HomeMy WebLinkAboutResolution - 5622 - Application For Funding - TDH - HIV Counseling Services, Prevention & Education - 09_11_1997Resolution No. 5622
Item #28
September 11, 1997
RESOLUTION
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 Application for Funding, by and between
the City of Lubbock and the Texas Department of Health to provide HIV counseling services
for prevention and education, attached herewith, and any associated documents, which
Application 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 11th day of September , IQQ?•
MAYOR PRO BEM
ATTEST:
/L&�'
Kayth• Darnell, City Secretary
APPROVED AS TO CONTENT:
Managing Doug Go n, g g Director of
Health an ommunity Services
I/ rim rA� � • !•� �
DMald G. Vandiver, First Assistant
City Attorney
da/ccdocs/apph iv. res
September 2, 1997
Resolution No. 5622
Item #28
September 11, 1997
RESOLUTION
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 Application for Funding, by and between
the City of Lubbock and the Texas Department of Health to provide HIV counseling services
for prevention and education, attached herewith, and any associated documents, which
Application 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 llth day of September , 1997.
MAYOR PRO FEM
ATTEST:
&A
Kayth' Darnell, City Secretary
APPROVED AS TO CONTENT:
ZC �Ld!�Vt—
Doug Go n, Managing Director of
Health and -Community Services
APPROVED AS TO FORM:
ald G. Vandiver, First Assistant
City Attorney
da/¢docs/apphiv,m
September 2, 1997
�1' tS*wN%eh C-'4-ZZ.
CONTRACT FOR PUBLIC HEALTH SERVICES TDH DOCUMENT NO. 7560005906 99
Contract Issued by: TEXAS DEPARTMENT OF HEALTH DV
(RECEIVING AGENCY) 1100 WEST 49TH STREET
AUSTIN, TEXAS 78756-3199
Legal Authority to Contract: Chapters 12 and 121, Health and Safety Code.
Venue: The provisions of this Contract shall be interpreted in accordance with Texas law. Venue for any court disputes shall be in
Travis County, Texas.
PERFORMING AGENCY NAME: LUBBOCK CITY HEALTH DEPARTMENT
MAILING ADDRESS: P. O. BOX 2548 LUBBOCK TX 79408-2548
(City, State, Zip)
STREET ADDRESS: 1902 TEXAS AVENUE LUBBOCK TX 79405-1117
(City, State, Zip)
NAME OF AUTHORIZED
CONTRACTING ENTITY: CITY OF LUBBOCK
(If different from PERFORMING AGENCY)
PAYEE DATA (If not the same as PERFORMING AGENCY or AUTHORIZED CONTRACTING ENTITY; must be on file with the Texas State
Comptroller's Office.):
NAME: CITY OF LUBBOCK HEALTH DEPARTMENT
ADDRESS: P. O. BOX 2000 LUBBOCK TX 79457-0000
(City, State, Zip)
State of Texas Vendor Identification No. (14 digits)
PAYEE AGENCY Fiscal
1
17560005906037
Year Ending Month: September
PAYEE BUSINESS INFORMATION FOR STATISTICAL REPORTING: Please check the categories that apply to your business.
_ Small Business - A corporation, sole proprietorship, or other legal entity formed for the purpose of making a profit which is independently
owned and operated and has fewer than 100 employees or has less than $1,000,000 in annual gross receipts.
_ Historically Underutilized Business (HUB) - A corporation, sole proprietorship, or joint venture formed for the purpose of making a profit
in which at least 51 % of all classes of the shares of stock or other equitable securities are owned by one or more persons who have been
historically underutilized (socially disadvantaged) because of their identification as members of certain groups: Black American, Hispanic
American, Asian Pacific American, Native American, and Women. The HUB must be certified by General Services Commission or
another entity.
For Profit Organization
SUMMARY OF CONTRACT DOCUMENTATION:
COVER PAGE 1 - Receiving and Performing Agency Data GENERAL PROVISIONS
COVER PAGE 2 - Details of Attachment(s) ATTACHMENT(S)
COVER PAGE 3 - Authorized Signatures EXHIBITS, IF APPLICABLE
Cover Page 1
1 ����,.� ,,;::.1 � 1,P v,
't��0 � . ,
.,, �,.
���°O��t����
DETAILS OF ATTACHMENTS
Att/
Amd
No.
TDH
Program/
ID
Term
Financial Assistance
Direct
Assistance
Total Amount
(TDH Share)
Begin
End
Source of
Funds*
Amount
O1
HIV/PCPEEDUC
1 01/01/98
12/31/98
193.940
41,933.00
0.00
41,933.00
TDH Document No.7560005906 99 Totals
$41,933.00
$0.00
$41,933.00
*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
EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN.
CITY OF LUBBOCK
Authorized Contracting Entity (type above if different
from PERFORMING AGENCY) for and in behalf of:
PERFORMING AGENCY NAME:
LUBBOCK CITY HEALTH DEPARTMENT
RECEIVING AGENCY NAME:
TEXAS DEPARTMENT OF HEALTH
C
a
By: By:
(Signature of rson au ortzed to sign contracts) (Sig cure of person a or' d to s g ontracts)
Linda Farrow, Chief
W 1 NnY S I TTQN - MAYQR Bureau of Financial Services _
(Name and Title) (Name and Title)
Date: 1'?-2-uw q
Date:
RECOMMENDED:
By:
(FERF010ifING AGENCY Director, if different
from persdin authorized to sign contract)
Doug Goodman, Managing Director of
Health & Community Services
APPROVED AS TO FORM:
L*'� -
Donald G. Vandiver, First Assistant
City Attorney
Cover Page 3
TDH Document No: 7560005906 99
..
GENERAL PROVISIONS FOR
TEXAS DEPARTMENT OF HEALTH CONTRACTS
PERFORMING AGENCY and RECEIVING AGENCY (the parties) agree to make and enter into this contract, to
faithfully perform the duties prescribed by this contract, and to uphold and abide by the terms and provisions of this
contract. PERFORMING AGENCY and RECEIVING AGENCY agree that this contract consists of RECEIVING
and PERFORMING AGENCY identifying data, Details of Attachment(s), authorized signatures, general and/or
special provisions, Attachment(s) with detailed Scope(s) of Work, budget(s), and exhibit(s) as applicable. This contract
represents the complete and entire understanding and agreement of the parties. No prior agreement or understanding,
oral or otherwise, of the parties or their agents will be valid or enforceable unless embodied in this contract.
The person or persons signing and executing this contract on behalf of PERFORMING AGENCY, or representing
themselves as signing and executing this contract on behalf of PERFORMING AGENCY, warrant and guarantee that
he, she, or they have been duly authorized by PERFORMING AGENCY to execute this contract on behalf of
PERFORMING AGENCY and to validly and legally bind PERFORMING AGENCY to all of its terms,
performances, and provisions.
PERFORMING AGENCY assures compliance with the following terms and conditions unless otherwise specified in
the Attachment(s) hereto:
ARTICLE 1. Scone of Work
PERFORMING AGENCY shall perform the work outlined in the Scope(s) of Work contained in the Attachment(s)
hereto (which is/are referenced in the Details of Attachments) and hereby incorporated into this contract for all
purposes as though it were set out word-for-word in this document along with any amendments.
Satisfactory performance of this contract will be measured in part by: 1) adherence to the contract; 2) results of CPA
or State Auditor reports; 3) timeliness, completeness, and accuracy of required reports; and 4) achievement of
performance measures.
ARTICLE 2. Term
The time period of this contract shall be governed by the term(s) of the Attachment(s). No commitment of contract
funds is permitted prior to the first day or subsequent to the last day of the term. The term may be extended or
shortened by amendment(s).
ARTICLE 3. Funding
This contract is contingent upon the availability of funding for the term of the Attachment(s), and PERFORMING
AGENCY will have no right of action against the State of Texas or the RECEIVING AGENCY in the event that
RECEIVING AGENCY is unable to fulfill its obligations under this contract as a result of the suspension, termination,
withdrawal, or failure of funding to RECEIVING AGENCY or lack of sufficient funding of RECEIVING AGENCY
for any Attachment(s) to this contract. If funds become unavailable, provisions of the Termination Article will apply.
ARTICLE 4. Amendments or Modifications
No different or additional services, work, or products shall be authorized or performed except pursuant to an
amendment or modification of this contract that is executed in compliance with this Article. No waiver of any term,
(LHS) 1998 GENERAL PROVISIONS - Page 1 (8/97)
covenant, or condition of this contract shall be valid unless executed in compliance with this Article. The
PERFORMING AGENCY shall not be entitled to payment for any services, work, or products which are not
authorized by a properly executed contract amendment or modification.
This contract may be modified unilaterally under the terms of the Sanctions and Terminations Articles. Otherwise,
this contract may not be amended or modified unless such amendment or modification is in writing and signed by
individuals with authority to bind the parties.
ARTICLE 5. Severability
If any provision of this contract is construed to be illegal or invalid, this will not affect the legality or validity of any
of its other provisions. The illegal or invalid provision will be deemed stricken and deleted to the same extent and
effect as if never incorporated herein, but all other provisions will continue.
ARTICLE 6. Applicable Laws and Standar
This contract will be governed by the laws of the State of Texas and enabling state and federal regulations, including
federal grant requirements applicable to funding sources. If PERFORMING AGENCY is a local governmental public
health entity, this contract will also be governed by the Local Public Health Reorganization Act, Chapter 121, Health
and Safety Code.
PERFORMING AGENCY agrees the Uniform Grant and Contract Management Act (UGCMA), Texas Government
Code, Chapter 783, VTCA, and the Uniform Grant and Contract Management Standards (UGCMS) as amended by
revised federal circulars and incorporated in UGCMS by the Governor's Budget and Planning Office, apply as terms
and conditions of this contract, and are adopted by reference in their entirety. If a conflict arises between the
provisions of this contract and the provisions of UGCMA and UGCMS, the provisions of UGCMA and UGCMS will
prevail unless expressly stated otherwise. A copy of the UGCMS manual and its references will be provided to
PERFORMING AGENCY by RECEIVING AGENCY upon request.
PERFORMING AGENCY must obtain prior approval from RECEIVING AGENCY for major project changes which
are specified in the applicable Administrative Requirements and Costs Principles. A listing of the Administrative
Requirements and Cost Principles is contained in this contract in the Allowable Costs and Audit Requirements Article.
Copies of these documents will be provided to PERFORMING AGENCY by RECEIVING AGENCY upon request
and are incorporated by reference as a condition of this contract.
In accordance with 31 USC § 1352, PERFORMING AGENCY may not use funds granted under this contract to lobby
Congress or any agency in connection with a specific grant or contract. If at any time a contract exceeds $100,000,
the PERFORMING AGENCY shall certify that none of the funds provided by RECEIVING AGENCY to
PERFORMING AGENCY have been used for payment to lobbyists. Regardless of funding source, if a contract
Attachment exceeds $100,000, PERFORMING AGENCY shall provide to RECEIVING AGENCY a certification
of the names of any and all registered lobbyists with whom PERFORMING AGENCY has an agreement.
PERFORMING AGENCY shall forward to RECEIVING AGENCY the executed certification form along with the
names of any lobbyists, if applicable, within 90 days of receipt of the executed contract. The certification form is
available from RECEIVING AGENCY upon request.
In accordance with the Tax Code, Chapter 171, VTCA, PERFORMING AGENCY, if a corporation, certifies by
execution of this contract that its payment of franchise taxes is currently in "good standing" with the State of Texas.
If PERFORMING AGENCY is exempt from payment of franchise taxes, PERFORMING AGENCY certifies by
execution of this contract that it is not subject to the State of Texas franchise tax. A false statement regarding franchise
tax status will be treated as a material breach of this contract and may be grounds for termination at the option of
(LHS) 1998 GENERAL PROVISIONS - Page 2 (8/97)
RECEIVING AGENCY. If franchise tax payments become delinquent during the Attachment term, payments under
this contract will be withheld until PERFORMING AGENCY's delinquent franchise tax is paid in full.
ARTICLE 7. Debarment and Suspension
PERFORMING AGENCY further certifies by execution of this contract that it is not ineligible for participation in
federal or state assistance programs under Executive Order 12549, Debarment and Suspension. PERFORMING
AGENCY certifies, by submission of this contract, that neither it nor its principals are presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any
federal department or agency. Where the PERFORMING AGENCY is unable to certify to any of the statements in
this certification, PERFORMING AGENCY shall attach an explanation. PERFORMING AGENCY specifically
asserts that it has not knowingly failed to pay a single substantial debt or a number of outstanding debts to a federal
or state agency and that it is not subject to an outstanding judgment in a suit against PERFORMING AGENCY for
collection of the balance. A false statement regarding PERFORMING AGENCY's status will be treated as a material
breach of this contract and may be grounds for termination at the option of RECEIVING AGENCY.
ARTICLE 8. Assurances
PERFORMING AGENCY shall establish safeguards to prohibit employees from using their positions for a purpose
that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain.
To the extent such provisions are applicable to PERFORMING AGENCY, PERFORMING AGENCY agrees to fully
comply with the following:
A. Title VI of the Civil Rights Act of 1964, 42 USC §§2000d, et seq.;
B. Section 504 of the Rehabilitation Act of 1973, 29 USC §794(a);
C. The Americans with Disabilities Act of 1990, 42 USC §§12101, et seq.; and
D. All amendments to each and all requirements imposed by the regulations issued pursuant
to these acts, especially 45 CFR Part 80 (relating to race, color and national origin), 45 CFR Part 84
(relating to handicap), 45 CFR Part 86 (relating to sex), and 45 CFR Part 91 (relating to age).
Collectively, such requirements obligate RECEIVING AGENCY to provide services without discrimination on the
basis of race, color, national origin, age, sex, disability, or political or religious beliefs. PERFORMING AGENCY
agrees that in carrying out the terms of this contract, it will do so in a manner which will assist RECEIVING
AGENCY to comply with such obligations to the fullest extent of PERFORMING AGENCY's ability.
PERFORMING AGENCY will use its best efforts to make available employment opportunities for qualified disabled
individuals.
PERFORMING AGENCY agrees to comply with the:
A. Texas Labor Code, Chapter 21, VTCA, which requires that certain employers not discriminate on the basis
of race, color, disability, religion, sex, national origin, or age.
B. Immigration Reform and Control Act of 1986, 8 USC §§1324a, et seq., as amended,
regarding employment verification and retention of verification forms for any individual(s) hired on or
after November 6, 1986, who will perform any labor or services under this contract.
C. Pro -Children Act of 1994, 20 USC §§6081-6084, regarding the provision of a smoke -
free workplace and promoting the non-use of all tobacco products.
(LHS) 1998 GENERAL PROVISIONS - Page 3 (8/97)
D. Environmental standards which may be prescribed pursuant to the following:
(1) Institution of environmental quality control measures under the National
Environmental Policy Act of 1969, 42 USC §§43214332 and Executive Order 11514 "Protection
and Enhancement of Environmental Quality."
(2) Notification of violating facilities pursuant to Executive Order 11738 "Providing
for Administration of the Clean Air Act and the Federal Water Pollution Control Act with Respect
to Federal Contracts, Grants, or Loans."
(3) Conformity of federal actions to state clean air implementation plans under the
Clean Air Act of 1955, as amended, 42 USC §§7401 - 7642.
(4) Protection of underground sources of drinking water under the Safe Drinking Water
Act of 1974, as amended, 21 USC §349, 42 USC §§300f-300j.
E. If applicable, the National Research Service Award Act of 1971, 42 USC §289L-1 and
20 USC §§2080-6081, regarding the protection of human subjects involved in research, development, and
related activities supported by any applicable award of federal assistance.
F. If applicable, the Clinical Laboratory Improvement Amendments of 1988, 42 USC
§263a, which establish federal requirements for the regulation and certification of clinical laboratories.
G. If applicable, the Occupational Safety and Health Administration Regulations on
Bloodborne Pathogens, 56 Fed. Reg. 64175 (1991), 29 CFR §1919.030, which set safety standards for
those workers and facilities who may handle bloodborne pathogens.
PERFORMING AGENCY agrees to comply with the requirements of the Texas Workers' Compensation Act, Labor
Code, Chapters 401-406, VTCA, and rules promulgated thereunder found at 28 Texas Administrative Code (TAC),
Chapter 410, et seq. , which cover compensation for employees' injuries.
PERFORMING AGENCY warrants that hardware, software, and firmware products used individually or together
as a system to comply with RECEIVING AGENCY contract requirements will be year-2000-compliant on or before
the date such hardware, software, firmware and systems are to be impacted. RECEIVING AGENCY warrants that
hardware, software, and firmware products used individually or together as a system, developed by RECEIVING
AGENCY, and provided to PERFORMING AGENCY for operation will be year-2000-compliant on or before the
date such hardware, software, firmware and systems are to be impacted.
PERFORMING AGENCY assures it shall not transfer, assign or sell its interest in this contract, or in any equipment
purchased with funds from this contract, without the written consent of the RECEIVING AGENCY.
ARTICLE 9. Certification Regarding License. Certificate. or Permit
PERFORMING AGENCY, by acceptance of funds provided through contract Attachment(s), agrees and assures that
personnel paid from these funds are duly licensed and/or qualified to perform the required services.
PERFORMING AGENCY certifies by signing this contract that, in accordance with Section 163 of Article IX of the
General Appropriations Act, 75th Legislature, no owner, operator, or administrator of the PERFORMING AGENCY
has had a license, certificate, or permit revoked by any of the Texas state agencies listed below:
Adjutant General's Department
(LHS) 1998 GENERAL PROVISIONS - Page 4 (8/97)
• Board of Private Investigators and Private Security Agencies
• Interagency Council on Early Childhood Intervention
• Texas Alcoholic Beverage Commission
• Texas Cancer Council
• Texas Children's Trust Fund of Texas Council
• Texas Commission for the Deaf and Hard of Hearing
• Texas Commission on Alcohol and Drug Abuse
• Texas Commission on Jail Standards
• Texas Commission on Law Enforcement Officers Standards & Education
• Texas Commission on Fire Protection
• Texas Council on Sex Offender Treatment
• Texas Criminal Justice Policy Council
• Texas Department of Criminal Justice
• Texas Department of Human Services
• Texas Department of Mental Health & Mental Retardation
• Texas Department of Protective and Regulatory Services
• Texas Department of Public Safety
• Texas Department of Health
• Texas Health & Human Services Commission
• Texas National Guard Armory Board
• Texas Polygraph Examiners Board
• Texas Rehabilitation Commission
• Texas Youth Commission
ARTICLE 10. Standards For Financial and Programmatic Management
PERFORMING AGENCY shall develop, implement, and maintain financial management and control systems that
meet or exceed the requirements of UGCMS as detailed in RECEIVING AGENCY's Financial Administrative
Procedures Manual. Those requirements shall include at a minimum:
A. Financial planning, including the development of budgets that adequately reflect all functions and resources
necessary to carry out authorized activities and the adequate determination of costs;
B. Financial management systems including accurate, correct, and complete payroll, accounting, and financial
reporting records; cost source documentation; effective internal and budgetary controls; determination of
reasonableness, allowability, and allocability of costs; and timely and appropriate audits and resolution of
any findings; and,
C. Billing and collection policies, including a charge schedule, a system for discounting or adjusting charges
based on a person's income and family size, and a mechanism capable of billing and making reasonable
efforts to collect from patients and third parties.
