Loading...
HomeMy WebLinkAboutResolution - 3711 - Contract - TDOH - Public Health Services - 09_12_1991Resolution No. 3711 September 12, 1991 Item #20 DGV : j s 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 a Contract and all associated documents, by and between the City of Lubbock and the Texas Department of Health for public health services, attached herewith, which 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 12th day of September , 1991. )t4. . (� . & * 1 4, - MCMINK, MAYOR ATTEST: et,te Boyd, APPROVED AS TO CONTENT: K. UOu9 WOW n �f'UD 1 iC Flea Administrator APPROVED AS TO FORM: Ud Id G. Vandiver, First ASS1S City Attorney Texas Department of Health Robert, Bernstein, M.D., EA.C.P. 1100 West 49th Street Robert A. MacLean, M.D. Commissioner Austin, Texas 78756-3199 Deputy Commissioner (512) 458-7111 October 2, 1991 Anthony B. Way, M.D. Director LUBBOCK CITY HEALTH DEPARTMENT P.O.Box 2548 Lubbock, TX 79408-2548 TDH Document No. C2000376 Dear Doctor Way: RECEIVED OCT 7-1991 LUBBOCK CITY HEALTH DEPL I have enclosed an approved copy of your public health services contract. Please file it with the office of record for your agency. If we may be of further assistance, please call us at 512/458-7470. Sincerely, -Pgt�-CXd,.,R. Julian M. Kosh, Jr., Director Grants Management Division JMK:am Enclosure 1 STATE OF TEXAS COUNTY OF TRAVIS TEXAS DEPARTMENT OF HEALTH CONTRACT 1100 west 49th Street Austin, Texas 78756-3199 TDH Document No. C2000376 This contract is between the Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, and the party listedbelowas PERFORMING AGENCY and includes general provisions and attachments detailing scope(s)- of work and special provisions. r PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT -------- _______� (PRINT or TYPE) Mailing Address: P.O. Box 2548 Lubbock T( 79408-25481 (City) (St) Z1..p 1 Street Address: 1902 Texas Ave. Lubbock TX 79405-11171 1 (it different) (City) I_ _I 1 Authorized I Contracting Entity: CITY OF LUBBOCK I- different rom -) I -====___________________________________________I 1 Payee Name: C F LUBBOCK HEALTH DEPARTMENT I CITY mac withven or identification number shown beeIow ) � I Payee Address: g.o. Box 2000 Lubbock TX 79457 00001 (Must match with vendor identification num er s own E-elow State of Texas Vendor Identification No. (14 digits): 17560005906037 Finance Officer/Contact: Doug Goodman 1 1 I Type of Organization: it i Designate: Elementary secon ary school, junior college, senior co egge university I city, county, other po itical subdivision council of governments, judicial district, community services program, individual, or other (define) Is this a small business (Yes/No) and/or minority/woman owned No (Yes/No) I Is this a non-profit business Yes (Yes/No) I PAYEE AGENCY Fiscal Year Ending Month: SEPTEMBER SUMMARY OF TRANSACTION: Contract for Public Health Services. 1 I 1 COVER - Page 1 DETAILS OF A T T A C H N E 9 T S ------------------ AttJ; --- - ; ;___Financial Assistance ______; Am. TDH Term ; Source of Direct Total Assistance ; No, Pra ram ,_; Besin ; End _; Funds* Amount ; Assistance Amount (TDH Share) 01 HIY-LHS 91 1/91: 8131192,t STATE 33,ti65,0U; .001 33,565.00, 1 1 1 I t 1 I 1 1 I I I 1 1 1 02 CRH-LHS 91 1/91: 8131192; STATE 93.269 91,114.00: 169,552.00: 260,666.00, 03 NCH-LHS 9/ 1/91: 8/31192, STATE 255,519.00: 29,004.00: 284,523.00: 1 1 1 I 1 1 1 i I 1 1 J 1 1 1 I 1 1 1 I i 1 I f 1 1 I 1 1 1 1 t 1 1 1 1 1 { 1 1 1 1 I 1 1 1 I 1 ! 1 I 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 t 1 I 1 1 I 1 1 1 1 1 1 1 1 I 1 1 P i I 1 I 1 i 1 I 1 1 I 1 1 1 1 I 1 I 1 1 1 1 i t I 1 1 1 I I 1 1 1 1 1 1 1 1 11 1 1 1 1 1 1 1 I I 1 I I I 1 1 1 I I I 1 1 1 I 1 1 1 1 t 1 I 1 1 1 1 1 1 I 1 1 1 1 I 1 1 i I 1 I 1 1 1 1 1 i t 1 1 1 1 1 1 1 1 1 1 1 I 1 I I i 1 I 1 I 1 I 1 1 1 I 1 1 I I 1 1 1 1 1 1 { 1 1 1 I 1 1 1 t 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 1 t I I 1 1 1 I 1 I 1 t 1 I 1 Y 1 1 1 1 t I 1 1 I 1 1 1 1 1 1 1 1 1 t 1 I 1 1 1 1 1 1 I t I 1 1 I 1 1 1 i 1 I 1 1 I t 1 1 1 I 1 1 1 1 1 I 1 1 I 1 1 1 1 I 1 1 1 1 1 1 1 1 I 1 1 1 1 1 i 1 I 1 I I I 1 I 1 1 i t 1 I i 1 I 1 l 1 1 1 1 1 1 I 1 1 1 1 1 t t 1 1 1 1 ! 1 I f 1 1 1 1 I I 1 1 1 11 1 1 1 1 1 1 1 1 I 1 1 1 1 I 1 1 1 l 1 l 1 1 1 1 t 1 1 t 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 Y 1 1 I I 1 1 1 1 1 1 1 1 -.---------------------------------------------------------------------------------------.------.------------------------j TDH Document No. C2000376 TOTALS 380,198.00: _ 198,556,00; _ 578,854.00: 1 I 1 1 *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. COYBR - Page 2 EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN. CITY OF LUBBOCK Authorised Contracting Entity (type above if different from PERFORMING AGENCY) for and in behalf of: LUBBOCK CITY HEALTH DEPARTKENT PERFORMING AGENCY By: • • Signature of person authorized to sign contracts) B. C. McMinn, Mayor (Name and Title) TDB Document No.: C 000376 AS DEPARTKENT OF HEALTH RECEIVING AGENCY By: T /�' (Signature of person authari ed to sign contracts) Roy L. Hogan, Assistant Deputy Commissioner for Administration (Name and Title) Date: September 12, 1991 Date: i v — Z — 7 / RECONKENDED: By:aA- ��nrY14AN— (PERFORKING AGENCY irector, if different from person authorized to sign contract) APPROVED AS TO FORM: flBy: mom` Office of General Counsel COVER - Page 3 r y r GENERAL PROVISIONS FOR TEXAS DEPARTMENT OF HEALTH CONTRACTS PERFORMING AGENCY and RECEIVING AGENCY agree this contract, assurances. general and/or special provisions, and attachment(s) with detailed scope(s) of work and budget(s), as applicable, incorporate all covenants and agreements pertaining hereto. 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, do hereby 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 terms, performances, and provisions herein set forth. PERFORMING AGENCY hereby assures compliance with the following terms and conditions unless otherwise specified in the attachment(s) hereto: ARTICLE 1. Scope of Work PERFORMING AGENCY will 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 and made a part of this contract, plus amendments which may be added by additional attachment(s) front time to time as hereinafter provided. Satisfactory performance of this contract will be measured in part by: (1) adherence to the contract; (2) results of CPA or 'State Auditor reports; and, 3) timeliness, completeness, and accuracy of required reports. ARTICLE 2. Term The time period of this contract will be governed by the term(s) on the attachment(s). No commitment of contract funds is permitted prior to the first day nor 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 funding being available for the term of the attachment(s) and PERFORMING AGENCY will have no right of action against RECEIVING AGENCY in the event that RECEIVING AGENCY is unable to perform 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 This contract may be amended, and such amendments will be in writing and duly executed by the parties hereto. 1992 GENERAL PROVISIONS - Page 1 (5/91) ARTICLE 5. Severability If any provision of this contract will be construed to be illegal or invalid, this will not affect the legality or validity of any of the other provisions hereof. The illegal or invalid provision will be deemed stricken and deleted herefrom to the same extent and effect as if never incorporated herein, but all other provisions will continue. ARTICLE 5. Ap-plicable Lau4 and Standards This contract will be governed by the laws of the State of Texas and enabling statelfederal regulations, including federal grant requirements applicable to funding sources as set out in attachment(s) hereto, and Treasury Circular 1075 (31 CPR Part 205) as applicable to advance of funds. If PERFORMING AGENCY is at 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 Article 4413 (32g), V.T.C.S., (Uniform Grant and Contract Management Standards Manual (UGCMS)], as may be amended by revised federal circulars to be incorporated in UGCMS by the Governor's Budget and Planning Office, applies as terms and conditions of this contract, and the standards are adopted by reference in their entirety. If a conflict arises between the provisions of this contract and UGCMS, the provisions of UGCMS Will prevail unless expressly stated otherwise. A copy of this manual and its references are 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 RECEIVING AGENCY's institutional prior approval,` procedures. These procedures are incorporated by reference as a condition of this contract. In accordance with. Section 1352 of Public Law 101-121, effective December 22, 1989, PERFORMING AGENCY is prohibited from using funds granted under this contract for lobbying Congress or, any agency in connection with a particular contract. In addition, if at any time, the contract exceeds $100,000, the law requires certification that none of the funds provided by RECEIVING AGENCY to PERFORMING AGENCY have been used for payment to lobbyists. Regardless of funding source, and if a contract exceeds $100,000, a disclosure form must be completed if PERFORMING AGENCY has any agreement with a lobbyist: This certification and/or form is available upon request and must be forwarded to RECEIVING AGENCY within 90 days of receipt. PERFORMING AGENCY certifies by execution of this contract that its payment of franchise taxes is current or, if PERFORMING AGENCY is exempt from payment of franchise taxes, 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 RECEIVING AGENCY. If franchise tax payments become delinquent during the attachment term, payments under this contract will be held until PERFORMING AGENCY's delinquent franchise tax is paid in full. PERFORMING AGENCY further certifies by execution of this contract that it is not ineligible for participation in federal or state assistance programs under 1992 GENERAL PROVISIONS - Page 2 (5/91) Executive Order 12549, Debarment and Suspension. PERFORMING AGENCY specifically asserts that it does not owe a single substantial debt or a number of outstanding debts to a federal or state agency. 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 7. Assurances PERFORMING AGENCY assures that no person will, on the grounds of race, creed, color, handicap, disability, national origin, sex, political affiliation or beliefs, be excluded from, be denied the benefit of, or be subjected to discrimination under any program or activity funded in whole or in part under this agreement. Incorporated by reference the same as if specifically written herein are the rules, regulations, and all other requirements imposed by law including, but not limited to, compliance with those pertinent rules and regulations of the State of Texas and those of United States agencies providing funds to the State of Texas. PERFORMING AGENCY assures it will not transfer or assign its interest in this contract without written consent of the the RECEIVING AGENCY. ARTICLE S. Standards For Financial Management PERFORMING AGENCY will develop, implement, and maintain financial management and control systems that meet or exceed the requirements of UGCMS. Those requirements include at a minimum: 1. 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; 2. Financial management system 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, 3. 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. ARTICLE 9. Allowable Costs Only those costs allowable under UGCMS and OMB Circular A-110, and any revisions thereto, plus any applicable federal cost principles are eligible for reimbursement under this contract. Applicable cost principles and audit requirements are as follows: Circular Applicable Cost Principles Audit Requirement A-87 State & Local Governments Circular A-128 To be -eligible for reimbursement under this contract, a cost must. have been 1992 GENERAL PROVISIONS - Page 3 (5191) incurred within the attachment term and paid by PERFORMING AGENCY prior to claiming reimbursement from RECEIVING AGENCY or encumbered by the last day of the attachment term and liquidated no later than 45 days after the end of the attachment term. Each PERFORMING AGENCY/AUTHORIZED CONTRACTING ENTITY receiving $25,000 or more in total federal/state financial assistance during their fiscal year shall arrange for an agency -wide financial and compliance audit of the PERFORMING AGENCY'S/AUTHORIZED CONTRACTING ENTITY'S fiscal year. The audit, must be conducted by an independent CPA and must be in accordance with the applicable OMB Circulars and Government Auditing Standards. Procurement of audit services will comply with state procurement procedures, as well as provisions of UGCMS. Within 30 days of receipt of audit report, PERFORMING AGENCY/AUTHORIZED CONTRACTING ENTITY will submit a copy to RECEIVING AGENCY'S Internal Audit Division. ARTICLE 10. Overtime Comyensation None of the funds provided by attachment(s) will be used to pay overtime. PERFORMING AGENCY will be responsible for any obligations of overtime pay due employees. ARTICLE 11. Terms and Conditions,o,f Pavment For services satisfactorily performed pursuant to the Scope(s) of Work, PERFORMING AGENCY will receive reimbursement for allowable costs. Reimbursements will not exceed the total of each attachment(s) hereto and are contingent on a signed contract. Claims for reimbursement will be made on a State of Texas Purchase Voucher (TDH Form 1AG-37). Vouchers for reimbursement of actual expenses will be submitted monthly within 20 days following the end of the month covered by the bill. A make-up claim may be submitted as a final close-out bill not later than 45 days following the end of attachment term(s). Advance payment may be requested in accordance with the applicable provisions of this contract. Payments made for approved claims or notice of denial of claims submitted against attachment(s) to this contract will be mailed not later than 60 days after receipt of monthly vouchers. Payment is considered made on the date postmarked. Any reimbursements made by PERFORMING AGENCY to subcontractors will be made in accordance with Article 601f, V.T.C.S. Funding from this contract will not be used to supplant state or local funds, but PERFORMING AGENCY will use such funds to increase state or local funds currently available to PERFORMING AGENCY for a particular activity. PERFORMING AGENCY further agrees to maintain to the best of its ability its current level of support, if any. PERFORMING AGENCY will refund to RECEIVING AGENCY 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 1992 GENERAL PROVISIONS - Page 4 (5/91) 40 payments to PERFORMING AGENCY to offset any reimbursement made to PERFORMING AGENCY for any ineligible expenditures not refunded to RECEIVING AGENCY by PERFORMING AGENCY. Payment may be denied for noncompliance if required financial reports are not on file for previous quarters or for the final period, or for failure to respond to financial compliance monitoring reports, or if program requirements are not met as specified in the Scope(s) of Work. ARTICLE 12. Advance Pavments PERFORMING AGENCY may request, in writing. a one time advance with proper justification and the concurrence of RECEIVING AGENCY. Amount of advance will be determined by the amount and term of the attachment(s); however, for each attachment, the amount of the advance will not exceed one -sixth (1/6th) of a twelve-month attachment. Advance will be requested on a State of Texas Purchase Voucher at the beginning of attachment period or at a single later time in the attachment period if circumstances so warrant and the request is approved. Advance funds will be liquidated during the attachment term so that, after final monthly billing, PERFORMING AGENCY will not have advance funds on hand. Advance funds may be drawn only to meet immediate cash needs for disbursement (UGCMS and federal circulars). Amendments to this contract may require upward or downward adjustment to the allowable advance until it equates 1/6th of a twelve-month attachment or approximates two months operating costs. In the case of a downward adjustment, PERFORMING AGENCY and RECEIVING AGENCY will agree on the amount of adjustment to the advance. RECEIVING AGENCY retains the option to reduce future claims by the required amount. In the case of an upward adjustment and PERFORMING AGENCY needs additional funds to meet immediate operating expenses, PERFORMING AGENCY may submit to RECEIVING AGENCY a written justification and State of Texas Purchase Voucher in the amount necessary to correct the ratio. ARTICLE 13. Program Income PERFORMING AGENCY will develop a fee for service system and a schedule of fees for personal health services in accordance with the provisions of Chapter 12. Sub -chapter D, Health and Safety Code, and the Texas Board of Health rules covering Fees for Clinical Health Services (25 TAC, Sec. 1.91) and other applicable laws provided, however, that a patient may not be denied a service due to inability to pay. All revenues received from the delivery of contract services will be identified, reported, and utilized as provided in this article. Such program income will be retained by PERFORMING AGENCY and: (1) be used by PERFORMING AGENCY for any purposes which further the objectives of the program and the Scope of Work for the attachment(s) and be deducted from total project costs; or, (2),be deducted from total project costs. This is according to RECEIVING AGENCY policy interpreting UGCMS, a copy of policy is provided on request and is incorporated by reference as a condition of this contract. 1992 GENERAL PROVISIONS - Page 5 (5/91) ARTICLE 14. Financial Re op its Financial reports are required as provided in UGCMS and will be filed regardless of whether or not expenses have been incurred. Quarterly Financial Status Report, State of Texas Supplemental Form 269a (TDH Form GC-4a), will be submitted within 20 days following the end of each quarter. Annual/Final A final financial report, Request for Advance or Reimbursement, Form 270 (TDH Form GC-10) will be submitted not later than 45 days following the and of attachment term(s). If necessary, a State of Texas Purchase Voucher will be submitted if all costs have not been recovered or a refund will be made of excess monies if costs incurred were less than funds received. ARTICLE 15. Reuorts and Inspections PERFORMING AGENCY will submit financial, program, progress, and other reports as requested by RECEIVING AGENCY in the format agreed to by the parties hereto. RECEIVING AGENCY and, when federal funds are involved, any authorized representatives) of the federal government have the right, at all reasonable times, to inspect or otherwise evaluate the work performed or being performed hereunder and the premises in which it is being performed, including subcontractors. PERFORMING AGENCY will participate in 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 delay the work. PERFORMING AGENCY agrees that RECEIVING AGENCY and the federal government, or any of their duly authorized representatives, will have access to any pertinent books, documents, papers, and records of PERFORMING AGENCY 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 or suspension of the contract attachment(s). Any such withholding of funds or suspension will remain in effect until the findings are properly remedied as determined by RECEIVING AGENCY. 