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HomeMy WebLinkAboutResolution - 4897 - Agreement - LHD, TDOH - Breast 7 Cervical Cancer Control Program - 07_13_1995Resolution No. 4897 July 13, 1995 Item #37 20_•_ • BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock BE and is hereby authorized and directed to execute for and on behalf of the City of Lubbock an Agreement, attached herewith, by and between the City of Lubbock Health Department and the Texas Department of Health, for a Breast and Cervical Cancer Control Program, and any associated documents, which Agreement shall be spread upon the minutes of the Council and as spread upon the minutes of this Council shall constitute and be a part of this Resolution as if fully copied herein in detail. Passed by the City Council this 13 th ATTEST: 6cvt"- 'tkc�L Betty A. Johnson, r2ity Secretary APPROVED AS TO CONTENT: Doug Go an, Director of Health and Community Services APPROVED AS TO FORM: Donald G. Vandiver, First Assistant City Attorney DW dalccdocslcancer. res June 29, 1995 _ day of July , 1995. 01 3 4. 5. TEXAS DEPARTMENT OF HEALTH Breast and Cervical Cancer Control Program Request for Continuation Funding, Year 5 Title Page Program Name: Lubbock Breast and Cervical Cancer Control Program Name of Organization Agency: City of Lubbock H e a l t h Department Type of Organization/Agency: Public X Private Mary Strange PO Box 2548 (1902 Texas Ave_1 Project Director Public Health Manager Title (806) 767-2899 (Area Code)/Phone Number David Langston Contract Official 6. City of Lubbock Vendor Name Street Address Lubbock. Texas 79408 City, State and Zip (806) 762-5506 (Area Code)/Fax Number PO Box 2000- Street Address Lubbock, Texas 79408 City, State and Zip (806) 767-2000 (Area Code)/Phone Number 7.17560005906037 State Vendor ID Number 8. Texas Department of Health Funds Requested (July 1, 1995 - June 30, 1996): S 7 0, 0 0 0. o o TEXAS DEPARTItENT OF HEALTH Breast and Cervical Cancer Control Program Request for Continuation Funding, Year 5 Title Page ProLubbock =ryas` and Cervical Cancer Contr7�1 Program 1. gram Name: 2. Name of Organization Agency: City of Lubbock -- a l t h D e o a r t m e n t 0 i. 5. Type of Organization/Agency: Public X Private Mary Strange Project Director Public Health Manager Title (806) 767-2899 (Area Code)/Phone Number David Langston Contract Official P© Box 2548 (1902 Texas ago 7 Street Address Lubbock, Texas 7940P City, State and Zip (806) 762-5506 (Area CodeyFax Number PO Box 2000 Sara Address Lubbock, Texas 7940a City, State and Tip (806) 767-2000 (Area Code)/Phone Number 6. City of Lubbock 7. 17560005935037 Vendor Name State Vendor ID Number 8. Texas Department of Health Funds Requested (July 1, 1995 - June 30, 19W: S 7 0 , 0 0 . 0 ffiiiiiiwl TEXAS DEPARTMENT OF HEALTH Breast and Cervical Cancer Control Program Request for Continuation Funding, Year S Title Page Lu �.�:.R 3rtas- an.� --ervica1 �a 1. Program Name. - r-- r o n t r__ ^ c a r am 2. Name of Organization Agency: - t '' °` L u o: k -- a 1- h D e P a r* m e n 3. Type of Organization/Agency: Public X Private 4. Mary Strange PO Box 2===3 ' t a--_ '�_ eXaS Project Director Street Address Public Heal t.- Manager Lug cck, Texas 7,9408 Title City, State and Zip 767-2899 (805) 762-„C6 (Area Code)/Phone Number (Area Code)/Fax Number 5. av �! -angston Conaact Official M a :r _ r Title V 8. Signature Ci --'; oe _ = c Vendor Name P-� 3_-( Street Address City, State and Zip '9105) 767-2000 (,Area Code)/Phone Number 7. 