HomeMy WebLinkAboutResolution - 2022-R0288 - Amendment No. 4 to Contract HHS000077800035 - HIV Grant with DSHSResolution No. 2022-RO288
Item No. 4.1.1
June 28, 2022
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and
on behalf of the City of Lubbock Amendment No. 4 to the Department of State Health
Services Contract No. HHS000077800035 under the HIV Prevention Services Grant, by and
between the City of Lubbock and the State of Texas' Department of State Health Services
(DSHS), and all related documents. Said Amendment is attached hereto and incorporated in
this Resolution as if fully set forth herein and shall be included in the minutes of the Council.
Passed by the City Council this June 28, 2022
ATTEST:
Rehehca Garza, City Sett
APPROVED AS TO
APPROVED AS TO FORM:
,t .
RES.DSHS-HHS000077800035 HIV Prevention Services Grant Amendment 4
5.5.22
DocuSign Envelope ID: 707CDABA-BCF1-432F-B642-942E7B80AFB3
Resolution No. 2022-RO288
DEPARTMENT OF STATE HEALTH SERVICES
CoNTRAcr No. HHS000077800035
AMENDMENT No. 4
The DEPARTMENT OF STATE HEALTH SERVICES (DSHS or System Agency) and CITY OF
LUBBOCK (Grantee), Parties to that certain HIV Prevention Contract, effective January 1, 2020,
and denominated as DSHS Contract No. HHS000077800035 (the "Contract"), now want to further
amend the Contract.
WHEREAS, DSHS wants to exercise its option to extend the Contract for an additional year;
WHEREAS, DSHS wants to make additional funds available in support of the services provided
during the extended term, and revise ATTACHMENT B-3, BUDGET FY 2022 (REVISED);
WHEREAS, the Parties want to replace ATTACHMENT A-2, STATEMENT OF WORK FY 2022
(REVISED); and
WHEREAS, the Parties want to incorporate ATTACHMENT F-1, FEDERAL FUNDING
ACCOUNTABILITY AND TRANSPARENCY (FFATA) CERTIFICATION to this Contract.
THEREFORE, the Parties agree as follows:
1. The Contract is extended for the period beginning September 1, 2022, through August
31, 2023 (the "Third Extension Option"), unless terminated sooner.
2. ARTICLE IV, BUDGET, of the Contract is amended to add $224,439.00 to pay for
Grantee's services during the Third Extension Option. The total not -to -exceed amount
of this Contract is increased to $775,170.00.
3. ATTACHMENT B-3, BUDGET FY 2022 (REVISED), is deleted and replaced in its entirety
with ATTACHMENT B4, BUDGET FY 2023.
4. All expenditures for the Third Extension Option shall be in accordance with
ATTACHMENT B4, BUDGET FY 2023.
5. ATTACHMENT A-2, STATEMENT OF WORK FY 2022 (REVISED), is deleted and replaced
in its entirety with ATTACHMENT A-3, STATEMENT OF WORK FY 2023.
6. ATTACHMENT F-1, FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY
(FFATA) CERTIFICATION is added by this Amendment and incorporated into the
Contract.
7. This Amendment shall be effective on September 1, 2022.
8. Except as modified by this Amendment, all terms and conditions of the Contract, as
amended, shall remain in full force and effect.
DSHS Contract No. HHS000077800035 Page 1 of 15
Amendment No. 4
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9. Any further revisions to the Contract shall be by written agreement of the Parties.