1992 GENERAL PROVISIONS - Page 6 (5/91) PERFORMING AGENCY from the date of attachment(s) or period is longer. will retain all such records for a period of three years the last expenditure report submitted under contract until resolution of all audit questions, whichever time ARTICLE 16. Client Records At the end of the attachment term, all client records are the property of PERFORMING AGENCY. RECEIVING AGENCY retains the right to hsive access to the records or obtain copies for audit, litigation, or other circumstances that may arise. 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 records upon written notice to PERFORMING AGENCY. Records may be transferred to another entity that agrees to continue the service or, at the option of RECEIVING AGENCY, the records may be transferred to RECEIVING AGENCY headquarters. ARTICLE 17. Confidentiality PERFORMING AGENCY will have a system in effect to protect from inappropriate disclosure of patient records and all other documents deemed confidential by law which are maintained in connection with the activities funded under contract attachment(s). Any disclosure of confidential patient information by PERFORMING AGENCY, including information required by the Reports and Inspections Article, will be in accordance with applicable law. If providing direct client care, services, or programs, PERFORMING AGENCY agrees to implement workplace policies based on the model guidelines adopted by RECEIVING AGENCY and to educate employees and clients concerning the human immunodeficiency virus (HIV) and its related conditions including acquired immunodeficiency syndrome (AIDS). PERFORMING AGENCY agrees to develop and implement policies regarding confidentiality of AIDS and HIV -related medical information for employees of PERFORMING AGENCY and for clients, inmates, patients, and residents served by PERFORMING AGENCY. Further, PERFORMING AGENCY agrees to develop and implement an anti -discrimination policy assuring all privileges and opportunities for any employee or client with a communicable disease. HIV -related policies will be based on accurate scientific information. Such policies will be consistent with the model guidelines published by RECEIVING AGENCY and with state and federal laws and regulations. A PERFORMING AGENCY that does not adopt a confidentiality policy as herein required is not legally eligible to receive state funds until the policy is developed and implemented. ARTICLE 18. Equipment and Supplies Equipment is defined as tangible nonexpendable property with an acquisition cost of over $500 and a useful life of more than one year. In accordance with Article 601b, V.T.C.S., Section 8.02(c), title to all equipment purchased from funds provided herein will be in the name of PERFORMING AGENCY throughout the attachment(s) term(s). Unless initially listed and approved in the attachment(s), prior written approval from RECEIVING AGENCY is required for any additions to or deletions 1992 GENERAL PROVISIONS - Page 7 (5/91) of approved equipment purchases having an acquisition cost exceeding $500. To receive approval for data processing hardware and software purchases with an acquisition cost over $500, PERFORMING AGENCY must submit a detailed justification which includes description of features, `make and model, and cost, etc. PERFORMING AGENCY will maintain an annual property and inventory listing and submit a report (TDH Form GC-11) to RECEIVING AGENCY not later than 45 days from the end of the attachment(s) term(s). PERFORMING AGENCY will administer a program of maintenance, repair, and protection of assets under this attachment(s) 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 attachment(s), it will use the proceeds to repair or replace said assets. PERFORMING AGENCY agrees that upon termination of attachment(s), title to any remaining equipment purchased from funds as hereinabove provided will be transferred to the RECEIVING AGENCY or any other party designated by the 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 19. Subcontractin PERFORMING AGENCY may enter into agreements with subcontractors unless restricted or otherwise prohibited in specific attachment(s). Subcontracts, if any, entered into by PERFORMING AGENCY will be in writing and subject to the requirements of this contract. PERFORMING AGENCY agrees that it will be responsible to RECEIVING AGENCY for the performance of any subcontractor. In addition, if PERFORMING AGENCY elects to enter into an agreement which subcontracts out a substantial portion of PERFORMING AGENCY's Scope of Work. prior written approval must be obtained from RECEIVING AGENCY. ARTICLE 20.. Copyrirthts and Publications PERFORMING AGENCY understands and agrees that where activities supported by the contract attachment(s) produce original books, manuals, films, computer programs (including executable computer programs and supporting data in any form), or other original material, PERFORMING AGENCY may copyright such material subject to any rights to same reserved by or vested in the federal government or any agency thereof; however, RECEIVING AGENCY may grant to PERFORMING AGENCY limited rights to produce, publish, and use such materials as appropriate. PERFORMING AGENCY may publish at its expense the results of contract performance with prior RECEIVING AGENCY review and approval. Any publication (written, visual, or sound) should include acknowledgment of the support received from RECEIVING AGENCY and the appropriate federal agency, if applicable. At least three 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. 1992 GENERAL PROVISIONS - Page 8 (5/91) a , r ARTICLE 21. sold Harmless PERFORMING AGENCY, which is not a state agency, assures that it is an independent contractor and not an agent, servant, or employee of the state. Except to the extent that Chapter 104 of the Texas Civil Practice and Remedies Code is applicable to this contract, PERFORMING AGENCY agrees to hold RECEIVING AGENCY and/or federal government harmless and to indemnify them from and against any and all claims, demands, and causes of action of every kind and character which may be asserted by any third party occurring or in any way incident to, arising out of, or in connection with the performance of services by PERFORMING AGENCY under this contract to the extent allowed by law, and to the extent ofdamages permitted under Chapter 101 of the Texas Civil Practice and Remedies Code. 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 22. Bondine Each person employed by PERFORMING AGENCY who handles funds under this contract, including persons authorizing payment of such funds, will be covered by the terms of a fidelity bond providing 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. This fidelity bond will be in the amount of not less than Ten Thousand Dollars ($10,000). In the event that PERFORMING AGENCY, being an independent contractor, maintains a self-insurance program that provides for the indemnification of losses as described in the above paragraph regarding fidelity bonds, then PERFORMING AGENCY will provide to RECEIVING AGENCY a certified statement which summarizes its self-insurance plan. The certified statement will be submitted at the time this contract is submitted for approval. Any changes to said plan, which occur during the term of this contract period, will be reported to RECEIVING AGENCY. The self-insurance program should be based on the determination that the coverage can be provided at a cost no greater than the cost of obtaining equivalent coverage from an insurance company. ARTICLE 23. Suspension/Termination If PERFORMING AGENCY fails to comply with RECEIVING AGENCY's reporting requirements, the program objectives, or the contract award conditions, RECEIVING AGENCY may withhold payments. RECEIVING AGENCY will provide advance written notice to PERFORMING AGENCY which will identify the deficiency and RECEIVING AGENCY's intent to withhold payments if the deficiency is not corrected within a specific number of days. When the deficiency is corrected, RECEIVING AGENCY will release any withheld payments with no further action. If PERFORMING AGENCY fails to comply with the terms, conditions, or standards of this contract, RECEIVING AGENCY may suspend the contract attachment(s) and prohibit PERFORMING AGENCY from incurring additional obligations of funds pending either corrective action or termination. RECEIVING AGENCY will provide written notice to PERFORMING AGENCY at least thirty (30) days in 1992 GENERAL PROVISIONS - Page 9 (5/91) advance of the suspension date. Such notice will detail the nature of noncompliance and specify a -correction date. PERFORMING AGENCY may request a hearing on the proposed suspension if such request is made in writing within ten (10) days from any final notification of suspension. This contract or any attachment(s) hereto may be terminated by either. of the parties hereto for noncompliance by the other party. A party intending to terminate for noncompliance by the other party will provide written notice to the other party at least thirty (30) days prior to the intended date of termination. Such notice will include the reasons ,for the termination and will provide the other party an opportunity to rebut the reasons in writing. A hearing may be requested on the proposed termination if such request is made in writing within ten (10) days from any final notification of termination. By such termination, neither party may nullify obligations already incurred for performance or failure to perform prior to the date of termination. Such termination will not be an exclusive remedy but will be in addition to any other rights and remedies provided by law or under this contract. This contract or any attachment(s) hereto may be terminated in whole, or in part, when both parties agree that continuation would not produce results commensurate with further expenditure of funds. Both parties will agree on the effective date and, in the case of partial termination, the portion to -be terminated. RECEIVING AGENCY will immediately send PERFORMING AGENCY written notice of the terms agreed to and such notice will become a part of the contract. PERFORMING AGENCY will not incur new obligations for the terminated portion after the effective date of termination and will cancel as many outstanding obligations as possible. RECEIVING AGENCY will allow full credit to PERFORMING AGENCY for noncancelable obligations which were properly incurred prior to the termination date. This contract or any attachment(s) hereto may be terminated if funds allocated for any attachment(s) hereto should become reduced, depleted, or unavailable during any attachment(s) budget period, and RECEIVING AGENCY is unable to obtain additional funds for such purposes.. RECEIVING AGENCY will immediately provide written notification to PERFORMING AGENCY of such fact and such attachment(s) to this contract is/are terminated upon receipt of that notification. PERFORMING AGENCY will not incur new obligations after the effective date of termination and will cancel as many outstanding obligations as possible. RECEIVING AGENCY will allow full credit to PERFORMING AGENCY for noncancelable obligations which were properly incurred prior to the termination date. This contract or any attachment(s) hereto may be terminated in the event that federal or state laws or other requirements should be amended or judicially interpreted so as to render continued fulfillment of this contract,. on the part of either party, unreasonable or impossible. If the parties should be unable to agree upon amendment which would therefore be needed to enable the, substantial continuation of the services contemplated herein, then, upon written notification by RECEIVING AGENCY to PERFORMING AGENCY, the parties will be discharged from any further obligations created under the terms of. this contract, except for the equitable settlement of the respective' accrued interests or obligations as of the date of termination. 1992 GENERAL PROVISIONS - Page 10 (5/91) ARTICLE 24. 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. PERFORMING AGENCY will have in place legally sufficient Due Process Searing 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 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 attachment(s) to 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 by RECEIVING AGENCY state warrants 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 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 1992 GENERAL PROVISIONS - Page 11 (5/91) PERFORMING AGENCY to complete the conversion. ARTICLE 25. Funding Participation Requirement PERFORMING AGENCY agrees funds provided through this contract will not be used for matching purposes in securing other funding. ARTICLE 26. Performance -Based Attacbments History RECEIVING AGENCY is responsible for developing performance -based public health services contracts in response to the State Auditor's Report.' This system will enhance service delivery and improve accountability and efficiency in the management of public health dollars. Plans for initial, implementation were designe to use the model objectives format stemming from recommendations of the Conttee on Modei"Objectives for Local Public Health in Texas. The committee was composed of representatives of local health departments and RECEIVING AGENCY'S central and public health region offices in consultation with the University of Texas School of Public Health in Houston. Purpose The overall goal of performance -based contracts is improved public health practices in Texas. The project is intended to: -identify public health needs and establish priorities which provide a rational basis for resource allocation; -project realistic outcomes based on activities which can be accomplished with current or planned resources, communicate needs, and build consensus at all levels regarding directions to be taken in specific programs; and, -institute a system for planning, implementing, managing, and evaluating programs and monitoring progress toward reducing and/or alleviating public health problems. , Process PERFORMING AGENCY will prepare outcome and process objectives relative to local needs and resources in the following selected program areas, if applicable: -AIDS /UIV -Chronic Disease Prevention and Control -Food Protection -Immunization Maternal and Child Health -Sexually Transmitted Diseases -Tuberculos*s -Refugee Health -Hansen's Disease -Other Communicable Disease Epidemiology and Surveillance 1992 GENERAL PROVISIONS - Page 12 ` 1� r• -Public Health Promotion -On-Site Wastewater Facility Management By the end of the current state fiscal year, PERFORMING AGENCY will show evidence of a monitoring system to evaluate progress towards the objectives. RECEIVING AGENCY will provide training, written documentation, and ongoing technical assistance to PERFORMING AGENCY in the development of objectives and a monitoring system. RECEIVING AGENCY contact for matters pertaining to the performance -based public health services project is the Office of the Associate Commissioner for Community and Rural Health. It is understood and agreed to by both parties that some objectives may not be met and achievement levels may be different than estimated. The objectives are recognized as test processes and achievement below the established levels will not affect the right of PERFORMING AGENCY to funds provided through Attachment(s) when the basic program scope of work has been fulfilled. Any disputes arising from procedures or actions taken as part of this project will be addressed and resolved to the mutual satisfaction of both parties. 1992 GENERAL PROVISIONS - Page 13 (5191) DOCUMENT NO. C2000376 ATTACHMENT NO. 01 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: HIV DIVISION TERM: September 1, 1991 THROUGH August 31, 1992 SECTION I. SCOPE OF WORK: PERFORMING AGENCY agrees to conduct program activities to help reduce the spread of AIDS/HIV (acquired immunodeficiency syndrome/human immunodeficiency virus). PERFORMING AGENCY will perform counseling, testing, referral, and partner notification (CTRPN) activities which include establishing and/or maintaining anonymous or confidential HIV testing programs for persons at increased risk of HIV infection due to individual sexual behavior, intravenous drug abuse, or other risk behaviors. 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 will provide CTRPN services to the target population defined as: 1. Males who routinely have sex with other males. 2. Males who occasionally have sex with other males. 3. Males who have sex with males and females. 4. Males and females with multiple sex partners. 5. Persons with a history of sexually transmitted diseases. 6. Persons with a history of high risk behavior. PERFORMING AGENCY will perform the following Counseling and Testing Services: 1. Offer voluntary anonymous and/or confidential HIV testing to clients who may want to be tested. 2. Provide culturally sensitive and effective pretest and posttest counseling based on Centers for Disease Control (CDC) approved model. 3. Publicize HIV counseling and testing services so that potential clients will know where and when services are available. 4. Offer HIV counseling and testing services at a location that is convenient for the majority of the target population and during hours established to reach these clients. 5. Use scannable forms supplied by RECEIVING AGENCY for collection of demo- graphic information and blinded test result data. 6. Utilize RECEIVING AGENCY'S laboratory for all ELISA and Western Blot testing. me 7. PERFORMING AGENCY will 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: a. ensuring that behavior changes occur and are sustained; b. providing psychosocial services; c. medical intervention; d. substance abuse treatment; e. family planning services; f. financial and legal assistance; g. ongoing case management; h. long term care. PERFORMING AGENCY will perform the following Partner Notification Services: 1. All partner notification services are to be consistent with RECEIVING AGENCY'S Serologic Test Counseling and Partner Notification Techniques guidelines which are incorporated by reference and made a part hereof. 2. Encourage HIV+ clients to voluntarily refer their sexual and/or needle sharing partners for HIV counseling and testing. 3. Encourage intravenous drug users (IVDU) to voluntarily refer their sexual and/or needle sharing partners for HIV counseling and testing. 4. If the client wishes to make the partner notification personally, provide guidance in making contacts. 5. If the client does not want to make the partner notification, but wishes partners to be notified, elicit adequate information for RECEIVING AGENCY STD clinic personnel to make the notification. PERFORMING AGENCY agrees to comply with the following CTRPN Quality Assurance Guidelines: 1. PERFORMING AGENCY assures that pretest and posttest counseling sessions are performed by staff who have received counseling training from a course approved by RECEIVING AGENCY. 