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HomeMy WebLinkAboutMINUTES - 03221994 - 1.71 r TO:` BOARD OF SUPERVISORS ' '' 71 FROM: Mark Finucane, Health Services Director c--c Contra By: Elizabeth A. Spooner, Contracts AdministratCosta DATE: March 10, 1994 County SUBJECT: Approve Submission of Funding Application #29-316-16 with the State Department of Health ' Services for the High Risk Infant Follow-Up Pro-iect SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION I. RECOMMENDED ACTION: Approve and authorize the submission of Funding Application #29-316-16 with the State Department of Health Services, in the amount of $251,886 per fiscal year, for the period July 1, 1994 through June 30, 1996, for continuation of the County's High Risk Infant Follow-Up Project. II. FINANCIAL IMPACT: Approval of this application by the State will result in $251,886 per fiscal year of State funding (via Federal Maternal Child Health Block Grant) to continue the High Risk Infant Follow-Up Project through June 30, 1996. No County matching funds are required. III. REASONS FOR RECOMMENDATIONS/BACKGROUND: On October 1, 1991, the Board of Supervisors approved Standard Agreement #29-316-10 with the State Department of Health Services, for the County's High Risk Infant Follow-Up Project. Subsequently, the Board approved amendments which added funds and extended the term of the agreement through June 30, 1994 . Approval of Funding Application #29-316-16 continues State funding for this project through June 30, 1996. In order to meet the deadline for submission, a draft copy of the application has been forwarded to the State, subject to Board approval. Seven sealed copies of this Board Order should be returned to the Contracts and Grants Unit for submission to the State. CONTINUED ON ATTACHMENT: YES SIGNATURE: ' RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMEN ATIO OF BOARD CO MITTEE APPROVE OTHER SIGNATURE(S) ACTION OF BOARD ON 0.44 �. �a�99 y APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS _ ' UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A.TRUE AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD OF SUPERVISORS ON THE DATE SHOWN. Contact: Wendel Brunner, M.D. (313-6712) CC: Health Services (Contracts) ATTESTED ` Y 1a�►,c� �.�. ( � ''�' _ Auditor-Controller (Claims) Phil Batchelor, Clerk of the Board of State Dept. of Health Services SupejvWrljWG 1yAdministratV a 41 M3e2/7-e3 BY l 0_r,,,,,�) DEPUTY - FUNDING APPLICATION Control No. 94- 19605 FISCAL YEAR (FY) 1994-95 Submit original and 2 copies complete with attachments to: 29 - 316 - 16 Maternal and Child Health Branch County of Contra Costa Health Services P.O. Box 942732 94-19605 HRIF 714 "P" Street, Room`h4Q'-709 $251.886.00 Sacramento, CA 94234-7320 REVIEW ATTACHED INSTRUCTIONS CAREFULLY BEFORE COMPLETING APPLICATION Indicate all MCH-related state programs to which you have applied for fiscal year 199495 funding (blacken appropriate boxes): 0 Farm workers H California Children Services [] Indian Health [] Primary Care Grant (AS 1317) [] Rural Health R Child Health Disability Program n Maternal and Child Health [] Adult Day Health Care (AS 1611) 31 Office of Family Planning [] Genetically Handicapped Persons Program [] Immunization Assistance If Women, Infants, and Children Supplemental Food ROtherBlack-Inf ant Health Project X Other Childhood Injury Prevention Project A. APPLICATION INFORMATION 1 . OFFICIAL AGENCY NAME AND ADDRESS (as it is to appear on agreement): Name: Contra Costa dealth Services Department/Public Health Division Address:. 595 Center, Suite 310 City: Martinez ZIP Code 94553 County:. Contra Costa Telephone (510) 313-6250 2. CATEGORY OF PROJECT: MCHHigh Risk Infant Follow-up local assistance 3. AMOUNT REQUESTED FOR FY 1994-95: $ 251,886.00 AMOUNT REQUESTED FOR FY 1995-96:. $ 251,886.00 PROPOSED FUNDING PERIOD: From 07/01/94 to 06/30/96- PM 6/30/96PM 166 (MCH) 11/94 Page 7 of 51 4. PROPOSED NARRATIVE SUMMARY: (Do not exceed this space.) y_ 1. Prevent or minimize developmental disabilities or delays for high risk infants and promote the infants optimal health and development by pro- viding home based early intervention services to high risk infants and caregivers, maintaining an active caseload of at. least 140 infants 0-3 years. 