In addition, PERFORMING AGENCY shall bill third party payors, at no cost to the client, for services provided
under the Attachment(s). These potential payors include, but are not limited to, Medicaid, private insurance carriers,
other available federal, state, local, and private funds. PERFORMING AGENCY shall become a Medicaid provider
for eligible activities funded in the Attachment(s) hereto and will maximize efforts to obtain payment from Medicaid
and all other available sources.
PERFORMING AGENCY and its governing body shall bear full responsibility for the integrity of fiscal and
programmatic management. Such responsibility shall include: accountability for all funds and materials received from
(LHS) 1998 GENERAL PROVISIONS - Page 5 (8/97)
the RECEIVING AGENCY; compliance with RECEIVING AGENCY rules, policies, procedures, and applicable
federal and state laws and regulations; and correction of fiscal and program deficiencies identified through self -
evaluation and RECEIVING AGENCY's monitoring processes. Ignorance of any contract provisions or other
requirements contained or referenced in this contract shall not constitute a defense or basis for waiving or appealing
such provisions or requirements.
ARTICLE 11. Allowable Costs and Audit Requirements
Only those costs allowable under UGCMS and any revisions thereto plus any applicable federal cost principles are
eligible for reimbursement under this contract. Applicable cost principles, audit requirements, and administrative
requirements are as follows:
Applicable Cost Principles" I Audit Requirements" I Administrative
Requirements"
OMB Circular A-87, State & I OMB Circular A-133 and UGCMS I UGCMS
Local Governments
• OMB Circulars shall be applied with the modifications prescribed by UGCMS.
To be eligible for reimbursement under this contract, a cost must have been incurred by PERFORMING AGENCY
within the applicable Attachment term prior to claiming reimbursement from RECEIVING AGENCY. Vouchers for
costs encumbered by the last day of the applicable Attachment term must be received by RECEIVING AGENCY no
later than 45 days after the end of the applicable Attachment term.
PERFORMING AGENCY or the AUTHORIZED CONTRACTING ENTITY shall arrange for a financial and
compliance audit (Single Audit) if required by OMB Circular A-133 and/or UGCMS. The audit shall be of
PERFORMING AGENCY's or the AUTHORIZED CONTRACTING ENTITY's fiscal year. The audit must be
conducted by an independent certified public accountant and must be in accordance with applicable OMB Circulars,
Government Auditing Standards, and UGCMS. PERFORMING AGENCY shall procure audit services in compliance
with state procurement procedures, as well as the provisions of UGCMS.
If PERFORMING AGENCY is not required to have a Single Audit, RECEIVING AGENCY may provide
PERFORMING AGENCY with written audit requirements if a limited scope audit will be required.
Within 30 days of receipt of the audit reports required by this section, PERFORMING AGENCY/AUTHORIZED
CONTRACTING ENTITY shall submit a copy to RECEIVING AGENCY's Internal Audit Division.
ARTICLE 12. Overtime Compen. as tion
PERFORMING AGENCY shall not use any of the funds provided by the Attachment(s) hereto to pay the premium
portion of overtime. PERFORMING AGENCY shall be responsible for any obligations of premium overtime pay due
employees. Premium overtime pay is defined as any compensation paid to an individual in addition to the normal rate
of pay for hours worked in excess of normal working hours.
(LHS) 1998 GENERAL PROVISIONS - Page 6 (8/97)
ARTICLE 13. Terms and Conditions of Payment
For services satisfactorily performed pursuant to the Scope(s) of Work set out in the Attachment(s) hereto,
PERFORMING AGENCY will receive reimbursement for allowable costs. Reimbursements are contingent on a
signed contract and will not exceed the total of each Attachment(s) hereto. The PERFORMING AGENCY is not
entitled to, and shall not pursue, payment for any claim unless the service, work, or product forming the basis of the
claim has been authorized in accordance with this contract.
PERFORMING AGENCY must submit claims for reimbursement on a State of Texas Purchase Voucher (TDH Form
B-13) or any other form designated by the RECEIVING AGENCY. PERFORMING AGENCY shall submit vouchers
for reimbursement monthly within 20 days following the end of the month covered by the bill. PERFORMING
AGENCY shall submit a reimbursement claim as a final close-out bill not later than 45 days following the end of the
applicable Attachment term(s). Claims submitted and postmarked more than 45 days following the end of the
applicable Attachment term may or may not be reimbursed, at the discretion of the RECEIVING AGENCY.
PERFORMING AGENCY may request, in writing, to be placed on Direct Deposit status. If this request is approved
by RECEIVING AGENCY, PERFORMING AGENCY will no longer receive copies of reimbursement vouchers.
Funding from this contract may not be used to supplant state or local funds, but PERFORMING AGENCY shall use
such funds to increase state or local funds currently available to PERFORMING AGENCY for a particular activity.
PERFORMING AGENCY shall maintain its current level of support, if possible.
PERFORMING AGENCY shall refund to RECEIVING AGENCY within 30 days any funds PERFORMING
AGENCY claims and receives from RECEIVING AGENCY for the reimbursement of costs which are determined
by RECEIVING AGENCY to be ineligible for reimbursement.
RECEIVING AGENCY will have the right to withhold all or part of any future payments to PERFORMING
AGENCY to offset any reimbursement made to PERFORMING AGENCY for any ineligible expenditures not
refunded to RECEIVING AGENCY by PERFORMING AGENCY. Repayment may be taken from funds available
under any contract Attachment, active or expired, with the same funding source in amounts necessary to fulfill
PERFORMING AGENCY repayment obligations.
Without waiving rights to impose other sanctions, RECEIVING AGENCY shall temporarily or permanently withhold
payment(s) from PERFORMING AGENCY for the following programmatic and financial noncompliance items:
• failure to submit required financial reports for previous quarters or for the final period;
• failure to respond to financial compliance monitoring reports;
• failure to submit required independent audit reports;
• failure to meet program requirements as specified in an Attachment's Scope of Work;
• inadequate or inappropriate resolution of program or financial monitoring findings
• and for other items of noncompliance.
ARTICLE 14. Advance Payments
PERFORMING AGENCY may request, and with proper justification and RECEIVING AGENCY's approval, receive
a one-time advance for each Attachment. Advance funds may be drawn only to meet immediate cash needs for
disbursement. PERFORMING AGENCY must request the advance on a State of Texas Purchase Voucher at the
beginning of the applicable Attachment period or at a later time in the applicable Attachment period if circumstances
so warrant. The Purchase Voucher must be accompanied by written justification and supporting documentation as
specified in RECEIVING AGENCY's Financial Administrative Procedures Manual, REIMBURSEMENT
PROCEDURES.
(LHS) 1998 GENERAL PROVISIONS - Page 7 (8/97)
If RECEIVING AGENCY concurs with PERFORMING AGENCY's request for an advance, RECEIVING AGENCY
will determine the amount of the advance by the amount and term of the applicable Attachment(s). For each
Attachment, the amount of the advance shall not exceed an amount equal to the amount of the Attachment divided by
the number of months covered by the Attachment multiplied by two (2) less any Program Income carried forward
from the previous year. Advance funds will be liquidated during the applicable Attachment term so that, after the final
monthly billing, PERFORMING AGENCY will not have advance funds on hand.
Amendments to applicable Attachment(s) which increase or decrease the total amount of the Attachment may require
upward or downward adjustment to the allowable advance in accordance with the above formula. In the case of a
downward adjustment, RECEIVING AGENCY will determine the amount of adjustment to the advance and the
method of repayment. If PERFORMING AGENCY is requesting an upward adjustment, PERFORMING AGENCY
must submit to RECEIVING AGENCY a written justification and State of Texas Purchase Voucher in the amount
necessary to correct the ratio.
ARTICLE 15.
PERFORMING AGENCY shall develop a fee for service system and a schedule of fees for personal health services
in accordance with the provisions of Chapter 12, Subchapter D, Health and Safety Code, VTCA; the Texas Board
of Health rules covering Fees for Clinical Health Services, 25 TAC § 1.91; and other applicable laws provided,
however, that a patient may not be denied a service due to inability to pay.
Both parties agree that all revenues directly generated by an Attachment(s) supported activity or earned only as a result
of the Attachment(s) during the term of the Attachment(s) are considered program income. PERFORMING AGENCY
shall identify and report this income quarterly and annually utilizing the forms and frequencies specified in the
Financial Reports Article of these provisions.
PERFORMING AGENCY shall retain the program income and select either the additive or deductive method for
calculating program income:
Under the additive method, PERFORMING AGENCY will add the program income to the funds
already committed to the project by both the RECEIVING AGENCY and PERFORMING
AGENCY. PERFORMING AGENCY shall use program income to further the program objectives
of the state/federal statute under which the Scope of Work for the Attachment(s) was made, and
PERFORMING AGENCY shall spend program income on the same project in which it was
generated. Program income earned in a current budget period and not expended in that budget
period may be carried forward to the next budget period, but PERFORMING AGENCY must spend
the program income in the next budget period or the program income shall be deducted from
program expenditures. This policy will apply unless specifically stated otherwise in the Special
Provisions of the applicable contract Attachment(s).
Under the deductive method, the PERFORMING AGENCY shall deduct the program income from
the total allowable costs to determine the net allowable costs.
RECEIVING AGENCY may base future funding levels, in part, upon the PERFORMING AGENCY's proficiency
in identifying, billing, collecting, and reporting program income, and in utilizing it for the purposes and conditions
of the applicable Attachment(s).
(LHS) 1998 GENERAL PROVISIONS - Page 8 (8/97)
ARTICLE 16. Financial Reps
Financial reports are required as provided in UGCMS, and PERFORMING AGENCY shall file them regardless of
whether or not expenses have been incurred.
PERFORMING AGENCY shall submit a Financial Status Report, State of Texas Supplemental Form 269a (TDH
Form GC-4a), within 30 days following the end of each of the first three quarters. PERFORMING AGENCY shall
submit a final financial report on State of Texas Supplemental Form 269a (TDH Form GC-4a), not later than 45 days
following the end of the Attachment term(s). PERFORMING AGENCY shall submit a State of Texas Purchase
Voucher if all costs have not been recovered, or PERFORMING AGENCY shall refund excess monies if costs
incurred were less than funds received.
ARTICLE 17.
PERFORMING AGENCY shall submit financial, program, and progress reports as requested by RECEIVING
AGENCY in the format agreed to by the parties hereto. PERFORMING AGENCY shall provide RECEIVING
AGENCY such other reports as are determined by RECEIVING AGENCY to be necessary for the accomplishment
of the objectives of this contract. If PERFORMING AGENCY is legally prohibited from providing such reports, it
shall immediately notify RECEIVING AGENCY of this fact. PERFORMING AGENCY's failure to comply with
these requirements shall be grounds for the imposition of sanctions as provided for in the Sanctions Article.
RECEIVING AGENCY and, when federal funds are involved, any authorized representative(s) of the federal
government have the right, at all reasonable times, to inspect or otherwise evaluate the work (including client or
patient records) performed by PERFORMING AGENCY and its subcontractor(s), if any, and the premises on which
it is being performed, including subcontractors. PERFORMING AGENCY and its subcontractor(s) shall participate
in inspections and provide reasonable access, facilities, and assistance to the representatives. All inspections and
evaluations will be performed in such a manner as will not unduly interfere with the work.
PERFORMING AGENCY and its subcontractor(s), if any, shall give RECEIVING AGENCY and the federal
government, or any of their duly authorized representatives, access to any pertinent books, documents, papers, and
client or patient records of PERFORMING AGENCY and its subcontractor(s), if any, for the purpose of making
audit, examination, excerpts, and transcripts of transactions related to contract Attachment(s). RECEIVING AGENCY
will have the right to audit billings both before and after payment. Payment under Attachment(s) will not foreclose
the right of RECEIVING AGENCY to recover excessive or illegal payments.
Any deficiencies identified by RECEIVING AGENCY upon examination of PERFORMING AGENCY's records will
be conveyed in writing to PERFORMING AGENCY. PERFORMING AGENCY's resolution of findings will also
be conveyed in writing to RECEIVING AGENCY within 30 days of receipt of RECEIVING AGENCY's findings.
A determination by RECEIVING AGENCY of either an inadequate or inappropriate resolution of the findings may
result in the withholding of funds, as provided in the Terms and Conditions of Payment Article and the Sanctions
Article. Any such withholding of funds will remain in effect until the deficiencies are properly remedied as determined
by RECEIVING AGENCY.
PERFORMING AGENCY will retain all such records for a period of three years from the date of the last expenditure
report submitted under contract Attachment(s) or until all audit questions are resolved, whichever time period is
longer.
(LHS) 1998 GENERAL PROVISIONS - Page 9 (8/97)
ARTICLE 18.
PERFORMING AGENCY, or any subcontractor, shall not transfer an identifiable client record, including a patient
record, to another entity or person without written consent from the client or patient, or someone authorized to act
on his or her behalf; however, the RECEIVING AGENCY may require the PERFORMING AGENCY, or any
subcontractor, to transfer a client or patient record to another agency or to the RECEIVING AGENCY if the transfer
is necessary to protect either the confidentiality of the record or the health and welfare of the client or patient.
At the end of the Attachment term, all client or patient records are the property of PERFORMING AGENCY.
PERFORMING AGENCY shall give RECEIVING AGENCY access to the records or provide copies for audit,
examination, evaluation, inspection, litigation, or other circumstances that may arise, to the extent authorized by law.
If at any time during the Attachment term(s), PERFORMING AGENCY and/or RECEIVING AGENCY should
decide to terminate the agreement, RECEIVING AGENCY may require the transfer of client or patient records as
authorized by law upon written notice to PERFORMING AGENCY, either to another entity that agrees to continue
the service or to RECEIVING AGENCY.
Notwithstanding any other provision herein, if requested by RECEIVING AGENCY, the PERFORMING AGENCY
shall share all patient information with the RECEIVING AGENCY when the contract involves patient care by the
PERFORMING AGENCY. The PERFORMING AGENCY shall attempt to obtain a release of medical information
from the client or patient or someone authorized to act on his or her behalf permitting the transfer of information
outside the PERFORMING AGENCY on forms supplied by the RECEIVING AGENCY. If the patient refuses to sign
the release of information form, the information will be shared with the RECEIVING AGENCY devoid of all
identifiers of a personal nature, as specified by RECEIVING AGENCY.
ARTICLE 19. Confidentiality
PERFORMING AGENCY shall have a system in effect to protect client or patient records and all other documents
deemed confidential by law which are maintained in connection with the activities funded under contract
Attachment(s). PERFORMING AGENCY may not disclose or transfer confidential client or patient information,
including information required by the Reports and Inspections Article, except in accordance with applicable law.
If providing direct client care, services, or programs, PERFORMING AGENCY shall implement workplace policies
based on the model guidelines adopted by RECEIVING AGENCY, and PERFORMING AGENCY shall educate
employees and clients concerning the human immunodeficiency virus (HIV) and its related conditions, including
acquired immunodeficiency syndrome (AIDS), in accordance with the Health and Safety Code, §85.113, VTCA.
ARTICLE 20. Equipment and Supplies
In accordance with Health & Safety Code, §12.053, VTCA, title to all equipment and supplies purchased from funds
provided herein will be in the name of PERFORMING AGENCY throughout the Attachment(s) term(s) or until the
Attachment is terminated.
Equipment is defined as tangible nonexpendable property with an acquisition cost of over $1,000 and a useful life of
more than one year, with the following exceptions: fax machines, stereo systems, cameras, video recorder/players,
microcomputers, medical equipment, laboratory equipment, and printers. If the unit cost of these exception items is
over $500, they will still be considered equipment, must be approved for purchase, and are considered capital assets
for inventory purposes. Medical and laboratory equipment in this category is defined as microscopes, oscilloscopes,
centrifuges, balances, and incubators. Medical and laboratory equipment not included in these five categories is not
considered a capital asset unless the unit value is over $1,000.
(LHS) 1998 GENERAL PROVISIONS - Page 10 (8/97)
Unless initially listed and approved in the Attachment(s), prior written approval from RECEIVING AGENCY is
required for any additions to, or deletions of, approved equipment purchases meeting the above equipment definition.
To receive approval to purchase data processing hardware and software or enhancements thereto, PERFORMING
AGENCY must submit a detailed justification which includes description of features, make and model, and cost, etc.
PERFORMING AGENCY shall maintain a property inventory and submit an annual cumulative report (TDH Form
GC-11) to RECEIVING AGENCY no later than October 15th of each year. PERFORMING AGENCY shall
administer a program of maintenance, repair, and protection of assets under this contract so as to assure their full
availability and usefulness. In the event PERFORMING AGENCY is indemnified, reimbursed, or otherwise
compensated for any loss of, destruction of, or damage to the assets provided under this contract, it shall use the
proceeds to repair or replace said assets.
In the event of bankruptcy, PERFORMING AGENCY agrees to sever RECEIVING AGENCY property, equipment,
and supplies in possession of PERFORMING AGENCY from the bankruptcy and title reverts to RECEIVING
AGENCY.
Upon termination or expiration of applicable Attachment(s), title to any remaining equipment and supplies purchased
from funds as hereinabove provided reverts to RECEIVING AGENCY. Title may be transferred to any other parry
designated by RECEIVING AGENCY, provided, however, that RECEIVING AGENCY may, at its option and to
the extent allowed by law, transfer title to such property to the PERFORMING AGENCY.
ARTICLE 21. Subcontractiniz
PERFORMING AGENCY may enter into agreements with subcontractors unless restricted or otherwise prohibited
in specific Attachment(s). PERFORMING AGENCY agrees that it shall be responsible to RECEIVING AGENCY
for the performance of any subcontractor.
If PERFORMING AGENCY enters into subcontract agreements, PERFORMING AGENCY agrees that all
subcontracts shall be in writing and include the following:
• name and address of all parties;
• a detailed description of the services to be provided;
• measurable method and rate of payment and total amount of the contract;
• clearly defined and executable termination clause;
• beginning and ending dates which coincide with the dates of the applicable contract Attachment(s)
or be executed annually;
• access to inspect work performed, and the premises on which it is performed, in accordance with
the Reports and Inspections Article contained in this contract; and
• all clauses required by state/federal statutes, executive orders, and their implementing regulations.
PERFORMING AGENCY agrees that all subcontracts containing a categorical budget shall include audit requirements
referenced in the Allowable Costs and Audit Requirements Article of this contract, as appropriate.
If PERFORMING AGENCY plans to enter into an agreement which subcontracts out a substantial portion of an
Attachment's Scope of Work, prior written approval must be obtained from RECEIVING AGENCY. Subcontracts
that must have prior written approval are those that exceed $25,000 or 25% of the applicable Attachment amount,
whichever is greater.