Signature Page Follows
DSHS Contract No. HHS000077800035 Page 2 of 15
Amendment No. 4
DocuSign Envelope ID: 707CDABA-BCF1-432F-B642-942E7B80AFB3
SIGNATURE PAGE FOR AMENDMENT No. 4
DSHS CONTRACT No. HHS000077800035
DEPARTMENT OF STATE HEALTH SERVICES
CDocuSigned by:
Y—fAlCA8984021413
Date of Signature: July 1, 2022
CITY OF LUBBOCK
DocuSigned by:
y FnrA;:r8X[4AF411
The Honorable Tray Payne
Name:
Title: Mayor
Date of Signature: June 30.2022
THE FOLLOWING DOCUMENTS ARE ATTACHED TO THIS AMENDMENT AND THEIR TERMS ARE
INCORPORATED INTO THE CONTRACT BY REFERENCE:
ATTACHMENT A-3.................STATEMENT OF WORK FY 2023
ATTACHMENT B-4.................BUDGET FY 2023
ATTACHMENT F-1 .................FFATA
ATTACHMENTS FOLLOW
DSHS Contract No. HHS000077800035 Page 3 of 15
Amendment No. 4
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ATTACHMENT A-3
STATEMENT OF WORK FY 2023
I. GENERAL REQUIREMENTS FOR ALL GRANTEES
All activities conducted under this Contract shall support the goals and objectives of the National
HIV STD Strategy and the Texas HIV Plan. The goals of the Texas HIV Plan are to:
• Increase Human Immunodeficiency Virus (HIV) awareness among members of the
general public, community leaders, and policymakers;
• Increase access to HIV prevention efforts for communities and groups at highest risk;
• Successfully diagnose all HIV infections;
• Increase timely linkage to HIV -related treatment for those newly diagnosed with HIV;
• Increase continuous participation in systems of treatment among people living with HIV;
and
• Increase viral suppression among people living with HIV.
For ALL activities funded under this award, Grantee will:
A. Conduct (HIV -Prevention activities in accordance with the Department of State Health
Services (DSHS) RFA #HHS0000778 to ensure HIV Prevention services are provided to
all eligible persons according to the specific requirements detailed per funding opportunity.
B. Submit a FY 2023 Work Plan to DSHS for review and approval. Comply with the terms
of the approved Work Plan for this Contract.
C. Comply with all applicable state and federal policies, standards and guidelines, including,
but not limited to:
1. DSHS HIV and STD Program Operating Procedures and Standards (POPS), including
any revision, located at hqRs-//dshs.texas.gov/hivsLd/pp
2. DSHS TB/HIV/STD Confidential Information Security policy, TB/HIV/STD Breach
of Confidentiality Response Policy, and Breach Report Form/Breach Report
Instruction at: https:;'www.dshs.texas.gov/hivstd/12olicy:'security.shtm;
3. DSHS Policy Guidelines for Home Self -Collection and Testing Kits including any
revisions, located at httys://www.dshs.texas.gov/hivstd/;
4. Any letters or memos with additional directions and policies issued by DSHS; and
5. All of the above -named applicable documents are incorporated herein by reference and
made a part of this Contract. Grantee must receive advance written approval from
DSHS before varying from any of these requirements and must update its
implementation documentation within forty-eight (48) hours of making approved
changes so that staff working on activities under this Contract know of the change(s).
D. Comply with all applicable federal and state regulations and statues, including but not
limited to:
1. Chapters 81 and 85 of the Texas Health and Safety Code;
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Amendment No. 4
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2. Chapter 94 of the Texas Health and Safety Code (relating to Education and Prevention
Programs for Hepatitis C);
3. Title 25 of the Texas Administrative Code (TAC) Chapters 97 and 98, Subchapter C;
and
4. Texas Health and Safety Code, §85.085, Physician Supervision of Medical Care, to
ensure a licensed physician supervises any medical care or procedure (including HIV
testing) provided as part of activities conducted under this Contract.
5. As an update to provision of services, and in accordance with Texas Government Code
Section 531.02161, where there is delivery of an in -person service, there must also be
an option of that service via telecommunications or through the use of information
technology.
E. Ensure activities begin no later than 90 days following the Contract start date.
F. Submit data on program activities and client contacts using timelines, systems and formats
specified by DSHS.
G. Use collected data, together with input from clients and stakeholders, to improve services
and assure they meet intended outcomes and emerging needs of the priority population.
H. Submit written interim and annual reports to DSHS that summarize the activities and
services delivered and discuss the barriers and facilitators of the effective delivery of
services (refer to Section IV. Program Data Reporting, Security and Confidentiality
Requirements).