2. A quality assurance program will be developed and maintained and will include, but will be limited to, quarterly chart audits, case con- ferences, supervision of 'personnel responsible for care delivery, and in-service for personnel relating to their job description. 3. The HRIF program will incorporate and encourage awareness of health measures and practices that enhance and protect the health of infants and their families. 4. Information on infants and their families will be collected for the purpose of evaluating services, determining health outcomes and planning interventions. 5. The HRIF program is an integral participant in the delivery of services to at risk infants and their families in the community where the program resides. The program participates in interagency coordination and collaboration to insure optimal service delivery to infants and their families. PM 166 (MCH) 11/94 Page 8 of 51 5 Contra Costa County HIGH RISK INFAI�tI` FULL�}GJU PROGRAM = , PUBLIC HEALTH DIVISION 595 Center Ave., Suite 314 Martinez, CA 94553 ;. (510) 323-6250 COU January 27 , 2994 Maternal & Child Health Branch P. 0. Box 942732 714 "P" Street, Room 708 Sacramento, CA 94234-7320 Re: High Risk Infant Follow-up Contract 94-19605 1994-1995, 1995-2996 To Whom It May Concern: We are submitting this application pending Board of Supervisors approval. RFA checklist is attached. Sincerely, Diana Jo ensen, L.C.S.W. Director, High Risk Infant Follow-up -DJ:cw V. RFA CHECKLIST Please use this checklist when submitting your RFA package to MCH. Are the following documents enclosed? Is the following information contained in the package? Original and two copies of the RFA package Is the application information complete? r/ Is the Federal Employer ID number correct (PM 166, Page 9, Section B, Item 5)? - 'V-" Are there original signatures (PM 166, Page 11 , Section D)? [v1� Affirmative Action Information Sheet Scope of Work (Exhibit B) ✓Is the SOW included? i/ Is the SOW readable. and legible? Budget Worksheet ✓Are all personnel positions listed? � ,,Does the total support requested equal the amount of funding requested/provided? Is a budget justification narrative attached? [✓]" ✓Is the information in the RFA 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: �95( —� Name Sim — c313 — L 03 V Telephone Number Page 38 of 51 B. AGENCY INFORMATION. (Please type or print all information and indude ZIP and Area Codes). 1 .. Agency Director: Name: Wendel Brunner, M.D. Title: Assistant Director, Dept. of Health Services, Public Health Division Address: 597 Center, Ste. 200 Martinez ZIP Code: 94553 Telephone: (510) 313-6712 2. Agency Fiscal Officer: Name: Alan Abreu (Jan Woodward/Rich Krause) Title: Public Health Controller Address: 20 Allen Street, Martinez ZIP Code: 94553 Telephone: (510) 370-5031 3. Agency Official with Board Authority to Commit Agency to an Agreement: Name: Mark Finucane Title: Director, Department of Health Services Address: 20 Allen Street, Martinez -- - ZIP Code: 94553 Telephone: (510) 370-5001 4. Project. Director (if none, agency contact regarding application): Name: Diana Jorgensen, MSW, LCSW Title: Project Director Address: 595 Center, Ste. 310, Martinez ZIP Code: 94553 Telephone: ( 510 313-6250 / 313-6034 FAX Number:(510) 313-6029 5. Provider Numbers: Medi-Cal 22 R 114791 Federal Employer ID # 1N !--! ! ; 1 ! 