(LHS) 1998 GENERAL PROVISIONS - Page 11 (8/97)
PERFORMING AGENCY shall ensure that:
• all subcontractors are fully aware of the requirements imposed upon them by state/federal statutes
and regulations;
• all subcontractors comply with all financial management requirements as defined by RECEIVING
AGENCY and the applicable OMB circulars;
• subcontractors complete required audits;
• an adequate tracking system is maintained to ensure timely receipt of any subcontractor's required
audit reports and the resolution of any findings and questioned costs cited by these reports.
ARTICLE 22. Copyrights. Publications. and Patents
PERFORMING AGENCY agrees that all work performed that results in the production of original books, manuals,
films, or other original material is the exclusive property of the RECEIVING AGENCY unless the contract
Attachment(s) that result in the production of original books, manuals, films, or other original material is financed
by a federal grant, the terms of which provide otherwise. All right, title, and interest in and to said property shall vest
in the RECEIVING AGENCY upon creation. All work performed shall be deemed to be a "work made for hire" and
made in the course of the services rendered pursuant to this contract. To the extent that title to any such work may
not, by operation of law, vest in RECEIVING AGENCY or such work may not be considered a work made for hire,
all rights, title and interest therein are hereby irrevocably assigned to the RECEIVING AGENCY. RECEIVING
AGENCY shall have the right to obtain and to hold in its own name any and all patents, copyrights, trademarks,
service marks, certification marks, collective marks, registrations, or such other protection as may be appropriate to
the subject matter, and any extensions and renewals thereof. PERFORMING AGENCY shall ensure all rights, titles,
and interest in and to said property are secured to RECEIVING AGENCY from PERFORMING AGENCY and its
subcontractors. PERFORMING AGENCY agrees to give RECEIVING AGENCY and agrees to require its
subcontractors to give RECEIVING AGENCY, or any person designated by RECEIVING AGENCY, all assistance
required to perfect the rights defined in this Article, without any charge or expense beyond those amounts payable
to PERFORMING AGENCY for the services rendered under the contract.
PERFORMING AGENCY understands and agrees that, if federal funds are used to finance activities supported by
the contract Attachment(s) that result in the production of original books, manuals, films, or other original material,
the federal awarding agency reserves a royalty -free, nonexclusive, and irrevocable license to reproduce, publish or
otherwise use, and to authorize others to use, for federal government purposes (1) the copyright in any work
developed under a grant, subgrant, or contract under a grant or subgrant; and (2) any rights of copyright to which a
PERFORMING AGENCY or its subcontractor purchases ownership with grant support. PERFORMING AGENCY
shall place an acknowledgment of federal awarding agency grant support and a disclaimer, as appropriate, on any
publication written or published with such support and, if feasible, on any publication reporting the results of or
describing a grant -supported activity. An acknowledgment shall be to the effect that "This publication was made
possible by grant number from (federal awarding agencvl" or "The project described was supported
by grant number from (federal awarding agency)" and "Its contents are solely the responsibility
of the authors and do not necessarily represent the official views of the (federal awarding agency)."
In the event the terms of a federal grant award the copyright to the PERFORMING AGENCY, RECEIVING
AGENCY reserves a royalty -free, nonexclusive, and irrevocable license to reproduce, publish or otherwise use, and
to authorize others to use, for RECEIVING AGENCY and state government purposes (1) the copyright in any work
developed under a grant, subgrant, or contract under a grant or subgrant; and (2) any rights of copyright to which a
grantee, subgrantee or a contractor purchases ownership with grant support.
PERFORMING AGENCY may publish at its expense the results of contract performance with prior RECEIVING
AGENCY review and approval. If RECEIVING AGENCY owns the copyright, any publication should include "m
Texas Department of Health, 1100 West 49th Street, Austin, Texas, (the year of publication), All Rights Reserved."
(LHS) 1998 GENERAL PROVISIONS - Page 12 (8/97)
If the PERFORMING AGENCY is the copyright holder, any publication shall include acknowledgment of the support
received from RECEIVING AGENCY. At least six copies of any such publication must be provided to RECEIVING
AGENCY. RECEIVING AGENCY reserves the right to require additional copies before or after the initial review.
PERFORMING AGENCY and any subcontractor, as appropriate, must comply with the standard patent rights clauses
in 37 Code of Federal Regulations §401.14 or Federal Acquisition Regulations 52.227.11.
ARTICLE 23. Hold Harmless
PERFORMING AGENCY, as an independent contractor, agrees to hold RECEIVING AGENCY and/or the federal
government harmless and to indemnify them from any and all liability, suits, claims, losses, damages and judgments,
and to pay all costs, fees, and damages to the extent that such costs, fees, and damages arise from performance or
non-performance of PERFORMING AGENCY under this contract. PERFORMING AGENCY's agreement to
indemnify RECEIVING AGENCY is limited to the extent permitted under Title 5 of the Civil Practice and Remedies
Code, VTCA, and to the extent allowed by any other laws. RECEIVING AGENCY, as a state governmental agency,
agrees to hold PERFORMING AGENCY harmless and to indemnify it against any and all liability, suits, claims,
losses, damages and judgments that arise from the performance or non-performance of RECEIVING AGENCY under
this contract to the extent authorized by the governmental liability provisions of Title 5 of the Civil Practice and
Remedies Code, VTCA, and to the extent allowed by any other laws.
PERFORMING AGENCY, by acceptance of funds provided through contract Attachment(s), agrees and ensures that
personnel paid from these funds are duly licensed and/or qualified to perform the required services.
ARTICLE 24. Bondine
PERFORMING AGENCY is required to carry a fidelity bond, insurance coverage, or self-insurance equal to the
amount of funding provided under the contract Attachment(s) up to $100,000 that covers each employee of the
PERFORMING AGENCY handling funds under this contract, including person(s) authorizing payment of such funds.
The fidelity bond, insurance, or self-insurance will provide for indemnification of losses occasioned by: 1) any
fraudulent or dishonest act or acts committed by any of PERFORMING AGENCY's employees, either individually
or in concert with others, and/or 2) failure of PERFORMING AGENCY or any of its employees to perform faithfully
his/her duties or to account properly for all monies and property received by virtue of his/her position or employment.
ARTICLE 25. Historically Underutilized Businesses
RECEIVING AGENCY shall comply with Texas Government Code, Chapter 2161, VTCA, and 1 Texas
Administrative Code (TAC) §§l11.11-111.24, whereby state agencies are required to make a good faith effort to assist
historically underutilized businesses (HUBS) in receiving contract awards issued by the state to purchase "goods,"
which are defined as "supplies, materials, or equipment," services, or public works.
A HUB is defined in the Texas Government Code §2161.001(2), VTCA, as:
A. a corporation formed for the purpose of making a profit in which 51 percent or more of all classes
of the shares of stock or other equitable securities are owned by one or more socially disadvantaged
persons who have a proportionate interest and actively participate in the corporation's control,
operation, and management;
B. a sole proprietorship created for the purpose of making a profit that is completely owned, operated,
and controlled by a socially disadvantaged person;
(LHS) 1998 GENERAL PROVISIONS - Page 13 (8/97)
C. a partnership formed for the purpose of making a profit in which 51 percent or more of the assets
and interest in the partnership are owned by one or more socially disadvantaged persons who have
a proportionate interest and actively participate in the partnership's control, operation, and
management;
D. a joint venture in which each entity in the venture is a historically underutilized business; or
E. a supplier contract between a historically underutilized business and a prime contractor under which
the historically underutilized business is directly involved in the manufacture or distribution of the
goods or otherwise warehouses and ships the goods.
"Socially disadvantaged person" is defined in Texas Government Code §2161.001(3) as "... a person who is socially
disadvantaged because of the person's identification as a member of a certain group, including Black Americans,
Hispanic Americans, women, Asian Pacific Americans and Native Americans, and who has suffered the effects of
discriminatory practices or other similar insidious circumstances over which the person has no control."
A HUB is defined in the General Appropriations Act, 75th Legislature, Regular Session, ARTICLE IX, General
Provisions, Section 124, Contracting with Historically Underutilized Businesses, Subsection 3, in the same manner
except that "socially disadvantaged person" is replaced with the term "economically disadvantaged person." The term
"economically disadvantaged person is defined in the General Appropriations Act as " . . . a person who is
economically disadvantaged because of the person's identification as a member of certain groups, including Black
Americans, Hispanic Americans, women, Asian Americans and Native Americans, and who has suffered the effects
of discriminatory practices or other similar insidious circumstances over which the person has no control."
PERFORMING AGENCY agrees to make a good faith effort to subcontract with HUBs during the performance of
its contract Attachment(s) with the RECEIVING AGENCY and will report HUB subcontract activity on a quarterly
basis to RECEIVING AGENCY.
ARTICLE 26. Sanctions
PERFORMING AGENCY agrees and understands that sanctions may be imposed by RECEIVING AGENCY both
for programmatic and financial noncompliance. RECEIVING AGENCY may, at its own discretion, impose one or
more sanctions for each item of noncompliance and will determine sanctions on a case -by -case basis. Both parties
agree that a state or federal statute, rule, regulation, or federal guideline will prevail over the provisions of this Article
unless the statute, rule, regulation, or guideline can be read together with the provision(s) of this Article to give effect
to both. RECEIVING AGENCY may:
A. terminate all or a part of the contract. Termination is the permanent withdrawal of the PERFORMING
AGENCY's authority to obligate previously awarded funds before that authority would otherwise expire,
or the voluntary relinquishment by the PERFORMING AGENCY to obligate previously awarded funds.
PERFORMING AGENCY costs resulting from obligations incurred by the PERFORMING AGENCY
after termination of an award are not allowable unless expressly authorized by the notice of termination;
B. suspend all or part of the contract. Suspension is the temporary withdrawal of the PERFORMING
AGENCY's authority to obligate funds pending compliance by the PERFORMING AGENCY or its
subcontractor(s) or pending a decision to terminate or modify the contract. PERFORMING AGENCY
costs resulting from obligations incurred by the PERFORMING AGENCY during a suspension are not
allowable unless expressly authorized by the notice of suspension;
C. temporarily or permanently withhold cash payments. Withholding of cash payment means that the
RECEIVING AGENCY retains funds claimed by the PERFORMING AGENCY in order to: a) recover
(LHS) 1998 GENERAL PROVISIONS - Page 14 (8/97)
payments already made for undocumented, disputed, inaccurate, or erroneous claims; b) obtain refunds
for overpayment for any reason; or c) obtain compliance;
D. deny contract renewal or future contract awards to a PERFORMING AGENCY for a certain period of
time not to exceed five years;
E. delay contract execution with the PERFORMING AGENCY while other proposed sanctions are pending
resolution;
F. amend all or a part of the contract as a result of noncompliance;
G. place the PERFORMING AGENCY on probation. Probation means that the PERFORMING AGENCY
will be placed on accelerated monitoring for a period not to exceed six months at which time items of
noncompliance must be resolved or substantial improvement shown by the PERFORMING AGENCY;
H. conduct accelerated monitoring of the PERFORMING AGENCY. Accelerated monitoring means more
frequent or more extensive monitoring will be performed by RECEIVING AGENCY than would routinely
be accomplished;
I. require the PERFORMING AGENCY to obtain technical or managerial assistance;
J. disallow claims by disapproving costs or fees claimed for payment or reimbursement by PERFORMING
AGENCY;
K. establish additional prior approvals for expenditure of funds by the PERFORMING AGENCY;
L. require additional, more detailed, financial and/or programmatic reports to be submitted by
PERFORMING AGENCY;
M. demand repayment from the PERFORMING AGENCY;
N. reduce the contract funding amount for failure to achieve or maintain the proposed level of service, to
expend funds appropriately and at a rate which will make full use of the award, or to provide services as
set out in the contract;
O. take any other action which RECEIVING AGENCY deems appropriate.
RECEIVING AGENCY will formally notify the PERFORMING AGENCY in writing when a sanction is imposed
(with the exception of accelerated monitoring, which may be unannounced.) PERFORMING AGENCY is required
to file, within 15 days of receipt of notice, a written response to the RECEIVING AGENCY's program/division that
sent the notice, acknowledging receipt of such notice and stating how the PERFORMING AGENCY will correct the
noncompliance.
RECEIVING AGENCY may immediately terminate or suspend all or part of the contract, temporarily or permanently
withhold cash payments, deny contract renewal or future contract awards, delay contract execution, or amend all or
part of the contract in an emergency by delivering written notice to a PERFORMING AGENCY, by any verifiable
method, stating the reason for the emergency action. The emergency may be a result of the PERFORMING
AGENCY's noncompliance having a direct adverse impact on the public or client health or safety, failure to achieve
a performance measure, being reimbursed for expenditures which are not in accordance with applicable federal or
state laws and regulations or the provisions of the contract, or expending funds inappropriately.
(LHS) 1998 GENERAL PROVISIONS - Page 15 (8/97)
PERFORMING AGENCY may request a review of the imposition of the following sanctions: termination of all or
part of the contract, suspension of all or part of the contract, permanent withholding of cash payments, denial of
contract renewal or future contract awards, and contract amendment as a result of noncompliance in accordance with
RECEIVING AGENCY's Administrative Policy No. XO - 0109. PERFORMING AGENCY must make the request
for review in writing to RECEIVING AGENCY within fifteen (15) days from the date of notification.
ARTICLE 27. Termination
In addition to other provisions herein allowing termination, this contract shall terminate upon full performance of all
requirements contained herein, unless extended in writing; or all or a part of this contract may be terminated prior
to completion of the contract term for any of the following reasons:
A. Termination in the Best Interest of the State. This contract may be terminated by RECEIVING AGENCY
at any time when, in the sole determination of RECEIVING AGENCY, termination is in the best interests
of the State of Texas.
B. Termination by Agreement. This contract may be terminated, in whole or in part, when both parties
mutually agree that continuation of the contract would not achieve the objectives and goals of the contract
and that continuation would not be mutually beneficial.
C. Termination for Cause. RECEIVING AGENCY reserves the right to terminate this contract, in whole or
in part, upon the following conditions:
(1) The PERFORMING AGENCY makes an assignment for the benefit of its creditors, or admits in
writing its inability to pay its debts generally as they become due, or consents to the appointment
of a receiver, trustee, or liquidator of the PERFORMING AGENCY or of all or any part of its
property; if judgment for the payment of money in excess of $50,000.00 (which is not covered by
insurance) is rendered by any court or governmental body against the PERFORMING AGENCY,
and the PERFORMING AGENCY does not discharge the judgment or provide for its discharge in
accordance with its terms, or procure a stay of execution thereof within 30 days from the date of
entry thereof, and within the 30-day period or a longer period during which execution of the
judgment shall have been stayed, appeal therefrom and cause the execution thereof to be stayed
during such appeal while providing such reserves therefore as may be required under generally
accepted accounting principles; or a writ or warrant of attachment or any similar process shall be
issued by any court against all or any material portion of the property of the PERFORMING
AGENCY, and such writ or warrant of attachment or any similar process is not released or bonded
within 30 days after its entry; or
(2) A court of competent jurisdiction finds that the PERFORMING AGENCY has failed to adhere to
any laws, ordinances, rules, regulations or orders of any public authority having jurisdiction; or
(3) PERFORMING AGENCY fails to communicate with the RECEIVING AGENCY as required by
the contract; or
(4) The PERFORMING AGENCY breaches a standard of confidentiality with respect to the services
provided under this contract; or
(5) The RECEIVING AGENCY makes a written determination that the PERFORMING AGENCY has
failed to substantially perform under this agreement, which determination specifies the events
resulting in the RECEIVING AGENCY's determination that the PERFORMING AGENCY has
failed to substantially perform under this agreement; or
(LHS) 1998 GENERAL PROVISIONS - Page 16 (8/97)
(6) RECEIVING AGENCY makes a written determination that PERFORMING AGENCY has
committed a material breach of any term(s) of this contract; or
(7) The RECEIVING AGENCY determines that the PERFORMING AGENCY is without the personnel
or resources to perform under the contract; or
(8) A receiver, conservator, liquidator, or trustee of the PERFORMING AGENCY, or any of its
property is appointed by order or decree of any court or agency or supervisory authority having
jurisdiction; or an order for relief is entered against the PERFORMING AGENCY under the
Federal Bankruptcy Code; or the PERFORMING AGENCY is adjudicated bankrupt or insolvent;
or any portion of the property of the PERFORMING AGENCY is sequestered by court order and
the order remains in effect for more than 30 days after such party obtains knowledge thereof; or a
petition is filed against the PERFORMING AGENCY under any state, reorganization, arrangement,
insolvency, readjustment of debt, dissolution, liquidation, or receivership law of any jurisdiction,
whether now or hereafter in effect, and such petition is not dismissed within 30 days; or
(9) Termination for failure of funding. This contract may be terminated in the event state and/or federal
funding for this contract is terminated, limited, suspended, or withdrawn; or
(10) The PERFORMING AGENCY files a case under the Federal Bankruptcy Code or is seeking relief
under any provision of any bankruptcy, reorganization, arrangement, insolvency, readjustment of
debt, dissolution, receivership or liquidation law of any jurisdiction, whether now or hereafter in
effect, or consents to the filing of any case or petition against it under any such law; or
(11) The PERFORMING AGENCY fails to comply with any of the terms, conditions or provisions of
the contract, in any manner whatsoever.
D. Termination for Cause by PERFORMING AGENCY. If the RECEIVING AGENCY is in breach of this
contract or fails to make payments as required by the contract, the PERFORMING AGENCY may
terminate the contract.
E. Termination without Cause. This contract and any Attachment hereto may be terminated by either party
without cause provided ninety (90) days written notice is provided to the other party.
Written notice will be provided by the terminating party at least 30 days prior to the intended date of termination
unless an emergency exists or stated otherwise.
If either party gives notice of its intent to terminate all or a part of this contract, RECEIVING AGENCY and
PERFORMING AGENCY will try to resolve any issues related to the anticipated termination in good faith during
the notice period. Upon termination of all or part of this contract, RECEIVING AGENCY and PERFORMING
AGENCY will be discharged from any further obligation created under the applicable terms of this contract except
for the equitable settlement of the respective accrued interests or obligations incurred prior to termination. Termination
does not, however, constitute a waiver of any remedies for breach of this contract. In addition, the obligations of the
PERFORMING AGENCY to retain records and maintain confidentiality of information shall survive this contract.
ARTICLE 28. Personnel
All personnel funded by Attachment(s) to this contract are employees of PERFORMING AGENCY which will be
responsible for their direction and control and liable for any of their acts or omissions.
(LHS) 1998 GENERAL PROVISIONS - Page 17 (8/97)
PERFORMING AGENCY will have in place legally sufficient Due Process Hearing Procedures for all of its
employees filling state budgeted positions.
