, if possible. Do not attach extraneous information such as
data collection reports, subcontracts, or subcontractor reports. If such information is needed,
the persons preparing the report will be contacted.
1. Summarize the progress of the HIV Care Consortium in meeting local HIV service goals
and objectives. Include a description of efforts to address the continuum of health and
support services; a summary of issues and/or problems which may have impeded
implementation: and the strategies used to address them. Use quantifiable terms, if
possible.
Page 1 of 3
2. Give a brief summary of implementation and evaluation activities.
3. Review, analyze, and interpret subcontractors' progress reports and summarize relevant
information data. Write an overall summary. Do not write a summary for each
subcontractor.
Page 2 of 3
Discuss personnel transactions (including vacancies and inability to fill planned positions)
which have had an impact on meeting objectives.
Address any issues needing the attention of State Office of AIDS staff.
CERTIFICATION BY DESIGNATED CONSORTIUM REPRESENTATIVE:
i certify that the information presented in this report accurately reflects the current status of this
-,,oroject to the best of my knowledge.
C(Driginal Signature Date
y�xh-E eff. 07/01/94) Page 3 of 3
6 '
STATE Of CALIFORNIA DEPARTMENT OF HEALTH SERVICES
Exhibit G
Prior to July 1, 1994 Language
1. It is mutually understood betweenthe parties that this contract may have
been written and executed prior to July 1, 1994 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, 1994.
2. This contract is valid and enforceable only if sufficient funds are made
available by the Budget Act of 1994 for the Fiscal Year 1994-95 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 be the Legislature
which may affect the provisions, terms, or funding of this contract in any
manner.
3. It is mutually agreed that if the Budget Act of 1994 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.
CMS Insimc:ional Bulletin No.03(12193)
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E=IT N
SUBCONTRACTOR LISTL G
TITLE II YEAR 04/HOPWA YEAR 03 FUNDS
{CONSORTIUM NAiV1E:
CONTRACTOR TITLE II HOPWA TOTAL
j NA\IE YEAR 04 YEAR 03
i
i
SUBTOTAL
Carried forward from attached
page.
ADMINISTRATIVE
RELN/IBURSEVMNNT (10%Max) (7% Max)
TOTAL FL--N;D iG
Attach additional pages as necessary
.-=:ch-0 effective 07/01/94)
. , . EXMBIT O
SUBCONTRACTOR INFORMATION & BUDGET (page 1 of Z)
1. CONSORTTUIM NAME:
2. SUBCONTRACTOR.NAME:
3: CONTRACT NO-. :
4..ADDRESS::::::::
5. CITY/ZIP.`CODE..
6. ZIP CODE OF PR gCIPAL TOTAL NO. OF SITES
SITE:
7. PROGRA.V, DIRECTOR'S.
NA1�fE: .
8. TITLE:.
9. (AREA.CODE) PHONE NO.:.
10. (AREA.CODE) FAX NO.:
11. SERVICES PROVIDED: (Refer to Glossary of Service.Categories for definitions'*check.where applicable.
HEALTH CARE SERVICES
( ) Case Management ( ) Dental Care ( ) Developmental Services
( } Drug Reimbursement ( ) Durable Medical Equipment ( ) Health Insurance
( ) Home Health Care ( ) HIV-Related Meds/Supplies ( ) Hospice Care (Home-Based)
( j Hospice Care (Residential) ( ) Mental Health Therapy ( ) Medical Care
( ) Nursing Home Care ( ) Rehabilitation Care ( ) Substance Abuse Treatment
( ) Other* (specify)
SUPPORT SERVICES
O Adoptioa/Foster Care ( ) Attendant Care ( ) Benefits Counseling
( ) Buddy/Companion ( ) Client Advocacy ( ) Counseling
( ) Day/Respite Care ( ) Direct Emergency Fin. Asst. ( ) Education/Risk Reduction
( ) Food Bank/Delivered deals ( ) Homemaker/Health Aide ( ) Housing Assistance
( ) Housing Services (Res.) ( ) Information & Referral ( ) Legal Services
( ) Nutritional Services ( ) Transportation ( ) Other* (specify)
12. SCOPE OF WORK: (Briefly describe service(s) to be Provided including the number of clients to be served.)
i
M
EXHIBIT O
SUBCONTRACTOR INFORMATION & BUDGET (page 2 of 2)
13. PRIMARY DATA.,
CONTACT'SNAME:
11 TITLE i
15. (.AREA CODE):PHONE NO._:. .
16. (AREA CODE).FAX NO
17. CONTRACT`TYPE-..(Check one) O Direct Service O Consultant
IS. SELECTION:METHOD:.:(Check one) O Competitive Bid O Sole Source
14. PROVIDER:TYPE:.(Refer to ne=page fore provider definitions_ .Check one)
( ) Health department ( ) Other community-based service organization
( ) Hospital or hospital-based clinic ( ) Other public agency
( )Public-funded community health center O Other -
( ) Public-funded community mental health center ( ) Solo/group private health practice
( ) PWA coalition ( ) Unknown
20. OWNERSHIP STATUS: (Check one) _.
Public/local O Public/state O Public/federal O Unknown
( ) Private/nonprofit O Private/for profit O Unincorporated
21. Do members ofminority racial/ethnic groups constitute a majority of Board members O Yes O No
and/or a majority.of staff(volunteer or paid)providing care? (Check one)'
?? Do you receive funding.from both Title)and Title M I(Clieck ome O Yes O No
BUDGET:CATEGORIES
CATEGORIES. TITLE II YEAR 04 -HOPWA"YEAR 03 TOTAL.
')2. Personnel
24.. Indirect (1.5 o max.)
2.5. Operating.Expenses
26. Equipment
?_ Client Services
28.TOTAL CHARGES