1 ! ! Clinic License Number and Expiration Date N/A 6. Agency Tax Status: (X] Public (Government/University) [ ] Private, Nonprofit [ l Other(Specify) PM 166 (MCH) 11/94 Page 9 of 51 C. FISCAL.YEAR 1994-95 ANTICIPATED FUNDS BY SOURCE List all federal, state, and local grants; contract and agreements for generic maternal, child, and adolescent health services to which you have applied for FY 1994-95 funding. NAME OF FUNDING SOURCE SPECIFY FEDERAL, AMOUNT OF FUNDING STATE, OR LOCAL SUPPORT PERIOD (INCLUDING PRIVATE) CHDP` : State, County $266,860 19.94-95 EPSDT Federal, State, Cty $1,344,477 1994-95 CCS State, County $4,600,000 1994-95 High Risk Infant Follow-up State $251,886 1994-95 MCH (CPSP,CPO, PCG) Federal, State, Cty $172997644 1994-95 Family Planning State $1347500 1994-95 WIC Federal, State $993,214 1994-95 Dental Disease Program State 96,552 1994-95 African-American Infant State $102,500 1994-95 Health Project PM 166 (MCH) 11/94 Page 10 of 51 OTHER COSTS DETAIL WORKSHEET Contractor: Contra Costa County FISCAL YEAR: 1995/1996 Contract No.: 94-19605 Program/Project: High Risk Infant Follow Up STATE FUNDING MCH (1) (2) (3) (4) (5) (6) TOTAL STATE FUNDING SUBCONTRACTS 1 Baxter, Ophelia/Reisterer,Amy 4,259.00 100.0% $4,259.00 2 3 4 5 6 7 ....._................... ._.. _.._._._........_ ....111-....1.. ...... .- 1 .....111.. _._. _. .111 1..._.. .. . . .... .._. .. ...... _ .. ..._.... ...... ._. . ._ .1111. .. . 1111.... ..1 1. ......... ......._ .......... ....--_.. ... 1. ..... .............. ...._ _...... ... 1- ....... . .. . ......... ........ 11 11. .._ ..1111... ._....... ....... .. .... .... ......... .......... .......... ......_.._. ..... . .. ...... ....-- ._....._... .......... ......... .._..... ....._... ......... .--... . ......... _.... .. .. ... .... _.. . ...... 9 10 11 . _..........._.._.................................... ............._............................ ;12 13 ............. ___._................................__............ .... .1111.. _.........._._._._......_..................___........... ...._................_............._.._.......... . ..._............_.._ _. .1111_............ .1.111. 1111._ _....... . _ 1111_... _ ..._ _1.1.11 _...... .._.... .... 15 : ................ ...I......_..-..._........_.. .. I. 111 1.. .................. .....1111_...... __ ................._........_... . .._ .. 11 .11..................._............ ...1111.. _ _ _ _ _ _ __ _.. 1111_ .1111 _....... ........ .._..... ......._. _. ... ........... . . .. 111.1 .. .1.11.1 _ ... 1111.. . ........ _.. ... .._... . ......... _.. .1.111. ... ..... ... ....... .1...111.. 1111 .. . ....... ..._ . .. ....... _....... ._... .._._....... ._..... ..1...111 .... 1111. 1111 _. ...... _. . ......_........... ... ....... ......... . ...... ..........._._.. 11 ...11.......... ... _ .... ...._. ............ ..._......._ . ... ...11.11... ._.._.. _....... .1.111. _........ .111..1_ .............................._....._...._........ ...-. ...................-....... ..._......_.-_. .... .........................._....-................. .__..... ............................................__.. 17 ............... _.....-............. .. ... . ..... .................._.._..._................... ............. _............_....._....................._.... .1111. 1111... ......... ......._...1111.. - ... . ...111.1_ ...1111.. _........ _ .1111 1111. _. .1111.. _........ .....__... _ 1111 _1111.. .. ....._... ......... _ _.. ... ........ .._... _....... . _ . . ....... .111.1.. ......... __1111... 1111. . ...... .._.. . .. 1.111.. _. ... ... . .1111... _.._.......... . __1111.. ..-11.11 ...... .... .. ... ......_..-.. .._.. .11..1.1 . ..._.. . ..._._.... ......... _........ .111.1 .1.11.1... 111.1 1111. .1111... . . 19 ................. ............................................................ .................... ........................I-- .._.......... _...............__................__.................. _....... ..._......................... _..... .. ................_..............._... .......... _......._........._............. ...... .. ........_._. .. _. ._ 1 111. ... ..............................I._........_..... ...:.:-,...-:-..I..:1-...-.I.:....::.I..-..-:-.::.....I.::.:...--.....::..:.....-..I.-:.-.::-......:-::--�..-:-::'.*..1-....�1'..I�:-.:.-,.�.�-.:.--:,.�-..-I��..:�:,.��....---�-..1-...,I:'.�-...�-..-.....-.....-.�..�..'--...:.:..-"..�....1...:..'-.I..1�.......................-:.-..'....-....-..1-....,�;..........�.,...1,-:..-,......1-.I..1,.-,..-'.-...