PERFORMING AGENCY will have full authority to employ, promote, suspend, demote, discharge, and transfer
within its organization any and all state budgeted personnel funded by Attachment(s) to this contract provided,
however, that any demotion, suspension, or discharge of such state budgeted employees will be in accordance with
the Due Process Hearing Procedures as set out above. The only distinction between state budgeted and local paid
employees is that employees on state budgeted positions receive state benefits and are subject to certain duties,
obligations, and restrictions as state employees as contained in state law. One such restriction, as contained in the State
Appropriations Act, is that no employee paid on a state budgeted position may receive a salary supplement from any
source unless specifically authorized in the Appropriations Act or other state law. This prohibition includes, but is not
limited to, the payment to such employee of a so-called "flat rate" car allowance or travel allowance. Any such travel
or per diem allowance to these employees must be on a reimbursement basis, supported by appropriate records, and
may not exceed the reimbursement for mileage and/or per diem allowed under the Appropriations Act and current
state travel regulations. This restriction will apply whether travel funds are provided in Attachment(s) under this
contract or from any other source.
PERFORMING AGENCY will utilize RECEIVING AGENCY's policies and procedures for hiring and promoting
individuals into state budgeted positions funded by this contract. Qualifications of any individuals filling these positions
will be subject to approval of RECEIVING AGENCY's Bureau of Personnel Management. The purpose of the
approval is to ensure that individuals occupying these positions meet minimum educational and experience
requirements.
PERFORMING AGENCY will maintain required records and submit documents necessary to process personnel,
payroll, leave and time records, and travel claims on state budgeted positions. PERFORMING AGENCY will be
furnished state warrants by RECEIVING AGENCY for salary compensation or travel reimbursement for issuance
to employees on state budgeted positions.
An independent audit is not required as a condition of this contract if the Attachment provides assistance through
assignment of state budgeted positions and no funds are budgeted for local costs.
PERFORMING AGENCY may be reimbursed for local personnel costs or other categories of expense used to fulfill
the scope of work of applicable Attachment(s) in lieu of being furnished state payroll warrants after a state budgeted
position becomes vacant. Reimbursement will not exceed the balance of funds on the state budgeted position after all
benefits, obligations, and/or other entitlements are met. PERFORMING AGENCY's Director, or other person(s)
authorized elsewhere in this contract, may submit a request for conversion. RECEIVING AGENCY will transmit
formal approval and a revised budget to PERFORMING AGENCY to complete the conversion if the request is
granted.
PERFORMING AGENCY agrees to defend and indemnify RECEIVING AGENCY for any and all claims and/or
judgments taken against any employees, state or local, or against the RECEIVING AGENCY, arising out of any
claims or cause of action against any such employees, except to the extent that employees on state budgeted positions
may be indemnified and the state may be liable for certain acts pursuant to Chapter 104 of the Civil Practice and
Remedies Code of Texas and any other applicable law. The PERFORMING AGENCY agrees to indemnify and hold
harmless the RECEIVING AGENCY for any and all claims and/or judgments taken against RECEIVING AGENCY
by employees of the PERFORMING AGENCY that are funded by the Attachment(s) to this contract.
ARTICLE 29. Funding Participation Requi
PERFORMING AGENCY agrees funds provided through this contract will not be used for matching purposes in
securing other funding unless otherwise directed or approved by RECEIVING AGENCY.
(LHS) 1998 GENERAL PROVISIONS - Page 18 (8/97)
so -
ARTICLE 30. ,Survival of Terms
Termination or expiration of this contract for any reason shall not release either party from any liabilities or
obligations set forth in this contract that (a) the parties have expressly agreed shall survive any such termination or
expiration, or (b) remain to be performed or by their nature would be intended to be applicable following any such
termination or expiration.
ARTICLE 31. No Waiver of Sovereign Immunity
THE PARTIES EXPRESSLY AGREE THAT NO PROVISION OF THIS CONTRACT IS IN ANY WAY
INTENDED TO CONSTITUTE A WAIVER BY RECEIVING AGENCY OR THE STATE OF TEXAS OF
ANY IMMUNrIIES FROM SUIT OR FROM LIABILITY THAT RECEIVING AGENCY OR THE STATE
OF TEXAS MAY HAVE BY OPERATION OF LAW.
(LHS) 1998 GENERAL PROVISIONS - Page 19 (8/97)
DOCUMENT NO. 7560005906 -99
ATTACHMENT NO. 01
PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT
RECEIVING AGENCY PROGRAM: BUREAU OF HIV AND STD PREVENTION
TERM: January 01, 1998 THRU: December 31, 1998
SECTION I. SCOPE OF WORK:
PERFORMING AGENCY agrees to conduct HIV prevention activities to help prevent infection
and reduce the transmission of human immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS). Project activities and materials will be appropriate to the target
populations identified in PERFORMING AGENCY'S objectives described below. Strategies to
accomplish the projects must demonstrate cost-effectiveness, innovation, coordination, and
collaboration with other community efforts.
All information and educational materials developed and provided by PERFORMING AGENCY
will be accurate, comprehensive, and consistent with current findings of the United States Public
Health Service.
PERFORMING AGENCY agrees that all activities will be performed in accordance with
RECEIVING AGENCY'S request for proposal (RFP) and assurances, and PERFORMING
AGENCY'S objectives, activities work plan, and detailed budget as approved by RECEIVING
AGENCY, and with the relevant Regional Action Plan for the region/area in which
PERFORMING AGENCY is providing services. All of the above -named documents are
incorporated herein by reference and made a part of this Attachment. All revisions to said
documents will be approved by RECEIVING AGENCY and transmitted in writing to
PERFORMING AGENCY.
Prevention activities under this Scope of Work may include Prevention Counseling/Partner
Elicitation (PCPE) OR Health Education/Risk Reduction (HERR) OR both PCPE and HERR.
PCPE ACTIVITIES:
PCPE activities include establishing and maintaining anonymous and/or confidential HIV
counseling and testing programs for persons at risk of HIV infection due to individual sexual
behavior, injecting drug use, or other risk behaviors.
If PERFORMING AGENCY provides PCPE services, these services must be targeted to those
populations identified as priority populations in the relevant Regional Action Plan and specified
in PERFORMING AGENCY'S objectives. PERFORMING AGENCY must:
ATTACHMENT - Page 1
1. Offer voluntary HIV counseling and testing to clients with the option of receiving
services either anonymously or confidentially according to RECEIVING AGENCY
HIV/STD Guidelines, October 1997.
2. Provide culturally competent and effective PCPE counseling based on
RECEIVING AGENCY approved guidelines.
3. Publicize HIV counseling and testing services so that potential clients will know
where and when services are available.
4. Offer HIV PCPE services at locations that are convenient for the majority of the
target population and during hours established to reach these clients.
5. Use optically scannable forms supplied by RECEIVING AGENCY or a similar
RECEIVING AGENCY approved instrument to collect demographic information
and unlinked test result data. This includes the accurate completion and timely
submission of scannable forms within thirty (30) days of the test date.
6. Utilize RECEIVING AGENCY'S laboratory for all testing of specimens unless
otherwise approved in writing by RECEIVING AGENCY.
7. Develop and maintain a referral plan by which reciprocal linkages are established
with other service providers (especially other RECEIVING AGENCY funded
providers) for the purpose of effectively referring individuals for appropriate
medical, case management, mental health, and social and support services.
PERFORMING AGENCY will perform the following Partner Elicitation (PE) Services:
1. All PE services will be consistent with RECEIVING AGENCY'S HIV
Seropositive and Partner Notification Guidelines, November 1997, or most current
version, which has been provided by RECEIVING AGENCY, and are
incorporated by reference and made part hereof.
2. Partner elicitation/notification will be addressed as an element of every test
decision counseling session.
3. Notification of partners to PERFORMING AGENCY'S area local health
department will be encouraged. Adequate partner locating/descriptive information
will be elicited and referred to PERFORMING AGENCY'S area local STD
Control Program.
4. If the client prefers to make the partner notification personally, provide counseling
guidance/coaching on how, when and where to make each notification.
ATTACHMENT - Page 2
5. Counselors will make a good faith effort to elicit information on spouses of known
HIV -infected clients. A spouse is defined as "any individual who is the marriage
partner of an HIV -infected patient, or who has been the marriage partner of that
client at any time within the 10-year period prior to the diagnosis of HIV
infection. "
6. PERFORMING AGENCY agrees to report PE data to RECEIVING AGENCY on
the Partner Elicitation Report Form (PERForm) that has been provided by
RECEIVING AGENCY.
PERFORMING AGENCY agrees to comply with the following Quality Assurance Guidelines:
1. PERFORMING AGENCY assures that prevention counseling sessions are
performed by staff who have successfully completed PCPE training from a course
and instructor approved by RECEIVING AGENCY, and who have demonstrated
quality performance of PCPE standards per the immediate supervisor.
2. PERFORMING AGENCY will conduct monitoring of PCPE sessions. Through
the use of Quality Assurance Systems (QAS), PERFORMING AGENCY'S
program manager will possess QAS information and will monitor counselor
performance (at least monthly for months 1-6 of employment, bimonthly for
months 7-12, and quarterly for experienced counselors whether directly supervised
or on independent assignment). A written record (RECEIVING AGENCY skills
assessment form or other RECEIVING AGENCY approved model, a copy of
which has been provided by RECEIVING AGENCY) of the monitored session is
to be kept on file for a minimum period of one (1) year.
3. PERFORMING AGENCY agrees to facilitate RECEIVING AGENCY review of
scheduled PCPE sessions.
PERFORMING AGENCY agrees to comply with Chapters 81 and 85 of the Health and Safety
Code, relevant portions of Chapter 6A (Public Health Service) of Title 42 (The Public Health &
Welfare) of the U.S. Code, as amended, and the Client Services Standards for Public Health and
Community Clinics, revised June 1997.
PERFORMANCE MEASURES
RECEIVING and PERFORMING AGENCIES agree that the following performance measures
will be used to assess, in part, the PERFORMING AGENCY'S effectiveness in providing the
ATTACHMENT - Page 3
services set forth in this contract Attachment, without waiving the enforceability of any of the
other terms of the contract.
PERFORMING AGENCY will provide an estimated 1.600 PCPE sessions which involve one-on-
one interaction between a counselor and client that includes the following characteristics:
-- assisting the client to assess personal risk level,
-- formulating individualized risk reduction plans,
-- test decision counseling,
-- elicitation from HIV -infected clients of partner information, including information
about any spouses the client has had within the ten-year period prior to diagnosis,
and,
-- appropriate referrals, particularly of HIV -infected pregnant females for pre -natal
care.
These activities will occur in one or more sessions with each client. Each session may or may
not result in an HIV -antibody test. Clients will be targeted based on the relevant Regional Action
Plan for the region/area in which PERFORMING AGENCY is providing services. Services shall
be provided in or benefiting the county(ies)/area defined as: Lubbock.
PERFORMING AGENCY agrees to use the HIV Counseling and Testing Report Form, by
completing a form on each client receiving a PCPE session. PERFORMING AGENCY also
agrees to remit these completed forms to RECEIVING AGENCY in a timely manner no later than
thirty (30) days after PCPE sessions have been rendered in order to aid RECEIVING AGENCY
in tracking the number of persons obtaining PCPE services statewide.
PERFORMING AGENCY agrees to maintain client counseling records, both anonymous and
confidential, which include all issues discussed in counseling which are relevant to HIV/STD risk
and prevention. Documentation will show relevant counseling standards were met, or will explain
why they were not met. Counseling records will be confidentially secured, maintained for a
minimum of one (1) year, and will be available for review by RECEIVING AGENCY.
HERR ACTIVITIES:
HERR programs and services are efforts to reach persons at increased risk of becoming HIV -
infected or, if already infected, of transmitting the virus to others. The goal of HERR programs
is to reduce the risk of these events occurring.
If PERFORMING AGENCY provides HERR services, these services will be targeted to those
populations identified as priority populations in the relevant Regional Action Plan and specified
in PERFORMING AGENCY'S objectives. PERFORMING AGENCY will:
ATTACHMENT - Page 4
1. Provide educational and counseling interventions that promote and reinforce safer
behavior. HERR programs will include interpersonal skills training for clients
in negotiating and sustaining appropriate behavior change (e.g., delaying the
initiation of sexual activity, avoiding unsafe sex, negotiating safer sex, needle
cleaning, and relapse prevention).
2. Ensure that all educational materials used in the program are written in words and
terms used by the target populations and at the appropriate age and educational
levels, including low -literacy materials.
3. Conduct appropriate interventions and activities as described in the relevant
community plan (e.g., one-on-one counseling, group presentations, street and
community outreach, prevention case management).
4. Establish written referral procedures or protocols. HIV -positive clients will be
referred as appropriate to early intervention services: TB testing and treatment;
substance abuse counseling and treatment; family planning services; and further
risk reduction or prevention counseling. HIV -infected pregnant women must be
referred as appropriate to pre -natal care. At -risk seronegative clients will be
referred as appropriate to mental health providers or other services that can help
initiate healthy behaviors; substance abuse assessment, treatment, and counseling;
family planning services; prenatal services; routine medical care; and shelters.
5. Maintain consistent and accurate data collection procedures which collect client
level data as specified by RECEIVING AGENCY. PERFORMING AGENCY
agrees to report client data and progress on objectives in a manner and format
specified by RECEIVING AGENCY.
PERFORMING AGENCY agrees to comply with the following Quality Assurance Guidelines:
1. Staff supervisor monitors individual HERR staff performance at least monthly for
months 1-6 of employment, bi-monthly for months 7-12, and quarterly thereafter.
Feedback is provided to staff on any area needing improvement. Monitoring
session evaluations are kept on file and available for RECEIVING AGENCY
review for a minimum of one (1) year.
2. Facilitate RECEIVING AGENCY review of HERR activities.
10,11 • i�
ATTACHMENT - Page 5
RECEIVING and PERFORMING AGENCIES agree that the following performance measures
will be used to assess, in part, the PERFORMING AGENCY'S effectiveness in providing the
services set forth in this contract Attachment, without waiving the enforceability of any of the
other terms of the contract.
PERFORMING AGENCY will make an estimated Q contacts with clients in the behaviorally
defined target population(s) to provide priority HERR interventions that are consistent with those
priorities specified in the Regional Action Plan for the region/area in which PERFORMING
AGENCY is providing services defined as: Lubbock.
PERFORMING AGENCY agrees to provide proof, in each quarterly activity report, of the
number of contacts with clients in the behaviorally defined target population(s) in which priority
HERR intervention services are provided. Such reports will be submitted in the standard format
provided by RECEIVING AGENCY.
SECTION II. SPECIAL PROVISIONS:
RECEIVING AGENCY will supply PERFORMING AGENCY with the most current version of
the document entitled "Content of AIDS -Related Written Materials, Pictorials, Audiovisuals,
Questionnaires, Survey Instruments, and Educational Sessions in Centers for Disease Control
Assistance Programs." PERFORMING AGENCY has provided RECEIVING AGENCY with
written acknowledgment of receipt and assurance of compliance with these guidelines. All of the
above -referenced documents are incorporated herein and made a part of this Attachment as though
written herein verbatim.
Due to the sensitive and highly personal nature of HIV/AIDS-related information, strict adherence
to the General Provisions, CONFIDENTIALITY Article is required. In addition to these
conditions, PERFORMING AGENCY will comply with RECEIVING AGENCY Program,
Bureau of HIV/STD Guidelines, October 1997. All of the above -referenced documents are
incorporated herein and made a part of this Attachment as though written herein verbatim.
PERFORMING AGENCY, or any subcontractor, shall not transfer a client record (including a
patient record) to another entity or person without written consent from the client or patient, or
someone authorized to act on his or her behalf; however, RECEIVING AGENCY (The Texas
Department of Health) may require PERFORMING AGENCY, or any subcontractor, to transfer
a client or patient record to RECEIVING AGENCY (The Texas Department of Health) if the
transfer is necessary to protect either the confidentiality of the record or the health and welfare
of the client or patient.
RECEIVING AGENCY (The Texas Department of Health) shall have access to a client record
(including a patient record) in the possession of PERFORMING AGENCY, or any subcontractor,
under authority of the Health and Safety Code, Chapters 81 and 85, and the Texas Revised Civil
Statutes, Article 4495b (Medical Practice Act). In such cases, RECEIVING AGENCY (The
ATTACHMENT - Page 6
Texas Department of Health) shall keep confidential any information obtained from the client or
patient record, as required by the Health and Safety Code, Chapter 81, and the Texas Revised
Civil Statutes, Article 4495b.
PERFORMING AGENCY will submit quarterly activity reports within twenty (20) days after the
end of each quarter that are prepared in the format provided by RECEIVING AGENCY.
PERFORMING AGENCY will authorize their staff to attend training, conferences, and meetings
for which funds were budgeted and approved by RECEIVING AGENCY.
ATTACHMENT - Page 7
SECTION III. BUDGET:
PERSONNEL
$30,764.00
FRINGE BENEFITS
8,660.00
TRAVEL
684.00
EQUIPMENT
0.00
SUPPLIES
50.00
CONTRACTUAL
0.00
OTHER
175.00
TOTAL DIRECT CHARGES $40,333.00
INDIRECT CHARGES 1,600.00
TOTAL $41,933.00
Total reimbursements will not exceed $ 41,933.00.
Financial status reports are due the 30th of April, 30th of July, 30th of October, and the 15th of
February.
Indirect cost is based on UGCMS, Table 1. Indirect charges to this contract may not exceed the
amount shown above, except by prior written approval of RECEIVING AGENCY.
ATTACHMENT - Page 8
Resolution No.5622
APPLICATION FOR FUNDING Item # 28
TEXAS DEPARTMENT OF HEALTH September 11, 1997
HIV/STD HEALTH RESOURCES DIVISION
DATE RECEIVED BY STATE, ! /
APPLICANT INFORMATION
1) LEGAL NAME: C i ty of Lubbock Health Dept
8)
ADDRESS: (sveaAd&c.. P.O. Bo: Nuber, city, County, sure.
2) PAYEE NAME: C i ty of Lubbock
wWZip Code)
3) HSDA NAME:
1 �02 Texas Ave.
4) TDH REGION NO: 1
PO Box 2548
Lubbock, T;;. 79408
5) EXECUTIVE DIRECTOR:
a) Name: Mary Strange, RN
Lubbock County
b) Phone No: (806) 775-2899
9)
PAYEE ADDRESS: ardiff.)
c) FAX No. ( 804 775-3209
14/A
d) E-mail Address: mstrange@ci.lubbock.tx.us
6) CONTACT: -
a) Name: Tammy Foskey
b) Phone No: (806) 767-2953
7) FINANCIAL OFFICER AND PHONE NO:
10)
TAX I.D. NUMBER:
a) Name: Anna Mosqueda
17560005906
b) Phone No: ( 804 775-2002
11) TYPE OF APPLICANT: (enter appropriate letter:)
A
a) City Health Department
f)
Private Non -Profit Organization
b) County Health Department
g)
Higher Education
c) District Health Department
h)
Indian Tribe
d) Community -Based Organization
i)
Minority Organizations
e) Hospital
j)
Other (specify)
12) TYPE OF APPLICATION: ❑ NEW { CONTINUATION
13) DESCRIPTIVE TITLE OF PROJECT:
14)
REQUESTED FUNDING:
H_1 V PREVE_NT.I 01`l COUNSELING AND PARTNER
$41,933.00
-ELICITA ON -
15) START DATE END DATE
16)
LIST ALL COUNTIES TO BE SERVED:
0 a
Lubbock
15) AUTHORIZED REPRESENTATIVE:
a) Name: ALEX "TY" COOKE
b) Title: Mmmr MAYOR PRO TEM
c) Phone No: (80t 7,7L-2qnn
17) SIGNATURE F �PRIZED REPRESENTATIVE
18)
DATE SIGNED:
'PerUofDir
answer questions about application other than Executive Director.