2. PERFORMING AGENCY will conduct monthly monitoring of counseling, testing, referral, and partner notification sessions and give performance feedback to counselors. 3. PERFORMING AGENCY agrees to facilitate RECEIVING AGENCY review of scheduled counseling, testing, referral, and partner notification sessions. All activities will be performed in accordance with the applicable RECEIVING AGENCY current program rules and guidelines, which are adopted by reference as part of this attachment. PERFORMING AGENCY agrees to comply with the following: -2- Chapter 81, Health and Safety Code; Article 4419b-4, V.T.C.S., Human Immunodeficiency Virus Services Act. PERFORMING AGENCY will provide an estimated 1000 clients with services/units of service in or benefiting the county(ies)/area defined as: LUBBOCK. SECTION II. LEGAL AUTHORITY TO CONTRACT: Chapters 12, and 121, Health and Safety Code. SECTION III. 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 Education Sessions in Centers for Disease Control Assistance Programs," and its preface which is written by RECEIVING AGENCY. Said document and its preface are incorporated as part of this attachment as though it were written herein verbatim. PERFORMING AGENCY will provide to RECEIVING AGENCY written acknowledgment of receipt and acceptance of this document and its preface and will comply with the guidelines contained in this document and its preface. Due to_the sensitive and highly personal nature of AIDS/HIV-related information, strict adherence to the General Provisions Confidentiality Article is required. PERFORMING AGENCY success depends upon whether persons at risk believe that the program observes this principle. In addition to these conditions, PERFORMING AGENCY will comply with the following specific requirements regarding individual patient information/data when conducting counseling, testing, referral, and partner notification activities. 1. If a client chooses to be anonymous when the mandatory offer of anonymity is made, then: a. no record will be maintained linking the person's identity with his/her real name or pseudonym or other identifiers; and �. b. upon notice to the client, the lab slip(s) containing the test results will be shredded/destroyed. Originals and copies of test results will not be maintained longer than 30 days. 2. If a client elects to have a confidential file made for the testing and counseling, this file will be maintained in a fashion consistent with RECEIVING AGENCY'S HIV Testing Guidelines which are incorporated by reference and made a part hereof. If confidential testing is needed, then the lab slip containing the test results may be provided to the client if requested. 3. No log containing personal information or identifiers or HIV status will be maintained in anonymous or confidential testing situations. PERFORMING AGENCY will submit required programmatic reports quarterly on the -3- same cycle as financial status reports. PERFORMING AGENCY will authorize their staff to attend in -state and out-of- state training, conferences, and meetings for which funds were budgeted and approved by RECEIVING AGENCY. SECTION IV. BUDGET: Personnel Fringe Benefits Travel Equipment Supplies Contractual Other $23,830.00 5,958.00 700.00 .00 1,500.00 .00 500.00 Total Direct Costs $32,488.00 Indirect * 1,177.00 TOTAL $33,665.00 * Negotiated amount less than UGCMS, Table 1. Financial status reports (FSRs) are due the 20th of December, March, June, September and the 15th of October. Total reimbursements will not exceed $33,665.00. -4- CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant,, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-111, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. t ` September 12, 1991 Signature Date B. C. McMinn Name of Authorized Individual C2000376 Application or Contract Number City of Lubbock P.O. Box 2000 Lubbock, TX 79457 Name and Address of Organization DISCLOSURE OF LOBBYING ACTIVITIES - ipcm.aftr°&fe Compieti this four to disclose lobbyinngg ac tivilles pursuant to 31 U.S.C.1352 (See reverse for public burden dfsdosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: L Contract a. bidloffer/application b. Inkild award s. iMtial filing D b. material change b. grant c, cooperative agreement d, ban c. post award For Material Change Only: e. ban guarantee f. ban insurance year quarter„ date o7ot apart 4. Name and Address of Reporting Entity. fi. If Reporting Entity In No. 4 is Subawarde% Enter Name and address of Prima: 13 Prime G Sub ward" . raurown.• Congresslonal DlsWM rknown: T. Federal Program Name/Doscriptlon: Congressional District, rknown: L Federal Department/Agency: CFDA Number, U applicable: L Federal Action Number, rknown: L Awar&Amourtt; U known: i 10.a. Name and Address of Lobbying End b. Individuals Performing Sorvlces (&WudV address r (rkx*Vua4 Awns". ftrsarne. M. r NnaI Oa �n rr blq: Arm CGMWU MOnQ/na e) SF -=.A. Inac swy) 11. Amount of Payment (check ap UW apply): 13. Type of Payment (check all that apply). i p Actual p planned a. retainer b. one-time fee c commission 12. Form of Payment (chock ad that apply): d. contingent foe a. cash e. deferred p b. in-kind;specify: nature f. other, specify: value 14. Brief Description of Servlces Performed orto be Performed and Date(s) of Servlc% Including offlcer(a), employee(s). or Member(i) contacted for Payment Indicated In Item I I: (awean Car4x4WW Sl WS) Sr- rff,A. 8raCSS W 15. Continuation Sheet(a) SF111+A attached-. Q Yes Q No IL MaornMM wausoa >trougn ng WM • autr == car aoa 31 1r.a.C. aaesant332.Thtsalwosuaa�oeoy�esgacams"Mamamm P --an= Signature: or as wan WSM mew" %= saws or to ow aoaw wow I* aaraacaon was Mite@ or a+arna Mao. TMs at emm is maurw purumm Print Name: 0 31 t1.S.C.1= Ttrs rllormsaon wo aanoorme m rw Cangrm semi Tide: aruwary am we be avaram for ouoac rapacom Any person writ aril 0 as °"'rtw" asaaswe wwo to sm a aA pally or= rasa nin Telephone No.: Date: staAOo ono roc maro am ssaaAw for weal am m"*. Awimus01ar LOCar Aa0r000Wan SINWam Foley • I 1 t CONTINUATION SHEET r Reporting Entity: Page � of AnMZM 1W LOM ASWO I smnwd Farm • t 11 •A S � . DOCUMENT NO. C2000376 ATTACHMENT NO. 02 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: COMMUNITY AND RURAL HEALTH TERM: September 1, 1991 THROUGH August 31, 1992 SECTION I. SCOPE OF WORK: PERFORMING AGENCY will use direct assistance and/or financial assistance from RECEIVING AGENCY to supplement the delivery of comprehensive public health services. Comprehensive health services encompass a wide variety of personal health services, environmental health services, and other problems of the jurisdiction. Personal health services may include but are not limited to adult health/chronic disease, AIDS/HIV, chronically ill/disabled children, dental, immunization, laboratory, maternal and child health, public health promotion/education, sexually transmitted disease control, and tuberculosis control. Environmental health services/inspections may include but are not limited to food, premise, swimming pool, vector control, and wastewater control. Other services may be provided as needed when agreed to by both parties. Reports of comprehensive health services performed will be submitted to RECEIVING AGENCY, Community and Rural Health, in a format and time frame agreed upon by both parties. Direct assistance will be provided by RECEIVING AGENCY to PERFORMING AGENCY for the implementation of an immunization program. The goal of the immunization program is to prevent, control, and eradicate vaccine -preventable disease by providing/administering biologicals, promoting immunization, and applying epidemiologic/outbreak controls within budgetary constraints. This will be accomplished by performing the following activities and reports. A. Investigations/Control Measures PERFORMING AGENCY will investigate 100% of suspected cases of measles, rubella, pertussis, poliomyelitis, and diphtheria within 24 hours after a report is received. PERFORMING AGENCY will investigate 90% of suspected mumps cases and 100% of suspected tetanus cases within 48 hours after a report is received. For the above diseases, PERFORMING AGENCY will implement the most current outbreak control procedures/measures and contact RECEIVING AGENCY, Immuniza- tion Division, within 48 hours after an investigation is initiated. B. Reporting Requirements PERFORMING AGENCY understands that all vaccines used in RECEIVING AGENCY Immunization Programs are purchased with public funds and must be accounted for the same as other public property. PERFORMING AGENCY further understands that vaccine loss, destruction, spoilage, or other waste, may be investigated by the RECEIVING AGENCY, Immunization Division, who may then require -1- reimbursement or replacement of the lost vaccines. PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunization Division, by January 31st, of each year, a report detailing storage measures and methods used to control vaccine loss including method to monitor and record daily vaccine storage temperatures. The report shall be submitted in a format provided by RECEIVING AGENCY, Immunization Division. PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunization Division, monthly reports of vaccine utilization/loss, within ten working days after the end of each month, on forms provided by RECEIVING AGENCY (forms C5, C5A, C33, C33A). PERFORMING AGENCY will obtain monthly biological reports from private physician offices and others who receive state supplied biologicals. PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunization Division, by September 15th, of each year, a report on the number of people served with immunizations (unduplicated count) and the number of visits for immunizations in the preceding State Fiscal Year. In addition to support for the above activities, RECEIVING AGENCY, Bureau of Laboratories, agrees to provide direct assistance of laboratory supplies to PERFORMING AGENCY to execute laboratory analyses for the following RECEIVING AGENCY programs: water bacteriology, milk bacteriology, chemistry, syphilis serology, gonorrhea testing, and other approved laboratory analyses. PERFORMING AGENCY agrees to meet standards for such analyses as set forth by RECEIVING AGENCY, Bureau of laboratories, the Clinical Laboratories Improve- ment Act, the Safe Drinking Water act, the National Conference of Interstate Milk Shippers, and/or the Public Health Service Grade A Pasteurized Milk Ordinance. PERFORMING AGENCY agrees to comply with: Texas Immunization Laws, Rules and Regulations; Chapter 42, Human Resources Code; Sections 2.09 and 2.09A, Texas Education Code; and, Section 317 of the PHS Act as amended. PERFORMING AGENCY will provide an estimated 13,000 clients with services/units of service in or benefiting the county(ies)/area defined as: LUBBOCK. SECTION II. LEGAL AUTHORITY TO CONTRACT: Chapters 12 and 121, Health and Safety Code. SECTION III. SPECIAL PROVISIONS: General Provisions, Program Income Article, paragraph one, is amended to include the following sentence: PERFORMING AGENCY understands that federal law guarantees access to immunization services in public clinics regardless of ability to pay and agrees to post in the waiting room of each immunization clinic the bilingual poster "Fees for Vaccine Administration" (Form 6-36 available from Immunization Division). -2- 5 SECTION IV. BUDGET: ' FINANCIAL ASSISTANCE Financial assistance involves payment of funds to PERFORMING AGENCY for costs incurred in carrying out approved activities. Personnel $53,698.00 Fringe Benefits 13,416.00 Travel .00 Equipment .00 Supplies .00 Contractual 24,000.00 Other .00 Total Direct Costs $91,114.00 Indirect .00 TOTAL $91,114.00 Financial status reports (FSRs) are due the 20th of December, March, June, September and the 15th of October. RECEIVING AGENCY financial assistance will not exceed $91,114.00. DIRECT ASSISTANCE Direct assistance involves the assignment of state funded positions or the provision of materials or supplies such as vaccines in lieu of cash. Personnel [03 position(s)] $64,488.00 Laboratory Support 14,000.00 Vaccine 91,064.00 TOTAL $169,552.00 Direct assistance for personnel in the amount of $64,488.00 is shown on the attached list of positions and budgetary amounts which is an integral part of this attachment. State salary warrants for net earnings will be issued in accordance with state regulations. Direct assistance for public health laboratory services is provided by RECEIVING AGENCY, Bureau of Laboratories, through requisition for supplies processed in accordance with RECEIVING AGENCY guidelines. Financial status reports (FSRs) are not required on direct assistance. Program income generated from activities supported with direct assistance will be reported on FSRs required for financial assistance provided through this attachment, if applicable, or through other program attachment(s) benefiting from this assistance. RECEIVING AGENCY direct assistance will not exceed $169,552.00. Total RECEIVING AGENCY assistance will not exceed $260,666.00. -4- LUBBOCK CITY HEALTH DEPARTMENT PAGE 643 TEXAS DEPARTMENT OF HEALTH PHR 2 OPERATING BUDGET FOR YEAR ENDING AUGUST 31, 1992 AS OF APRIL 30. 1991 BUDGET NO. LCOGG H21311/K13028 CATE• DESCRIPTION OR TITLE FUND END ITEM JOB PAY PAY EFFECTIVE MONTHLY BUDGETED AMT GORY OESC. MONTH NO. CLASS 6P STP DATE RATE 1 NURSE It STATE AUG 018 4385 14 01 SEP 91 1,995.00 23,940.00 LIC VOCATIONAL NURSE II STATE AUG 083 4412 2O 04 SEP 91 1,717.00 20,604.00 ADMINISTRATIVE TECH I STATE AUG 104 1501 08 07 SEP 91 1.662.40 19,944.00 64,468.00 a CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-111, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. � c September 12, 1991 ignature Date B. C. McMinn Name of Authorized Individual C2000376 Application or Contract Number City of Lubbock P.O. Box 2000 Lubbock, TX 79457 Name and Address of Organization Ci SCLOSURE OF LOBBYING ACTIVITIES • 1' Complets this tone to disciase losbyinngg atxivitiea pursuant to 31 U.S.C.1352 (See reverse for publk burden dtsciosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Typo: a. contract b. a. b. initiial awant�atlon a. Initial flWV 11 b. material change grant C. cooperative agreement c. post -award d, ban For Material Change Only: e. ban Q�utrararttoe t. loan Ksurance Year quarter r _ dale oiTst report 4. Marna and Address of Reporting Entity: L H Reporting Entity In No. 4 Is Subawardse, Enter Nance and address of Prima: Q Prime Q Subawardee TMr_ 1►known: Congressional District, rknow»: 7. Federal Program Name/Description: Congressional District, ►known: f1. Foderaf Departrnent/Agoncy: CFDA Number, g applicable: L Federal Action Number,1known: L Awan*Amount; I known: s 10.a. Name and Address of Lobbying Entl b. Individuals Performing Services (inducOng address Lf (fk)dWu&4 AM name, !lrstname, Mr `a �nar Imfi�st name? MO OWNS Catafr AUM a WWA) sFit -4 rnraeuaW 11. Amount of Payment (check as that apply): 13. Type of Payment (check as that appty): s p Actual Q planned a. retainer b. one4me Ice C. commission 12 Form of Payment (check ad that *#y): d. fee p a. cash e. deeti�rredct (] b. In -kind; specify: nature f. other, specify: value 14. Brief DescrWon of Services Performed orto be Porfomnsd and Date(s) of Service, including officer(sh employee(s), or Members) contacted for Payment indicated in Item 11: /8100 Canarnenat shown SF- I #A I racers" 1S. Continuation Shest(s) SF-111-A attached: 13 yes Q No 1& raanrnum ameam rvown no titan a aunmaw ey no 31 u.a.c mewni=Tk sm.aour at,n n- amossaaammmmpss«wauon Signature: of Am won WNM mum* was otacm er to W 4o0w won I" tavacuan was aam or wum Tic wo. firs d*xwn +s aQ wa wvAm Print Name' 031 N.S.C. ISM T±ri v$anT9ww wet N /lt+anaa w vw canwm sNt! Title. mmmay am wo oe avemm for Pw mpecoon. Any wwn ww tour a Me Mo Mwno *Sams* ~ 00 Vj*a b a a" Maly W sat a" tt m Telephone No.: Date _ a10A00 WW not RMS awn $100A00 or cam wcn gdun. .1�+tAont�e for �ocat ii�o�eouCgn 6tanooro iwn.. � n r CONTINUATION SHEET ` Reporting Entity: Page c_.__._._. stanava Farm • 111•A INSTRUCTIONS FOR COMPLETION OF SF-111, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal reraient. at the initiation or. receipt of a covered Federal action, or a material change to a previous tiling, pursuant to title 31 U.S.C. section 1351 The filing of a form is required far eacn payment or agreement to maKe payment to any lobbying entity far influencing or attempting to influence an offtcerar employee of any agency. a Member of Congress. an officer or employee at Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-t 11 •A Continuation Sheet tar additional information it the space an the form is inadequate. Complete ail items that apply for both the initial filing and material orange report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identity the type of covered Federal action tar which lobbying activity is and/or has been secured to influence the out came of a covered Federal action. 2 Identity the status of covered Federal action. 3. Identity the appropriate classification of this report. It this is a foltowup report caused by a material change to Me infommtton previously reported. enter the year and quarter to which the change occurred. Enter the date at the last previously submitted report by this repotting entity mrthfs covered Federal action. 4. Enterthe full name, address, city, state and zip code of the reporting entity. Include Congressional Oftict. if known. Check the appropriate clasan at the reporting entity that designates it it is. or expects to be. a prime or subaward recipient. Identify the tier of the subawardee, e.g.. the first subawardee at the prime is the 1 st tt+er. Subawards include but are not limited to subcontracts. subg rants and contract awards under grants. I It the organization filing the report In item 4 checks'Subawardes% then enter the full name, address. city. state and Zip code of the prime Federal recipient. Include Congressional Otstrb= if known. 6. Enterthe name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, 0 known. For example. Department of Transportation, United States Coast Guard. 7. Enterthe Federal program name or description for the covered Federal action (item 1). If known. enter the tuft Catalog at Federal Oorrmestic Assistance (CFDA) numberfor grams. cooperative agreements. loam and ban commitments. 8. Enterthe most appropriate Federal identifying number available for the Federal action Identified In Item t (e.g- Request for Proposal (RFP) number. Invitation for Bid (IFS) number. grant announcement number, the contract. grant, or loan award number. the applingonlpiroposall control number assigned by the federal agency). Include prefixes, e.g, ORFP-OE-90.001 9. For a covered Federal action where there has been an award or ban commitment by the Federal agency, enter Me Federal amount of the award/loan commitr merit for the prime entity identif led In item 4or S. 10. (a) Enterthe tug name, address, city, state and zip code of the lobbying entity engaged by the reporting entity Identified in item 4 to influence the covered Federal action. (b) Enter the full names of the Individual(s) performing services, anctindude full address it different from 10 (a). Enter I = Name. First Name. and Mkidfe Initial (MI). 