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HomeMy WebLinkAboutMINUTES - 05181993 - 1.31 t .,..31 TO: BOARD OF SUPERVISORS rl �j FROM: Mark Finucane, Health Services Director /f/r Contra By: Elizabeth A. Spooner, Contracts Administrat Costa DATE: May 6, 1993 County SUBJECT: Approve submission of Funding Application #28-509-1 to the State Department of Health Services for Childhood Injury Prevention Project SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION I. RECOMMENDED ACTION: Approve and authorize the submission of Funding Application #28-509- 1 to the State Department of Health Services in the amount of $45, 000 for the period July 1, 1993 through June 30, 1994 for the Department's Childhood Injury Prevention Project. II. FINANCIAL IMPACT: Approval of this application by the State Department of Health Services will result in $45, 000 of funding for the Department's Childhood Injury Prevention Project for FY 1993-94. No County match is required. III. REASONS FOR RECOMMENDATIONS/BACKGROUND: Injuries are the leading cause of death and disability among children and adolescents in the Nation. Over the past decade, health professionals have come to agree that injuries are both costly and preventable. The Childhood Injury Prevention Project will maintain a Childhood Injury Prevention Coalition to strengthen childhood injury prevention programs throughout the County. In order to meet the deadline for submission, the application has been forwarded to the State, but subject to Board approval. Four certified copies of the Board Order authorizing submission of the application should be returned to the Contracts and Grants Unit for submission to the State. CONTINUED ON ATTACHMENT: YES SIGNATURE: O RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMME ATl N OF BOARD 60MMITTEE APPROVE OTHER SIGNATURE(S) 921 ACTION OF BOARD ON 77, APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A TRUE AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD OF SUPERVISORS N THE DATE SHOWN. Contact: Wendel Brunner, M.D. (313-6712) _ CC: Health Services (Contracts) ATTESTED 2? _ Auditor-Controller (Claims) Phil Batchelo , Clerk of the Board of State Dept. of Health Services Supwvl r3xdCe0wtJAd1*08t0f M3e2/7-83 BY DEPUTY 1 -31 �� III. FUNDING APPLICATION Control No. 93- 17556 , I FISCAL YEAR 1993-94 II Submit original and 2 copies complete with attachments to: III Maternal and Child Health Branch P.O. Box 942732 714 P Street, Room 740 Sacramento, CA 94237-7320 REVIEW ATTACHED INSTRUCTIONS CAREFULLY BEFORE COMPLETING APPLICATION Indicate all HCH-related state programs to which you have applied for fiscal year 1993-94 funding (blacken appropriate boxes): ❑ Farm workers ❑ California Children Services ❑ Indian Health ❑ Primary Care Grant (AB 1311) ❑ Rural Health ❑ Child Health Disability Program ❑ Maternal and Child Health ❑ Adult Day Health Care (AB 1611) ❑ Office of Family Planning ❑ Genetically Handicapped Persons Program ❑ Immunization Assistance ❑ Women. Infants and Children Supplemental Food M other Childhood Injury erevention A. APPLICATION INFORMATION 1. OFFICIAL AGENCY NAME AND ADDRESS (as it is to appear on agreement): Name: Contra Costa Health Services Department Address: 75 Santa Barbara Road City: Pleasant Hill ZIP Code 94523 County: Contra Costa Telephone (510)646-6511 2. CATEGORY OF PROJECT: Childhood Injury Prevention Project 3. AMOUNT REQUESTED FOR FISCAL YEAR 1993-94: $ 45.000 PROPOSED FUNDING PERIOD:. From 07/01/93 to06 x.30 4 MM/OD/YY MM/DO/YY 4. PROPOSED NARRATIVE SUMMARY: (Do not exceed this space.) The goal of Contra Costa Childhood Injury Prevention Project is to maintain and institutionalize a childhood injury prevention project an community based childhood injury prevention coalition with coordination of activities provided by the Health Services Department. The 1993-1994 fiscal year objectives include increasing the number of injury prevention programs delivered through existing Health Department programs, worldng to establish and ongoing funding mechanism for the project and providing injury prevention activities to the community through a 60 member coalition. PM 166 (MCH) 12/92 8 B. AGENCY INFORMATION (Please type or print all information and include ZIP and Area Codes). 