•«Bators mem rship is 50`� minority.
AT- APP ED AST CON T:
Kaythi 11arne-1 1, City Secretary—'-----,— Doug Good anaging Director of
Health and ommunity Services
VED AS TO FN:
D d To
e -irst Assistant
City Attorney
APPLICATION CHECKLIST
NAME OF APPLICANT: City of Lubbock Health Department
Instructions: Send all items checked below with the 1998 Targeted Prevention application.
Required forms are attached.
PREFATORY DOCUMENTS
✓_Application for Funding Form
_Abstract
✓_Application Checklist
_Table of Contents
PROJECT NARRATIVE
Background and Need
Overall Project Design
Capacity of the Organization
Coordination with other Agencies
✓_ 1998 Workplan
✓_Target Group Chart for Objective
Other Project Objectives
Evaluation Plan
Education Curriculum
BUDGET
Funding from Other State Agencies Form
✓_Budget Summary Form
✓ Personnel Form
✓_Equipment List and Equipment Justification Form
✓_Contractual Form
Multiple Funding Sources Form
✓_Categorical Budget Justification
ASSURANCES
✓ TDH Certifications
✓ TDH Assurances
✓_HIV Contractor Assurances
✓_Board Member and Executive Officer Assurances
✓_Statement of Understanding and Agreement
OTHER REQUIRED DOCUMENTATION
✓_HUB forms
APPENDICES:
Indirect cost rate agreement, if applicable
Other documentation you deem necessary
SMMISSI®N OF APPLICATION:
✓ '` ORIGINAL AND ONE COPY OF APPLICATION TO' AUSTIN TDH ADDRESS ` .,
✓ SEND ONE COPY OF APPLICATION TO REGIONAL HIV COORDINATOR
1998 WOMPLAN
The City of Lubbock Health Department Prevention Counseling/Partner Elicitation
Activities will focus on the target populations identified by the 1996 Region 1 Action Plan
as determined by the Region 1 HIV Planning Coalition and the Texas Department of
Health. Specifically, these targeted groups are: men who have sex with men (MSM) who
are adolescents, college -aged, men of color and anglo men; injecting drug users (IDU) who
are incarcerated, sex workers, and/or homeless; and people who have or have had
unprotected heterosexual sex (UHS) and who are migrants, gang members and/or female
partners of injecting drug users and/or female partners of men who have sex with men. The
City has targeted all these groups during past years. During the first six months of 1997,
the City's HIV Counselor has served:
20
MSM-Adolescent
136
MSM-College-Aged
113
MSM-Of Color
139
MSM-Anglo
46 IDU-Homeless
46 IDU-Sex Worker
191 IDU-Incarcerated
27 UHS-Migrant
167 UHS-Gang member
309 UHS-Female Partner of IDU and/or MSM
23 9 Other
1433 TOTAL
From July 1, 1996 through June 30, 1997, the City of Lubbock provided counseling and
testing for 2395 individuals. Of those tested, 2199 returned for post-test counseling for a
return rate of 91.82%. The return rate is very important, as it is an indication of the ability
of the HIV Counselor to "relate" with the individuals she is testing. The clients report that
they find the testing experience comfortable, non judgmental, and respectful. These
attributes appear to be the reason so many individuals return for their test results. These
attributes also make it possible for the HIV Counselor to overcome many perceived barriers
to service.
These perceived barriers to service include: 1) the lack of a peer providing the testing and
counseling; 2) the location of the primary testing site in a local government building; 3)
number of people sitting in the STD waiting room, and 4) the need to make an appointment
for testing and counseling, if one wants to be seen quickly. All of these perceived barriers
to service have been overcome by time. When the Health Department started the HIV
testing and counseling program, many clients asked to be tested anonymous and/or off -site.
As time has passed and noone has been identified by Health Department staff as HIV
positive or as having been tested, the confidence level of potential clients has increased.
The high -risk populationsn have developed a sense of trust in the Health Department staff
primarily due to a word-of-mouth publicity campaign. As individuals come in to be tested
and are treated with respect and nonjudgmentally, they relate their experience to their peers.
Presently, we are finding that we are testing some individuals who could choose to be tested
by peers, but they prefer our system, our location and our reputation for maintaining
confidentiality.
To increase the number of individuals we are reaching in each specific target group, we
have spent the last year adding locations for off -site testing. The Health Department staff
plans to continue to reach out to individuals in their communities rather than waiting for
them to come to us. The HIV Counselor will continue to collaborate with various agencies
in the Lubbock area to provide testing after HIV Educational presentations. The agencies
that are currently sources of collaborative activities are: Central Lubbock Church of
Christ's Inside/Out program, Texas Tech University, Lubbock Regional Mental Health/
Mental Retardation, Catholic Family Services, Lubbock County Community Correctional
Facility, Lubbock County Jail, Lubbock County Youth Center, Managed Care facilities (in-
patient and out -patient drug treatment), South Plains College, the South Plains AIDS
Resource Center and Captain Hollywood (gay club).
On -site testing is available at the Health Department Monday through Friday, by
appointment. Off -site testing is currently being provided weekly at the Lubbock County
Jail, Texas Tech University, and Inside/Out. Testing is provided on a monthly basis at the
Lubbock County Community Correctional Facility, Lubbock County Youth Center and at
the gay club. Testing is provided bi-monthly at the managed care facilities (drug treatment
facilities). Other testing opportunities off -site are scheduled as needed. The HIV
Counselor also allows for her schedule to include time to provide testing at a person's
home, business, etc. as requested.
The workplan for 1998 will be very similar to that of the 1997 workplan. The schedule has
been one that has allowed for targeted groups to be addressed on a regular basis and
prevention counseling and testing provided. The collaborative efforts between agencies
have been positive and have allowed for persons desiring testing to be reached. Two
agencies in Lubbock provide HIV testing and both agencies are working together to
prevent duplication of services so that the needs of the community can be served in a timely
manner.
HIV OUTREACH ACTIVITIES
1. AGENCY RECEIVING PCPE ACTIVITY: LUBBOCK COUNTY COMMUNITY
CORRECTIONAL FACILITY
COLLABORATIVE AGENCY: INSIDE/OUT
PCPE ACTIVITIES PROVIDED (DAY/TIME): 1ST MONDAY OF THE MONTH 9AM-
12NOON
ACTIVITY: SMALL GROUP PRESENTATION
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED); IDU
(INCARCERATED); UHS (GANGS)
2. AGENCY RECEIVING PCPE ACTIVITY: LUBBOCK COUNTY JAIL
COLLABORATIVE AGENCY: LUBBOCK MENTAL HEALTH/MENTAL RETARDATION
PCPE ACTIVITIES PROVIDED (DAY/TIME): WEEKLY WHEN TRUSTEE BLOOD
DRAWN
ACTIVITY: SMALL GROUP PRESENTATION
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED); IDU
(INCARCERATED, SEX WORKER); UHS (GANGS, FEMALE PARTNER OF
IDU/MSM, MIGRANTS)
3. AGENCY RECEIVING PCPE ACTIVITY: LUBBOCK COUNTY YOUTH CENTER
PCPE ACTIVITIES PROVIDED (DAY/TIME): AS NEEDED
ACTIVITY: 1:1
TARGET GROUPS REACHED: MSM (ADOLESCENT); IDU(INCARCERATED); UHS
(GANGS)
4. AGENCY RECEIVING PCPE ACTIVITY: MANAGED CARE (IN -PATIENT)
COLLABORATIVE AGENCY: LUBBOCK MENTAL HEALTH/MENTAL RETARDATION
PCPE ACTIVITIES PROVIDED (DAY/TIME): TWICE A MONTH (TUES/THURS 1-3)
ACTIVITY: SMALL GROUP PRESENTATION
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED); IDU
(HOMELESS, SEX WORKER); UHS (FEMALE PARTNERS OF MSM/IDU)
5. AGENCY RECEIVING PCPE ACTIVITY: MANAGED CARE (OUT -PATIENT)
COLLABORATIVE AGENCY: LUBBOCK MENTAL HEALTH/MENTAL RETARDATION
PCPE ACTIVITIES PROVIDED (DAY/TIME): ONCE A MONTH (WED 6-8PM)
ACTIVITY: SMALL GROUP PRESENTATION
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED); IDU
(HOMELESS, SEX WORKER); UHS (FEMALE PARTNERS OF MSM/IDU,
MIGRANTS)
6. AGENCY RECEIVING PCPE ACTIVITY: CAPTAIN HOLLYWOOD (GAY CLUB)
PCPE ACTIVITIES PROVIDED (DAY/TIME): ONCE A MONTH (FRI/SAT 10PM-2AM)
ACTIVITY: 1:1
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED,
ADOLESCENT)
7. AGENCY RECEIVING PCPE ACTIVITY: TEXAS TECH UNIVERSITY
PCPE ACTIVITIES PROVIDED (DAY/TIME): WEDNESDAY AND FRIDAY 14PM
ACTIVITY: 1:1
TARGET GROUPS REACHED: MSM (COLLEGE -AGED, OF COLOR, ANGLO); UHS
(FEMALE PARTNERS OF MSM/IDU)
8. AGENCY RECEIVING PCPE ACTIVITY: INSIDE/OUT
COLLABORATIVE AGENCY: INSIDE/OUT
PCPE ACTIVITIES PROVIDED (DAY/TIME): MONDAY, TUESDAY, THURSDAY 12-1:30
ACTIVITY: 1:1
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED,
ADOLESCENT); IDU (HOMELESS, SEX WORKER); UHS (GANGS, FEMALE
PARTNERS OF IDU/MSM, MIGRANTS)
9. AGENCY RECEIVING PCPE ACTIVITY: INSIDE/OUT
COLLABORATIVE AGENCY: INSIDE/OUT
PCPE ACTIVITIES PROVIDED (DAY/TIME): OUTREACH ACTIVITIES AS REQUESTED
ACTIVITY: 1:1 IN NEIGHBORHOODS, PARKS, ETC.
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED,
ADOLESCENT); IDU (HOMELESS, SEX WORKER); UHS (GANGS, FEMALE
PARTNERS OF IDU/MSM, MIGRANTS)
10. AGENCY RECEIVING PCPE ACTIVITY: SOUTH PLAINS COLLEGE
COLLABORATIVE AGENCY: LUBBOCK MENTAL HEALTH/MENTAL RETARDATION
PCPE ACTIVITIES PROVIDED (DAY/TIME): AS REQUESTED
ACTIVITY: SMALL GROUP PRESENTATION
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE -AGED); UHS
(FEMALE PARTNERS OF MSM/IDU)
11. AGENCY RECEIVING PCPE ACTIVITY: CITY OF LUBBOCK HEALTH DEPARTMENT
PCPE ACTIVITIES PROVIDED (DAY/TIME): MONDAY-FRIDAY BY APPOINTMENT
ACTIVITY: 1:1
TARGET GROUPS REACHED: MSM (OF COLOR, ANGLO, COLLEGE AGED,
ADOLESCENT); IDU (HOMELESS, SEX WORKER); UHS (GANGS, FEMALE
PARTNERS OF IDU/MSM, MIGRANTS) AND OTHERS (OCCUPATIONAL RISK,
SEXUAL ASSAULT, UHS WITH ALCOHOL/OTHER DRUG USE, BLOOD
TRANSFUSION, SEX WITH UNFAITHFUL PARTNER, STD HISTORY)
12. ALL OTHER REQUESTS FOR PCPE ACTIVITY (SMALL GROUP PRESENTATIONS
AND/OR I:1)WILL BE CONSIDERED AND GIVEN CONSIDERATION AND
ATTENTION TO AS NEEDED. THIS INCLUDES HOME TESTING REQUESTS.
PCPE OBJECTIVE 1: TARGET GROUP CHART
REGION 1
By December 31, 1998, the City of Lubbock PCPE Program will provide HIV prevention counseling, according to TDH guidelines, to
1600 persons, as outlined below:
BDTP
(2)
(3)
(4)
(5)
(6)
Subpopulation
Priority
Number To
Percent of
Activity/ Setting(s)
H, M, L
Be Served
Total
MSM
Adolescent
H
75
4.69%
LCYC, Inside/Out (HERR),
Catholic Family Services
(HERR), STD Clinic, club
1:1/sm group
MSM
College -aged
H
200
12.50%
TTU, club, theaters/bookstores,
STD Clinic, Inside/Out
(HERR), Managed Care,
correctional facilities
1:1 /sm. group
MSM
Of Color
H
225
14.06%
Club, theaters/bookstores, TTU
Inside/Out, STD Clinic,
Managed Care, correctional
facilities
1:1 /sm. group
MSM
Anglo
M
200
12.50%
Club, theaters/bookstore, STD
Clinic, TTU, Managed Care,
correctional facilities
1:1/sm. group
IDU
Homeless
H
125
7.81%
Correctional facilities, Managed
Care, Inside/Out, STD Clinic
1:1/sm. group
IDU
Sex worker
H
125
7.81%
Correctional facilities, TTU,
STD Clinic, Managed Care,
1:1/sm. grou
IDU
Incarcerated
M
175
10.94%
Correctional facilities,
Inside/Out, STD Clinic
1:1 /sm. group
UHS
Migrants
H
75
4.69%
Catholic Family Services,
Inside/Out, Managed Care
1:1/sm. grou
UHS
Gang Member
M
200
12.50%
LCYC, Inside/Out, Correctional
facilities, STD Clinic
1:1 /sm. group
UHS
Female Partners
M
200
12.50%
TTU, CFS, STD Clinic,
Inside/Out, Managed Care,
correctional facilities
1:1/sm. group
Other
Other
L
STD Clinic, TTU, Managed
Care, Inside/Out, correctional
facilities
1:1
TOTAL
:•i
..:.�..............................
1600
100 /o
:•i:•::•iYi
':.::•Y.•i:•i:•i:•::•i:::•i:•i:•i:•iiisv'.i:•i:•iii::•i::>.ii:•is....i::K;:::.....i:•i::•
...:....................................n:
AGENCY: City of Lubbock Health Department
#M-B
BUDGET SUMMARY -CATEGORIES
Instructions: Show funds related to the programming for this application only.
Object Class
Categories
TDH FUNDS
REQUESTED
(1)
DIRECT FEDERAL
FUNDS
(2)
OTHER STATE
AGENCY FUNDS
(3)
LOCAL FUNDING
SOURCES
(4)
OTHER
FUNDS
(5)
TOTAL
(6)
a. Personnel
$
$
$
$
$
$ 0 64.00
b. Fringe Benefits
R 660 . o0
3,660.00
c. Travel
684.00
684.00
d. Equipment
e. Supplies
50.00
50.00
f. Contractual
g. Construction
N.A.
h. Other
175.00
17 5.0 0
I. Indirect Charges
1 , 600.OJ
1,600.00
j. Total (Sum of a. -I.)
$
$
$
$
$
$41 .00
k. Program Income
$
KEY PERSONNEL OF ADMINISTRATIVE AGENCY
AGENCY NAME City of Lubbock Health Department
Instructions: List the salary by funding source for each staff person supported by this proposal. Source I is the current proposal funding source. List the salary
amounts charged to other funding sources in columns 3-6 (Eg: CTRPE, HERB, HOPWA, Ryan White Title II, etc.).
NAME AND
Annual
Amount of
Amount of
Amount of
Amount of
Amount of
Total Salary
POSITION TITLE
Salary
salary charged
Salary
Salary
Salary
Salary
to Source 1
charged to
charged to
charged to
charged to
(this proposal)
Source 2
Source 3
Source 4
Source 5
Tammy Foskey, HIV
$30,764.00
$30,764.00
$0.00
$0.00
$0.00
$0.00
$30,764.00
Counselor
TOTALS
$ 30,764.00
$30,764.00
$0.00
$0.00
$0.00
$0.00
$30,764.00
N/A
AGENCY: City of Lubbock Health Department
#III-D
EQUIPMENT LIST
Amount Requested in budget for equipment: $
Itemize, describe and justify each item below. Attach complete specifications or a copy of the purchase order. Equipment is defined as
tangible nonexpendable personal property having a useful life of more than one year and an acquisition cost of $1000.01 or more per
item, with the following exceptions: Fax Machines, Stereo Systems, Cameras,Video Recorders/Player, Microcomputers, and Printers,
which cost over $500. These exceptions must still be approved for purchase as equipment and are considered as capital assets for
inventory purposes. Attach the Checklist for Request for Equipment Purchases and Equipment Justification form to this list.
I1'E11+I
$1000 or Exceptions)'' ,
AivIOIJNT DER YTEiVL:
'I'®A]LE][t ITEM
PURPOSE
III-D con't.
JUSTIFICATION FOR REQUEST FOR EQUIPMENT PURCHASES '
Instructions: Use one Justification form for each item listed on the Equipment List.
Contractor Name:
Scope of Work:
Contract Number: Contract Term:
Description of Equipment Requested (attach additional sheets if necessary and copies of specifications
and/or other pertinent documentation):
ALL APPLICANTS MUST COMPLETE THIS SECTION:
1. Does the cost include shipping and handling?
2. Does the cost include a warranty?
3. Does the cost include a maintenance agreement?
4. Does the cost include training in the use of the equipment?
5. If the equipment"is a lease -to -purchase agreement, is a copy of the agreement attached?
6. Why is the equipment needed? What is the purpose of the equipment? Who will benefit and how? Who
will use the equipment? Where will it be located?
7. Why is this equipment more appropriate than other alternatives considered or a less expensive piece
equipment?
8. If the equipment has "special" or "optional' features, explain why they are necessary.
19. If the equipment is being leased with no option to buy, explain the benefit(s).
10. If lease -purchase costs are spread across several funding sources, other than TDH, who are the other)
funding sources and what is their percent of funding?
HIV SERVICES PROVIDERS ONLY:
If requesting computer equipment, does the program use the COMPIS program?
a. If yes, what is the memory capacity of the equipment currently used for COMPIS activity?
b. Does the equipment request have a larger memory capacity than the current COMPIS equipment?I
C. What enhancements will the new equipment provide?
3
2. If equipment is for an administrative agency does it match the service priorities established by the local
consortia?
THIS SECTION FOR USE BY TDH STAFF ONLY:
11. Do the item(s) fit the current TDH definition of equipment?
12. Are any of the item(s) "exception" items as listed in the equipment definition?
J 3. Is the equipment reflected in the correct budget category?
J4. Is the equipment specifically allowed or disallowed by the TDH RFP/RFA?
15. Is the equipment appropriate to the contract attachment's scope of work?
I6. If the equipment is of a technical nature, describe the process and the knowledgeable resources used to
determine appropriateness of equipment request.