11. Enterthe amount of compensation paid ar reasonabty expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whetherthe payment has been made (actual) or will be made (planned). Check all boxes that apply. It this is a material change report. enter time cumulative amount of payment made or planned to be made. 12 Checkthe appropriate bcx(es). Check all boxes that allply. it payment is made through an in-kindcantribution. specify the nature and value of the in -kind payment. 13. Check the appropriate box(es). Check all boxes that apply. If other. specify nature. 14. Provide a specific and detailed description of the services that the lobbyist has performed. orwifl be expected to perform. and the date(s) of any services rendere(l. Include all preparatory and related activity. not just time spent in actual contact with Federal officials. Identify the Federal offktal(s) aremployee(s) contacted orthe officer(s). employee(s). or Member(s) of Congress that were contacted 15. Check whether or not a SF-1 11 -A Continuation Sheets) is attached 16. The certifying otflcial shall sign and date the form print hivher name, title. and teieptsone number. Rtofe reowang Did& for T" eoseeaort of k[tor[r+aam is esan+aM ea anon" 30 WtvitM aer response. WfCkWM are tw roywar q rurrucaans. searawq +nsanq dm s&A"& owunng am rttsutta" ale frets needed. am wmpwang aria mowmq m =wcow at wdornuum. Sdm camm tits regar=ng M mmen esomate W a W caw a:o= of na cauteoort dt uftnmocn. r+avaM wggaoara a r reouang ass ouro w. mate Ofte of bmnagerneru aria auoget. Paaerw it Reaucw prorea (034640-AM. waatungton. D.C. 20= a DOCUMENT NO. C2000376 ATTACHMENT NO. 03 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: BUREAU OF MATERNAL AND CHILD HEALTH TERM: September 1, 1991 THROUGH August 31, 1992 SECTION I. SCOPE OF WORK: PERFORMING AGENCY will use direct assistance and/or financial assistance from RECEIVING AGENCY to provide health services to women and children. Emphasis will be placed on prenatal care, family planning services, especially during the first year post partum, and preventive child health services. Special emphasis should be given to low income women and children. In addition, the PERFORMING AGENCY will provide case management services to these women and children with an emphasis on services to high risk women and infants. Case management services include an assessment of the individual's and family's services needs and the development, implementation and evaluation of a plan to meet these needs. Services will be performed in accordance with the standards for maternity, family planning, and child health services as promulgated by the RECEIVING AGENCY, Bureau of Maternal and Child Health. Maternity/Family Planning and Child Health Clinic reports will be submitted to RECEIVING AGENCY, Bureau of Maternal and Child Health, in a format and time frame to be agreed upon by both parties. PERFORMING AGENCY will participate in the development of networks under the leadership of its Public Health Regional Director. The Public Health Region ("Region") will be inviting a broad -based participation in its. meetings to include community -based providers, county judges, city commissioners, community health center personnel, migrant health center personnel, medical schools, and agricultural extension agents. PERFORMING AGENCY will participate in a least 50% of the meetings called by the Region. PERFORMING AGENCY will work with the Region in order to coordinate services, avoid duplication, and develop "One Stop Shopping Care Centers" where possible. PERFORMING AGENCY will provide an estimated 3.900 clients with services/units of service in or benefiting the county(ies)/area defined as: LUBBOCK. SECTION II. LEGAL AUTHORITY TO CONTRACT: Chapters 12 and 121, Health and Safety Code. SECTION III. SPECIAL PROVISIONS: General Provisions, Program Income Article, requires that a fee for services system and a schedule of fees be developed. Low income mothers and children provided health services under this attachment will not be charged a fee. The -1- term "low income" refers to an individual or family with an income determined to be below the nonfarm income official poverty line defined by the Office of Management and Budget and revised annually in accordance with Section 624 of the Economic Opportunity Act of 1964. General Provisions , Reports and Inspections Article, is modified to include the following: PERFORMING AGENCY will provide unduplicated reports based on: (1) patients seen in maternity, child health and family planning clinics, including duration and scope of services, and (2) case management for each of the items listed in (1), noting referrals made and identifying each instance when PERFORMING AGENCY acts as the community -based comprehensive case manager. SECTION IV. BUDGET: FINANCIAL ASSISTANCE Financial assistance involves payment of funds to PERFORMING AGENCY for costs incurred in carrying out approved activities. Personnel Fringe Benefits Travel Equipment Supplies Contractual Other Total Direct Costs Indirect TOTAL $179,173.00 43,413.00 .00 .00 16,733.00 16,200.00 .00 $.255 , 519.00 .00 $255,519.00 Financial status reports (FSRs) are due the'20th of December, March, June, September and the 15th of October. RECEIVING AGENCY financial assistance will not exceed $2550519.00. DIRECT ASSISTANCE It Direct assistance involves the assignment of state funded positions or the provision of materials or supplies such as vaccines in lieu of cash. Personnel [ 2 position(s)] $29,004.00 TOTAL $29,004.00 Direct assistance for personnel in the amount of $29,004.00 is shown on the attached list of positions and budgetary amounts which is an integral part of this attachment. State salary warrants for net earnings will be issued in accordance with state regulations. Financial status reports (FSRs) are not required on direct assistance. Program income generated from activities supported with direct assistance will be reported on FSRs required for financial assistance provided through this attachment, if applicable, or through other program attachment(s) benefiting from this assistance. RECEIVING AGENCY direct assistance will not exceed $29,004.00. Total RECEIVING AGENCY assistance will not exceed $284,523.00. -3- LUBBOCK CITY/FAMILY HEALTH SERVICES PAGE 644 TEXAS DEPARTMENT OF HEALTH PHR 2 OPERATING BUDGET FOR YEAR ENDING AUGUST 31. 1992 AS OF APRIL 30. 1991 BUDGET NO. LC301 H21311^13028 CATE- DESCRIPTION OR TITLE FUND END ITEM 10B PAY PAY EFFECTIVE MONTHLY BUDGETED AMT GORY DESC. MONTH NO. CLASS 6P STP DATE RATE 1 CLERICAL SUPERVISOR II STATE AUG CBS 0063 07 01 SEP 91 1,300.00 15.600.00 COMMUNITY SERV AIDE Ii STATE AUG 131 5502 OA 01 SEP 91 1.117.00 13,404.00 29,004.00 = M 16 CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS. GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-111, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. ` September 12, 1991 S gnature Date B. C. McMinn Name of Authorized Individual C2000376 Application or Contract Number City of Lubbock P.O. Box 2000 Lubbock, T% 79457 Name and Address of Organization r_ "ISISCLOSURE OF LOBBYING ACTiVMES Corripiste this four to disclose lobbying ac uvities pursuant to 31 U.S.C.1352 (See reverse for public burden disclosure.) 1 03AS-00J6 1. Type of Federal Action: 2 Status of Federal Action: 3. Repo Type: ype: contract b. b. initial awaarrdppcation ED b. materialchange grant -award C. cooperative agreement d. loan c post For filah"W Change Only: s. ban guarantee f. ban insurance year quarter we o t report 4. Name and Address of Reporting Entity: 6. It Reporting Entity In No. 4 is Subawrardse, Enter Name and address of Prime: Q Prim Q �N ,i !1 kr>own. Congressional District,1kaown: T. Federal Program Name/Desw iption: Congressional DUMIct, ftnown: 8. Federal DepanmerwAgenty: CFDA Number. U appUcabJe: * Federal Action Number, dknown. !. AwantAmount; B known: s 10.a. Name and Address of Lobbying Entity b. Individuals Performing Services (Jndud 3g address Or (9f xMddu4 hWasme, first name. MI) d emXfoal Na I0a) (last name. drat name, MO: peseta COttdeuWM &*48) 6FUL A. rasotnary) 11. Amount of Payment (ohm* ad that apply): 13. Type of Payment (check all Vat Apply). i (3 Actua! C3 planned a. retainer b. one-time fee Q commission 12 Form of Payment (dW& ad that apply): d. contingent tee cash rred a pbb. . W*4d 1d; specify: nature f. mar. specity: value 14. Brief Description of Services Performed orto be Perfonned and Oat*) of Service, Including offIcer(s), employee(s), or Uember(s) contacted for Payment Indicated in item 11: ~ CaraYsaisoa SN+wa) Sr-111 t• laacusary) 15. Continuation Sheets) SF-111-A attached: Q Yes C3 No 16. NOWMMoan mamma twour rxs WM a aurmcm by no 31 N.S.C. ..e�as1932ThUmsao.ur.or�000r�rgaowia aoaare�wrrvr+anoocn Signature: a tsa uaoe Mach osranoa wY Paco by VW rsr &MV4 WM oft taroscaon was am* or sraaao km This sacs= is nauwo tx+aurnt Print Name: a 31 N.S.C.1= the inwn w wet a ie mua m r* Co vna &ev*- Tkle: &v%9 sy area wM to ararawe W MM raoscmm ,trey owwn was taps n as e+a requrao asoosv* anon to suoMctto a avr osnMY «sot ass rmn Telephone No.: Date: o0 i10AWM as am* emn ft00A00 for no wen rwaws. - AW�On2ed or coati a.woauown ilaeoare con. • � n CONTINUATION SHEET Au M=d ar LOW Floom oom StWx" Form • III -A GRANT AWARD NOTIFICATION AND REQUEST FOR ASSIGNMENT OF ACCOUNTING CODE NUMBERS TO: Grants Coordinator (Accounting Department) FROM: Grantee Department HEALTH Grant Administrator or Representative DOUG GOODMAN Please Check: New Grant X Amend/Modification Extension (1) Grant or Contract No x 2 n o n 3 7 is Amount (Th i s not ice) t 5 7 s, s 5 4(Total ) s 5 7 a, s s a Title or Project Description TEXAS nFPARTMFNT nF HFAITH Grantor Agency TEXAS DEPARTMENT OF HEALTH Period of Grant/Contract n9-n1-91 - 08-31-92 Audit Requirements AgPnrV-widP finanrial and rnmpliance audit by an indPppndPnt fPA in arrnrdnnrP with 2pplirahle nM5 firrulars (2) Local Matching Fund Requirements NnNF Source of Local Matching Funds NnNF Does Grant allow funding for Indirect Costs? _ PARTIAL (3) Does Grant allow funding for Audit Expense? Nn Date of City Council Resolution on Approval or Acceptance SEPTEMBER 4, 1991 (4) If modification/Amendment/Extension, will new Account Codes be needed? FOR USE BY FINANCE/ACCOUNTING Grant File Established Internal Audit Notified Grant Sect. Assigned Revenue Acct. Nr Exp W/0 Nr INSTRUCTIONS: (See referenced notes () above) (1) Furnish copy of approved Grant Award, Approval or Acceptance Document along with copy of Contracts, Terms & Conditions, Application, etc. (2) Audit requirements usually specified in Contract terms & Conditions. Provide copy of any Accounting & Audit Guides or Manuals required if this is a new Grant. (3) If contract provides for indirect costs, obtain such cost rate from approved & Cost Allocation Plan and Indirect Cost Rate Proposals' prepared by City Auditor. (4) Provide copy of resolution or Council minutes approving or accepting Grant. :•i'.-.; - .s.-.�-,?r:-:.' ..:_..�. s ..K-.w�.r.- Page I of F ATTACHMENT 2 GRANT PROPOSAL EVALUATION FORM COVER SHEET GRANT NAME: TEXAS DEPARTMENT OF HEALTH GRANT GRANT AGENCY: TEXAS DEPARTMENT'OF HEALTH GRANT FISCAL PERIOD: 09-01-91 through 08-31-92 MONTH/DATE/YEAR TO MONTH/DATE/YEAR CITY DEPARTMENT/INDIVIDUAL PREPARING GRANT: :,�. (Whom to contact in case of questions) APPROVALS: DEPARTMENT HEAD DATE DIVISION DIRECTOR A SISTANT CITY MANAGER OR CHIEF OF POLICE ET & RESEARCH DIRECTOR DEPUTY CITY MANAGER DATE zL F ATE F--2 7 q / DATE DATA' Upon completion of approvals, return to: l by INDIVIDUAL CITY DEPARTMENT OR SECTION DEADLINE DATE (IF APPLICABLE) A25-1 Page 2 of i CITY OF LUBBOCK GRANT PROPOSAL EVALUATION FORM INSTRUCTIONS: This form must be completed and signed by the appropriate individuals in order for a grant application to be evaluated and approved by the City Manager. 1. State, as clearly as possible, the goals and objectives of the proposed project for which a grant is being sought. Attachment 01- Conduct program activities to help reduce the spread of AIDS/HIV. Attachment 01 - To supplement the delivery of comprehensive public health services including personal health services, environmental health services, and laboratory services. Attachment 03 - To provide health services to women and children with emphasis on prenatal care, family planning services, and preventive child health services. A. Is this the fulfillment of an identifiable community (Lubbock) goal? If so, list the source of the identified goal. B. Is this the fulfillment of an identifiable community (Lubbock) need? If so, please provide quantifiable data (studies, etc.) that illustrate the community need and how this grant will meet that need: For 1989, 15% of the Lubbock population was below the poverty level. Papers have been submitted to have 16 Census Tracts designated as Health Manpower Shortage Areas. Several Census Tracts are without physicians. Of the individuals coming to the Lubbock Clinics, 85% earn less than $3,000 per year per family member. i i A25-2 Page 3 of f 2. List at least three measures by which City Staff and City Council might be able to evaluate the program in order to determine that it has reached the goals and objectives described in Question 1. 1. Number of patient visits 2. Number of patients receiving 1st trimester care 3. Number of laboratory tests. 3. Will this program benefit the Lubbock community as a whole? If not, please provide a detailed profile of the individuals or groups that will benefit from the program. Yes i 4. Are other agencies (other than the City of Lubbock) available to administer this program? If so, list the agencies: Parts of the program such as disease.investigation can only be administered by a governmental agency. The operation of clinics can be administered by anyone the State is willing to contract with. the Texas Department of Health prefers to deal with the local governmental agency. I A25-3 Page 4 of i 5. Are other agencies administering similar programs? If so, list the other agencies. If not, why not? Lubbock Children's Health Clinic Presbyterian Doctor's Clinic Guadalupe Economic Services Corporation Texas Tech Health Sciences Center 6. Is the program or activity provided by this grant required by state or federal law or required as a condition of other ongoing state or federal programs? Please explain: Only on the basis of the Government is to protect its citizens. 7. Does the grant require a local match? If so, in what amount? Is the match in the form of cash or an in -kind contribution? No. All fees -for -service must be returned to the program for expanded services. A25-4 f.YiY.. .y,_. .... .. �. •. :. :?�'-:: "I:. 't. •': •Y�-a •..`_1 � C".. t-. 4 � .F _.� G ::�f�y�b..'-�sJSM g* i>'• .6, of ... . ;aa .,:.,•.: ...: ..... .::...... :"�»r .,r'.'•:Y,�`.:�s b'.,�,�r_��rr�ar:nta+�.�a�.a,>ca.�r.u...,kg�..�+�•. Page 5 of ! 8. Is the grant for capital or operating programs? Please describe specifically what the funds will be used for (personnel, supplies, services, capital outlay, capital project, etc.). SEE GRANT BUDGET A. If the grant is for capital outlay or a capital project, will it result in ongoing City operational costs? If so, explain in detail. NO B. If the grant is for an operating program or programs, is it a one-time grant which will result in ongoing City expenses, -if the program is to be continued in the future? NO i A25-5 Page 6 of i C. Does the grant require continuation of the program, at City expense, after grant funding has expired? If so, how long will the City be obligated to expend local funds, and in what areas? Be specific. NO 9. Is the grant a one-time grant, a one-time grant with an option to renew the grant, or an on -going grant? If the grant is ongoing, how many years has the grant been provided to the City, and what year does the upcoming period represent (2nd year, 5th year, etc.). If the grant has an option to renew, how often can it be renewed, and what are the terms of renewal? Please explain. On -going. Documents indicate the City has received funds from the State since 1951. 10. Are indirect costs reimbursed by the grant? Some A25-6 Page 7 of 8 11. Are grant audit costs reimbursed by the grant? NO 12. What is the immediate (twelve-month) impact of the grant program on City employee allocation and utilization? How will this affect their work hours, productivity, etc. on City programs and activities? The Texas Department of Health provides between 14% and 18% of the Lubbock City Health Department's total budget and about 35% of the Personal Health Services budget. The State Health Department provides money to fund approximately 38% of Personal Health Services employees. 13. What is the long-term (five-year) financial and manpower impact of the grant program both on the community and on the City organization? There are dramatic changes occurring at the Texas Department of Health pertaining to reorganization of ten agencies all having offices in Lubbock. It is my hope to maintain and increase funding from the State. However, jwe could be lost in the shuffle if we do not maintain strong leadership. ':'iC4ivq,`1•:_.-t+..�:,�..r.. `LirY.'•w�� :^�' :,.1TL< �. :tx� w�..a: .�.:� . f, R-•.... _ ten.}'� 'C., N`::✓<. ra. '.�'P"Y..a.. .. .. .. JfA.rS _1. .i 3�'s.:f .argil canrn-�r�.ncr..n_a:a-.-s..: �.�.-_�._.�--... ______.. _ Page 8 of F c 14. Provide, its as much detail as possible, a 5-year Revenue and Expenditure Projection'for the grant related program beginning with the current year or the first sear this grant will be in effect. Show any on -going costs to the City, evenlif the grant is only for one year. If the grant is renewable or ongoing, show the estimated revenues and expenditures for future years that you intend to renew/continue the grant (up to five years). Be sure to fully explain the source and type of revenues (in -kind contribution, reimbursement of expenses, etc.) and fully explain the specific types of expenditures (payroll for 1/2 time clerk, purchase desk, capital project construction, etc.). Attach additional sheets if necessary. FOR GRANT FISCAL YEAR (From1992 t01996 ); 19 92 19 93 19 94 19 95 1996 Revenues Federal Grant State Grant 578,854 615,000 615,000 615,000 615,000 Local Match Other FEES 186,000 186,000 186,000 186,000 186,000 Total Revenues 765,000 801,000 801,000 801,000 801,000 FOR GRANT FISCAL YEAR (From to ): 19 19 19 19 19 Expenditures Personnel Supplies Maintenance Other Charges Capital Outlay Capital Project Total Expenditures A25-8 i �• a TEXAS DEPARTMENT OF HEALTH CONTRACT 110U West 49th Street Austin, Texas 78756-3199 STATE OF TEXAS COUNTY OF TRAVIS TDH Document No. C2000376 This contract is between the Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, and the party listed below as PERFORMING AGENCY and includes general provisions and attachments detailing scope(s) of work and special provisions. PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT ______________________________s-====_______--___=====a=�zz==rssz=====_==_=_______==--i -1 (PRINT or TYPE) 1 �Q,� �54Q1 Mailing Address: P.O.Box 254$ j�b�jl�� ('� {tip) , I Street Address: 1902 Texas Ave. Lubbock (If different) lultyj I Authorized 1 I Contracting Entity: CITY OE LUBBOCK 1 I different rom 1 ______________________________________________________________=====1 Payee Name: CITY OF LUBBOCK HEALTH DEPARTZANT I(must match with vendor IdentirIcation number s own ow) 1 Payee Address: E.O. Box 2900 bubbeck79j57-00001 (MMust match with vendor identification number s ownBelow) State of Texas Vendor Identification No. (14 digits): 17560,005906037 Finance Officer/Contact: Doug Goodman I 1 1 Type of Organization: Cit 1 Designate: Elementary/secon ary school, Jun ior college, senior co ege vn vets y 1 city, county, other political subdivision council of governments, u icia 1 1 district, community services program, individual, or other (define) 1 1 Is this a small business No (Yea/No) and/or minority/woman owned pg (Yes/No) Is this a non-profit business Xu (Yes/No) PAYEE AGENCY Fiscal Year Ending Month: SEPTEBER_ SUMMARY OF TRANSACTION: 1 Contract for Public Health Services. I 1 1 1 COVER - Page 1 la j DETAI11S OF ' ATI"Au1It1TS '----- 7-------------- 1 An. TDH -----------Att/----� -w Financial '--------- Ters Source of Direct Total Assistance ; llo._; Pra�ra0_ Betin ' Eno ; Funds$ Asouat Aninimet koevot (TD1 $hart) ; dI HIY S i_; ; 91 1191; 3/31/920 STATE 77,ii6.00; .00; 77,i63.0O; 1 t , �12 S ; 9' 1/91; 3/31192: STATE 93.268 91.11i.00; ti9,Sil.00; li0,iii.00; I 1 1 1 1 03 ;NCH-SriS ; 9/ 1/91; 3131192; STATE ; 2SS,S1l.00; l9,001.00; l�I,il7.i0; I 1 1 1 1 1 1 1 1 1 1 1 I I 1 1 1 1 1 1 1 1 1 I I 1 1 1 1 1 1 1 1 1 1 1 1 , 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 r�.l I 1 1 1 1 I • 1 1 j 1................».._......o_.