1 7�5 State Vendor M Number Texas Department of Health Funds Requested (July 1, 1995 - June 30, 1996): S ,- - I. Description of Client Population lComelete on BCCCP Nnded services onivi 2. Agency Name: �7' ty C r t, U 1, h" C Luhb� Targeted Geographic Area: k 3. BCCCP Service Delivery Site(s): ' ` ' 9 0 2 Texas Ave 2 ",, m s _ 1 :1311 K Crn (add a pate to complete list of sites if needed) 4. Year 4 Screening Activity and Proposed Year S Screening Activity: A. Breast Screening Bross: Screening' 4049 yrs 50-59 yrs 60-64 yrs 65 + yrs Total 0 and proportion receiving 200 1 3 5 47 q 402 scrag. Yr 4' 0 and proportion proposed - 40 1 5 0 5 0 Yr. S 2 5 0 B. Cervical Screening aps < -19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-64 yrs 65+ yrs Total 5 5 4 2 7 1 1 5 9 '2 [andproportion rns. - ^ 7Yr a" propoctiony^ �^ 7i 2-- - proposed 5 • Give your best esamarn for ttie contract period ending June 30, 1995. S. projected unduplicated number of persons to receive any BCCCP funded breast or cervical cancer screening services in the service period (account for each person only once, even if client is to receive multiple services): 6. Women Targeted for Services by Race/Ethnicity: Year S White/non-Hispanic: T_% Blacktnon-Hispanic: % Hispanic: 96 Native American: % Other. % Clinical breast exam and screening mammogram Pelvic exam. clinical breast exam. and Pap test H. Proposed Activities, Year 5 INTRODUCTION: The City of Lubbock Health Department is applying for Year 5 funding of the Breast and Cervical Cancer Control Program for Lubbock, Texas. The lead agency for years 1 - 4 for this grant has been Guadalupe Economic Services Corporation. The City Health Department has been the primary provider of services. After much discussion, all the involved parties agreed that the City Health Department would assume the role of lead agency when applying for Year 5 funding. With the change in roles and the change in sub -contractors, the Texas Tech University School of Nursing's Clinic will become the primary service provider, this proposal tends to resemble a first - year project rather than a fifth year project. Health Department staff will continue to do a limited amount of screening on site. Health Department staff will increase their role in case finding activities, case management activities, and education. The new levels of activity will require that new mechanisms be put in place to enable these activities to succeed. The School of Nursing will need to be included in the loop of activities. New channels of communication will need to be developed to enhance the delivery of services to the patients. All these activities will need to be accomplished quickly, so patient services will not suffer. A. BREAST CANCER SCREENING: Last year, 47.5% (or 191 women) of all women screened for breast cancer were 50 years of age or older. In order to increase this percentage and meet the 801/6 mark, we will build on the success of last year's program, encouraging current patients to refer their relatives and friends. We will conduct outreach activities in the following locations: All 5 City of Lubbock Senior Citizen Centers; City of Lubbock Health Department Screening Clinics; Local Churches; the YWCA, Commodities Distribution Sites; and the School of Nursing's Screening Clinic. The City Health Department is in the process of reorganizing services, placing a stronger emphasis on the Core Functions of Public Health. We have designated one section, consisting of seven employees, as the Health Education and Outreach section The primary emphasis of this section is to go into individual neighborhoods and empower those neighborhoods to step up to better health. In order to accomplish this mission, they will provide health education to groups and individuals; provide screenings, or referral for screenings, to residents of the neighborhoods; and follow-up on all referrals to ascertain that the residents received the