-....I..........-.....4...,1...:.-:...'..'.......1...:.�:..-..'.�..-�:...:.-......'-�....:..�-.-..-..*.--.�,....:.."...-....-.,--I.:.I...'"-...:...:.-....�I..-..:......'..I...i....*.,..:l,...*--..I..'.:.....-....��-......'.:.,.-.-I1.�.'...�-.-:...--'I.�..-..:....'.....-..�...:..*-.........-.....:-..-."...I........:..,...-........:..-"-I.......-....:.:.-.....,....---...-."..:.-..:.....,..�...:....-........�:.*'....�........��:..*......-.-...-......."..:..1..,....:�..�,...1,.....�I�.�.�:.I.II0i�-.-..:-.�....6..-..:...1...�:I...-..1-6-..�:....--l6...:1....-.'61.....--I..1l6...4..b.-.*16�......*..6.*.........161..1I..-..�6.1 1...�I....4".'.1.*..6....,.'......6".I..�..6."I I.....i..:..I.i�..:-....:-........:.6.�,.:�....:.6.,.�..�.-.i,:1....�".i...:.....:-.i.....:.-...�.i--....:...i..:..."..: ......_._.... .........._..........--...................... .............. ._..........1.....-.............. _...._. ....... ........ .....................__.._. _....--... 11 -....................._......_................ ............................................_......_... ...- ............ .._............._.......... ......__.._..... ... ............ ........ ........__...... . ................ ................................................. .1....-. ...............___.. . ......... ...................._... . ......... 1 ..111.. ._........... ........ . ........ ......... ......1111 ...1111_. . ... ....... ........... .. ..... ......... . . . . _ .::. 21 >22 ` .. OTHER ............... ................_..... ..-_. ..1...1.11 I.- _......... 1111.. _1111... _ .............._........... _..............._.._...................._... TOTAL OTHER COSTS 4,259 4,259 CONTRA COSTA COUNTY HIGH RISK INFANT FOLLOW-UP PROGRAM PROPOSED BUDGET 1994-1995, 1995-1996 BUDGET JUSTIFICATION 1. PERSONNEL: Project Director: (50%) Overall responsibility for the program content, budget and personnel. Coordinates and integrates program activities with other Maternal, Child and Adolescent Health (MCAH) programs. Represents program on Interagency Council of Infant Services (ICIS) (PL99-0457 (H) Board and committees. Participates directly in program staff meetings, case, reviews and case consultation. Responsible for program direction; supervision of staff; case assignments; budget preparation, revision and monitoring; assurance of inservice training; direct liaison with State consultants, including State meetings; monitoring/evaluation and consultation as needed. Weekly and twice monthly participation in team intake process via ICIS. Represents the program in meetings, and both government and community agencies and individual health providers involved with caseload families. Project Director has an M.S.W. & L.C.S.W and provides psycho/social consultation to the nursing staff. Public Health Nurses: (300%) The program is staffed by 4 FTE Public Health Nurses. Three are funded by the HRIF contract and one is funded by the County. There are 5 employees - 2 F T. , 1 32 hours with the program and 8 hours with CHDP, 1 24 hours and, 1 halftime. Each has a caseload of between 25 and 60 children/families. Additional children have been added to the program to meet community service needs identified through ICIS. Three of the 5 nurses are Pediatric Nurse Practitioners. Assignments include: social, health, physical and developmental assessments; parent education, parent support; help for families in accessing needed community services including infant development programs; data collection; participation in ICIS coordinating teams; consultation on infant development with other programs; nursing consultation and supervision of medically fragile infants. Page 2 Budget Justification Clerk: (50%) Responsible for all correspondence, report and case evaluation document typing; maintaining files on caseload; data entry and processing for state reports; receptionist activities; meeting scheduling, etc. Accounting Technician: (25%) Assistance with budget preparation; invoice preparation; personnel time accounting; operation expense accounting; journaling of internal expenditures. 