I. Participate in local HIV planning and evaluation activities and in local efforts to coordinate
HIV prevention and treatment services.
J. Maintain formal agreements that include active collaboration and coordination with local
providers of services that are relevant to the needs of the client.
K. Ensure staff and volunteers (if applicable) are appropriately and adequately trained to
provide relevant services.
L. Cooperate with any DSHS-funded activities to raise awareness of HIV, promote prevention
services, or encourage testing and use of pre -exposure prophylaxis (PrEP) and non -
occupational post -exposure prophylaxis (nPEP).
M. Participate in Data to Care activities as requested by local health departments and DSHS.
N. Deliver all services in a culturally responsive and sensitive manner, taking low health
literacy into account, using the National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care. Grantee must implement
strategies to ensure that the program is culturally, linguistically and educationally
appropriate to meet the needs of the priority population(s), and ensure that program staff
have strong socio-cultural identification with the priority populations(s).
O. Make free condoms readily available to clients.
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P. Submit literature:'materials to be used in prevention activities funded by DSHS for review
and approval by a locally constituted review panel that meets DSHS requirements found at
httys:,-'.,,"www.dshs.texas.gov/hivstd/info,.--'pM.shtm.
Q. Perform other activities as may be reasonably requested by DSHS to meet the goals of the
Texas HIV Plan at Texas DSHS HIV/STD Program - HIV and STD Planning; and
R. Ensure that content in publications partially or fully funded by this award are verified and
approved by DSHS and that DSHS is acknowledged.
II. FUNDING OPPORTUNITY -SPECIFIC REQUIREMENTS
CORE HIV PREVENTION
Grantee will:
A. Implement the following four components of a core HIV prevention program:
1. Engagement of groups and communities to be served;
2. Condom distribution;
3. Focused HIV and syphilis testing and tailored health education; and
4. Linkage enrollment in medical care for clients who are living with HIV, and referral to
PrEP and nPEP and other needed services for clients with a negative HIV test result
who are at a higher risk for acquiring HIV.
B. Provide outreach and education to the priority population(s) identified in the approved
Work Plan.
C. Engage in active recruitment and outreach strategies that include traditional outreach,
social network activities, and the use of social media platforms.
D. Maintain a Community Advisory Board to assist with programmatic decision -making.
E. Maintain a condom distribution program with the essential elements described in the DSHS
POPS (https://www.dshs.texas.gov/hivstd/potys/).
F. Establish and maintain focused HIV testing programs that expand the availability of HIV
testing to the proposed priority populations. Grantee must use a combination of strategies
to encourage testing, such as offering testing in a variety of settings, providing testing to
couples, using tangible reinforcements, or using text messages or other electronic
communication to provide testing reminders.
G. Ensure that syphilis testing is provided to all individuals testing for HIV unless the client
refuses. Grantee will consider collecting specimens for:
1. Other Sexually Transmitted Infections (STI) (including specimens for extragenital
screening for chlamydia and gonorrhea); and/or
2. Hepatitis C antibody testing for vulnerable populations.
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H. Maintain an active Clinical Laboratory Improvement Amendment (CLIA) Certificate of
Waiver if performing rapid testing.
I. Ensure that HIV testing programs include all required components of a testing session as
described in the appropriate DSHS POPS (see Section I: General Requirements for All
Grantees).
J. Implement testing processes that follow the requirements in DSHS Policy 2013.02
(hqps://www.dshs.texas.gov/hivstd/policy/12olicies/2013-02.shtm .
K. If at-home HIV testing is offered, create and maintain policies and procedures to support
implementation (see Section I: General Requirements for All Grantees). Policies and
procedures must be approved by DSHS prior to implementation.
L. Ensure that all pregnant women who do not report being in prenatal care are actively
referred to prenatal care.
M. Ensure clients receive their HIV test results in a timely and appropriate manner.
N. Ensure that clients with negative HIV test results receive information on PrEP and nPEP.
If the client is eligible for PrEP or nPEP services, provide an active referral to these
services.