4
Professional Services &
HIV PREVENTION COUNSELING AND PARTNER ELICITATION
BUDGET JUSTIFICATION
A. PERSONNEL
HIV Counselor (Tammy Foskey)
100% FTE for PCPE Activities
2563.67 /month X 12 months =
This position will continue to provide
counseling, testing, referral, and
partner elicitation in Lubbock County
for STD clients, female trustees, women
who are partners of men who have sex
with men or use injecting drugs, gang
members, men who have sex with men,
injecting drug users, and others seeking
testing for HIV at the City of Lubbock
Health Department.
B. FRINGE (29%)
FICA: rate x salary
Insurance: cost per month x FTE's
(Health ins: 2,613
Life ins. 33
Dental ins. 209
Retirement 3,587)
Total Fringe Rate
C. TRAVEL
Expenses for HIV Counselor to
attend one state conference.
Airfare
Hotel @ $55 x 4 days
Meals @ $25 x 4 days
Car Allowance ($.30/mi. x 800 mi/yr)
D. SUPPLIES
Funds are requested for the purpose of
general office supplies.
E. OTHER
Educational Supplies
Conference Registration
F. TOTAL DIRECT COSTS
G. TOTAL INDIRECT COSTS (UGCMS)
$30,764.00
$2,218.00
$6,442.00
29%
$100.00
$220.00
$100.00
$264.00
$100.00
$75.00
$30,764.00
$8,660.00
$684.00
$50.00
$175.00
$40,333.00
$1,600.00
H. TOTAL BUDGET $41,933.00
Bureau of HIV & STD Prevention
HIV/STD Health Resources Division
1 TEXAS DEPARTMENT OF HEALTH
2 CERTIFICATIONS
4 The undersigned (authorized official signing for the applicant organization) certifies to the best of his
5 or her knowledge and belief, that the applicant, defined as the primary participant in accordance with
6 45 CFR Part 76, and its principals:
7 (a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or
s voluntarily excluded from covered transactions by any Federal Department or Agency;
9 (b) have not within a 3-year period preceding this proposal been convicted of or had a civil
10 judgment rendered against them for commission of fraud or a criminal offense in connection
11 with obtaining, attempting to obtain, or performing a public (Federal, State, or local)
12 transaction or contract under a public transaction; violation of Federal or State antitrust statutes
13 or commission of embezzlement; theft, forgery, bribery, falsification or destruction of records,
14 making false statements, or receiving stolen property;
15 (c) are not presently indicted or otherwise criminally or civilly charged by a governmental entity
16 (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (b)
17 of this certification; and
18 (d) have not within a 3-year period preceding this application/proposal had one or more public
19 transactions (Federal, State, or local) terminated for cause or default.
20 Should the applicant not be able to provide this certification, an explanation as to why should be placed
21 after the assurances page in the application package.
22 The applicant agrees by submitting this proposal that it will include, without modification, the clause
23 titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion -Lower
24 Tier Covered Transaction" (Appendix B to 45 CFR Part 76) in all lower tier covered transactions (i.e.,
25 transactions with subgrantees and/or contractors) and in all solicitations for lower tier covered
26 transactions.
Ilya M•Z aa cccyna0•::
28 Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated funds to
29 influence certain Federal contracting and financial transactions," generally prohibits recipients of
30 Federal grants and cooperative agreements from using Federal (appropriated) funds for lobbying the
31 Executive or Legislative Branches of the Federal Government in connection with a SPECIFIC grant
32 or cooperative agreement. Section 1352 also requires that each person who requests or receives a
33 Federal grant or cooperative agreement must disclose lobbying undertaken with non -Federal (non-
34 appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING
35 $100,000 in total costs (45 CFR Part 93).
-1-
t The undersigned (authorized official signing for the applicant organization) certifies, to the best of his
2 or her knowledge and belief, that: '
3 (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
4 undersigned, to any person for influencing or attempting to influence an officer or employee
5 of any agency, a Member of Congress, an officer or employee of Congress, or an employee
6 of a Member of Congress in connection with the awarding of any Federal contract, the making
7 of any Federal grant, the making of any Federal loan, the entering into of any cooperative
8 agreement, and the extension, continuation, renewal, amendment, or modification of any
9 Federal contract, grant, loan, or cooperative agreement.
10 (2) If any funds other than Federally appropriated funds have been paid or will be paid to any
11 person for influencing or attempting to influence an officer or employee of any agent, a
12 Member of Congress, an officer or employee of Congress, or an employee of a Member of
13 Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the
14 undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying
15 Activities," in accordance with its instructions, and continuation sheet are included at the end
16 of this application form.)
17 (3) The undersigned shall require that the language of this certification be included in the award
18 documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
19 grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose
20 accordingly.
21 This certification is a material representation of fact upon which reliance was placed when this
22 transaction was made or entered into. Submission of this certification is a prerequisite for
23 making or entering into this transaction imposed by Section 1352, U.S. Code. Any person who
24 fails to file the required certification shall be subject to a civil penalty of not less than $10,000
25 and not more than $100,000 for each such failure."
;ro •.; :;�.;• ; • t�
27 The undersigned (authorized official signing for the applicant organization) certifies, to the best of his
28 or her knowledge and belief, that the statements herein are true, accurate, and complete, and agrees
29 to comply with the TDH terms and conditions if an award is issued as a result of this application.
30 Willful provision of false information is a criminal offense (Title 18, U.S. Code, Section 1001). Any
31 person making any false, fictitious, or fraudulent statement may, in addition to other remedies available
32 to the Government, be subject to civil penalties under the Program Fraud Civil Remedies Act of 1986
33 (45 CFR Part 79
34 Signature Awed rtitying UtticW Title
—
35 Date ALEX "TY" COOKE MAYOR PRO TEM
36 11 Legal Name of Applicant Organization
City of Lubbock Health Department
ATT T: PROVED AS TO NTENT:
-2-
Kayythy Darnell,City ary . g an, Managing Director of
AP D AS TO FORM:C.°t�l .L'&A�Q.
.n Health d Community Services
Bureau of HIV & STD Prevention
HIV/STD Health Resources Division
TEXAS DEPARTMENT OF HEALTH ASSURANCES
2
3 As the duly authorized representative of the applicant I certify that the applicant:
4 1. Has the legal authority to apply for state/federal assistance, and the institutional,
s managerial and financial capability (including funds sufficient to pay the non-
6 state/federal share of project costs) to ensure proper planning, management and
7 completion of the project described in this application.
s 2. Has a financial system that demonstrates accounting, budgetary and internal controls;
9 cash management; reporting capability; cost allowability determination; and source
10 documentation.
11 3. And parent, affiliate, or subsidiary organization, if such a relationship exists will give
12 TDH, the Comptroller General of the United States, and if appropriate, the federal
13 government, through any authorized representative, access to and the right to examine
14 all records, books, papers, or documents related to the award; and will establish a
15 proper accounting system in accordance with generally accepted accounting standards
16 or agency directives.
17 4. Will establish safeguards to prohibit employees from using their positions for a
18 purpose that constitutes or presents the appearance of personal or organizational
19 conflict of interest, or personal gain.
20 5. Will honor for 90 days after the application due date the technical and business terms
21 contained in the application.
22 6. Will initiate the work after receipt of a fully executed contract and will complete it
23 within the contract period.
24 7. Will comply with the requirements of the Immigration Reform and Control Act of
25 1986, 8 U.S.C. 1324a(b)(1), and Immigration Act of 1990, 78 U.S.C.A. §1101,
26 regarding employment verification and retention of verification forms for any
27 individual(s) hired on or after November 6, 1986, described in this application who
28 will perform any labor or services.
-1-
t 8. Will comply with all federal statutes relating to nondiscrimination. These include but
2 are not limited to: Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d) which
3 prohibits discrimination on the basis of race, color or national origin; Title IX of the
4 Education Amendments of 1972, as amended (20 U.S.C. §§ 1681-1683, and 1685-
5 1686), which prohibits discrimination on the basis of sex; Section 504 of the
6 Rehabilitation Act of 1973 (29 U.S.C. 794), which prohibits discrimination on the
7 basis of handicaps; The Americans with Disabilities Act of 1990 (12 U.S.C. § 12101);
s and all amendments to each, and all requirements imposed by the regulations issued
9 pursuant to these acts, especially 45 CFR Part 80 (relating to race, color and national
10 origin), 45 CFR Part 84 (relating to handicap), 45 CFR Part 86 (relating to sex), and
11 45 CFR Part 91 (relating to age).
12 9. Will comply with the Uniform Grant and Contract Management Act (UGCMA),
13 Chapter 783, Texas Government Code Annotated, and the Uniform Grant and Contract
14 Management Standards (UGCMS) as amended by revised federal circulars to be
15 incorporated in UGCMS by the Governor's Budget and Planning Office which apply
16 as terms and conditions of any resulting contract. If a conflict arises between the
17 provisions of this contract, UGCMA and UGCMS, the provisions of UGCMA and
is UGCMS will prevail unless expressly stated otherwise. A copy of this manual and its
19 references are available upon request.
20 10. Will remain current in its payment of franchise tax or is exempt from payment of
21 franchise taxes, if applicable.
22 11. Will comply with the non-discriminatory requirements of Texas Labor Code, Chapter
23 21, which requires that certain employers not discriminate on the basis of race, color,
24 disability, religion, sex, national origin, or age.
25 12. Will comply with environmental standards which may be prescribed pursuant to the
26 following: (a) institution of environmental quality control measures under the National
27 Environmental Policy Act of 1969 (42 U.S.C.A. 4321, & 4332) and Executive Order
28 (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c)
29 conformity of Federal actions to State (Clean Air) Implementation Plans under Section
30 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§ 7401 et seq.); and (d)
31 protection of underground sources of drinking water under the Safe Drinking Water
32 Act of 1974, 42 U.S.C.A. § 300j-9 as amended (P.L. 93-523).
33 13. Will comply with the Pro -Children Act of 1994, P.L. 103-227; 108 Stat 271 §104;
34 U.S.C.A. Title 20 §§ 6080-6081, regarding the provision of a smoke -free workplace
35 and promoting the non-use of all tobacco products.
36 14. Will comply with National Research Service Award Act of 1971, (42 U.S.C.A. 289L-
37 1), regarding the protection of human subjects involved in research, development, and
-2-
related activities supported by this award of assistance.
2 15. Will comply with the Clinical Laboratory Improvement Amendments of 1988 (CILIA),
3 P.L. 100-578 (42 U.S.C. 263 a), which establish Federal requirements for the
4 regulation and certification of clinical laboratories.
5 16. Will comply with the OSHA Regulations on Blood borne Pathogens, 56 Fed. Reg.
6 64175 (1991), 29 C.F.R. 1919.030, which set safety standards for those workers and
7 facilities who may handle Blood borne pathogens.
8 17. Will bear, if a private non-profit organization or a for -profit organization, along with
9 its governing board, full responsibility for the integrity of the fiscal and programmatic
10 management of the organization which includes accountability for all funds and
11 materials received, compliance with applicable federal/state rules, policies, procedures,
12 laws and regulations, and correction of fiscal and program deficiencies identified
13 through self -evaluation or future state/federal monitoring processes. Ignorance of
14 requirements contained or referenced herein or in the resultant contract shall not
15 constitute a defense or basis for waiving or appealing such provisions or requirements.
16 Further, the governing board shall ensure separation of powers, duties, and functions
17 of board members and organization staff.
18 18. Will cause to be performed the required financial and compliance audits in accordance
19 with the Single Audit Act of 1984, 31 U.S.C. § 7501-7507, and any revisions thereto.
20 19. Will supplement the project/activity with funds made available through a contract
21 award as a result of this RFP and will not supplant funds.
22 20. Affirms that it has not given, nor intends to give, at any time hereafter any economic
23 opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or
24 service to a public servant or any employee or representative of same, in connection
25 with this procurement.
26 21. Will not, if a for -profit organization, charge a fee for profit. A profit or fee is
27 considered to be an amount in excess of actual allowable, allocable, and reasonable
28 direct and indirect costs which are incurred in conducting an assistance project.
29 22. Will comply with all applicable requirements of all other state/federal laws, executive
30 orders, regulations, and policies governing this program.
31 23. Is in good standing with any state/federal agency that it has a contracting relationship
32 with and has not had a contract terminated within the last 12 months for deficiencies
33 in contract performance.
34 24. Is, at the time of application submission and will remain throughout the application
192
1 cycle, in good standing with current and past State contracts.
2 25. Has not defaulted or is not delinquent on an agreed repayment schedule for amounts
3 owed to TDH.
4 26. Is, in accordance with Texas Family Code, Section 231.006, eligible to receive the
5 specified contract or payment and acknowledges that any resulting contract may be
6 terminated and payment may be withheld if this certification is inaccurate.
7 27. In accordance with Section 149 of Article IX of the General Appropriations Act, the
8 undersigned certifies that no owner, operator, or administrator of the facility or entity
9 applying for this contract has had a license, certificate, or permit revoked by any of
10 the Texas state agencies listed below:
11
•
Texas Department on Aging
•
Texas Health & Human Services Commission
12
•
Texas Commission on Alcohol
•
Texas Department of Human Services
13
and Drug Abuse
•
Texas Department of Mental Health & Mental
14
•
Texas Commission for the Blind
Retardation
15
•
Texas Cancer Council
•
Texas Department of Protective and Regulatory
16
•
Children's Trust Fund of Texas Council
Services
17
•
Texas Commission for the Deaf and
•
Texas Rehabilitation Commission
18
Hard of Hearing
•
Texas Department of Health
19
•
Adjutant General's Department
•
Texas Commission on Law Enforcement Officers
20
•
Texas Alcoholic Beverage Commission
Standards & Education
21
•
Texas National Guard Armory Board
•
Texas Polygraph Examiners Board
22
•
Texas Department of Criminal Justice
•
Board of Private Investigators and Private
23
•
Texas Criminal Justice Policy Council
Security Agencies
24
0
Texas Commission on Fire Protection
•
Texas Department of Public Safety
25
•
Texas Commission on Jail Standards
•
Texas Council on Sex Offender Treatment
26
•
Texas Juvenile Probation Commission
•
Texas Youth Commission
27
•
Interagency Council on Early Childhood
Intervention
28
30
Signature Au oriz d,Certifying Official Title
-�4ayor
"- -- ALEX TY COOKE MAYOR PRO TEM
Date
Legal Name of Applicant Organization
City of Lubbock Health Department
31 The above certifications and assurances are made as a required element of the proposal to which it is attached, understanding
32 that the truthfulness of the facts affirmed here and the continuing compliance with these requirements are conditions
33 precedept to the award or ontinuation of the related contract(s):
EST• ROVED AS TO CONTENT: APPROVED T FORM:
ay a Darnell, Go an, -Managing Director ld G. Vandiver,
Cit ecretary of Heal & Community Services First Asst. City Attorney
-4-
Texas Department of Health
Bureau of HIV & STD Prevention
1 HIV Contractor Assurances
3 1. ADVOCATE AND PROMOTE
a The applicant agency assures that it does not advocate or promote conduct that violates state law, in
5 compliance with the HIV Services Act, Texas Health and Safety Code, Section 85.011, as follows:
6 "Grants may not be awarded to an entity or community organization that advocates or
7 promotes conduct that violates state law. This subsection does not prohibit the award
8 of a grant to an entity or community organization that provides accurate information
9 about ways to reduce the risk of exposure to or transmission of HIV."
10 2. CONFIDENTIALITY
11 The applicant agency and its employees or subcontractors, if applicable, provide assurance to the Texas
12 Department of Health that confidentiality of all records shall be maintained. No information obtained
13 in connection with the examination, care, or provision of programs or services to any person with HIV
14 shall be disclosed without the individual's consent, except as may be required by law, such as for the
15 reporting of communicable diseases. Information may be disclosed in statistical or other summary
16 form, but only if the identity of the individuals diagnosed or provided care is not disclosed.
17 We are aware that the Health and Safety Code, §81.103, provides for both civil and criminal penalties
18 against anyone who violates the confidentiality of persons protected under the law. Furthermore, all
19 employees and volunteers who provide direct client care services or handle direct care records wherein
20 they may be informed of a client's HIV status or any other information related to the client's care, are
21 required to sign a statement of confidentiality assuring compliance with the law. An entity that does
22 not adopt a confidentiality policy as required by law is not eligible to receive state funds until the policy
23 is developed and implemented.
24
3. CONFLICT OF INTEREST
25 The applicant agency and its employees or subcontractors, if applicable, provide assurance to the Texas
26 Department of Health that no person who is an employee, agent, consultant, officer, board member,
27 or elected or appointed official of this agency, and, therefore, in a position to obtain a financial interest
28 or benefit from an activity, or an interest in any contract, subcontract, or agreement with respect
29 thereto, or the proceeds thereunder, either for himself or herself or for those with whom he or she has
30 family or business ties, during his or her tenure or for one year thereafter shall participate in the
HIV/STD Form No. 500.001 -1-
Contractor Assurances
1 decision making process or use inside information with regard to such activity. Furthermore, this
2 agency will adopt procedural rules which require the affected person to withdraw from his or her
3 functions and responsibilities or the decision -making process with respect to the specific assisted
4 activity from which they would derive benefit.
5 4. HIV/AIDS MODEL WORKPLACE GUIDELINES FOR PROVIDERS OF DIRECT
6 CARE, SERVICES, OR PROGRAMS
7 The applicant agency assures that its Project Director and Authorized Business Official have:
8 A. received a copy of the HIV/AIDS Model Workplace Guidelines for Businesses, State
9 Agencies, and State Contractors;
10 B. have read them;
11 C. agree to adopt and implement workplace policies on HIV/AIDS to include at a minimum:
12 1) the provision of education for employees and clients concerning HIV, its related
13 conditions, and AIDS;
14 2) confidentiality of AIDS and HIV -related and all other medical information for
15 employees, clients, inmates, patients, and residents served by the applicant agency;
16 and
17 3) an anti -discrimination policy assuring all privileges and opportunities for any employee
18 or client with a communicable disease, unless based on accurate scientific information.
19 5. ENVIRONMENTAL TOBACCO SMOKE
20 Public Law 103-227, also known as the Pro -Children Act of 1994, requires that smoking not be
21 permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used
22 routinely or regularly for the provision of health, day care, early childhood development services,
23 education or library services to children under the age of 18, if the services are funded by Federal
24 programs either directly or through State or local governments, by Federal grant, contract, loan, or
25 loan guarantee. The law also applies to children's services that are provided in indoor facilities that
26 are constructed, operated, or maintained with such Federal funds. The law does not apply to children's
27 services provided in private residences; portions of facilities used for inpatient drug or alcohol
28 treatment; service providers whose sole source of applicable funds is Medicare or Medicaid; or
29 facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may
30 result in the imposition of a civil monetary penalty of $1,000 for each violation and/or the imposition
31 of an administrative compliance order on the responsible entity.
32 The contractor assures that the submitting organization will comply with the requirements of the Act
33 and will not allow smoking within portion of any indoor facility used for the provision of services for
34 children as defined by the Act.