2 . OPERATING EXPENSES: a. Travel: Mileage expenditures for project personnel; includes travel for client home visits county-wide and to required meetings. b. Training: Includes required State Project meetings, interagency infant program coordination meeting, and other courses relevant to Program work. (eg. : possible courses include: working with drug exposed toddlers, training or updates on assessment tools such as NCAST, etc. ) C. Space Rental: Partially covers building rent, janitorial and utilities. d. General Expenses: Includes office supplies, patient education and assessment materials, etc. 3 . CAPITAL EXPENDITURES: None anticipated 4. INDIRECT COSTS: 10% of salaries, excluding benefits. 5. OTHER COSTS a. Software - no expenses anticipated b. Consultants: Includes physical and occupational therapy consultation as needed for caseload infants and only if no other resources are available. Includes funding for advanced staff education consultation or stipends. D. AGREEMENT AND CERTIFICATION 1 . Agreement: To be completed by all applicants The undersigned hereby affirms thatthe 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. Assistant Director, Health Services Public Health Division Original Signature Title Wendel Brunner, MD Name (Type or Print) Date 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. Project Director Original Solattipb Title Diana Jorgensen, MSW /�.2 -71C/-e/ Name (Type or Print) 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 Health Service programs, the membership of which meets the requirements of the Health and Safety Code Section 321 .7. Local Health Officer Title (Original Signature) Name (Type or Print) Date ti PM 166 (MCH) 11/94 Page 11 of 51: • Statis of caiifornia—Heann and welfare Agency Department or Mealtn Services AFFIRMATIVEACTION 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 1 Name of Firm OGS Vendor Number Contra Costa County, Department of Health Services Name of Principal(if other than an indiviauai term) Title Business Address City 'LID 595 Center, Suite 310 Martinez 94553 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 06 = 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, ute.) 11 =California State Agency 12—Other entity, includino Federal Government,another State,any entity not identified in 1 thru 11. Indicate Ownership digit(s) here: 09 Type of Business Contractor's License Heid, if any: Statistical Information Ethnic Codes: Male Female Male Female Black Americans 1 A American Indians/Alaska Natives 7 G Asian-Pacific.Americans 2 B 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: NSA 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 ('Z If yes,enter the date of the letter OSMS 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 Entetprise or a Disadvantaged Business Enterprise? Yes 0 No (X If yes, ranter CalTrans seven-digit Ct:rtifiCate number given to Vendor/Contractor: Enter certificate expiration date: Is Vendor/Contractor a "Women-Owned Enterprise"? Yes ❑ No 0 DHS Information. Date Received: By: " Date entered OHS 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 (9161322-6722. 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N N m p 'dG co E a' o °•v Gcs O Q U N CO ?r m ty Y = Uw � b n� ice• � � w00 _ co ai U ga. d v vu (y1 d? *' CO Z N L T co U r co J o M UA 1Y CD G r` o O a 7 o S r o p p•' m o � O G y GN �+ N S N O N OO N O c. r- o V- 0 o U 0- G 0 N n as sco m o in o co >- ~ G co N ts' 0 7 O cNv � o °.3 � t`- or U O m U N dY L) -) d _ CO CO cc .r- Z .r 'CS mCO N v w G tb �- d CO + 0 .0 f0 N GN CL- r v U G N 7 O N W O N c N t6 O N N +^ O co r +, N G sCD0 _ m Ad tr) 3 � �- d Q O U -S CO U) 4 O 7 0 d U co +' -oma v ona� " co i co d am► U W.� U U � d d U p �i m Cil C U o d C o 'V cGa J �, o co O N m CO (J) G cN O 3 0i 7- d 2 N N Z� N O .