O. Ensure referrals are made to any needed health and social services as appropriate.
P. All individuals receiving a positive HIV test result must be offered the opportunity for face-
to-face encounter in accordance with Texas Health and Safety Code §81.109.
Q. Facilitate initial linkage to care within 30 days for newly diagnosed clients and facilitate
engagement in care within 30 days for previously diagnosed clients who are not currently
in care for their HIV infections. Grantee is responsible for confirming clients are linked to
care.
R. Address barriers to successful linkage to HIV medical care and coordinate with area
providers that offer services to facilitate access to HIV -related care.
III. TANGIBLE REINFORCEMENTS
A. Receive approval for tangible reinforcements in advance and in writing by DSHS program.
Funds may be used to purchase tangible reinforcements (bus tokens, movie gift cards, food
gift cards, t-shirts, grocery store gift cards, etc.) to encourage at -risk clients to participate
in prevention programs.
B. Maintain a policy regarding the use of tangible reinforcements and a log for tracking the
purchase and distribution of tangible reinforcements (including security measures that are
in place). The policy and log are subject to review by DSHS Program during program
reviews and at any other time. The policy must limit the use of tangible reinforcements to
the following types of situations: for participation in rapid assessment activities; for
recruitment of clients into prevention with persons living with HIV (PLWH), testing and
linkage programs and evidence -based interventions (EBIs); for retention of clients in EBIs
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and prevention with PLWH; for clients upon completion of all sessions of an EBI; for
recruitment and retention of peer volunteers; for clients who return for HIV testing; for
participation in community assessments or focus groups; and to encourage clients to return
for test results. Funds may not be used to make cash payments or cash -equivalent payments
to intended recipients of services except as noted above.
IV. PROGRAM DATA REPORTING, SECURITY AND CONFIDENTIALITY
REQUIREMENTS
DSHS may make alterations to reporting systems and requirements or require the use of new
reporting systems or collection methods, at its sole discretion. In the event of such a change,
Grantee will be notified at least thirty (30) days in advance of the changed requirements, except in
cases where the system in use suffers technical failure. Information submitted through the DSHS
systems will be considered the performance data of record in evaluating attainment of goals and
programmatic performance.
Grantee must safeguard all confidential information accessed in the performance of this Contract
in compliance with all applicable federal and state privacy, security and breach notification laws
and regulations, including without limitation the terms set forth in Attachment G — HHS Data Use
Agreement v. 8.5.
Any data obtained by Grantee as a result of activities performed under this Contract may be
included in a report to a party other than DSHS provided DSHS is acknowledged in the report and
the data is aggregated in such a way that no individual or personally identifiable information is
identified. Data may not be used for research purposes by Grantee or any other party without prior
written approval of DSHS' Institutional Review Board and pre -approval by DSHS Program.
Grantee may not share electronic data sets with other parties without advance written approval of
DSHS.
In addition to the data privacy and security requirements set forth in Attachment G — HHS Data
Use Agreement v. 8.5, Grantee must comply with all the following:
A. The requirements for prevention data collection, submission, and quality assurance found
in the DSHS data work plan located on the DSHS data resource website page at
b=s:,.'.-'www.dshs.texas.gov/hivstd/prevdata/.
B. The following DSHS policies and procedures:
1. 2016.01 - TB/HIV/STD Section Confidential Information Security Procedures:
https://www. dshs. texas. govlhivstd/policv'procedures/2016-0 l . shtm
2. 2012.01 - TB/HIV/STD Section Overall Responsible Party for TB/HfV STD
Surveillance Data: https://www.dshs.texas.gov/hivstd/policv/policies/2012-
O l .shtm
3. 2011.01- TB/HIV/STD Section Confidential Information Security:
httys:,f',.-www.dshs.texas.gov/hivstd/policyi'policies/201 1-Ol.shtm
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4. 2011.04- TB/HIV/STD Section Breach of Confidentiality Response:
https:l:'www.dshs.texas.gov/hivstd/policKpolicies!'2011-04.shtm
5. 302.001- Release of TB/HIV/AIDS and STD Data:
https: � www.dshs.texas.stov/hivstd/yolicy, policies. 302-001.shtm
C. Create policies and procedures to comply with the following:
1. Local Responsible Party Handbook:
https://www.dshs.texas gov/hivstd/yolicyipolicies/'LRPHandbook pdf
2. DSHS TB/HIV/STD Bi-Annual LRP Security Assessment
D. Submit data on program activities and client contacts using systems, formats and
submission deadlines specified by DSHS. DSHS may change the program reporting
requirements or formats during the project period based on program evaluation or reporting
needs.