__.._.._..._..._......_.....•... .. ....................w................�......�.....�., 1 -. ' TD1 DocaseRt No. C2000371 it SIPILUMO.- $Federal pads are indicated Is a amber froa tle Catalai of Pedenl hatatie AMMON (Mile 11FIR TO BUDGIT SICTIOI OF ANT 1110 UO01T ATTICIIIIT POI 11T11U- ;A1;,', COYBI - Pate ! r �• MUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN. CITY OF LUBBOCK toe Doceseat No.: C2000311 Authorized Contracting Entity (type above if different (roe PRIMING AGENCY) for and in behalf of: LOBBOC[ CITY HEALTH DEPARTNENT THAS DBPARTNINT OF [tALTR PERFORMING AGENCY UCtIYI[G IQB[CT By: (Signature of person authorized to sign contracts). (wage and Title) Date: RECOKKENDED: BY: (PERFORMING AGENCY Director, if different Eros person authorized to sign contract) BY: (Signatere of person authorized to sign contracts) toy L. [Giant Assistant Deputy Cosaissioner flr Adeinistratios (lane aad title) Date: APPROitD AS TO FOU: Office of Coneral Cossstl ' COYRt • Page 3 ... ,.. .. , �. .. '.5... _ ._ _' � T , s..�'.+. f ... i..�TT�. 4•`.; :"3'+.-..�.Y:' ��N. S�>.�1.�-. _ ... ,r!�'i a GENERAL PROVISIONS FOR TEXAS DEPARTMENT OF HEALTH CONTRACTS PERFORMING AGENCY and RECEIVING AGENCY agree this contract* assurances, general and/or special provisions, and attachment(s) with detailed scope(s) of work and budget(s), as applicable, incorporate all covenants and agreements pertaining hereto. 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, do hereby 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 terms, performances, and provisions herein set forth. PERFORMING AGENCY hereby assures compliance with the following terms and conditions unless otherwise specified in the attachment(@) hereto: ARTICLE 1. Scope of Work PERFORMING AGENCY will perform the work outlined in the Scope(s) of Kork contained in the attachment(s) hereto which is/are referenced in the Details of Attachments and hereby incorporated and made a part of this contract, plus amendments which may be added by additional attachments) from time to time as hereinafter provided. Satisfactory performance of this contract will be measured in part by: (1) adherence to the contract: (2) results of CPA or State Auditor reports; and, 3) timeliness, completeness, and accuracy of required reports. ARTICLE 2. Term The time period of this contract will be governed by the term(s) on the attachment(s). No commitment of contract funds is permitted prior to the first day nor 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 funding being available for the term of the attachment(*) and PERFORMING AGENCY will have no right of action against RECEIVING AGENCY in the event that RECEIVING AGENCY is unable to perform 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(@) to this contract. If funds become unavailable, provisions of the Termination Article will apply. ARTICLE 4. Amendments This contract may be amended, and such amendments will be in writing and duly executed by the parties hereto. 1992 GENERAL PROVISIONS - Page 1 (5191) .. ix.ti., ... -! .,... 4.. .. ., r _ _.. .':7 ._^,.A�.. -�.�. _•c: nn.....*r2:',tt i_:a� a..k?r ARTICLE 5. Severabilit If any provision of this contract will be construed to be illegal or invalid, this will not affect the legality or validity of any of the other provisions hereof. The illegal or invalid provision will be deemed stricken and deleted herefrom to the same extent and effect as if never incorporated herein, but all other provisions will continue. ARTICLE 6. Applicable Laws pnd Standards This contract will be governed by the lave of the State of Texas and enabling state/federal regulations, including federal grant requirements applicable to funding sources as set out in attachment(s) hereto, and Treasury Circular 1075 (31 CFR Part 205) as applicable to advance of funds. If PERFORMING AGENCY is a local governmental public health entity, this contract will also be governed by the Local Public Health Reorganisation Act, Chapter 121. Health and Safety Code. PERFORMING AGENCY agrees Article 4413 (32g), V.T.C.S., [Uniform Grant and Contract Management Standards Manual (UGCMS)J, as may be amended by revised federal circulars to be incorporated in UGCMS by the Governor's Budget and Planning Office. applies as terms and conditions of this contract, and the standards are adopted by reference in their entirety. If a conflict arises between the provisions of this contract and UGCMS, the provisions of UGCMS will prevail unless expressly stated otherwise. A copy of this manual and its references are 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 RECEIVING AGENCY's institutional prior approval procedures. These procedures are incorporated by reference as a condition of this contract. In accordance with Section 1352 of Public Law 101-121, effective December 22, 1969, PERFORMING AGENCY is prohibited from. using funds granted under this contract for lobbying Congress or any agency in connection with a particular contract. In addition, if at any time, the contract exceeds $100,000, the law requires certification that none of the funds provided by RECEIVING AGENCY to PERFORMING AGENCY have been used for payment to lobbyists. Regardless of funding source, and if a contract exceeds $100,000, a disclosure form must be completed if PERFORMING AGENCY has any agreement with a lobbyist: This certification and/or form is available upon request and mun be forvarded to RECEIVING AGENCY within 90 days of receipt. PERFORMING AGENCY certifies by execution of this contract that its payment of franchise taxes is current or. if PERFORMING AGENCY Le exempt from payment of franchise taxes, 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 RECEIVING AGENCY. If franchise tax payments become delinquent during the attachment term, payments under this contract will be hold until PERFORMING AGENCY's delinquent franchise tax is paid in full. PERFORMING AGENCY further certifies by execution of this contract that it is not ineligible for participation in federal or state assistance programs under 1992 GENERAL PROVISIONS - Page 2 (3/91) i c C' 1 Executive Order 12549. Debarment and Suspension. PERFORMING AGENCY specifically asserts that it does not owe a single substantial debt or a number of outstanding debts to a federal or state agency. 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 7. Assurances PERFORMING AGENCY assures that no person will, on the grounds of race, creed, color, handicap, disability, national origin, sex, political affiliation or beliefs, be excluded from, be denied the benefit of, or be subjected to discrimination under any program or activity funded in whole or in part under this agreement. Incorporated by reference the same as if specifically written herein are the rules, regulations, and ,all other requirements imposed by law including, but not limited to, compliance with those pertinent rules and regulations of the State of Texas and those of United States agencies providing funds to the State of Texas. PERFORMING AGENCY assures it will not transfer or assign its interest in this contract without written consent of the the RECEIVING AGENCY. ARTICLE S. Standards For Financial Management PERFORMING AGENCY will develop, implement, and maintain financial management and control systems that meet or exceed the requirements of UGCMS. Those requirements include at a minimum: 1. 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; 2. Financial management system 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, 3. 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. ARTICLE 9. Allowable Costs Only those costs allowable under UGCMS and OMB Circular A-110, and any revisions thereto, plus any applicable federal cost principles are eligible for reimbursement under this contract. Applicable cost principles and audit requirements are as follows: Circular Applicable Cost Principles Audit Rgauiremut A-87 State & Local Governments Circular A-128 To be eligible for reimbursement under this contract, a cost 'must have been 1992 GENERAL PROVISIONS - Page 3 (5191) incurred within the attachment term claiming reimbursement from RECEIVING the attachment term and liquidated no attachment term. and paid by PERFORMING AGENCY prior to AGENCY or encumbered by the last day of later than 45 days after the end of the Each PERFORMING AGENCY/AUTHORIZED CONTRACTING ENTITY receiving $25.000 or more in total federal/state financial assistance during their fiscal year shall arrange for an agency -wide financial and compliance audit of the PERFORMING AGENCY'S/AUTHORIZED CONTRACTING ENTITY'S fiscal year. The audit mist be conducted by an independent CPA and must be in accordance with the applicable OMB Circulars and Government Auditing Standards. Procurement of audit services will comply with state procurement procedures. as 'roll as provisions of UGCMS. Within 30 days of receipt of audit report. PERFORMING AGENCY/AUTHORIZED CONTRACTING ENTITY will submit a copy to RECEIVING AGENCY'S Internal Audit Division. ARTICLE 10. Overtime Compensation None of the funds provided by attachment(s) will be used to pay overtime. PERFORMING AGENCY will be responsible for any obligations of overtime pay due employees. ARTICLE 11. Terms and Conditions of PaTment For services satisfactorily performed pursuant to the Scope(s) of Vork. PERFORMING AGENCY will receive reimbursement for allowable costs. Reimbursements will not exceed the total of each attachment(s) hereto and are contingent on a signed contract. Claims for reimbursement will be made on a State of Texas Purchase Voucher (TDH Form #AG-37). Vouchers for reimbursement of actual expenses will be submitted monthly within 20 days following the end of the month covered by the bill. A make-up claim may be submitted as a final close-out bill not later than 45 days following the end of attachment term(s). Advance payment may be requested in accordance with the applicable provisions of this contract. Payments made for approved claims or notice of deaial of claims submitted against attachment(s) to this contract will be mailed not later than 60 days after receipt of monthly vouchers. Payment is considered made on the date postmarked. Any reimbursements made by PERFORMING AGENCY to subcontractors will be made in accordance with Article 601f, V.T.C.S. Funding from this contract will not be used to supplant state or local funds. but PERFORMING AGENCY will use such funds to increase state or local funds currently available to PERFORMING AGENCY for a particular activity. PERFORMING AGENCY further agrees to maintain to the beat of its ability its current level of support, if any. PERFORMING AGENCY will refund to RECEIVING AGENCY any funds PERFORMM 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 1992 GENERAL PROVISIONS - Page 4 (3/91) I L' s ' payments to PERFORMING AGENCY to offset any reimbursement made to PERFORMING AGENCY for any ineligible expenditures not refunded to RECEIVING AGENCY by PERFORMING AGENCY. Payment may be denied for noncompliance if required financial reports are not on file for previous quarters or for the final period,. or for failure to respond to financial compliance monitoring reports, or if program requirements are not met as specified in the Scope(s) of Work. ARTICLE 12. Advance Pavments PERFORMING AGENCY may request, in writing, a one time advance with proper justification and the concurrence of RECEIVING AGENCY. Amount of advance will be determined by the amount and term of the attachment(s); however, for each attachment, the amount of the advance will not exceed one -sixth (1/6th) of a twelve-month attachment. Advance will be requested on a State of Texas Purchase Voucher at the beginning of attachment period or at a single later time in the attachment period if circumstances so warrant and the request is approved. Advance funds will be liquidated during the attachment term so that, after final monthly billing, PERFORMING AGENCY will not have advance funds on hand. Advance funds may be drawn only to meet'imnediate cash needs for disbursement (UGCMS and federal circulars). Amendments to this contract may require upward or downward adjustment to the allowable advance until it equates 116th of a twelve-month attachment or approximates two months operating costs. In the case of a downward adjustment. PERFORMING AGENCY and RECEIVING AGENCY will agree an the amount of adjustment to the advance. RECEIVING AGENCY retains the option to reduce future claims by the required amount. In the case of an upward adjustment and PERFORMING AGENCY needs additional funds to meet immediate operating expenses, PERFORMING AGENCY may submit to RECEIVING AGENCY a written justification and State of Texas Purchase Voucher in the amount necessary to correct the ratio. ARTICLE 13. Program Income PERFORMING AGENCY will develop a fee for service system and a schedule of fees for personal health services in accordance with the provisions of�Chapter igJ Sub -chapter D, Health and Safety Code, and the Texas Board of Health rules covering Fees for Clinical Health Services (25 TAC. Sec. 1.91) and other applicable laws provided, however, that a patient may not be denied a service due to inability to pay. All revenues received from the delivery of contract sorvices will be identified. reported, and utilized as provided in this article. Such program income will be retained by PERFORMING AGENCY ands (1) be used by PERFORMING AGENCY for any purposes which further the objectives of the program and the Scope of Work for the attachment(s) and be deducted from total project cost$$ or, (2) be deducted from total project costs. This is according to RECEIVING AGENCY policy interpreting UGCMS, a copy of policy is provided on request and is incorporated by reference as a condition of this contract. 1992 GENERAL PROVISIONS - Page 5 (5191) ARTICLE 14. Financial Reports Financial reports are required as provided in UGCHS and will be filed regardless of whether or not expenses have been incurred. Quarterly Financial Status Report, State of Texas Supplemental Form 269a (TDS Form GC-4a), will be submitted within 20 days following the end of each quarter. Annual/Final A final financial report, Request for Advance or Reimbursement, Form 27o (TDH Form GC-10) will be submitted not later than 45 days following the end -oach --of term(s)). If necessary, a State of Texas Purchase Voucher will be submitted if all costs have not been recovered or a refund will be made of excess monies if costs incurred were less than funds received. if . ARTICLE 15. Reports and Inspections PERFORMING AGENCY will submit financial, program, progress, and other reports as requested by RECEIVING AGENCY in the format agreed to by the parties hereto. RECEIVING AGENCY and, when federal funds are involved, any authorized representatives) of the federal government have the right, at all reasonable times, to inspect or otherwise evaluate the work performed or being performed hereunder and the premises in which it is being performed. including subcontractors. PERFORMING AGENCY will participate in 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 delay the work. PERFORMING AGENCY agrees that RECEIVING AGENCY and the federal government. or any of their duly authorized representatives. will have access to any pertinent books, documents, papers. and records of PERFORMING AGENCY 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 AGSNCY's findings. A determination by RECEIVING AGENCY of either as inadequate or inappropriate resolution of the findings may result in the withholding of funds or suspension of the contract attachment(s). Any such withholding of funds or suspension will remain in effect until the findings are properly remedied as determined by RECEIVING AGENCY. 1992 GENERAL PROVISIONS - Page 6 (S/91f 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 resolution of all audit questions. whichever time period is longer. ARTICLE 16. Client Records At the end of the attachment term, all client records are the property of PERFORMING AGENCY. RECEIVING AGENCY retains the right to have access to the records or obtain copies for audit, litigation, or other circumstances that may arise. 