necessary services. This section will lead the City of Lubbock's outreach program. All Health Department staff will be knowledgeable about the program and will participate in case finding and follow-up as appropriate. The School of Nursing will encourage students to assist in case finding in relation to their community nursing coursework. The YWCA will provide outreach activities in several areas. The YWCA currently has a program which reaches out to the local Native American population. They will refer women to the Cancer Control Program from this population. The YWCA also has a Rehabilitation program for women who have had mastectomies. They will refer participants of this program for appropriate screenings and encourage the participants to refer friends and family for screening. We will be contacting private physicians in Lubbock to educate them about this screening program. We believe that they may become a good referral source for their patients who refuse to be screened due to lack of ability to pay. B. CERVICAL CANCER SCREENING: 23% (or 252 women) of the women screened for cervical cancer were 40 years of age or older. We believe that we will be able to maintain this level of effort. Our goal is to increase these numbers. We will conduct outreach activities in the same locations as those mentioned in Section A. Due to the younger age, 40 vs. 50, we will also conduct outreach activities at the City of Lubbock Community Centers. The other case finding activities will mirror those described in Section A. C. TCC FUNDING: We do not receive TCC funding. In the past breast diagnostic services have been provided by University Medical Center's Dimensions Program. It is a fully certified mammography program operated by the hospital. We will continue to use this program. D. CASE MANAGEMENT & DATA COLLECTION: The City of Lubbock Health Department has case managers on stag. Our case managers routinely monitor patients to make sure they are receiving appropriate care. The case managers assist with social service -related needs as well as health -related needs. Patients are assigned to a case manager, who assists in making appointments, sending out reminder notices, fo with the patient after the date of the appointment, and re -scheduling, if needed. In the Cervical Cancer Control Program, the Health Department has set up an electronic tickler file which lists the names of patients who need to be reseen. Case managers are involved in locating these patients and scheduling their next appointment. The case managers on staff have all been through diversity training and are sensitive to the different needs of the patients of varying ethnic and racial groups. The Health Department has a data base which was designed for the Breast and Cervical Cancer Control Program. This D-Base Program has been used, on a limited basis, to capture statistical information about the participants in the program. The program has primarily been used to monitor the health of the patients. It needs to be expanded to increase our capability of capturing statistical information. The Health Department staff will work with both the City's Information Services Department and the School of Nursing's Information Services Department to develop an electronic system for capturing this information. IF E. MONITORING MECHANISM: The City of Lubbock Health Department has been the recipient of contracts from the Texas Department of Health for over 15 years. The contract between the City of Lubbock and the Texas Department of Health for FY 1994 -1995 was for $934,000. We have one employee, Judy Henderson, who monitors all grants. She has set up a system for monitoring all expenditures from grants. Each separate attachment