35 The submitting organization further agrees that it will require that the language of this certification be
36 included in any subawards which contain provisions for children's services and that all subrecipients
HIV/STD Form No. 500.001 -2-
shall certify accordingly.
2
6. GOOD STANDING
Contractor Assurances
i
3 Applicant agency certifies that it is in good standing with any State/Federal agency that it has a
4 contracting relationship with and has not had a contract terminated within the last 12 months for
5 deficiencies in contract performance.
6 Applicant certifies that it is, at the time of this application and throughout the application cycle, in good
7 standing with the Texas Department of Health (TDH) in regard to current and past TDH contracts.
8 Applicant certifies that it has not defaulted on an agreed repayment schedule for amounts owed to the
9 TDH. If funds owed to the TDH have not been repaid, the applicant understands it is ineligible to
10 apply for funds from the TDH until the amounts owed are paid in full.
11 7. CONTRACTOR USE OF EQUIPMENT AND SUPPLIES
12 The submitting organization certifies that the contractor will comply with the requirements of HIV/STD
13 Policy No. 500.003 and will not permit unauthorized use of equipment and supplies. The contractor
14 agrees that it will require the language of this assurance be included in applicable subawards or
15 subcontracts and that all subrecipients sign the assurance. The contractor agrees to enforce subrecipient
16 compliance with this policy.
17 8. DRUG -FREE WORKPLACE REQUIREMENTS
18 The undersigned (authorized official signing for the applicant organization) certifies that it will provide
19 a drug -free workplace in accordance with 45 CFR Part 76 by:
20 (a) Publishing a statement notifying employees that the unlawful manufacture, distribution,
21 dispensing, possession or use of a controlled substance is prohibited in the grantee's
22 workplace and specifying the actions that will be taken against employees for violation of such
23 prohibition;
24 (b) Establishing a drug -free awareness program to inform employees about-
25 (1) The dangers of drug abuse in the workplace;
26 (2) The grantee's policy of maintaining a drug -free workplace;
27 (3) Any available drug counseling, rehabilitation, and employee assistance
28 programs; and
29 (4) The penalties that may be imposed upon employees for drug abuse violations
30 occurring in the workplace;
31 (c) Making it a requirement that each employee to be engaged in the performance of the grant
32 be given a copy of the statement required by paragraph (a) above;
33 (d) Notifying the employee in the statement required by paragraph (a), above, that, as a
34 condition of employment under the grant, the employee will-
HIV/STD Form No. 500.001 -3-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
T1
17
Contractor Assurances
t
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later that five days after such conviction;
(e) Notifying the agency within ten days after receiving notice under subparagraph (d)(2),
above, from an employee or otherwise receiving actual notice of such conviction;
(f) Taking one of the following actions, within 30 days of receiving notice under
subparagraph (d)(2), above, with respect to any employee who is so convicted-
(1) Taking appropriate personnel action against such an employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug free workplace through
implementation of paragraphs (a), (b), (c), (d), (e), and (f), above.
Signature of A thor' ttify g Official Title
-Mayo r
ALE " COOKE MAYOR PRO TEM
Date
Legal Name of Applicant Organization
City of Lubbock Health Department
ATTEST:
/44� &W-�A- -
Kayt i Darnell, City Secretary
APPROVED AS TO CONTENT:
i at
D(iug-Gbooqan, Managing Director of
Health a Community Services
APPROVED AS TO FORM:
DoW d G. Vandiver, First Ass stant
City Attorney
HIV/STD Form No. 500.001
l:9
Texas Department of Health
Bureau of HIV & STD Prevention
10
1 BOARD MEMBER AND EXECUTIVE OFFICER
2 ASSURANCES
3 The persons signing on behalf of the above named organization certify that they are duly
4 authorized to sign this Assurances Form on behalf of the organization.
s 1) The undersigned acknowledges that an annual budget has been approved for each
6 contract with the Texas Department of Health.
7 2) The Board of Directors convenes on a regularly scheduled basis (no less than
8 quarterly) to discuss the operations of the organization.
9 3) Actual income and expenses are being compared with the approved budget, variances
10 are noted, and corrective action taken as needed (with board approval).
11 4) Timely and accurate financial statements are presented by the designated financial
12 officer on a regular basis to the board.
13 5) Any required financial reports and forms whether federal or state are being filed on
14 a current and timely basis.
1s 6) Adequate internal controls are in place to ensure fiscal integrity and accountability and
16 to safeguard assets.
17 7) The Treasurer of the Board has been fully informed of his or her responsibilities as
18 Treasurer.
19 8) The Board of Directors has Audit and/or Finance Committees that convene regularly
20 and communicate effectively with the Board Treasurer and other board members in
21 understanding and responding to financial developments.
22 9) The organization observes Generally Accepted Accounting Principles when preparing
23 financial statements and fund accounting practices are observed to ensure integrity
24 among specific contracts or grants.
25 10) This form will be discussed in detail at the next official board meeting and that
26 discussion and a copy of this form will be included in the minutes of the meeting. A
27 copy of the minutes will be forwarded to the Texas Department of Health's Grants
28 Management Division no later than 45 days after the meeting in which the form was
discussed.
City of Lubbock Health Department
3 1902 Texas Ave. PO Box 2548 Lubbock, TX 79408
4 (NAME & ADDRESS OF ORGANIZATION) n
S Rich 011 er / ',I4 E66= 9/Z/C77
6 Chairman of the Board Sigtiature Date
7 Doug Goodman
s Executive Officer
9 Rev 9/13195
ture ate
Texas Department of Health
Bureau of HIV & STD Prevention 10
STATEMENT OF UNDERSTANDING & AGREEMENT
I understand and agree that the requirements outlined in the Request for Proposals for Targeted
2 HIV Prevention Activities, dated July 1, 1996, remain fully in effect and shall serve as the basic
3 program guidance for this agency's HIV Targeted Prevention Project for Calendar Year 1998,
4 (January I through December 31, 1998).
5
0
7 ri ry of luhhnrk_HPn1 th nPnartmAnt
8 Applicant Agency �'
9 ) . , /, "
10
11 Sigr
pie (of Authorized Official
SITTON, MAYOR ALEX "TY" COOKE, MAYOR PRO TEM
12 ATTEST:
�44�_ lv_Q�
K yth Darnell, City Secretary
APPROVED AS TO CONTENT:
& —�k,
Doug Good , anagfng Director of
Health and ommunity Services
APPROVED AS TO FORM:
e
D6W d G. Vandiver, First Assi tant
City Attorney
Date
3
4
s
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Texas Department of Health
Bureau of HIV & STD Prevention
BOARD MEMBER AND EXECUTIVE OFFICER
ASSURANCES
10
The persons signing on behalf of the above named organization certify that they are duly
authorized to sign this Assurances Form on behalf of the organization.
1) The undersigned acknowledges that an annual budget has been approved for each
contract with the Texas Department of Health.
2) The Board of Directors convenes on a regularly scheduled basis (no less than
quarterly) to discuss the operations of the organization.
3) Actual income and expenses are being compared with the approved budget, variances
are noted, and corrective action taken as needed (with board approval).
4) Timely and accurate financial statements are presented by the designated financial
officer on a regular basis to the board.
5) Any required financial reports and forms whether federal or state are being filed on
a current and timely basis.
6) Adequate internal controls are in place to ensure fiscal integrity and accountability and
to safeguard assets.
7) The Treasurer of the Board has been fully informed of his or her responsibilities as
Treasurer.
8) The Board of Directors has Audit and/or Finance Committees that convene regularly
and communicate effectively with the Board Treasurer and other board members in
understanding and responding to financial developments.
9) The organization observes Generally Accepted Accounting Principles when preparing
financial statements and fund accounting practices are observed to ensure integrity
among specific contracts or grants.
10) This form will be discussed in detail at the next official board meeting and that
discussion and a copy of this form will be included in the minutes of the meeting. A
copy of the minutes will be forwarded to the Texas Department of Health's Grants
Management Division no later than 45 days after the meeting in which the form was
I discussed.
2 City of Lubbock Health Department
3 1902 Texas Ave. PO Box 2543 Lubbock TX 79408
4 (NAME & ADDRESS OF ORGANIZATION)
S pp�X( CJKMXX
6 Chairman of the Board Signature Date
7 Doug Goodman
8 Executive Officer Signature Date
9 Rev 9/13195
City of Lubbock
WINDY SITTON, MAYOR
ATTEST:
Kaythie Darnell, City Secretary
APPROVED AS TO CONTENT:
Doug oo n, Managing Director
of Health nd Community Services
APPROVED AS TO FORM:
Do d G. Va iver, FirKt Assistant
City Attorney
1 discussed.
2
3
4
5
6
7
8
9
City of Lubbock Health Department
1902 Texas Ave. PO Box 2548 Lubbock, TX 79408
(NA,�IE & ADDRESS OF ORGANIZATION)
UXj0X2)UjeXX
Chairman of the Board Signature
Doug Goodman
Executive Officer Signature
Rev 9/13/95
City of Lubbock
WINDY SITTON, MAYOR
ATTEST:
Kaythie Darnell, City Secretary
APPROVED AS TO CONTENT:
Doug ood n, Managing Director
of Healt nd Community Services
APPROVED AS TO FORM:
Don G. a er, rs ss stint
City Attorney
Date
Date
K*2
TDH
TEXAS DEPARTMENT or HEALTH
Dear Applicant:
APPEND, X A
This is to provide an explanation of the forms included in the Historically Underutilized Business (HUB) packet
as part of your Request for Proposal.. The Texas Department of Health (TDH) is very committed to the HUB
Program. It is the intent of Senior Management and the Board of Health that all TDH contractors show a good
faith effort to subcontract with HUBS.
Following is a clarification regarding which forms applicants are required to complete and submit with their
application.
Applicants whose grant request is less than $100,000 are not required to complete any of the HUB
forms.
Applicants whose grant request is $100,000 or greater must complete the Professional Services Contract
Form and submit it and any justification with the application, or no longer than seven working days
thereafter. In completing the Professional Services Contract Form, applicants are asked to respond to
the three questions found at the bottom of the form. Applicants will not be required to adhere to the
section that outlines the five procedures for designating a good faith effort.
•-091ZON4T ., Z•,
.� �.. �• •• �., ,. ..� �•
Met IL
Applicants do not have to complete the Good Faith Effort checklist, Letter of Intent, or the Solicitation
Forms included in the HUB Packet. However, if you do subcontract with a HUB for commodities or
services, you will be required to submit a Progress Assessment Report (PAR) on a quarterly basis, based
on the deadlines outlined on the NON -HUB -PAR form.
Hopefully, this will answer any questions applicants may have regarding fulfilling the HUB requirements. If
you have questions regarding these requirements, please contact the TDH HUB Program at 1-800-243-7487 or
(512)458-7111, extension 3760. The TDH HUB Program fax number is (512) 458-7694. We appreciate your
assistance in promoting equal business opportunity for all businesses by subcontracting with HUBS.
1
TEXAS DEPARTMENT OF HEALTH
GOOD FAITH EFFORT PROGRAM
In accordance with Texas Government Code Title 10, Subtitle D, Chapter 2161 and Title I Texas Administrative
Code (TAC) § 111.11 through § 111.24, state agencies are required to make a good faith effort to assist
historically underutilized businesses (HUBS) in receiving contract awards issued by the state. The goal of this
program is to promote full and equal business opportunity for all businesses in contracting with the state. It is
the intent of the Texas Department of Health (TDH) that all TDH contractors make a good faith effort to
subcontract with HUBS during the performance of their contract. Contractors shall report their HUB subcontract
activity to TDH on a quarterly basis. However, for contracts exceeding $100,000 there are specific good faith
effort TAC requirements that a contractor must comply with as a condition of awarding any contract.
Contractors are responsible for being familiar with the good faith effort requirements of TAC. Further assistance
and/or copies of the applicable sections of TAC can be obtained by contacting the TDH HUB Program at (512)
458-7111, extension 3760 or 1-800-243-7487. The following forms and/or documentation will be required to
be submitted during the application/request for proposal process:
The completed Good Faith Effort Program (GFEP) Form(s) which addresses the requirements of 1 TAC
§ 111.14(b) must be submitted with your offer or no later than 7 working days following your offer.
This primarily applies to the Professional Service Contract form, but subcontracting opportunities
in the Commodity Contract and Other Service Contract areas are also encouraged. This is especially if
HUB subcontracting opportunities in the Professional Service area are limited or non-existent.
If TDH determines you have complied with the good faith effort requirements and awards you a contract,
you will be required to submit one of the following quarterly reports, if HUB subcontracting
opportunities are executed:
(1) Progress Assessment Report by Non -Historically Underutilized Businesses of Work Sub -
Contracted (NON -HUB -PAR). Due quarterly in December, March, June and September.
(2) Progress Assessment Report by Historically Underutilized Business of Work Sub -Contracted
(HUB -PAR -A). Due quarterly in December, March, June and September.
NOTE: A list of all GSC certified HUBs may be electronically accessed through the Internet. The GSC
information server is available through the Internet based World -Wide -Web. Although there are alternatives
to connect to this data, the preferred method is through the Internet using a Web Browser (like Netscape,
Mosaic, etc.). Using a Web Browser, please connect to http://w,,v�,v.gsc.state.tx.us (this is the home page for
GSC).
Contractor:
Application/RFP Deadline:
TDH Grant/Contract Name:
v, ,
GOOD FAITH EFFORT PROGRAM (GFEP)
Commodity Contract
In accordance with Texas Government Code Title 10, Subtitle D, Chapter 2161, state agencies are required to make a good faith effort
to assist historically underutilized businesses (HUBS) in receiving contract awards issued by the State. A HUB is defined in the Texas
Government Code Title 10, Subtitle D, Chapter 2161, Subchapter A, Section 2161.001. The General Services Commission Rules,
I TAC § I 1 1.11-111.24, outlines the commission's policy to encourage the use of HUBS by state agencies and to assist agencies to
achieve these goals through race, ethnic, and gender neutral means. The goal of this program is to promote full and equal business
opportunity for all businesses in state contracting.
In accordance with the commission's policy of encouraging the use of HUBS in state procurement, the Texas Department of Health
(TDH) shall make a good faith effort to utilize HUBS in contracts for commodities and service purchases. TDH will achieve the annual
program goals by contracting directly with HUBS or indirectly through subcontracting opportunities. Therefore, any business that
contracts with TDH shall be required to make a good faith effort to award subcontracts to HUBs to meet the goal of 11.5% for
commodity contracts (e.g. medical supplies, ofrice supplies, laboratory supplies). A subcontractor is an entity that enters into a
contract with a contractor (vendor) to provide the goods or services for which the contractor is responsible under the terms of its
contract with TDH. This Good Faith Effort Program goal does not prevent any business group from participating in contracting
opportunities with the State of Texas.
A contractor shall be required to make a good faith effort to award necessary subcontracts to HUBS in accordance with the goal set
forth above. When the contractor is a HUB, it must satisfy the good faith effort requirements by performing at least 25% of the
contract work with its employees. The HUB prime contractor may subcontract the remaining 75% of the contract with HUB or non -
HUB subcontractors. Any HUB prime contractor that seeks to satisfy the good faith effort requirement in this manner shall report
quarterly to TDH, the volume of work performed under the contract and the portion of the work that was performed with its
employees. If a HUB prime contractor performs less than 25% of the cumulative total contract with its employees, then for the next
quarter, the contractor shall report its subcontractors as required by a non -HUB contractor.
By implementing the following procedures, a contractor shall be presumed to have made a good faith effort by complying with the
criteria set forth in 1 TAC § 111.14(c) (1-5):
I. To the extent consistent with prudent industry practice, divide the contract work into reasonable lots.
2. Notify HUBS of the work that the contractor intends to subcontract The notice shall be in writing. The notice shall include
a description of the subcontracting opportunities and identify the location to review contract specifications. The notice shall
be provided to potential subcontractors prior to submission of the contractor's offer to TDH.
3. The contractor shall send the notice described in subsection I11.14(cx2) to at least five (5) businesses in the current
commission directory of certified HUBS that perform the type of work required in the area in which the work will be
performed.
4. If a non -HUB subcontractor is selected through means other than competitive bidding, or a HUB bid is the lowest price
responsive bidder to a competitive bid, but not selected, the contractor will be required to document the selection process.
The contractor shall maintain business records documenting its compliance with this section 111.14 and shall make a
compliance report to the contracting agency and report in the format required by the agency's contract documents, provided
that reporting shall be required at least once for each calendar quarter during the term of the contract.
Are you certified as a Texas Historically Underutilized Business (HUB)? Yes No
If an award is issued, do you plan to utilize a HUB Subcontractor or Supplier for all or any portion of the contract?
Yes No
(Attach separate documentation based on your answer as follows
amount listed; "No" -provide written explanation)
"Yes" -list specific commodity areas that compile the percentage
If yes, what percentage of the total dollar amount of the award will be or is estimated to be subcontracted?
Contractor Name:
Please return this form with your Application/RFP or within seven days after Application/RFP deadline.
Contractor: _
Application/RFP Deadline:
s
rn TDH Grant/Contract Name:
GOOD FAiTH EFFORT PROGRAM (GFEP)
Professional Service Contract
In accordance with Texas Government Code Title 10, Subtitle D, Chapter 2161, state agencies are required to make a good faith effort
to assist historically underutilized businesses (HUBs) in receiving contract awards issued by the State. A HUB is defined in the Texas
Government Code Title 10, Subtitle D, Chapter 2161, Subchapter A, Section 2161.001. The General Services Commission Rules,
1 TAC § 111.11-111.24, outlines the commission's policy to encourage the use of HUBs by state agencies and to assist agencies to
achieve these goals through race, ethnic, and gender neutral means. The goal of this program is to promote full and equal business
opportunity for all businesses in state contracting.
In accordance with the commission's policy of encouraging the use of HUBS in state procurement, the Texas Department of Health
(TDH) shall make a good faith effort to utilize HUBs in contracts for commodities and service purchases. TDH will achieve the annual
program goals by contracting directly with HUBs or indirectly through subcontracting opportunities. Therefore, any business that
contracts with TDH shall be required to make a good faith effort to award subcontracts to HUBs to meet the goal of 18.10% for
professional service contracts (e.g. physicians,nursing, laboratory services, pharmacy). A subcontractor is an entity that enters
into a contract with a contractor (vendor) to provide the goods or services for which the contractor is responsible under the terms of
its contract with the State. This Good Faith Effort Program goal does not prevent any business group from participating in contracting
opportunities with the State of Texas.
A contractor shall be required to make a good faith effort to award necessary subcontracts to HUBS in accordance with the goal set
forth above. When the contractor is a HUB, it must satisfy the good faith effort requirements by performing at least 25% of the
contract work with its employees. The HUB prime contractor may subcontract the remaining 75% of the contract with HUB or non -
HUB subcontractors. Any HUB prime contractor that seeks to satisfy the good faith effort requirement in this manner shall report
quarterly to TDH, the volume of work performed under the contract and the portion of the work that was performed with its
employees. If a HUB prime contractor performs less than 25% of the cumulative total contract with its employees, then for the next
quarter, the contractor shall report its subcontractors as required by a non -HUB contractor.