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 records upon written notice to PERFORMING AGENCY. Records may be transferred to another entity that agrees to continue the service or, at the option of RECEIVING AGENCY, the records may be transferred to RECEIVING AGENCY headquarters. ARTICLE 17. Confidentiality PERFORMING AGENCY will have a system in effect to protect from inappropriate disclosure of patient records and all other documents deemed confidential by law which are maintained in connection with the activities funded under contract attachment(s). Any disclosure of confidential patient information by PERFORMING AGENCY, including information required by the Reports and Inspections Article, will be in accordance with applicable law. If providing direct client care, services, or programs, PERFORMING AGENCY agrees to implement workplace policies based on the model guidelines adapted by RECEIVING AGENCY and to educate employees and clients concerning the human immunodeficiency virus (HIV) and its related conditions including acquired immunodeficiency syndrome (AIDS). PERFORMING AGENCY agrees to develop and implement policies regarding confidentiality of AIDS and HIV -related medical information for employees of PERFORMING AGENCY and for clients, inmates, patients, and residents served by PERFORMING AGENCY. ftxther, PERFORMING AGENCY agrees to develop and implement an anti -discrimination policy­iii*iag all privileges and opportunities for any employee for client. with a communicable disease. HIV -related policies will be;based.,an accurate scientific information. Such policies will be consistent with the model guidelines published by RECEIVING AGENCY and with state and federal laws and regulations. A PERFORMING AGENCY that does not adopt a confidentiality policyo as herein required is not legally eligible to receive state funds _until. the s policy is developed and implemented. `w ARTICLE 18. ggui=ent and SuQplies Equipment is defined as tangible nonexpendable property with an acquisition cost of over $500 and a useful life of more than one year: In accordance with Article 601b. V.T.C.S., Section 8.02(c), title to all equipment purchased from funds provided herein will ]?a in the name of PERFORMING AGEltCY throughout the attachment(s) term(s). Unless initially listed and approved in the attachmbent(s), prior written.' approval from RECEIVING AGENCY is required for any additions to or deletions 1992 GENERAL PROVISIONS - Page 7 (S/P1I of approved equipment purchases having an acquisition cost exceeding $500. To receive approval for data processing hardware and software purchases with an acquisition cost over $500, PERFORMING AGENCY must submit a detailed justification which includes description of features. make and model. and cost, etc. PERFORMING AGENCY will maintain an annual property and inventory.listing and submit a report (TDH Form GC-11) to RECEIVING AGENCY not later than 45 days from the end of the attachment(s) term(s). PERFORMING AGENCY will administer a program of maintenance. repair. and protection of assets under this attachment(s) 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 attachment(s), it will use the proceeds to repair or replace said assets. PERFORMING AGENCY agrees that upon termination of attachment(e), title to any remaining equipment purchased from funds as hereinabove provided will be transferred to the RECEIVING AGENCY or any other party designated by the 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 19. Subcontracting PERFORMING AGENCY may enter into agreements with subcontractors unless restricted or otherwise prohibited in specific attacbment(a). ,Subcontraate, if any. entered into by PERFORMING AGENCY will be in writing and subject to the requirements of this contract. PERFORMING AGENCY agrees that it will be responsible to RECEIVING AGENCY for the performance of any subcontractor. In addition, if PERFORMING AGENCY elects to enter into at; 'agreement Vork, chMINGsubcontracts out a substantial portion of PERFORAGENCY•s Scope of prior written approval must be obtained from RECEIVING AGENCT.` ARTICLE 20. Copyrights and Publicatiams PERFORMING AGENCY understands and agrees that where activities supported by the contract attachment(s) produce original books, manuals. Mae. computer programs (including executable computer programs and supporting data in any form), or other original material, PERFORMING AGENCY may copyright such material subject to any rights to same reserved by or vested in the federal government or any agency thereof; however, RECEIVING AGENCY may grant to PERFORMING AGENCY limited rights to produce, publish, and use such materials as appropriate. PERFORMING AGENCY may publish at its expense the results of contract performance with prior RECEIVING AGENCY review and approval. Any publication (written, visual, or sound) should include acknowledgment of the support received from RECEIVING AGENCY and the appropriate federal _agency. if applicable. At least three 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. 1992 GENERAL PROVISIONS - Page 8 (S/SIj • "- :.. ._ . - , .... ... .:.. �' l <. �.� r, �nr .- •�+a "�r,i 'ti M�*rS rj v,21� n'^'ST�*�2'?;�r,.�.�.�.�.��j".�a��. ARTICLE 21. Hold Harmless PERFORATING AGENCY, which is not a state agency, assures that it is an independent contractor and not an agent, servant, or employee of the state. Except to the extent that Chapter 104 of the Texas Civil Practice and Remedies Code is applicable to this contract, PERFORMING AGENCY agrees to hold RECEIVING AGENCY and/or federal government harmless and to indemnify them from and against any and all claims, demands, and causes of action of every kind and character which may be asserted by any third party occurring or in any way incident to, arising out of, or in connection with the performance of services by PERFORMING AGENCY under this contract to the extent allowed by law, and_t$ the extent of damages permitted under Chapter 101 of the Texas Civil Practice and Remedies Code. 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 22. Bondina Each person employed by PERFORMING AGENCY who handles funds under this contract, including persons authorizing payment of such funds. will be covered by the terms of a fidelity bond providing 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. This fidelity bo:id will be in the amount of not less than Ten Thousand Dollars 010.000). In the event that PERFORMING AGENCY, being an independent eontract9r, maintains a self-insurance program that provides for the Lndemnification of losses as described in the above paragraph regarding fidelity' "bonds. them PERFORMING AGENCY will provide to RECEIVING AGENCY a certified statement UUCP summarizes its self-insurance plan. The certified statement will`be,submitted at the time this contract is submitted for,,approvaL.. Any changes to said plan, which occur during the term of thia'coa'tract period. will be reported to RECEIVING AGENCY. The self-insurance program should be based on the determination that the coverage can be provided at a cost no greater than the cost of obtaining equivalent coverage from an insurance company. ARTICLE 23. Susnension/Termination If PERFORMING AGENCY fails to comply with RECSIVING A+UCY•s reporting requirements. the program objectives, or the contract award conditions. RECEIVING AGENCY may withhold payments. RECEIVING ARSKCY will provide advance written notice to PERFORMING AGENCY which will identify the deficiency and RECEIVING AGENCYYIs intent 'to withhold payments if the deficiency is'not corrected within a specific number of days. When the deficiency is corrected. RECEIVING AGENCY will release any withheld payments with no further action. If PERFORMING AGENCY fails to comply with the terms, conditions, or standards of this contract, RECEIVING AGENCY may suspend the contract attacbtent(s) and prohibit PERFORMING AGENCY from incurring additional obligations of funds pending either corrective action or termination. RECEIVrIM AGENCY will provide written notice to PERFORMING AGENCY at least thirty (30) days in 1992 GENERAL PROVISIONS - Page 9 -\ advance of the suspension date. Such notice will detail the nature of noncompliance and specify a correction date. PERFORMING AGENCY may request a hearing on the proposed suspension if such request is made in writing within ten (10) days from any final notification of suspension. This contract or any attachment(s) hereto may be terminated by either of the parties hereto for noncompliance by the other party. A party intending to terminate for noncompliance by the other party will provide written notice to the other party at least thirty (30) days prior to 'the intended date of termination. Such notice will include the reasons for the termination and will provide the other party an opportunity to rebut the reasons in writing. A hearing may be requested on the proposed termination if such request is made in writing within ten (10) days from any final notification of termination. By such termination, neither party may nullify obligations already incurred for performance or failure to perform prior to the date of termination. Such termination will not be an exclusive remedy but will be in addition to any other rights and remedies provided by law or under this contract. This contract or any attachment(s) hereto may be terminated in whole, or in part, when both parties agree that continuation would not produce results commensurate with further expenditure of funds. Both parties will agree on the effective date and. in the case of partial termination, the portion to 'be terminated. RECEIVING AGENCY will immediately send'PERFORHING AGENCY written notice of the terms agreed to and such notice will become a part of the contract. PERFORMING AGENCY will not incur new obligations for the terminated portion after the effective date of termination and will cancel as many outstanding obligations as possible. RECEIVING AGENCY will allow full credit to PERFORMING AGENCY for noncancelable obligations which were properly incurred prior to the termination date. This contract or any attachment(s) hereto may be terminated if funds allocated for any attachment(s) hereto should become reduced, depleted, or unavailable during any attachment(s) budget period, and RECEIVING AGENCY is unable to obtain additional funds for such purposes. RECEIVING AGENCY will immediately provide written notification to PERFORMING AGENCY of such fact and such attachment(s) to this contract is/are terminated upon receipt of that notification. PERFORMING AGENCY will not incur new obligations after the effective date of termination and will cancel as many outstanding obligations as possible. RECEIVING AGENCY will allow full credit to PERFORMING AGENCY for noncancelable obligations which were properly incurred prior to the termination date. 1\ This contract or any attachment(s) hereto may be terminated in the event that federal or state laws or other requirements should be amended or judicially interpreted so as to render continued fulfillment of this contract, on the part of either party, unreasonable or impossible. If the parties should be unable to agree upon amendment which would therefore be needed to enable the substantial continuation of the services contemplated herein, then. upon written notification by RECEIVING AGENCY to PERFORMING AGENCY, the parties will be discharged from any further obligations created under the terms of this contract, except for the equitable settlement of the respective accrued interests or obligations as of the date of termination. 1992 GENERAL PROVISIONS - Page IO (5191) ► • 0, ARTICLE 24. 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. 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 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 iu 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 attachment(s) to 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 Brill be furnished by RECEIVING AGENCY state warrants for salary compensation or travel reimbursement for issuance to employees oa.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 attachment(*) 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 1992 GENERAL PROVISIONS - Page 11 (5/91) I PERFORMING AGENCY to complete the conversion. ARTICLE 25. Fundina Participation Requirement PERFORMING AGENCY agrees funds provided through this contract will not be used for matching purposes in securing other funding. ARTICLE 26. Performance -Based Attachments History RECEIVING AGENCY is responsible for developing performance -based public health services contracts in response to the State Auditor's Report: This system will enhance service delivery and improve accountability and efficiency in the management of public health dollars. Plans for initial implementation were designed to use the -modal objectives format stemming from recommendations of the Committee on Model Objectives for Local Public Health in Texas. The committee was composed of representatives of local health departments and RECEIVING AGENCY'S central and public health region offices in consultation with the University of Texas School of Public Health in Houston. 0 Purpose The overall goal of performance -based contracts is improved public health practices in Texas. The project is intended tos -identify public health needs and establish priorities which provide a rational basis for resource allocation; -project realistic outcomes based on activities which can be accomplished with current or planned resources, communicate needs, and build consensus at all levels regarding directions to be taken in specific programs; and. -institute a system for planning. implementing, managing, and evaluating programs and monitoring progress toward reducing and/or alleviating pub�tc health problems. Process PERFORMING AGENCY will prepare outcome 4" process objective a''ralatl*e 'to local needs and resources in the following selected program`'areaeq ' Jf applicable: -AIDS/HIV -Chronic Disease Prevention and Control -Food Protection -Immunization -Maternal and Child Health ' -Sexually Transmitted Diseases -Tuberculosis -Refugee Health -Hanson's Disease -Other Communicable Disease Epidemiology and Surveillance 1992 GENERAL PROVISIONS - Page 12 (Sl91� -Public Health Promotion -On-Site Wastewater Facility Management By the end of the current state fiscal year, PERFORMING AGENCY will show evidence of a monitoring system to evaluate progress towards the objectives. RECEIVING AGENCY will provide training, written documente.tion. and ongoing technical assistance to PERFORMING AGENCY in the development of objectives and a monitoring system. RECEIVING AGENCY contact for matters pertaining to the performance -based public health services project is the Office of the Associate Commissioner for Community and Rural Health. It is understood and agreed to by both parties that some objectives may not be met and achievement levels may be different than estimated. The objectives are recognized as test processes and achievement below the established levels will not affect the right of PERFORMING AGENCY to funds provided through Attachment(s) when the basic program scope of work has been fulfilled. Any disputes arising from procedures or actions taken as part of this project will be addressed and resolved to the mutual satisfaction of both parties. 1992 GENERAL PROVISIONS - Page 13 (3I91) . � -... � .. .: _ : „ • ' � 'w i2 ; IfI G�.� � y.1< Y y.,'Mt � T1rw l�A ')V - ) _ - .. - y�,...afA—e. .nnun. ....K.. •. �L1.�. .......,M-ai!'e.,. _,.... .___ .�r..TL."� r• • DOCUMENT NO. C2000376 ATTACHMENT NO. 01 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: HIV DIVISION TERM: September 1, 1991 THROUGH August 31, 1992 SECTION I. SCOPE OF WORK: PERFORMING AGENCY agrees to conduct program activities to help reduce the spread of AIDS/HIV (acquired immunodeficiency syndrome/human immunodeficiency virus). PERFORMING AGENCY will perform counseling, testing, referral, and partner notification (CTRPN) activities which include establishing and/or maintaining anonymous or confidential HIV testing programs for persons at increased risk of HIV infection due to individual sexual behavior, intravenous drug abuse, or other risk behaviors. 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 will provide CTRPN services to the target population defined as: 1. Males who routinely have sex with other sales. 2. Males who occasionally have sex with other sales. 3. Males who have sex with sales and females. 4. Males and females with multiple sex partners. 5. Persons with a history of sexually transmitted diseases. 6. Persons with a history of high risk behavior. PERFORMING AGENCY will perform the following Counseling and jesting Services: 1. Offer voluntary anonymous and/or confidential HIV testing!to clients who may want to be tested. 2. Provide culturally sensitive and effective pretest and posttest counseling based on Centers for Disease Control (CDC) approved modal. 3. Publicise HIV counseling and testing services to that potential clients will know where and when services are available. 4. Offer HIV counseling and testing services at a location that ie convenient' for the majority of the target population and during hovers established to reach these clients. 5. Use scannable forms supplied by RECEIVING AGENCY for collection'of deco- graphic information and blinded test result data. 6. Utilise RECEIVING AGENCY'S laboratory for all SLISA and Vestern Slot '' testing .'.. e—r '... .. T"`3 u, `•g; •T �.�Y"'C ... ••�w+.i� $-.—:.k 3.r2 .]twl1... _.....L !Y. i 7. PERFORMING AGENCY Will develop and maintain a referral plan by which • reciprocal linkages are established with other service providers (especially other RECEIVING AGENCY funded providersf for the purpose of: a. ensuring that behavior changes occur and are sustained; b. providing psychosocial services; c. medical intervention; d. substance abuse treatment; e. family planning services; f. financial and legal assistance; g. ongoing case management; h. long term care. PERFORMING AGENCY will perform the following Partner Notification Services: I. All partner notification services are to be consistent with RECEIVING AGENCY'S Serologic Test Counseling and Partner Notification Techniques guidelines which are incorporated by reference and Bade a part hereof. 2. Encourage HIV+ clients to voluntarily refer their sexual and/or needle sharing partners for HIV counseling and testing. 3. Encourage intravenous drug users (IVDU) to voluntarily refer their sexual and/or needle sharing partners for RIV counseling and testing. 4. If the client wishes to make the partner notification personally, provide guidance in making contacts. 5. If the client does not want to 'make the partner notification, but wishes partners to be notified, elicit adequate information for RECEIVING AGENCY STD clinic personnel to make the notification. PERFORMING AGENCY agrees to comply with the following CTRPN•Quality Assurance Guidelines: 1. PERFORMING AGENCY assures that pretest and posttest counseling sessions are performed by staff who have received counseling training from a course approved by RECEIVING AGENCY. 2. PERFORMING AGENCY will conduct monthly monitoring of counseling, testing, referral, and partner notification sessions and give performance feedback to counselors. 3. PERFORMING AGENCY agrees to facilitate RECEIVING AGENCY review of scheduled counseling, testing, referral, and partner notification sessions. All activities will be performed in accordance with the applicable RECEIVING AGENCY current program rules and guidelines, which are adopted by reference as part of this attachment. PERFORMING AGENCY agrees to comply with the following: t Chapter 81, Health and Safety Code; Article 4419b-4, V.T.C.S., Human Immunodeficiency Virus Services Act. PERFORMING AGENCY will provide an estimated `clients with services/units of service in or benefiting,the county(ies)/area defined as: LUBBOCK. SECTION II. LEGAL AUTHORITY TO CONTRACT:' Chapters 12, and 121, Health and Safety Code. SECTION III. SPECIAL PROVISIONS: RECEIVING AGENCY will supply PERFORMING AGENCY with the cost current version of the document entitled "Content of AIDS -Related Written !Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, and $ducation Sessions in Centers for Disease Control Assistance Programs," and its preface which is written by RECEIVING AGENCY. Said document and its preface are incorporated as part of this attachment as though it were written herein verbatim. PERFORMING AGENCY will provide to RECEIVING AGENCY written acknowledgment of receipt and acceptance of this document and its preface and will comply with the guidelines contained in this document and its preface. r 1, 2. 