to the contract has a separate routing number in the City's Accounting system. Ms. Henderson has worked with TDH's Grants Management Division and does not hesitate to ask for help, if something unusual develops. The Health Department has a proven record of staying within budgetary limits. City staff members have worked with fee -for -service grants in the past. We have worked with a WIC contract and with a grant program which provided home health care for HIV- infected patients. The West Texas AIDS Foundation was the recipient of the Home Health Care Grant, but city staff assisted them with the administration of the grant. F. TARGETED SERVICES The City of Lubbock Health Department has a history of cooperating with other agencies in the City of Lubbock. We envision that the Breast and Cervical Cancer Control Program will add to this history. We will work with Texas Tech Health Sciences Center, the School of Nursing, University Medical Center, the Community Health Center of Lubbock, the YWCA, the Neighborhood Associations, and other organizations and agencies in order to promote this program and the needs of the women in the program. The Community and Neighborhood Initiatives Department of the City of Lubbock is in the same Division as the Health Department. The Community and Neighborhood Initiatives Department administers Lubbock's Community Development Block Grant Funding and Lubbock's Community Services Block Grant Funding. The Health Department can refer women to the programs funded by these grants by routing the referrals through our sister department. This should reduce barriers to care, facilitating the client's receipt of services. n III. BUDGET TABLE A SLNEfARY OF CATEGORICAL BUDGET REQUEST FOR SUPPORT SERVICES, YEAR 5 Contractor: City of Lubbock Healt�- Dept. � Service Area/S u-�bock Prepared by: Mary Strange Telephone: ' 6' - 2 S 9 CATEGORY ICHARGE A. Personnel 0.00 B . Fringe Benefits 0.00 C . Travel 632.00 D. Equipment 0.00 E. Supplies 1, 2 0 5.0 0 F. Contractual 0.00 G. Other 15 , 60 C.00 H. Total Budget Requested (sum A-G, this amount is the numerator in the support service rate formula) ° u 0 BUDGET TABLE B: SCREEI'MiG a.YD DGIGNOSTIC PROCEDURES , YEAR FIVE 4—./County: - : r' ' c k Contractor: City :- f r uCbock Health Completed by: Mary Strang- Telephone Number: 7 E ' - 2 3 9 9 Ptcpaswd t ulas ; �: Medicate T" Rcq+w%W [or L13ad Brach ;::: ROW p4ocedwea. CPr a ,: aftre�ees ;. memba�smsatRaw _. each ::: (bta>iR fot lltsatCwetr Pox ssev�ea � ���?� Scmtun g 76092 225 �a �U ** 12 771 1 Mammograms Diagnostic 2 Mammograms 76090 (Unilateral) Diagnostic Mammograms 76091 i 3 (Bilateral) 4 Fine Needle $8170 2 4 9. 9 3 ? 0 0 Aspiration i S Office Visit 99203 9, a 2, (New Pat.) 99212 ' = 22 . 59 3 , 404 6 Office Visit (established pat.) J .' 4 1' 7 7 i Office Visit 99244 3 5 ? T�,� :, 3, 042 7 (Consultation) 01 8 Colposcopy 57452 5;. Colposcopy with 57454 9 biopsy Supportive N/A 4 ^ ^ , - 3 2 , 10 Services 11 Grand Total :.: ? 0 ? 2 ? , 9 9 ? 2 , 8 8 C Supportive Services, please include in Column D the reimbursement rate that applies to your agency (see general information). "Not listed on provided rate shee,. gel= n ned ty telephone 1! BUDGET TABLE C: TOTALS FOR BCCCP SERVICES, YEAR FIVE - V7 A. B. C. BUDGET NARRATIVE FOR SUPPORT SERVICES, YEAR 5 PERSONNEL Total $ FRINGE BENEFITS Total $ TRAVEL Total $ State Meeting in Austin: 2 Persons for 2 Days Round-trip Airfare @ 150 X 2 Persons = $ 300 2 Days per Diem @ 25/day X 2 Persons = $ 100 1 Night Lodging @ 55/night X 2 Persons = $ 110 Regional Meeting 2 Persons for 1 Day 1 Trip X 120 Miles X 2 Persons X .30/mi. = $ 72 1 Day per Diem @ 25/day X 2 Persons = $ 50 TOTAL $ 632 D. EQUIPMENT E. SUPPLIES General Office Supplies (pens, pencils, paper, etc.) 12 months X $50/month = $ 600 Education Pamphlets 1100 copies @ $.55 each = S 605 TOTAL $ 1,205 F. CONTRACTUAL G. OTHER Contract Clerical Services 20 hours/week X 50 weeks @ 9.00/hour $ 9,000 Postage $50/month X 12 months = $ 600 Total $ Total $ Total $ Total $ 0.00 0.00 632.00 0.00 1,205.00 0.00 15,600.00 Budget Administrative Costs For Staff Time of City of Lubbock Health Department to Monitor Grant Compliance, Bill TDH, Prepare Reports, Oversee In -kind Case Management Services, Outreach Services, and Education Services $500/month X 12 months = $ 6,000 TOTAL $15,600 H. TOTAL BUDGET REQUEST Total $17,437.00 I. IN -KIND MATCHING CONTRIBUTION Total Case Management Provided by Lubbock Health Department 7.501hr X 3 hours/week X 50 weeks = $ 1,125 Health Education Provided By Lubbock Health Department 11.70/hr X 3 hours/week X 50 weeks = $ 1,755 TOTAL $ 2,880 IV. Program Updates Agency Name: CITY OF Luago(-K HFAj TH ..m Table 1: Referral Sources for Diagnostic and Treatment Services Identify all health care professionals and/or agencies that serve as a referral source for women participating in your BCCCP services. Use as many sheets as necessary. Name: TEXAS Address: TTUHSC City/State/Zip: I Dg811rK T6xns 7943Q Phone: 743-2340 For: dScreeaing :Mammogram U Diagnostic Mammogram C9 Ultrasound 0 Breast Biopsy M Fine Needle Aspiration ❑ Other: �7 Colposcopy ZLEEP MCancer Treatment (surgery, radiation, etc.) Name: COMMUNITY HEALTH CENTER OF LUBBOCK Address: City/State/Zip: Lugo _K, TX 79401 Phone: ) 765-2611 For: O Screening Mammogram C1 Diagnostic Mammogram O Ultrasound C] Breast Biopsy Fine Needle Aspiration Colposcopy CN LEEP ❑Cancer Treatment (sure 0Other: ery. radiation. etc.) Name: UNIVERSITY MEDICAL CENTER - DIMFNSfONS Address: 35 - City/StMte/Zip: UBBOCK. TEXAS 79417 Phone: (nfi) 7u3-4377 For: ®Screening Mammogram InDiagnostic Mammogram O Ultrasound C7 Breast Biopsy OFine Needle Aspiration C7colposcopy CILEEP O Cancer Treatment (surgery, :Other. Name: ST. MA Address: 4000-24TH. ST. City/State/Zip: IggprK . TEXAS 79410 Phone: -6ggg_ For: Screening Mammogram CIFine Needle Aspiration EDiagnostic Mammogram a Colposcopy C 1 Ultrasound ❑ LEEP 0 Boast Biopsy EXCancer Treatment (surgery, C Other: radiation, etc.) IV. Program updates Agency Name: C I Ty (y I i jFtgnr f HEALTH DEPARTMENT Table 1: Referral Sources for Diagnostic and Treatment Services Identify all health care professionals and/or agencies that serve as a referral source for women participating in your BCCCP services. Use as many sheets as necessary. Name: MICHELLE HOWELL, CNP Address: 7474 Sf TH City/State/Zip: LUBBOCK, TEXAS 79412 Phone: (806) 797-0000 For: ❑ Screening Mammogram ❑ Fine Needle Aspiration ❑ Other: O Diagnostic Mammogram n Colposcopy ❑ Ultrasound ❑ LEEP ❑ Breast Biopsy ❑ Cancer Treatment (surgery, radiation, etc.) Name: Address: City/State/Zip: Phone: For: ❑Screening Mammogram ❑Fine Needle Aspiration ❑Other: ❑ Diagnostic Mammogram ❑ Colposcopy ❑ Ultrasound ❑ LEEP 0 Breast Biopsy O Cancer Treatment (surgery, radiation, etc.) Name: Address: City/State/Zip: Phone: For. OScreening Mammogram ❑Fine Needle Aspiration DOts: ODiagnostic Mammogram ❑Colposcopy OUltrasound ❑ LEEP ❑Breast Biopsy ❑Cancer Treatment (surgery, radiation, etc.) Name: Address: City/State/Zip: Phone: For: ❑ Screening Mammogram O Fine Needle Aspiration ❑ Other: O Diagnostic Mammogram ❑ Colposcopy 0 Ultrasound O LEEP ❑ Breast Biopsy O Cancer Treatment (surgery, radiation, etc.) Agency Name: -ITY OF LuboOCK HEALTH UENAH(MENI Table ?: Staff for BCCCP Activities, Year 5 Identify your agency's staff for the required Program activities. Provide an address and phone number only if these are different than your