1. Agency Director Name: Mark Finucane Title: Health Services Department Director Address: 20 Allen Street, Martinez CA ZIP Code: 94553 Telephone: (510 ) 370-5003 2. Agency Fiscal Officer.: Name: Alan Abreu Title: Public Health Accounting Address: 20 Allen Street, Martinez, CA ZIP Code:94553 Telephoner (510) 370-5025 3. Agency Official with Board Authority to Commit Agency to an Agreement: Name: Dr. William Walker Title: Health Officer Address: 20 Allen Street, Martinez, CA ZIP Code• 94553 Telephone: (5_U)370-5012 4. Project Director (if none, agency contact regarding application): Name: Susan Leahy Title:—Project Coordinator Address: 75 Santa Barbara Road, Pleasant Hill ZIP Code. 94523 Telephone: (510 ) 646-6511 5. Provider Numbers: Medi-Cal Federal Employer ID # 14 1--16 V V o 15 V 19 Clinic License Number and Expiration Date 6. Agency Tax Status: [x] Public (Government/University) [ ] Private, Nonprofit [ ] Other (Specific) PM 166 (MCH) 12/92 9 C. FISCAL YEAR 1993-94 ANTICIPATED FUNDS BY SOURCE List all federal, state, and local grants, contract. and agreements for generic matemai, child, and adolescent health services to which you have applied for fiscal year 1993-94 funding. NAME OF FUNDING SOURCE SPECIFY FEDERAL,STATE AMOUNT OF SUPPORT FUNDING OR LOCAL PERIOD (including private) Emergency Medical Service St07-01-93 Authority ate $81,000 requested 06-30-94 Emergency Medical Service 07-01-93 Authority State $89,000 requested 06-30-94 MLmicipal Courts Local unkown at this time, revenue from fines ongoing PM 166 (MCH) 12/92 10 I % ƒ « ° \ ) a - # & \ , & 0� \ \\} y � « 44 % to _ , I 5 \ %® - \ «i ai s #&® %\ ® « I\ @ t \� §k% CIN 00 ° o k\ \ \% @ �\ �- \ �\ $ \ � \ .\ r � f « \ � \ o m S --Z� m 'a 8 z z 0 c O o m� coo O m c �x a m c n o c x = o "> D vm (Dm n n z �mg c > m z m Z z m rl 3m 0 mx mn m m Z rco 9 _ m -mi 6 p O m m m m z m G)> a o K c m Z p m zz Z m C-) m m s m m r X '4 O Gr 8 x m z T m m m a � y 2 O s D IZ� , g o c m m r a 0 E T m Z0^ Q A u Zry v O o d 8 ae a D o ae m 3 c T CL n c T x z a 8 aR VJ 25 m 8 0 o m `c n Z ^' O W T T N m m B • p Vm m m N C _ n J r x O m v o y m N a m m m m z 0 x ZD m T m m O o— m n �v z r m :n# 8 c» c ZV n O c :k m 3 p o V qm� m r x �» w y �DU v m� V7 CD m O rR m z m T Z m = p� D m.� (7 Z D Z D r � p p Z O 10m CD o oa w.- y n O o o ca ? �•O^' D Gt a CD ✓a n 'G L 0CD n w ,a o CJ N 0CD CD �L 4 CSD fi C1 cam*+ v o 0 N O o h p ynON w 2 „ yam^ ? 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C) n -i m m .. m., CD N j ocO O O �a� Mcn -0 - Ow C ooov .m rn � o� �, d n o m m O O O 0) m m cpm 0CL 3 N CL CD Q v m r'� m y D a a m m m y C" y coCC CD m m m m m rY C+ N n y n y n O co m D. AGREEMENT AND CERTIFICATION 1. Agreement: To be completed by all applicants The undersigned hereby affirms that the statements contained in the application package are true and complete to the best of the applicant's. knowledge, and further, realizes this is a public document which is open to public inspection. du*,"i Health Officer Origina Signature Title Dr. -William Walker February 25, 1993 Name (Type -orPrint) ate 2. Certification Statement: To be completed by all applicants I certify that this Maternal , Child, and Adolescent Health Service Program will comply- with all federal and State legal requirements pertaining to the program. I understand that the State will use the materials submitted by this agency as a guideline for- program consultation and assessment. /j Health Officer Origin✓al Signature Jitle Dr. William Walker February 25, 1993 Name (Typo orPrint) Date 3. Certification Statement: For local health jurisdictions only I certify that the County has a Maternal, Child, and Adolescent Health Board advisory to the Maternal, Child, and Adolescent Service programs, the membership of which meets the requirements of the Heal h and Safety Code Section 321.7. 40-A –leHealth Officer —tea eat 0 icer Title (original signature) Dr. William Walker February 25, 1993 Name (Type or rent ate 4. Certification,Statement: .To be completed by other than local health jurisdictions I hereby certify that a copy of this proposal has been/will be sent to the health officer(s) for county(s) and/or local health jurisdiction in which proposed activities are to occur. Not Applicable Original Signature Title Name Type or Print Date PM 166 (MCH) 12/92 11 State of Callfornia—Health and Welfare Agency Department of Health services AFFIRMATIVE ACTION INFORMATION SHEET 1. For statistical purposes,please complete the following information to the questions below. 