3. e to the sensitive and highly personal nature of AIDS/HIV-related formation, strict adherence to the General Provisions Confidentiality ticle is required. PERFORMING AGENCY success depends.upon whether persons at sk believe that the program observes this principle. In addition to these nditions, PERFORMING AGENCY will comply with the following specific quirements regarding individual patient information/data,when conducting unseling, testing, referral, and partner notification activities. If a client chooses to be anonymous when the mandatory offer of anonymity is made, then: a. no record will be maintained linking the person's identity with his/her real name or pseudonym or other identifiers; and b. upon notice to the client, the lab slip(s) containing the test results will be shredded/destroyed. Originals and copies of test results will not be maintained longer than 30 days. If a client elects to have a confidential file made for the testing an;d counseling, this file will be saintained in a fashion consistent with RECEIVING AGENCY'S HIV Testing Guidelines which are incorporated by reference and made a part hereof. It confidential testing is needed, then the lab slip containing the test results say be provided , to the client It i" I ";..; requested. No log containing personal information or identifiers or HIV status will be maintained in anonymous or confidential testing situations. ING AGENCY will submit required programmatic reports Quarterly on the 51: same cycle its financial status reports. PERFORMING AGENCY will: authorize their staff to attend _in -state and out-of- state training, conferences, and meetings for which funds were budgeted and approved by RECEIVING AGENCY. SECTION IV. BUDGET: Personnel $239830.00 Fringe Benefits 50958.00 Travel 700.00 Equipment .00 Supplies 19600.00 Contractual .00 Other 500.00 Total Direct Costs $32,488.00 Indirect * 10111.00 TOTAL 533,665.00 s Negotiated amount less than UGCMS, Table 1. Financial status reports (FSRs) are due the 20th of December, March, June, September and the 15th of October. Total reimbursements Will not exceed $33,665.00. CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of -the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant,, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or.an employee of a member of congress in connection with this federal contract grant, loan, or cooperative agreement, the undersigned shali complete and submit Standard Form-111, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants and contracts under grants, loans and cooperative agreements and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Tgnature Name of Authorized Individual Date i Application or Contract Number Name and Address of Organization i i DISCLOSURE OF LOBBYING ACTIVITIES Complete this roar, to disclose lobbyinV acxh 05 pursuant to 31 U.S.C.1332 (See roverse for public burdendisclosure.) AMomme waW t. Type of Federal Action: Z. Staun of Federal Action: _. Report Type: a. bb. g wl b. initial abidtaftward application ntatsfiaJ�CUM* ooperattvo C.agreement post -award d. l For 1lamorbi Change Only: t. loanloan �attrdnce � o'te+sportf+spoatqAMr�'—�' 6. Hamm and Addrsss of Repon ling Entity: L U Ropotlkq Entttr In No. d 10 &Aawwds% gntor Nana M W addreds of Pftn e: 13 Prime (3 Tier 1'kn:ctrrt. �.�o Conomeakwa1 pta1rK FknoW T. Fodaral Program NattaaOfdeorptbn: Cangroaalonal District, irknotm: f3. Federal D*partmWWAgonCr. CFOA Bunter. C opplcable• L Federal Action Number f!'known: L Awar,&Arnount K Wow 10.a. Nam and Address of Lobbyer Entity b. Mdvktuab Perfottnfng seni=* (/rtCha—,7 !' (Il kxVveug fart mane. Arsr name, A40: alvarsnt ftM Na f flay (lasf nsrrts; f3f3t rtarrto, kda f� �r�ttca, i 11. Amount of Payment (chack ARCut PPly): 13. Type of Payment (cbecic of wq*6 j: S (Q Awns! Q planned a. (stainer D. oneAme too C.. OMM 12. Form of Payment ( 80 VW apply): (3 a. cash e. defend (1 b. trt*ind: specify: naturo L oilier. spedfy:,,,,__.„�,r, �_ value 1a. Brief Description of 8orvtcus Pentormod orto bo ---- nod anol OoWs) of $err M% Inck" ~*L entpryee(a). or Merrtbor(a) cattlmcisd for Payment Indicated b ftem 11: i t Cadet_N&A" SP-1114 swojj IL Continuation Shoot(*) SF-11VA attached: p Yq Q No I & nett .0" wgwe" nra+pn ns a" a aueWUN Or ems at U= "aeonl=rsrsasca.r:aamolyl.+pacarr.s.affe" +�swe.anmaon &ignatuts, maL.wowan woo mmnce wu PWMd 1W rd@EftrMr SW*6 s• .st A~ is vasms 0 3t u.s.c. test rm nonnanon we" , am w o re coign me line Tki•: ava+aw br ouoac MOSS on. Any oason. O eats s e. e+... W" eaao«a owe* wepa o a a+e qWWq mare in" Toiophons No.: caw. MAW arw no mars ~ stoo.oM for Man Mn arias. � a,rta+urw ar eaerr erwar. ererr, • t 1 t •. .. �.. „:Y � 1 .. :f ;�y.t� R...wi�r`� R�f�" .My�,1 T�}yy� �� 14"V Y�K2��L.i�i�/ .. .'•?�'�.�� Z+L aY•rir�lPri1R�IP2 DOCUMENT NO. C2000376 ATTACHMENT NO. 02 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: COMMUNITY AND RURAL HEALTH TERM: September 1, 1991 THROUGH August 31, 1992 SECTION I. SCOPE OF WORK: PERFORMING AGENCY will use direct assistance and/or financial assistance from RECEIVING AGENCY to supplement the delivery of comprehensive public health services. Comprehensive health services encompass a wide variety of personal health services, environmental health services, and other problems of the jurisdiction. Personal health services may include but are not limited to adult health/chronic disease, AIDS/HIV, chronically ill/disabled children. dental, immunization, laboratory, maternal and child health, public health promotion/education, sexually transmitted disease control, and tuberculosis control. Environmental health services/inspections may include but are not limited to food, premise, swimming pool, vector control, and wastewater control. Other services may be provided as needed when agreed to by both parties. Reports of comprehensive health services performed will bet submitted to RECEIVING AGENCY, Community and Rural Health. in a format and time frame agreed upon by both parties. Direct assistance will be provided by RECEIVING AGENCY to PERFORMING AGENCY for the implementation of an immunization program. The goal of the immunization program is to prevent, control, and eradicate vaccine -preventable disease by providing/administering biologicals, promoting immunization, and applying epidemiologic/outbreak controls within budgetary constraints. This will be accomplished by performing the following activities and reports. A. Investigations/Control Measures PERFORMING AGENCY will investigate 100% of suspected cases of measles. rubella, pertussis, poliomyelitis, and diphtheria within 24 hours after a report is received. PERFORMING AGENCY will investigate 90Y of suspected slumps cases and 100% of suspected tetanus cases within 48 hours after a report is received. For the above diseases, PERFORMING AGENCY will implement the most current outbreak control procedures/measures and contact RECEIVING AG NCy. Immunisa- tion Division, within 48 hours after an investigation is initiated. B. Reporting Requirements PERFORMING AGENCY understands that all vaccines used in RECEIVING AGENCY Immunization Programs are purchased with public funds and must be accounted for the same as other public property. PERFORMING AGENCY further understands that vaccine loss, destruction, spoilageo or other waste, may be investigated by the RECEIVING AGENCY, Immunization Division, who nay then require .:{.}" S +! '"` �•x+'c�'�t Tyi"t"!'+*`'v'4�'"'(''i'!y ;''.e•.K..'fG+rii`(f+Z71};'✓- > a.. 72 5"r reimbursement or replacement of the lost vaccines. PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunisation Division, by January 31st, of each year, a report detailing storage measures and methods used to control vaccine loss including method to monitor and record daily vaccine storage temperatures. The report shall be submitted in a format provided by RECEIVING AGENCY, Immunization Division. PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunisation Division, monthly reports of vaccine utilization/loss, within ten working days after the end of each month, on forms provided by RECEIVING AGENCY (forms C58 CSA, C339 C33A). PERFORMING AGENCY will obtain monthly biological reports from private physician offices and others who receive state supplied biologicals. PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunization Division, by September 15th, of each year, a report on the number of people served with immunizations (unduplicated count) and the number of visits for immunizations in the preceding State Fiscal Year. In addition to support for the above activities, RECEIVING AGENCY, Bureau of Laboratories, agrees to provide direct assistance of laboratory supplies to PERFORMING AGENCY to execute laboratory analyses for the following RECEIVING AGENCY programs: water bacteriology, milk bacteriology, chemistry, syphilis serology, gonorrhea testing, and other approved laboratory analyses. PERFORMING AGENCY agrees to meet standards for such analyses as set forth by RECEIVING AGENCY, Bureau of laboratories, the Clinical Laboratories Improve- ment Act, the Safe Drinking slater act, the National Conference of Interstate Milk Shippers, and/or the Public Health Service Grade A Pasteurized Milk Ordinance. PERFORMING AGENCY agrees to comply with: Texas Immunisation Laws, Rules and Regulations; Chapter 42, Human Resources Code; Sections 2.09 and 2.09A, Texas Education Code; and, Section 317 of the PHS Act as amended. PERFORMING AGENCY will provide an estimated clients with services/units of service in or benefiting the county(ies)/area defined as: LUBBOCK. SECTION II. LEGAL AUTHORITY TO CONTRACT: Chapters 12 and 121, Health and Safety Code. SECTION III. SPECIAL PROVISIONS: General Provisions, Program Income Article, paragraph one, is amended to include the following sentence: PERFORMING AGENCY understands that federal law guarantees access to immunization services in public clinics regardless of ability to pay and agrees to post in the waiting room of each immunization clinic the bilingual poster "Fees for Vaccine Administration" (Form 6-36 available from Immunization Division). -._2.' .-i s .Y.'4a.'.: _ �. ..ut_! ♦j�(a..�� ".e a_��; `.� #.;.4Y'C }♦ Xi M. `. yy4 JtEll SECTION IV. BUDGET: FINANCIAL ASSISTANCE Financial assistance involves payment of funds to PERFORMING AGENCY for costs incurred in carrying out approved activities. Personnel $53,698.00 Fringe Benefits 15j416.00 Travel .00 Equipment .00 Supplies .00 Contractual 14j000.00 Other .00 Total Direct Costs $91r114.00 . Indirect TOTAL $919114.00 Financial status reports (FSRs) are due the 20th of December, March, June, September and the 15th of October. RECEIVING AGENCY financial assistance will not ezeeed $91,114.00. err"`777 - t . DIRECT ASSISTANCE Direct assistance involves the assignment of state funded positions or the provision of materials or supplies such as vaccines in'Heu of cash. Personnel [03 position(s)] $64,488.00 Laboratory Support 149000.00 Vaccine 919064.00 TOTAL $169,552.00 Direct assistance for personnel in the amount of $64,488.00 is shown on the attached list of positions and budgetary amounts which is an integral part of this attachment. State salary warrants for net earnings will be issued in accordance with state regulations. Direct assistance for public health laboratory services is provided by RECEIVING AGENCY, Bureau of Laboratories, through requisition for supplies processed in accordance with RECEIVING AGENCY guidelines. Financial status reports (FSRs) are not required on direct assistance. Program income generated from activities supported with direct assistance will be reported on FSRs required for financial assistance provided through this attachment, if applicable, or through other program attacbment(s) benefiting from this assistance. RECEIVING AGENCY direct assistance will not exceed $169,552.00. Total RECEIVING AGENCY assistance will not exceed $260.666.00. r ` K 7 1 '+Vl eS •..« �a"...:- Li :'i'n(.1J �'' ��4i 1=•,-0 1�IR#` �i4_..'7' Ica 5.fll. :i.�iii, -_.. . LUBBOCK CITY HEALTH OEPAIITMENT ►A" dog TEXAS DEPARTMENT OF HEALTH PHR 2 OPERAT114G BUDGET FOR YEAR ENDING AUGUST 31, 1992 AS OF APRIL 30, 1991 MmIT NO. WOOD M21311/KI3028 CATE- DESCRIPTION OR TITLE FUND ENO MONTH ITEM JOB PAY ►AY.IFgCTIV9 NDXTHLY GORY OESC. NO. CLASS 6P STP A RACE i NURSE II STATE AUG 018 4385 14 01 SEP 91 1,095.00 LIC VOCATIONAL NURSE It STATE AUG 083 "12 10 04 SEP 91 i.i17.00 ADMINISTRATIVE TECH I STATE AUG 104 1501 08 07 SEP 91 1.002.00 MMETEO At 23.040.t 20.Q04.Q 19.944.4 64.4�.0 a. 1� r 6i %'"•' � 5+. . - - - .i ` ' - -.. .. .� _!, .. - �.. _ •3 .e' ;s .. l�t:i?!�'7M1i.% iy.1. �:.�]w�'3.`T.t. :.:,��x ..�.:t..t�`� L CERTIFICATION REGARYING'LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGRENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewil, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract grant, loan, or cooperative agreement, the undersigned shali complete and submit Standard Form-111, °Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants and contracts under grants, loans and cooperative agreements$ and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code: Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature Name of Authorized Individual Name and Address of Organization Date Application or Contract Number DISCLOSURE OF LOBBYING ACTiVMES IV CUM complete Nis font to disclose bbbyfng activloes pursuant to 31 u.S.c.13ST (See reversa for pubic burden dWosure.) 1. Typo of Federal Action: 2. Status of Fedaraf Action: L Report Types a_ contract b. a. bld/dWrtapplicadon b. fnitlal award a. hjbW b. matmrfai�ca ge grunt C. cooperatNe agmemena d. loan C goat -sweat For WWW tinge OW. f iapolt �„"�" ban usce 4 Name+ and Address of Repotting Entity: fie B Repotting B �y InHa.4 is 8 dean, UWMar» and oddr�s of : 13 Pwm C3 S4 9b wansee rknoarr. Corgroseienaa olet:ict. 1knaim T. Federal Program HatnavDesosiption: CongressJonal District, rknown: 6. Federal Departnunt/Ageney: CFDA Number. if appW09: L Federal Action Number, rknown: fie AwantAmourm fi known: Ia.a. Name and Address of lobbying Entity b. Indlvi�rals Pod*nning rvloss (k a r (r i 4Addual, last nsma, Arst nett:, M • d kTav x dnm No. 100 (fastnanm Amnarne, Mo: corseva+ar�x, a,a �ltt.4 raroea� 11. Amount of Payment (dwck a#Me appW 18. iyps of Peytt�trd (�'aNfhat rj: f C3 Actual G planned a. ratebw b, one•tlms fee C. comm alon 1 R Farm of Payment (Check all VW apply): ddeftd a. cash 0. 0 b. in -kind: specify: nature L fir. ap r..„ value 14. Brief Description of Services Performed art* be Perfonrrod and DaWs) of 9mvica, InchWing ~sh employee 4 or Marnbor(e) contacted for Payment Indicated In ftem 11: Mao co "Mam" SNOW SR-111 t. # w ona ! I& Coratnuatlon Sheegs) SF-111.,A attached: Q Yea Q No 16. nwone a aeAs to rvvAn m oxen r a wmaw er na at u.= mam 3UTlr 6"1GWaranooOrmean irf: Now or ace soon .rya rwanat on paced er we ow aawe MW M Pn�ntt �� sar+oacaan.raa anon or annrao ors. fAb Racioaaa s nlgtan0 ourwont c a1 u.s.C. tali Ths eW=mww w1 eaaoorra o e» Gor�rasa aam► Me:arvo. aer am 00 be Ovdaor tar ouora s moom m Mir o wun ww am a. na owe irsooau►a r+ao w M,opet:a a ava Orb elate eons tnan Tone f taAOo am no WOO man ste0AM far ow sum own. lreanwMwraa� e�Ihre.•sat •..r•••-••s,o:.-ti;';ti.,,��•.�!v:,i"�!".°' ��;a+`.i1'*AV+i71�K'.�Gf�+'�'Tl.�`�?rG'�!a'Y�il."IL'e.'•77CYi6a74M.trt+R71h3 DOCUMENT NO. C2000376 ATTACHMENT NO. 03 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: BUREAU OF MATERNAL AND CHILD HEALTH TERM: September 1, 1991 THROUGH August 31, 1992 SECTION I. SCOPE OF WORK: PERFORMING AGENCY will use direct assistance and/or financial assistance from RECEIVING AGENCY to provide health services to women and children. Emphasis will be placed on prenatal care, family planning services, especially during the first year post partum, and preventive child ho.alth,services. Special emphasis should be given to low income women and children. In addition, the PERFORMING AGENCY will provide case management services to these women and children with an emphasis on services to high risk women and infants. Case management services include an assessment of the individual's and family's services needs and the development, implementation and evaluation of a plan to meet these needs. Services will be performed in accordance with the standards for maternity, family planning, and child health services as promulgated by the RECEIVING AGENCY, Bureau of Maternal and Child Health. Maternity/Family Planning and Child Health Clinic reports will be submitted to RECEIVING AGENCY, Bureau of Maternal and Child Health, in a format and time frame to be agreed upon by both parties. PERFORMING AGENCY will participate in the development of networks under the leadership of its Public Health Regional Director. The Public Health Region ("Region") will be inviting a broad -based participation In its ' meetings to include community -based providers, county judges, city commissioners, community health center personnel, migrant health center personnel, medical schools, and agricultural extension agents. PERFORMING AGENCY will participate in a least 50X of the,meetings called by the Region. PERFORMING AGENCY will work with the Region In order to coordinate services, avoid duplication, and develop "One Stop Shopping Care Centers" where possible. PERFORMING AGENCY will provide an estimated clients,with services/units of service in or benefiting the county(ies)/area defined asi LUBBOCK. i •'" �. Fi SECTION II. LEGAL AUTHORITY TO CONTRACT: Chapters 12 and 121, Health and Safety Code. ` SECTION III. SPECIAL PROVISIONS: i General Provisions, Program Income Article, requires that alfee for services', system and a schedule of fees be developed. Low income eotherm and children provided health services under this attachment will not be charged a tee. .. .. .. _.. .i. _ - ..... _ i. '.'J?: ... _ i.tL'e Tn-,.... .. ...+Yv+lAl.nn.Y:na.+sw Y•..6aMl �uvwr.. e--•.. ...... .... __. ..�.w. term "low income" refers to an individual or family with an income determined to be below the nonfarm income official poverty line defined by the Office of Management and Budget and revised annually in accordance with Section 624 of the Economic Opportunity Act of 1964. General Provisions , Reports and Inspections Article, is nodified to include the following: PERFORMING AGENCY will provide unduplicated reports based on: (1) patients seen in maternity, child health and family planning clinics, including duration and scope of services, and (2) case management for each of the items listed in (1), noting referrals made and identifying each instance when PERFORMING AGENCY acts as the community -based comprehensive case manager. SECTION IV. BUDGET: FINANCIAL ASSISTANCE Financial assistance involves payment of funds to PERFORMING AGENCY for costs incurred in carrying out approved activities. Personnel $179.113.00 Fringe Benefits 43.413.00 Travel .00 Equipment .00 Supplies 160733.00 Contractual 169200.00 Other .00 ' Total Direct Costs $255.519.00 Indirect .00 TOTAL $255.519.00 Financial status reports (FSRs) are due the,,20th of Decemtxir. March. June, September and the 15th of October. RECEIVING AGENCY financial assistance will not exceed f255,5 9.00. it •y .. _..:.