main numbers. Use as many sheets as necessary. Name: Address: MARY STRANGE, R.N. City/State/Zip: Phone: 0intake/eligibility ❑Screening ❑Follow-up (case management) OTracking-CD forms []Administration 0Professional Education []Quality Assurance ❑Outreach ❑Other: Name: Address: City/State/Zip: ELIZABETH INSKIP-PAULK O intake/eligibility OTracldng-CD forms Cl Quality Assurance Name: Address: City/State/Zip: Phone: ❑Screening OFollow-up (case management) ❑ Administration ❑ Professional Education (nOutreach OOther: SUSAN SPORTSMAN, R.N., PH.D. UBBOCK, TX 794 Phone: O intake/eligibiliry ❑ Screening ❑ Follow-up (case management) OTra,cldng-CD forms MAdmin stration 0Professional Education 0Quality Assurance DOutreach OOther: Name: REBECCA BRAWLEY, R.N. Address: City/State/Zip: Phone: Ointake/eligibility gScreening OFollow-up (case management) OTracldng-CD forms O Administration O Professional Education 0Quality Assurance OOutreach OOther. Name: TIGI WARD, R.N. Address: City/State/Zip: Phone: O intake/eligibility M Screening O Follow-up (case management) OTracking-CD forms OAdministradon ❑Professional Education OQuality Assurance OOutreach ❑Other: Agency Name: CITY nE LtJlaa9�K, HEALTH DEPARTMENT Table 3: Sources Assisting with Referral to BCCCP or Providing Support for Women, Year S Identify all agencies and organizations that serve as a referral source or that provide support for women participating in your BCCCP services. Use as many sheets as necessary. Agency Name: Address: City/State/Zip: LUBBOCK YWCA For: t]Organization refers women to BCCCP O Mass media organization ®Provides education materials 93Provides marketing/outreach materials Agency Name: TEXAS D Address: 11 Phone: OProvides support for women during clinic visit and referral process (i.e., transportation, day care, assistance in navigating system, etc.) t]Provides volunteers City/State/Zip: LUBBOCK, TEXAS 79403 Phone: Mb) /44-3511 For: norganization refers women to BCCCP OProvides support for women during O Mass media organization clinic visit and referral process C3provides education materials (i.e., transportation, day rare, OProvides marketing/outreach assistance in navigating system, etc.) materials OProvides volunteers Agency Name: Address: City/State/Zip: For: OOrganiration refers women to BCCCP O Mass media organization OProvides education materials OProvides marketing/outreach materials Phone: OProvides support for women during clinic visit and referral process (i.e., transportation, day care, assistance in navigating system, etc.) OProvides volunteers Health Department Table 4: BCCCP Workplan, Year 5 Objectives Activities/Actions Time Frame I. Develop outcome objectives 1. Hoslth Department staff and School of Nursing staff 1. 7/l/95 - which are specific and measur- i roing jointly, will write outcome objectives to be 10/1/95 able.. %3W to evaluate effectiveness of program. 2. Develop program structure, 2. TTUHSC School of Nursing staff: 2. 7/l/95 - including referral flow and A) Set up clinic parameters 10/1/95 follow up mechanism, for TTUHSC B) Write referral protocols and procedures, assigning program site. tasks to appropriate persons. 3. Develop case finding 3. Health Department, School of Nursing, and YWCA staff: 3. 7/l/95 - mechanism for the BCCCP A) Informational meeting to educate regarding 10/l/95 program. eligibility criteria. B) Develop list of sites to conduct case finding activities. C) List case finding activities. Screen 400 women for breast 4. Health Department and School of Nursing staff: 4. 