By implementing the following procedures, a contractor shall be presumed to have made a good faith effort by complying with the
criteria set forth in 1 TAC §I 11.14(c) (1-5):
1. To the extent consistent with prudent industry practice, divide the contract work into reasonable lots.
2. Notify HUBS of the work that the contractor intends to subcontract. The notice shall be in writing. The notice shall include
a description of the subcontracting opportunities and identify the location to review contract specifications. The notice shall
be provided to potential subcontractors prior to submission of the contractor's offer to TDH.
3. The contractor shall send the notice described in subsection 111.14(cx2) to at least five (5) businesses in the current
commission directory of certified HUBs that perform the type of work required in the area in which the work will be
performed.
4. If a non -HUB subcontractor is selected through means other than competitive bidding, or a HUB bid is the lowest price
responsive bidder to a competitive bid, but not selected, the contractor will be required to document the selection process.
5. The contractor shall maintain business records documenting its compliance with this section 111.14 and shall make a
compliance report to the contracting agency and report in the format required by the agency's contract documents, provided
that reporting shall be required at least once for each calendar quarter during the term of the contract.
Are you certified as a Texas Historically Underutilized Business (HUB)? Yes No
If an award is issued, do you plan to utilize a HUB Subcontractor or Supplier for all or any portion of the contract?
Yes No
(Attach separate documentation based on your answer as follows: "Yes" -list specific professional areas that compile the percentage
amount listed; "No" provide written explanation).
If yes, what percentage of the total dollar amount of the award will be or is estimated to be subcontracted?
Contractor Name:
Please return this form with your Application/RFP or within seven days after Application/RFP deadline.
e+ Contractor:
y Application/RFP Deadline:
TDH Grant/Contract Name:
GOOD FAITH EFFORT PROGRAM (GFEP)
Other Service Contract
In accordance with Texas Government Code Title 10, Subtitle D, Chapter 2161, state agencies are required to make a good faith effort
to assist historically underutilized businesses (HUBs) in receiving contract awards issued by the State. A HUB is defined in the Texas
Government Code Title 10, Subtitle D, Chapter 2161, Subchapter A, Section 2161.001. The General Services Commission Rules,
l TAC § 111.11-111.24, outlines the commission's policy to encourage the use of HUBs by state agencies and to assist agencies to
achieve these goals through race, ethnic, and gender neutral means. The goal of this program is to promote full and equal business
opportunity for all businesses in state contracting.
In accordance with the commission's policy of encouraging the use of HUBs in state procurement, the Texas Department of Health
(TDH) shall make a good faith effort to utilize HUBs in contracts for commodities and service purchases. TDH will achieve the annual
program goals by contracting directly with HUBs or indirectly through subcontracting opportunities. Therefore, any business that
contracts with TDH shall be required to make a good faith effort to award subcontracts to HUBS to meet the goal of 33% for other
service contracts (e.g. legal services, consulting services, maintenance/repair services, computer services). A subcontractor is
an entity that enters into a contract with a contractor (vendor) to provide the goods or services for which the contractor is responsible
under the terms of its contact with the State. This Good Faith Effort Program goal does not prevent any business group from
participating in contracting opportunities with the State of Texas.
A contractor shall be required to make a good faith effort to award necessary subcontracts to HUBS in accordance with the goal set
forth above. When the contractor is a HUB, it must satisfy the good faith effort requirements by performing at least 25% of the
contract work with its employees. The HUB prime contractor may subcontract the remaining 75% of the contract with HUB or non -
HUB subcontractors. Any HUB prime contractor that seeks to satisfy the good faith effort requirement in this manner shall report
quarterly to TDH, the volume of work performed under the contract and the portion of the work that was performed with its
employees. If a HUB prime contractor performs less than 25% of the cumulative total contract with its employees, then for the next
quarter, the contractor shall report its subcontractors as required by a non -HUB contractor.
By implementing the following procedures, a contractor shall be presumed to have made a good faith effort by complying with the
criteria set forth in 1 TAC §I 11.14(c) (1-5):
1. To the extent consistent with prudent industry practice, divide the contract work into reasonable lots.
2. Notify HUBs of the work that the contractor intends to subcontract The notice shall be in writing. The notice shall include
a description of the subcontracting opportunities and identify the location to review contract specifications. The notice shall
be provided to potential subcontractors prior to submission of the contractor's offer to TDH.
3. The contractor shall send the notice described in subsection I11.14(c)(2) to at least five (5) businesses in the current
commission directory of certified HUBS that perform the type of work required in the area in which the work will be
performed.
4. If a non -HUB subcontractor is selected through means other than competitive bidding, or a HUB bid is the lowest price
responsive bidder to a competitive bid, but not selected, the contractor will be required to document the selection process.
5. The contractor shall maintain business records documenting its compliance with this section 111.14 and shall make a
compliance report to the contracting agency and report in the format required by the agency's contract documents, provided
that reporting shall be required at least once for each calendar quarter during the term of the contract.
Are you certified as a Texas Historically Underutilized Business (HUB)? Yes No
If an award is issued,, do you plan to utilize a HUB Subcontractor or Supplier for all or any portion of the contract?
Yes No
(Attach separate documentation based on your answer as follows: "Yes" -list specific areas that compile the percentage
amount listed; "No" -provide written explanation)
If yes, what percentage of the total dollar amount of the award will be or is estimated to be subcontracted?
Contractor Name:
Please return this form with your Application/RFP or within seven days after Application/RFP deadline.
Contractor:
Application/RFP Deadline:
> TDH Grant/Contract Name:
TEXAS DEPARTMENT OF HEALTH
HISTORICALLY UNDERUTILIZED BUSINESS
GOOD FAITH EFFORT CHECKLIST(GFEC)
The purpose of this checklist and supporting documentation is to provide appropriate evidence that the Contractor has made
a good faith effort to meet or exceed the Texas Department of Health (TDH) Historically Underutilized Business (HUB)
goals by subcontracting with HUBS. The contractor shall complete and submit the following checklist along with appropriate
supporting documentation explaining how the contractor made a good faith effort in accordance with the requirements of
1 Texas Administrative Code (TAC) § 111.14. The completed checklist and supporting documentation must be signed and
submitted to TDH within fourteen (14) days after the Contractor is notified that he/she has been selected. Did you comply
with the following good faith effort requirements?
(1) Advertise in general circulation, trade association, and/or minority/women focused media
concerning subcontracting opportunities.
(2) Provide written notice to at least five qualified HUBS allowing sufficient time for HUBS to
participate effectively.
(3) Divide the contract work into reasonable portions in accordance with standard industry practices.
(4) Document reasons for rejection or meet with the rejected HUB to discuss the rejection.
(5) Provide qualified HUBS with adequate information about bonding, insurance, plans, specifications,
scope of work and requirements of the contract.
(6) Negotiate in good faith with qualified HUBs. Contractor shall submit a description of the selection
process.
Note: Contractor may attach a supplemental letter clarifying the above six items. This clarification may include information
regarding contractor's limitations, contractor's current or pending HUB policies, etc. Additionally, the good faith effort
documentation should provide an overall description of the efforts the contractor has made, or commits to make, which are
consistent with the intent of the HUB good faith effort requirements.
NameofContractor:
Signature of Contractor Representative:
PrintedName of ContractorRepresentative:
Title:
Mailing Address:
Phone: / - Date of Submission:
Return completed checklist and supporting documentation to:
Texas Department of Health
Attention: TDH HUB Coordinator
Bureau of Support Services
1100 West 49th Street
Austin, TX 78756
The TDH HUB Coordinator, in consultation with appropriate TDH program staff, shall review the completed checklist and
supporting documentation submitted by the Contractor and issue a written notice of acceptance or deficiency of a good faith
effort within fourteen (14) days after receiving the checklist and supporting documentation. Any notice of deficiency shall
state the reasons for the deficiency. TDH must determine the Contractor complied with the good faith effort requirements
of 1 TAC 1 1 1.14 as a condition of aALading this contract.
W Contractor:
� Application/RFP Deadline:
TDH Grant/Contract Name:
HISTORICALLY UNDERUTILIZED BUSINESS
LETTER OF INTENT (HUB -LOT)
PLEASE SUBMIT SEPARATE FORM FOR EACH HUB SUBCONTRACTOR/SUPPLIER
For use by Contractor to identify HUB Subcontractors and Suppliers. This form would be appropriate supporting documentation to be
submitted as apart of the GFE Checklist supporting documentation.
Contractor:
Address:
Telephone:
TDH Program Name:: RFP Amount:
Description of services/specifications:
Time period covered:
Percentage/amount of contract with subcontractor/supplier S
Name of HUB Subcontractor/Supplier:
Address:
Telephone:
Proposed SubContract Amount:
Description of materials or services performed under agreement with HUB for amount indicated above:
Signature of Contractor
Date
Signature of HUB Subcontractor/Supplier
Date
Contractor:
TDH Grant/Contract Name:
PROGRESS ASSESSMENT REPORT BY
NON -HISTORICALLY UNDERUTILIZED BUSINESS
OF WORK SUB -CONTRACTED (NON -HUB -PAR)
Contractor Name:
Vendor Identification Number(VID#):
Mailing Address:
Total Contract Amount: S
Total Amount Paid to HUB Subcontractor(s): S
For HUB
Subcontractor/Supplier,
write in the letter "H" and
the GSC Certification #. If
NON -Certified HUB
Subcontractor, write in the
letter "N".
Name of
Subcontractor/
Supplier
VID#,
Social
Security, or
Federal ID #
S Amount Paid This Period
S Total Paid to Date
To be reported quarterly by the following dates:
Quarter
Months Included
Deadline
First
Sept., Oct., Nov.
December 5th
Second
Dec., Jan., Feb.
March 5th
Third
March, April, May
June Sth
Fourth
June, July, Aug.
September 5th
Signature
Title
Date
Telephone #
Return to: Texas Department of Health
Attn: TDH HUB Coordinator
Bureau of Support Services
1100 West 49th Street
Austin, Tx. 78756
Attach a narrative report describing your good faith efforts during the reporting period.
Contractor:
TDH Grant/Contract Name:
GO
PROGRESS ASSESSMENT REPORT BY
HISTORICALLY UNDERUTILIZED BUSINESSES
OF WORK SUB -CONTRACTED (HUB -PAR -A)
Contractor:
HUB Name registered with General Services Commission (GSC):
Mailing Address:
Total Contract Amount: S
Total Amount Paid to HUB Subcontractor(s): S
% of Contract performed by Contractor's employees for reporting period:
For HUB
Subcontractor/Supplier,
write in the letter "H" and
the GSC Certification N. If
NON -Certified HUB
Subcontractor, write in the
letter "N".
Name of
Subcontractor/
Supplier
VID#
Social Security,
or
Federal 1D #
S Amount Paid
This Period
Total S
Amount Paid
to Date
Percent of
Sub
Contract
Performed
To be reported quarterly by the following dates:
Months Included
Deadline
p
ept., Oct., Nov.
December 5th
ec., Jan., Feb.
March 5th
Third
March, April, May
June 5th
Fourth
June, July, Aug.
September 5th
Signature
Title
Date
Telephone #
Return to: Texas Department of Health
Attn: TDH HUB Coordinator
Bureau of Support Services
1100 West 49th Street
Austin, Tx. 78756
Attach a narrative report describing your good faith efforts during the reporting period.
Contractor:
Application/RFP Deadline:
c" TDH Grant/Contract Name:
HISTORICALLY UNDERUTILIZED BUSINESS
SOLICITATION FORM (HUB -SF)
For use by Contractor to identify HUB Subcontractors and Suppliers. This form would be appropriate supporting documentation to be
submitted as apart of the GFE Checklist supporting documentation.
Please complete this form when soliciting HUBs
Contractor:
Address:
Phone:
Description of Subcontract(s) Solicited:
Contact Name:
Contractor's Estimate of Approximate Dollar Value of Subcontract Advertised:
Date of Solicitation Letter:
'List each HUB to which a solicitation letter was sent and attach a copy of each solicitation letter. If additional space is needed, please attach a separate
sheet.
Name of HUB Subcontractor/Supplier-
Address:
Phone: Owner:
If certified, enter 5 digit GSC certification # If not GSC certified, please complete the following information:
{ } Black American _ Male Female { } Asian Pacific American _Male _Female
{ } Hispanic American _Male _ Female { } American Indian _Male _ Female { } Woman
2. Name of HUB Subcontractor/Supplier-
Address:
Phone: Owner:
If certified, enter 5 digit GSC certification #• If not GSC certified, please complete the following information:
{ } Black American _ Male _ Female { } Asian Pacific American _Male _Female
{ } Hispanic American _Male _ Female { } American Indian Male _ Female { } Woman
Name of HUB Subcontractor/Supplier-
Address:
Phone:
Owner:
If certified, enter 5 digit GSC certification # If not GSC certified, please complete the following information:
{ } Black American _ Male _ Female { } Asian Pacific American _Male _Female
{ } Hispanic American _Male _ Female { } American Indian _Male _ Female { } Woman
Signature:
Address:
City/State:
Title:
Phone:
Zip:
This form must be signed by an authorized representative of the Contractor.
1. Is this grant:
GRANT PROPOSAL EVALUATION FORM
Page 1
New Continuing XX
Number of
Years 8_
2. Is a match required? Yes No XX
If yes: Percentage Amount
Is it: In -kind OR Cash
Source
3. Are there any indirect costs, i.e. building use, computer time, administrative
supervision, associated with the grant? Yes XX No
If yes, please list the estimated
costs. Building Use, Computer Time,
Administrative Time = $1,600
4. If there are indirect costs, are they reimbursed by the grant?
Yes XX No
Percentage 4%
5. Are audit costs reimbursed? Yes No XX
Percentage
6. What are the audit requirements for this grant? Texas Department of Health's Grants Mana eg ment
Division performs on -site reviews of grantees and provides technical assistance on fiscal matters. The on -
site review consists of a review of internal controls, verification that reported expenses are properly
supported, and evaluation of compliance with contract terms and government regulations.
7. Can this grant be renewed?
No
Yes XX No
If yes, how many times?
As long as funds are made from
the State and the Federal Government.
What are the terms of renewal?
See Above
8. Does the grant require the City to gradually assume
the cost of the program?
Yes No XX
If yes, what is the timetable?
GRANT PROPOSAL EVALUATION FORM
Page 2
Please address whether other agencies are currently administering similar programs and whether any
other agencies are available to administer this program. SPARC receives this grant to provide testing
and counseling to at -risk populations outside of Lubbock County. This program is offered by other
agencies, however, there are limited agencies which provide education, testing, prevention counseling
and risk reduction at an affordable rate to the citizens of Lubbock. The City of Lubbock Health
Department not only focuses on homosexuals but also heterosexuals, teens, college students, incarcerated
persons (teens and adults), gangs and high -risk females through outreach activities.
10. For the "Current Year". Please identify how expenditures are to be made in the following categories
and how the program will be funded. If the grant is for an on -going program, pleases project revenue
and expenditures for future years. If the grant is for one year, show any on -going costs to the City, such
as the cost of maintenance on equipment purchased by the grant.
EXPENDITURES
Personnel
Full Time Salary
TMRS
Social Security
Health
Life
Dental
Supplies
Maintenance
Other(travel, educ. supplies
and indirect costs)
Indirect Costs
Capital
TOTAL EXPENDITURES
REVENUE
Federal Grant
State Grant
Local Match
Other
TOTAL REVENUE
CURRENT
YEAR
1998 19 19 19 19
$39,424
$30,764
$ 3,587
$ 2,218
$ 2,613
$ 33
$ 209
$ 50
$ 0
$ 859
$ 1,600
$41,933
0
$41,933
0
0
$41,933
11. Pleases list the number and title (s) of personnel funded by this grant: 1 HIV Counselor
12. Please list any new positions to be added: None
GRANT PROPOSAL EVALUATION FORM
Page 3
13. Please list any capital items to be purchased: None
14. Please discuss how this program will impact current employee allocation and utilization and whether it
will have a long-term financial or manpower impact. Attach additional pages if needed.
As this program has been in existence for 8 years, the impact will come if it is not funded. If that is the
case, one staff person will lose her job and 4 others will have to add HIV testing and counseling to their
other responsibilities in the STD Clinic. Due to the down -sizing of the Health Department persons at
risk for HIV would not be given adequate risk reduction and prevention counseling to encourage
behavior change to reduce or eliminate their risk. HIV infection rates would continue to climb and tax
dollars would increase due to the cost to treat HIV- infected individuals. Prevention of HIV infection is
the goal of the Health Department and the money received from the Texas Department of Health will
serve to increase awareness of HIV and protection from HIV for persons at risk.
15. In narrative form, pleases provide a brief description of the program, including the need which will be
addressed, the goals and objectives of the program, the target population to be served, and any other
significant aspects of the application. Attach additional pages if needed.
This proposal to provide prevention counseling and partner elicitation will be client -centered, focused on
producing behavioral changes, prevention -oriented, and directed toward the target groups determined by
the Regional HIV Coalition including Men who have Sex with other Men (Subcategories: adolescent,
college -aged, of color, anglo, and HIV+); Intravenous Drug User's (Subcategories: homeless, sex
workers, and incarcerated) and people who have Unprotected Heterosexual Sex (Subcategories: HIV+,
migrants, gang members, and sexual partners of IDU and/or MSM). The City of Lubbock Health
Department's STD Clinic will continue to be used as an HIV testing site. Other testing sites include
Texas Tech University, Lubbock County Jail, Lubbock County Youth Center, Lubbock County
Community Correctional Facility, the gay club, and Managed Care drug treatment facilities All clients
tested will receive pre -test counseling. Post-test counseling will be provided to 75% of those tested as
the goal of the Texas Department of Health; however, the City of Lubbock HIV Counselor has been
consistent in providing post-test counseling to 85-95% of those persons who are tested. 95% of those
testing seropositive will receive post-test counseling, referrals to case management and early intervention
services, and follow-up appointments. Partner elicitation will produce at least one partner for a
minimum of 80% of those testing seropositive.
Collaboration activities include assisting Catholic Family Services with Prevention Counseling and
Partner Elicitation (PCPE) activities as they provide education to migrants, adolescents, and female
partners of IDU's and MSM's; assisting Inside/Out with PCPE activities as they provide education to
gang members, IDU's, homeless and MSM's of color; and assisting Lubbock Mental Health/Mental
Retardation as they provide education to those in treatment for drug/alcohol abuse, sex workers, as well
as the IDU who is homeless/incarcerated and those involved with gangs. Testing referrals and/or on -site
counseling and testing following HIV education presentations will be offered to the target audiences of
these groups when requested.
Prevention of HIV infection is the main focus of all PCPE activities and testing is one realm of
prevention. Referrals for those testing seropositive will be coordinated through the South Plains AIDS
Resource Center (SPARC). Forming a support group for those who are high -risk seronegatives is a goal
for the coming year. Referrals for drug treatment will continue to be made to Lubbock MHMRR and to
the AA/NA groups in the Lubbock and surrounding areas when applicable.
No Text