=+ O Q 4 > co R1 O d N Q G CD Q G z U U Y 3 u N m r o 0 s N r EXHIBIT C — BUDGET Contractor: Contra Costa County FISCAL YEAR: 1994/1995 Contract No.: 94-19605 Program/Project: High Risk Infant Follow Up STATE FUNDING MCH (1) (2) (3) (4) (5) (6) TOTAL STATE EXPENSE CATEGORY FUNDING % (1) PERSONNEL $321,085 69.6% $223,439 .................................................................................................................................................................................................................................................................. .................................................................................................................................................................................. ........................................................................ (2) OPERATING EXPENSES $6,732 100.0% $6,732 ........................................................................................... ................................................................_._............._. .............._ __..._.............. ..... ._...._.............. . .. ........ ................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................ .................................................................................................................................................................................................... ............................................................................ (3) CAPITAL EXPENDITURES _....._..._._..._.......... ...._.._......................................................................_..._..................... ......._._..................................... (4) INDIRECT COSTS % 10% $25,085 69.6% $17,456 _._...... ........._._.._.._.. .......__............................................_..._. _.............._....................._.... (maximum 10%): (5) OTHER COSTS $4,259 100.0% $4,259 _... ... ......_.............._.._...._................................................................._.........................._......................._......... _.__._...._.........._..................................... ................................................................................................................................................................................................................................................................................ _..................................._.......... .._ .............._.........................._._.. ..........................-..._............................_._.............. _...._........._.............._._............................_. ................................................................................................................................................................................................................................................................................ TOTAL EXPENDITURES $357,161 $251,886 FUNDING SOURCE MCH State AIIoc. : $ $251,886< :` $251,886 State PCA:Summar $251,886:: $251,886:' PERSONNEL DETAIL WORKSHEET Contractor: Contra Costa County FISCAL YEAR: 1994/1995 Contract No.: 94-19605 Program/Project:High Risk Infant Follow Up STATE FUNDING MCH (1) (2) (3) 1 (4) (5) (6) % ANNUAL TOTAL STATE STAFFING FTE SALARY FUNDING % 1 Project Director 50.0% 55,236 27,618.00 100.0% 27,618.00 ................ ................. ................ ................. ................ I................ 2: PHN 300.0% 66,000 198,001. 0.00 100.0% 121,714.00 3 Clerk 50.0°� 31,308 15,654 00 1'00 0% 15,654 00 ?..4' Accounting Technician 25.0% 38,304 9,576.00 100.0% 9,576.00 5 6 7 8 9 I 11 ._.......... ...._... ............ ..._ .. ........_._.. ....................._....... ._ ...._. . _............................._._ .........-_........._...................._. 12 13 _....__ .. _ ___ ...... _.._.. .. . ........I.... i4 15 - ............_ _. ......__ _....._ _..._..-___........... % 16 17 ........ .. ....... ..... __._._._.. .........._.... ..__.. ............. .......... .......... .. .....__..__ _ ..._......_..._ ....._.__........._. .. 18 19 20 21 ......_ .... . ..._. ... _ .._.. .... ............. ..................:.........._. 