2. This information is for statistical use only. It is considered confidential and does not constitute a basis for award or rejection of any contract,work order,service authorization,or purchase order with the Department. VENDOR/CONTRACTOR INFORMATION Name of Firm DGS Vendor Number Contra Costa Health Services Department Name of Principal(if other Ihan an Individual firm) Title N/A Business Address City Zip 20 Allen Street Martinez, CA 94993 Type of Ownership(Use 2 digits,i.e.,01,02, 10,11,etc.); 01 = Individual 02=Partnership 03=For Profit Corp. 04=Not-for-Profit Corp. 05=For Profit Hospital/Skilled Nursing Facility 05 =Not-for-Profit Hospital/Skilled Nursing Facility 07=Unincorporated Association 08=College/University(Including both Public. and Private) including University Hospitals 09=County Government only 10=Other California governmental entity,except County and No. 11 below. (City,School District,Water District,Joint Powers,etc.) 11 =California State Agency 12-Other entity,including Federal Government,another State,any entity not identified in 1 thru 11. Indicate Ownership digit(s)here: 09 Type of Business contractor's Licvnse Held,It any; County Health Services Department Statistical Information Ethnic Codes:, Male Female Male Female Black Americans 1 A American Indians/Alaska Natives 7 G Asian-Pacific Americans 2 13 Filipino Americans 8 H Hispanic Americans 4- D Asian-Indian Americans 9 1 Pacific Islanders 6 F Caucasian/White Americans 5 E Enter Ethnicity of Vendor/Contractor from above list: Has Vendor/Contractor applied to and been approved by the Office of Small and Minority Business, Department of General Services,as a small business? (See reverse side). Yes ❑ No Q It yes,enter the date of the letter OSMB sent to the Vendor/Contractor approving the small business status: Has Vendor/Contractor applied to and been approved by the Office of Civil Rights, Department of Transportation,as a Minority Business Enterprise or a Disadvantaged Business Enterprise? Yes ❑ No fl If yes,enter CalTrans seven-digit certificate number given to Vendor/Contractor- Enter certificate expiration date: Is Vendor/Contractor a"Women-Owned Enterprise"? Yes ❑ No 93 OHS Inform=tion. Date Received: By: Date entered DHS Program Name: in CMS SA log: INFORMATION PRACTICES ACT STATEMENT This information is requested by the State of California,Department of Health Services for statistical purposes only.Completion of the form is voluntary and there are no consequences for not providing the information. Information will be provided to Contract Management Section, Business Services Section, Records Management and Administrative Support Section of the Department of Health Services, and possibly other public agencies. For more information or access to your records, contact the Section Chief, Contract Management Section, Department of Health Services,744 P Street,Sacramento,CA 95814,Telephone (91.6)322-6122. HAS 1090(2/88) - C. FUNDING APPLICATION CHECKLIST Please use this checklist when submitting your funding application package to Maternal and Child Health (MCH) Branch. Are the following documents enclosed? [X] Original and two copies of funding application package [X] PM 166 X Is the application information complete? X Is the Federal Employer ID number correct? X Are there original signatures in Section D? [X] Affirmative Action Information Sheet [X] Budget Worksheet for Exhibit C X Are all personnel positions listed? X Are line items calculated correctly? X Are non-benefitted positions identified? X Are subtotals and total calculated correctly? X Are line items numbered? X Does the total state support equal the amount of funding requested/provided? X Is a budget narrative/justification attached? X If this is a multi year contract, is there a separate Exhibit C for each fiscal year? PC ] Exhibit B (Scope of Work) X Are the timelines included for each objective/activity? X Is the SOW readable and legible? X If this a multi year contract, is there a separate Exhibit C for each fiscal year? ] Is the information in the funding application accurate and correct? ' The undersigned has checked this application for accuracy and can be reached at the telephone number listed if there are any questions. Dated: 2/25/1993 Susan Leah ame (510) 646-6511 _ Telephone Number 7