E. Ensure that all data submitted to DSHS is complete and accurate. Grantee must conduct
data quality assurance prior to monthly and quarterly submissions following the DSHS
Work Plan quality assurance procedures. Data quality assurance activities must be
documented and made available for review by DSHS staff upon request.
F. Implement policies and procedures for use of data in a secure manner that protects client
privacy and prevents against unauthorized access to, and use of, program data.
G. Implement policies and procedures (consistent with the requirements and constraints listed
herein) for publication and redistribution of data if program data are shared with other
parties or providers.
H. Maintain retention and disposal policies and procedures consistent with state and federal
retention requirements and the requirements of this Contract, and assure that program data
cannot be inappropriately accessed.
I. Agree to publish, implement, and make available policies on data security and client
privacy, and train staff regularly regarding those requirements (Grantee must maintain
records documenting such training).
J. Require each individual member of Grantee's staff, and volunteers, to sign an agreement
pledging to abide by Grantee's policies and procedures pertaining to data security and
client privacy. Grantee will maintain these written agreements and make them available
upon request to DSHS in a timely manner.
K. Develop a personnel sanction policy to hold Grantee staff, volunteers, and subgrantee staff
responsible for any violations of data security and client privacy policies. If Grantee uses
subgrantees: Grantee accepts full responsibility and accountability for each subgrantee's
performance under this Contract including all provisions related to data security, client
privacy and confidentiality.
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L. Immediately report breaches of confidentiality involving the program data reporting
systems to DSHS, and fully assist DSHS in any investigation resulting from such breach.
M. Comply with all requests by DSHS to inspect, or require copies of, any of the
documentation referenced herein at any time, and comply with such requests in a timely
manner. All documentation under this Contract will be readily available for inspection by
DSHS staff during site visits.
N. Use data collected through the above mechanisms for program planning, evaluation,
quality assurance, and monitoring, consistent with confidentiality restrictions in state and
federal law. Grantee shall use evaluation, quality assurance and monitoring of data to make
appropriate adjustments to program activities so that the Grantee performs quality services
and meets performance standards.
O. A minimum of 10% of the total Contract amount must be dedicated to planning, reporting,
and evaluation of the proposed activities. This includes expenditures for needs assessment
and consultation with community members to design or revise program design and
implementation; collection and reporting of required program data; evaluation of progress
towards program goals; and assessment of client satisfaction.
V. PROGRAM MONITORING AND PROGESS REPORTS
Grantee will:
A. The Grantee (and each subgrantee or volunteer, if applicable) shall cooperate with the
direct monitoring by DSHS. Monitoring will be conducted via on -site or virtual visits and
may be announced or unannounced. This monitoring may consist of the review of records
and reports, interviews of staff, required forms, educational materials and other materials
pertaining to this project, including testing documents (if applicable).
B. Submit required Interim and Annual Progress Reports in a format approved by DSHS, and
by deadlines given by DSHS, that include a cumulative data summary of its compliance
with the performance measures for the appropriate activities detailed on Form G:
Performance Measures and a detailed response to all items listed in the report.
C. Provide the above -referenced reports to hivstdLeport.tech,i )dshs.texas.rov with a copy to
the designated DSHS HIV/STD Program Consultant and the Public Health Region
HIV STD Program Manager/Coordinator per request by DSHS.
D. Provide to the DSHS Program Consultant and appropriate Contract Management Section
staff, the names of the contact person(s) responsible for programmatic concerns and all
communications regarding this program, the contact person for fiscal issues, and the names
of the contact persons for each of the subgrantees/vendors (if applicable).