7/l/95 - and cervical cancer. A) Screen for breast cancer, making appropriate 6/30/95 referrals. B) Screen for cervical cancer, making appropriate referrals. Time Frame should include starting date and the duration (add pages as needed). RESOLUTION NO. 4897 Item #37 July 7, 1995 MEMORANDUM DATE: August 29, 1996 LSEP 4 1996 TO: Bob Cass MAN 1? S Of FROM: Doug Goodman _.. RE: Breast and Cervical Cancer Control Program Contract Change There has been a recent change in the City Health Department's participation in the Breast and Cervical Cancer Control Program (BCCCP), a grant funded by the Texas Department of Health. In July, 1995, the City Health Department signed a contract with the Texas Department of Health to provide breast and cervical cancer screenings to qualified individuals. The original grant amount was $76,188. We have received a call from the Texas Department of Health's Breast and Cervical Cancer Control Program asking us to return a portion of the money ($1,362) to the Texas Department of Health. These funds will be used to assist other health departments across the state participating in the BCCCP program, who have run out of funding. Our program will maintain sufficient funds to cover expenses and would be returning these funds at the end of the contract period. The City Health Department did not reapply for the BCCCP grant for FY 96-97, as this would constitute a duplication of services. Clients who were originally served by the City Health Department for this program will now be referred to the Lubbock YWCA, the recipient of the grant for FY 96-97. This will be the sixth year for the BCCCP grant and eligible women will continue to receive cancer screening services without interruption of these services. Would you please submit to the Mayor for his signature. 0 TEXAS DEPARTMENT OF HEALTH 1100 WEST 49TH STREET AUSTIN, TEXAS 78756-31" STATE OF TEXAS TDH Document No.7560005906 96-07-9 COUNTY OF TRAVIS CONTRACT CHANGE NOTICE NO. 11 The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing with LUBBOCK CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto now desire to amen such contract attacnment(s) as touows: SUMMARY OF TRANSACTION: ATT. NO. 07B CHRONIC - BREAST & CERVICAL CANCER Total reimbursements will not exceed $ 74,826.00. Revised Number to be Served: 1,000 All terms and conditions not hereby amended remain in full force and effect. EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN. Authorized Contracting Entity (type above if different from PERFORMING AGENCY) for and in behalf of: PERFORMING AGENCY: LUBBOCK CITY By: (Signature of person ii f orizeb to sign contracts) Alex "Ty" rnnkp. (Name and Tide) Mayor Pro Tem Due: _I Attest: rnell,-City Secretary RECEIVING AGENCY: TEXAS DEPARTMENT�OFF EMALTH By: _ .A ' / /_ _ , baput of person authorized to sign contracts) Linda Farrow, Chief (Name and Title) Date: O _ _ q AS TO FORM: By- By: 16. (PPERFOR G AGENCY Director, if different Office of General Counsel from person authorized to sign contract) city -f T..1. ty�N'Ibin :74WFTnj APPROVED ASvTO`FORM: Do d G. andiver, First Assistant Attorney Cover Page 1 DETAILS OF ATTACHMENTS Att/ Amd TDH Program/ Term Financial Assistance Direct Assistance Total Amount (TDH Share) Begin End Source of Funds* Amount 01 HIV/SURV 01/01/95 12/31/95 State 35,398.00 0.00 35,398.00 02A HIV%GHC 01/01/95 12/31/95 93.940 35,000.00 0.00 35,000.00 03 M&D 09/01/95 08/31/96 State 0.00 0.00 0.00 04B ORAS 09/01/95 08/31/96 State 120,200.00 43,440.00 163,640.00 05 TB/OR/ST 09/01/95 08/31/96 State 20,073.00 0.00 20,073.00 06 IMM/0PTS 09/01/95 08/31/96 State 68,356.00 140,011.00 208,367.00 07B CHRONICBC 07/01/95 06/30/96 State 93.919 74,926.00 0.00 74,826.00 08B HIV/EIP 09/01/95 08/31/96 State 71,532.00 0.00 71,532.00 TDH Document No.7560005906 96 Totals Change No. 11 $425,385.00 $183,451.00 $608,836.00 *Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS. Cover Page 2