22 23 24 25 26 (1) TOTAL WAGES 250,848.00 174,562.00 AVG BENEFIT RATE 1 28.00% 2 TOTAL BENEFITS 70,237.44 48,877.36 TOTAL PERSONNEL COSTS 321,085.44 223,439.36 Salary ranges, percentage of time,and percentage of benefits listed for all personnel,percentage of State share,and unit costs are only yearly estimates and are subject to change over the contract period with prior written approval from the Matemal and Child (MCH) Branch. These amounts represent a portion of the full time equivalent(FTE) of positions whether or not the balance of the positions are funded by another source . OTHER COSTS DETAIL WORKSHEET Contractor: Contra Costa County FISCAL YEAR: 1994/1995 Contract No.: 94-19605 Program/Project: High Risk Infant Follow Up STATE FUNDING MCH (1) (2) (3) (4) (5) (6) TOTAL STATE FUNDING % SUBCONTRACTS 1 Baxter,Ophelia/Reisterer,Am 41259.00 100.0% $4,259.00 _.... _ .... _ ..................... __. _.._............. 2 3 .... _ .......... __........... 4 5 6 7 ............... _ ...__...............__.._........... __.._............. .... ..... ............... _ _ _ .............. _ _........ _...._......._. _.......... . .......... ............... ._ _.. _. ... . ... ..... _ _.... _ ........ .... _ __. .. _. ......_._ _......... __... 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 OTHER TOTAL OTHER COSTS 4,2591 4,259 EXHIBIT C — BUDGET Contractor: Contra Costa County FISCAL YEAR: 1995/1996 Contract No.: 94-19605 Program/Project: High Risk Infant Follow Up STATE FUNDING MCH (1) (2) (3) (4) (5) (6) TOTAL STATE EXPENSE CATEGORY FUNDING % (1) PERSONNEL $321,085 69.6% $223,439 (2) OPERATING EXPENSES $6,732 100.0% $6,732 ................_................_..._.........................._......._......................._..........I............_............_ ............................. .................................................................................................................................................... .................................................. ........ ......... .......... ............. ...... ........... ....._.. .... .. ._. ....... ._........ ..........._I........ ........_..._............._......................................................... .._........... ......._......._._......._._... ._.._ ....._...._....._. _ _... ... ........ .... . _...... ._...................................... _._._........._......_........_.............._................. ......_.._.............................._.._...._.. _........_........................_...... ._.................... _..... ........................................ (3) CAPITAL EXPENDITURES _..........................................................................._........................................................... ................._........................... (4) INDIRECT COSTS % 10% $25,085 69.6% $17,456 maximum 10% . .... ).. .. (5) OTHER COSTS $4,259 100.0% $4,259 TOTAL EXPENDITURES $357,161 $251,886 FUNDING SOURCE MCH StateAlloc. : $ $251,886 ?< ...'< >'<'` $251,886 State PCA;Sumriar $251,886: $251,886`; PERSONNEL DETAIL WORKSHEET Contractor: Contra Costa County FISCAL YEAR: 1995/1996 Contract No.: 94-19605 Program/Project: High Risk Infant Follow Up STATE FUNDING MCH (1) (2) (3) (4) (5) (6) % ANNUAL TOTAL STATE STAFFING FTE SALARY FUNDING % 1 Project Director 50.0% 55,236 27,618.00 100.0% 27,618.00 ................ 21 PHN 300.0% 66,000 198,000.00 100.0% 121,714.00 3 Clerk 50:0% 3i 308' 15,654 t)0 100;0% 15,6$4 00. 4 Accounting Technician 25.0% 38,304 9,576.00 100.0% 9,576.00 5 ..6 7 8 9 I0 11 12 13 14 15 16X XX 17 19 20 21 22 23 24 25 26 (1) TOTAL WAGES 250,848.00 174,562.00 AVG BENEFIT RATE 28.00°!° 2 TOTAL BENEFITS 70,237.44 48,877.36 TOTAL PERSONNEL COSTS 321,085.44 223,439.36 1 Salary ranges, percentage of time,and percentage of benefits listed for all personnel, percentage of State share,and unit costs are only yearly estimates and are subject to change over the contract period with prior written approval from the Matemal and Child (MCH) Branch. These amounts represent a portion of the full time equivalent(FTE) of positions whether or not the balance of the positions are funded by another source