E. Maintain expertise in any subcontracted project content, protocols and methods, and
provide technical assistance to subgrantee staff as needed.
F. The Grantee and any relevant subgrantee(s) or volunteer(s) shall cooperate with DSHS
policies to address any and all concerns or problems identified during the Contract term.
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VI. QUALITY ASSURANCE ACTIVITIES
If Grantee enters into any contract(s) with subgrantees, Grantee will be entirely responsible to
DSHS for the performance of the subgrantee. If subgrantees are used, Grantee is expected to
adequately monitor the implementation of interventions and other grant funded activities under
this Contract, including but not limited to, the efficient and effective use of resources by the
subgrantee(s), and the capacity and performance of subgrantee staff implementing interventions
and other grant funded activities under this Contract, and ensuring that subgrantees are properly
collecting and reporting data. DSHS staff may also monitor the subgrantees' activities and conduct
periodic site visits, with prior notification to the Grantee.
Grantee will:
A. Ensure that performance of activities under this Contract is of a high quality and consistent
with all the requirements of this Contract and meets with DSHS high performance
expectations.
B. Solicit feedback (e.g., client surveys) from clients being served by Grantee under this
Contract and create a summary of the client feedback for each intervention at least once
for each year of the Contract. This summary must be available for review during DSHS
site visits.
C. Designate and train staff to be responsible for quality assurance activities, including
ensuring accurate and consistent data collection and reporting.
D. Follow the appropriate DSHS POPS by funding opportunity (as per Section I: General
Requirements for All Grantees) for quality assurance requirements.
E. Maintain written monitoring and evaluation records of all staff involved in Contract
activities, including those of subgrantees. DSHS may specify an evaluation and monitoring
tools to be used. Information related to quality assurance activities, along with any other
documentation associated with activities under this Contract, are subject to review by
DSHS Program during program reviews and at any other time.
VII. TRAINING REQUIREMENTS
Grantee will:
A. Authorize and require staff (including volunteers) to attend training, conferences, and
meetings as directed by DSHS.
B. Appropriately budget funds to meet training requirements in a timely manner, and ensure
staff and volunteers are trained as specified in the training requirements listed at
https: ;"www.dshs.texas. ov/hivstd/traininy, and as otherwise specified by DSHS. Grantee
shall document that these training requirements are met.
C. Follow the appropriate DSHS POPS by funding opportunity (as per Section I: General
Requirements for All Grantees) for training and observation requirements.
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VIII. PERFORMANCE MEASURES
Performance Measures as outlined in Form G: Performance Measures table will be used, in part,
to assess the Grantee's and their subgrantees' effectiveness in providing the services described in
this Contract, without waiving the enforceability of any of the other terms of the Contract. The
Performance Measures outlined in Form G and approved by DSHS are hereby incorporated by
reference and made a part of this Contract.
Performance of the Grantee, including but not limited to compliance with program policies and
procedures referenced herein, attainment of performance measures, maintenance of adequate staff,
and submission of required data and narrative reports, will be regularly assessed. Failure to comply
with stated requirements and contractual conditions will constitute a breach of contract.
IX. INVOICE AND PAYMENT
A. Invoices must be submitted monthly to prevent delays in processing a subsequent month's
invoicing. Grantees that do not incur expenses for a month are required to submit, on a
timely basis, a "zero" dollar invoice. Invoices and all supporting documentation must be
emailed to invoices(ddshs.texas.gov and crosinvoices(a7dshs.texas.gov simultaneously.
B. Final Close -Out invoice and report: Grantee must submit a final close-out invoice and final
status report no later than 45 days following the end of the state fiscal year. Invoices
received more than 45 days past the end of the state fiscal year are subject to denial of
payment.
C. The Grantee will submit Financial Status Reports (FSR-269A) bi-annually during the
Contract term, as outlined below:
REPORTING PERIOD DUE DATE
September 1, 2022 — February 28, 2023 March 31, 2023
March 1, 2023 — August 31, 2023 October 15, 2023
D. DSHS reserves the right, where allowed by legal authority, to redirect funds in the event
of financial shortfalls. DSHS Program will monitor Grantee's expenditures on a quarterly
basis. If expenditures are below the amount in Grantee's total Contract, Grantee's budget
may be subject to a decrease for the remainder of the Contract term. Vacant positions
existing after ninety (90) days may result in a decrease in funds.
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ATTACHMENT B-4
BUDGET FY 2023
CATEGORY
AMOUNT
PERSONNEL
$101,789.00
FRINGE BENEFITS
$51,688.00
TRAVEL
$2,410.00
EQUIPMENT
$0.00
SUPPLIES
$30,052.00
CONTRACTUAL
$23,600.00
OTHER
$14,900.00
TOTAL DIRECT COSTS
$224,439.00
INDIRECT COSTS
$0.00
TOTAL
$224,439.00
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ATTACHMENT F-1
FFATA
Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
The certifications enumerated below represent material fads upon which DSHS relies when reporting
information to the federal government required under federal law. If the Department later determines
that the Contractor knowingly rendered an erroneous certification, DSHS may pursue all available
remedies in accordance with Texas and U.S. law. Signor further agrees that it will provide immediate
written notice to DSHS if at any time Signor learns that any of the certifications provided for below were
erroneous when submitted or have since become erroneous by reason of changed circumstances. If the
Sianor cannot certify all of the statements contained in this section, Signor must provide written
Legal Name of Contractor:
FFATA Contact # i Name, Email and Phone Number.
CITY OF LUBBOCK
KATHERINE WELLS
kwells@mylubbock.us
mylubbock.us
806-775-2941
Primary Address of Contractor:
FFATA Contact #2 Name, Email and Phone Number:
PO BOX 2000
AMBER AGUILAR
LUBBOCK, TX
aaguilar@mylubbock.us
mylubbock.us
806-775-2149
ZIP Code: 9-digits Required www.usos.com
DUNS Number: 9-digits Required www.sam.eov
State of Texas Comptroller Vendor Identification Number (VIN)14 Digits
Printed Name of Authorized Representative
Signature of Authorized Representative
Amber Aguilar
ft^��lziuc$8-4—j
(WhrAMA. 1�a PA lt&A'
Title of Authorized Representative
Date
Senior Grant Accountant
June 30, 2022
-1-
Department of State Health Services
DSHS Contract No. HHS000077800035
Amendment No. 4
Form 4734 — June 2013
Page 14 of 15
DocuSign Envelope ID: 707CDABA-BCF1-432F-B642-942E7B80AFB3
Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
As the duly authorized representative (Signor) of the Contractor, I hereby certify that
the statements made by me in this certification form are true, complete and correct to
the best of my knowledge.
Did your organization have a gross income, from all sources, of less than $300,000 in
your previous tax year? ❑ Yes ❑ No
If your answer is "Yes", skip questions "A", "B", and "C' and finish the certification.
If your answer is "No", answer questions "A" and "B".
A. Certification Regarding %of Annual Gross from Federal Awards
Did your organization receive 80% or more of its annual gross revenue from federal
awards during the preceding fiscal year? ❑ Yes ❑ No
B. Certification Regardine Amount of Annual Gross from Federal Awards
Did your organization receive $25 million or more in annual gross revenues from federal
awards in the preceding fiscal year? ❑ Yes ❑ No
If your answer is "Yes" to both question "A" and "B", you must answer question "C'.
If your answer is "No" to either question "A" or "B", skip question "C" and finish the
certification.
C. Certification Regarding Public Access to Compensation Information
Does the public have access to information about the compensation of the senior
executives in your business or organization (including parent organization, all branches,
and all affiliates worldwide) through periodic reports filed under section 13(a) or 15(d)
of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the
Internal Revenue Code of 1986? ❑ Yes ❑ No
If your answer is "Yes" to this question, where can this information be accessed?
If your answer is "No" to this question, you must provide the names and total
compensation of the top five highly compensated officers below.
Provide compensation information here:
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Department of State Health Services Form 47U — June 2013
DSHS Contract No. HHS000077800035 Page 15 of 15
Amendment No. 4