{qo •... �. �.J. DIRECT ASSISTANCE Direct assistance involves the assignment of state funded positions or the provision of materials or supplies such as vaccines Inlieu of cash. Personnel ( 2 position(s)) TOTAL $29404.00 $29v004.00 Direct assistance for personnel in the amount of $290004.00 is shown on the attached list of positions and budgetary amounts which is an integral part of this attachment. State salary warrants for pet earnings will be issued in accordance with state regulations. Financial status reports (FSRs) are not required on direct assistance. Program income generated from activities supported with direct assistance will be reported on FSRs required for financial assistance provided through this attachment, if applicable, or through other program attaehlment(s) benefiting from. this assistance. RECEIVING AGENCY direct assistance will not exceed $29,004.06. Total RECEIVING AGENCY assistance will not exceed $284,523.00. t �' a .. •' 4.. -I ! iT. -Y.1 • I °F • � •. 17.4'. i ty T It ` � � ,,` � � `_ nJ�� r. r,.`,� �: r'�'- .�Tr'!'�v"h'�.x� � � p""'�itit� �gr��r►rg�i�, r ii......+......� �+ 1•Y 4 V J w�•, i t ,,. .,r�� '���~'T•« �K 2' vh.i�G,ti"�Y'SiS �.3 a.4-7fdMS. UISBOCK CITY/FAMILY REAM SERVICE3 PAm G" TEXAS DEPARTMENT Of WEALTH PHR OPERATtNG BUDGET FOR YEAR ENDING AS OF 30. 11991 AUGUS 31. t992 SUOUT 80. =01 HAPRI %028 �Y• DESCRIPTION OR TITLE FUNDDISC M PAT � :j CTIV1 Y 9�ETEp AN MEND CJLASi ll i CLERICAL SUPERVISOR it STATE AUG 080 0003 IT 01 UP 9l 1.i00.00 10.900.0 COMMUNITY SERV AIDE II STATE AUG 131 IM 04 Ol - EEP' 91 l.umb U94".41 E8.004.AI MAt i 1• 5 i i 1 � ; F• ly i.. { � :i. i'r.: : •.9 „icy �I:; ' �r[.r:•rr.�.:.i-a_-}GT'r`•av�rs?�:�:w�.a.:xkt?1A2'!:�7�tp�.enT+1 .. _. CERTIFICATION REGARDING LOBBYING a CERTIFICATION FOR CONTRACTS, GRANTS. LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan. or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-111, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants and contracts under qrants, loans and cooperative agreements$ and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature Name of Authorized Individual— Name and Address of Organization Date Application or Contract Number 6. DISCLOSURE OF LOBBYING ACTIVITIES �►«ao� Comploro this torn to discim to ),a�htiWs�wnt to 31 U.S. C.1352 �� (See reverse for Darden u».) 1. Type of Federal Action: i Giam of Federd Action: !. asport Type: ®L contract b. (� a bld/dfierlappkadort b. inkW award a. !mite! MkV b. am ft amp Qrartt L3 C. native a0mor ent c. post-awalad CL oo ForlOeeerMd chove Only: e. ban guarantee f. loan rer *mrgr,r „ dace & naurance port sr Marne and Address at Fieportkig Entity: f. 0 R-qOOddtft+ e M Mo.4 k des, @tt�rii,eaa O Prime Q Su award" rknowrt. ccnodu Weal oeatrK IAormW T. Federal Prq�rasrs Narrn�or�tbrtz Congreeafonal 01drK rknown: E. Federal Depart wnVAgency: CFt1A M x1bw. E Wdcebis: * Fodwal Action Numbor,1known: a AwantAmount I know r to.a. Nacho and Addre" of Lobbying Ent b. bOviduaN P044 tr,Mng donrloss(hufi TaddnrstI (F lrrdlvkk=4 Nett awn. Arsr Arno. k(• tern NO. ION) PW AMA fiW rurrw. Moe pnarar a x.arauwr0 wu ,4 r >� 11. Amount of Payment (dwck a#Me iqpft): 13. type of Psyrnerrt (dndr aAlewop k S C7 AcxusQ Planned L MOW b. 01104 tte fee IL !corn cf Payment (clra& as dtar *pfY): d pt bound; apeWy: ammtum Valais L other 14. Billet Deecr4st3on of Servla m Performed or to be Pertom od and i e) of iervla y bukidhg oMlo sL ang*sre*4 or Member(s) contacted for Payment Indkated In Mm tit i taamOn GaArn�eaon 4treeral �nt� r+Meurrr� ` • IS. Conu u=ion Sh"t(e) Sr-1114 attached: Q Yee Q No IL rrone+..on wai+.s aea* H. ram • gwrmuaa fr me 91 u aQ ..con,su,s+o..aaa.u►.acbooyr�goo e"mamnrmmswimum or ba upon ufm n 06" e w Paco b ra w so** arise gm PrL�t i�ii±M. toruamm vas mass or encored Vm Ths amumm a aouwo Vjmm . w 0� u.a.c. past 11a niormsean wn e• sparred w to convem amiss Tile• anraa r ww wN a astaw Or PANG rnaeCoon. AAV eweon.na acre o ar o» reo-.res asooK+re Vw a euaNa w a ew web sr Aat me area Telephone No.: 08w SIGAoo ww no more ern f100A00 roc scan am raga. e.woarre+R soar . .. _• '. � .' .,�{ ' -fit r�D Y•.ai •Z,C •aY"FM't INSTRUCTIONS FOR COMPLETION OF SF-111. DISCLOSURE OF LOBBYING ACTIVITIES This aj=c3ure form snag be completed by trie reporting entity. whether subawartte orprime Federal mcioieM AIMS khisSn a receipt of a covered Federal action. cr a matenai change to a prwious AIN. psusuam to troe 3 t U.S.C. section 1 ail. Tin"* a form is required for each payment or agreement to rthake payment m any lobbying entity for inAuaxing or amempting to ktiusnes an afftcer or employee of any agency, a Memoer of Congress. afrn officer er employes ol Congress, or an employee of a AAealm of Congress in cornec:iort with a ==rod Federal aotfon. Use the SF-t t t-A Coftnstion Show for eadbbnat inter p vie space or the term is inadequate. Complete all items that apply for both the intial fight and rt au"tai change report Refer to the innlemarning guidance published by the Office of Management and Budget for aaddwnW Inforrnation. I. Identity the We of covered Federal action for which lobbying anaxlvky is sa Wor his boon secured to itt<ke nce ft out corm e of a covered Federal action. 2. identify the status of covered Federal action. 3. Identify the appropriate c Wssiflcadon of this report. A this Is a to4owtV report cattaed by a ahatww dt&Vt 10 the intainzanon previously reported. errortits year snd cAtow in which the ct::r+rge oo 0ft Entente ttsde of the last previously submitted report by ints reporting entity tortnis covered Federal aacxion. 4. Enter the full name. address. city, state and Zip code of the Ong entity. Include CAngresssk" ONtaiet. known. Check the appropriate csassdlcz:Wn of the reporting witty Mast designates it it is. or w T 1 P to to to. a prime or subaward recipient. Identify the tier of the subawardee. e.g. the Am subawardee of an pre mms is Me I st tier. Subawaids; include but are not limited to stbwntracM eubgnWo and conaw awards under grants a it the organization filing the report in gem 4 checks'Subawardos', then o mr the rust name, asddrem day. ttZsts and tip code of the prime Federal recipient. Include Congressional O ticL t known. S. Enter the name of the Federal agency twat$ the sword or ban conhariltmeim khdude as Nest one organizational level below agency name. N known. For oxamplo. CepamTwu of Transportation. United States Coast Guard. 7. ranter the Federal program name or description for the cmmmd Federal acdon (tram t ). A known. eraser tttt cup Catalog of Federal Domestic Assistance (CF0A) numbertorgrana, cooperative agrsecronts, llama, anti loan cammitments. a. Entente most appropriate Federal idertttlying muter nvseftle bran Federal action Iffe t1loplinileml (e g. Request for Proposal (RFP) munVer. Mvitatlon for Bid (FM raunber. grant wmauncomom aatftw. the camrdct gram or loan swami number. the anpp..—.onlprhhpoasd cMj0ot ahunow enigrnd by tiv Federal agora y). Include pretbtes. e.g.. 'RFP-09 4Q-OOt: 4. For a covered Federal action where atom has boo an award or ban comttitawt by the Fodsral agency. wcot the Federal arrioum at the awardlloan com itrthent for the prime entity d in item t or a to. (a) Enter the tug name. address. city, state and Zit Fode of the bbbyhg esttty wagaged by tin reporting witty identified in item 4 to Wiuence the covered FedwW action. (b) Ehterthe full rtartnss of the irtdvidual(s)meptsiommthMhg seervicsa. atmdbheltrds hA1 address f s>Btererhtirmm� t0 (a). Emor last Na. First Name. and l6�tiddie in" wl� t t . Enter the amount of compensation paid or reaeanabiy wipected to be paid by the arvooftV spy (twit 4) to the lobbying entity (item to). Inds, whether the payment has been made (actual) or tall be made (piamhsd). Chest all boxes that apply. K this is a material change report. enterin cvrtueative armwm of payrm wi: made orplanned to to ahadt. t 2 Check the appropriate box(es). Check all boxes that s&y. Spayment is made Mmgh an in*Wconaftam spay am nature and value of the in -kind payrnhart. 13. Check the appropriate box(es). Check all boxes that apply. ti other, silty nature. 14, Provide a specific and detailed description of the cervices that the WW*yW bits pwhx nsd. orwal be exi: acCo A to poton,h; and the dates) of any services rendered. Include all preparatory and mieW aalvity. hat jrstdms slpexa In a=W contact with Federal officials. Identify the Federal official(s) orenhpioyee(s) wed arms otfk•.er(s), wrpiayee(sk arm rr4mis) of Congress that were contacted. IS Check whether or not a SF-1 t t-A Conthuation Show(s) is attached. IS. The cartifyinq official shall sign and dote the fount print rA~ awmne. titre, and teknxtrw OWFA err. rtinra n aDog error+ for M coseeson or Won is eseeuw a erwp 30 aW%M w0esoeme. sme for NWOn q eofraseq ON" dam sa miic ear»nng and ~"awn ne oma Asoew. am caj n, -e ig rrna - p @ --- eke tin d aM"M oWt $ ee ftuvo n sego - 10 me ecrom seonme or rN oew asoset of s"rs ridden er Witamaoon. W%M4 q s igg"MM nor ree"p ess MGM. a ere 01W& of U=fta9enWK OV 06"K PUN WO 00&J W N.pea f034640-ash. wma+ungron. C.C. 20502. "�'' M' ". e ' ti 1 � 1 '' x `� -iw •i'Wi { � ...'.�-max? ir'u•y f .'yore'. �'I{3 `�'y� ".-r- a? ��� -'i ^r� ' "4 =TEi'"1TZED 3UST=FiGATION GRANT E}GPEND=TURE� �Y 1'95�'1--5►2 DIVISION: _ Public Safety & Services DEAARTt*M-- _ _ __ Health - GRANT NAME: E: _ Immunization/Community Health GRANT _ #: 3315-0001 .LviiNi ACCOUNT AMOLNT INCASE (DECREASE) OVER PREVIOUS DETAILED JUSTIFICATION # TITLE REMFS YEAR 511101 Permanent Full 118,186 1,284 Salaries for 8 nursing & laboratory employees Time Salary Fringe Following Accounts 13,416 Fringe for 8 employees in nursing & laboratory 511103 511104 511105 511106 512101 5IM03 512104 512105 512107 5121O8 521190 Other Mach & Equip 14,000 Supplies for laboratory to use in performing tests. Supplies 523102 Medical Supplies 91,064 Vaccine used to provide immunizations to Lubbock citizens. 541101 Professional services 24,000 Fund to pay for State Funded Dentist TOTAL $ 260,666 $ 1,2B4 L 1.1-UHM IU. Z =TE�"IY2'EI7�USTYE=��T=OiM G RdMrNT E]{ FEND = TU RES FY 1 c35� i —92 DIVISION: Public Safety & Services DEPARTMENT: Health GRANT NAME: HIV GRANT #: 3311-OWI AGCOI�iT ACCOIAVT AMOUNT INCREASE (DECFEASE) OVER PREVIOUS DETAILED JUSTIFICATION # TITLE fiEOLESTED YEAR 511101 Permanent Full 23,830 (23,830) Provide funding for two employees. Time Salary Fringe Following Accounts 5,958 (5,958) Fringe is based on amount State of Texas Allows. 511103 511104 511105 511106 512101 512103 512104 512105 512107 512108 522101 Office Supplies 1,500 (500) Office supplies to support an HIV/AIDS program. 522102 Education Supplies Supplies to support an HIV/AIDS education program. 549102 Training & Travel 1,200 (100) Funds to maintain training of employees in AIDS/HIV Intervention TOTAL $ 32,488 $ (30,388) LT . FORlM 10.2 =TEM2 ZED JrUST=�"=�PrT=aRI-P GFZARIT E}CPERII3=TURFEE S FY 1'g'91—'92 DIVISION: Public Safety & Services DEPARTMENT: Health GRANT NAPE: Maternal & Child Health GRANT #: 3310-0001 INCREASE A UVT ACCOUNT AMOUNT (DECREASE) OVER PRE/IOUS DETAILED JUSTIFICATION # TITLE REALESTED YEAR 511101 PERMANENT FULL 208,177 49,375 Salary for 8 eWloyees TIME SALARY Decrease is due to funding cycle. Fringe Following Aocounts 43,413 12,852 Fringe is based on amount State of Texas allows 511103 511104 511105 511106 512101 512103 SM04 512105 512107 512108 SM102 Medical Supplies 16,733 3,352 Supplies to operate maternity and family planning clinics. 541101 Professional 16,200 1,350 Funds to pay physicians to work the maternity and Services family planning clinics. TOTAL $ 284,523 $ 66,929 LT.FORM 10.2 Texas Department of Health Robert Bernstein, M.D., F.A.C.P. 1100 West 49th Street Robert A. MacLean, M.D. Commissioner Austin, Texas 78756-3199 Deputy Commissioner (512) 458-7111 October 25, 1991 Anthony B. Way, M.D. Director LUBBOCK CITY HEALTH DEPARTMENT P.O.Box 2548 Lubbock, TX 79408-2548 TDH Document No. C2000376 Change No. 01 Dear Doctor Way: RECEIVED OCT 3 11991 LUBBOCK CITY HEALTH DEPL I have enclosed an approved copy of your public health services contract. Please file it with the office of record for your agency. If we may be of further assistance, please call us at 512/458-7470. Sincerely, TV I JX- Julian M. Kosh, Jr., Director Grants Management Division JMK:am Enclosure TEXAS DEPARTMENT OF HEALTH 1100 WEST 49TH STREET AUSTIN. TEXAS 78756-3199 CONTRACT CHANGE NOTICE NO. 1 STATE OF TEXAS TDH Document No. g2000376 COUNTY OF TRAVIS The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing with LUBBOCK CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto now desire to amend such contract as follows: ------------------------------------------------------------------------------- SUMMARY OF TRANSACTION: ; Revision to public health services contract. ; Attachment 04 - New attachment for HIV education services. ; All terms and conditions not hereby amended remain in full force and effect. ; 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: LUBBOCK CITY HEALTH DEPARTK81T 13IAS DEPARTMENT OF HEALTH ; PERFORMING AGENCY RECEIVING AGENCY ; BY: 'h'r' By: (Si nature of person inthorized (Signature of p rson ant ariaed ; to sign contractsl to sign cant cts) ; Terry Faye Bleier. Chief ow',nn Bureau of Financial Services ; (game and Title) (Name and Title) ; Date: 10-11-91 - Date: Q RRCOHMENDRD: APPROVED AS TO FORM: By: IPRRFORMING AGENCY Director. Offye of General Counsel ; if different from person ; authorised to sign contract) ; RECEIVED Cover - Page I OCT 3 11991 LUBBOCK CITY HEALTH DEPT. UBTAILS OF ATTACHMENTS ---------------------------------------- Att/; ; ------------------- ;---_--_financial Assistance As. ; ?DR Tern ; Source of ; ; Direct ; Total Assistance ; No. :_Pro cart ; BejLin End _; Funds* Amount ; Assistance ; Amount ITDH Share! 01 ; HIY-LHS ; V 1191,' 8131192; STATE ; 33.665,001, .00; 33.665.UU; 02 ; CRH-LHS 9l 1/91; 8/31/92: STATE 93.268 ; 91.114.00: 169.552.00; 260.666.00: 03 ; NCH-LHS 9/ 1/91; 8/31/92, STATE ; 255.519.0U; 29.004.00; 284.523.00: 04 ; HIV-LHS ; 9/ 1191; 8/31/92; STATE 36.D00.00; .00; 36.000.00: , , , , , , , , , , -- - -- - - TDH Document No. C2000376 TOTALS416.298.001, S198.556.00: S614.854.00; Change No. 01 *Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance ICFDAI, if applicable. REFER TO BUDGET SECTION OF ANY ZERO AMOUNT ATTACHNENT FOR DETAILS. COVER - Page 2 DOCUMENT NO. C2000376 ATTACHMENT NO. 04 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: HIV DIVISION TERM: September 1, 1991 THROUGH August 31. 1992 SECTION I. SCOPE OF WORK: PERFORMING AGENCY agrees to conduct program activities to help reduce the spread of AIDS/HIV (acquired immunodeficiency syndrome/human immunodeficiency virus). PERFORMING AGENCY will establish and/or maintain health education/ risk reduction programs for the targeted populations and/or the general public. 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 all activities will be performed in accordance with the applicable RECEIVING AGENCY Program rules and guidelines, PERFORMING AGENCY'S objectives. activities work plans, and detailed budget as approved by RECEIVING AGENCY. All of the above named documents are adopted by reference as part of this Attachment. Any revisions to said documents will be approved by RECEIVING AGENCY and transmitted in writing to PERFORMING AGENCY. PERFORMING AGENCY assures that expenditure of funds will be in accordance with the respective activity's detailed budget. PERFORMING AGENCY agrees to comply with the following: Chapter 81, Health and Safety Code; Article 4419b-4, VTCS, Human Immunodeficiency Virus Services Act. PERFORMING AGENCY will provide an estimated 2.151 clients with services/units of service in or benefiting the county(ies)/area defined as: LUBBOCK. SECTION II. LEGAL AUTHORITY TO CONTRACT: Chapters 12 and 121, Health and Safety Code. SECTION III. 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 Education Sessions in Centers for Disease Control Assistance Programs," and its preface which is written by RECEIVING AGENCY. PERFORMING AGENCY has provided RECEIVING AGENCY with written acknowledgement of receipt and assurance of compliance with these guidelines. All of the above referenced documents are incorporated as part of this Attachment as though written herein verbatim. 5C Due to the sensitive and highly personal nature of AIDS/HIV-related information, strict adherence to the General Provisions Confidentiality Article and RECEIVING AGENCY program rules regarding confidentiality is required. PERFORMING AGENCY success depends upon whether persons at risk believe that the program observes this principle. PERFORMING AGENCY will submit required programmatic reports quarterly on the same cycle as financial status reports. PERFORMING AGENCY will authorize their staff to attend in -state training, conferences, and meetings for which funds were budgeted and approved by RECEIVING AGENCY. SECTION IV. BUDGET: Personnel $26,252.00 Fringe Benefits 6,038.00 Travel 780.00 Equipment .00 Supplies 292.00 Contractual .00 Other 1,638.00 Total Direct Costs $34,900.00 Indirect 1,100.00 TOTAL $36,000.00 Financial status reports (FSRs) are due the 20th of December, March, June, September and the 15th of October. Total reimbursements will not exceed $36,000.00. The negotiated amount is less than UGCMS, Table 1. -2- F a 1�3-7 % Texas Department of Health Robert Bernstein, M.D., F.A.C.P. 1100 West 49th Street Robert A. MacLean, M.D. Commissioner Austin, Texas 78756-3199 Deputy Commissioner (512) 458-7111 October 25, 1991 Anthony B. Way, M.D. Director LUBBOCK CITY HEALTH DEPARTMENT P.O.Box 2548 Lubbock, TX 79408-2548 TDH Document No. C2000376 Change No. 02 Dear Doctor Way: RECEIVED OCT 3 01991 LUBBOCK CITY HEALTH DEPT. I have enclosed an approved copy of your public health services contract. Please file it with the office of record for your agency. If we may be of further assistance, please call us at 512/458-7470. Sincerely, #qz.p-- C>41�4arl#� Julian M. Kosh, Jr., Director Grants Management Division JMK:am Enclosure STATE OF TEXAS COUNTY OF TRAVIS TEXAS DEPARTMENT OF HEALTH 1100 WEST 49TH STREET AUSTIN, TEXAS 78756-3199 CONTRACT CHANGE: NOTICE NO. 2 TDH Document No. C2000376 The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing with LUBBOCK CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto now desire to amend such contract as follows: ------------------------------------------------------------------------------- SUMMARY OF TRANSACTION: Revision to public health services contract. Attachment to add Amendment 03A - Amendment to revise budget to increase direct assistance and decrease financial assistance for upgrade of state position. CSA II, LC301-131 to CSA III, LC301-131 effective 10/01/91. All terms and conditions not hereby amended remain in full force and effect. RECEIVING AGENCY Texas Department of Health By: IV— -1 / /rj (Si ature of pe o autho i d to sign) Julian M. Kosh, Jr., Director Grants Management Division (Name and Title) Date: o Cover - Page 1 DETAILS 11F ATTACRNENTF Att/; ; --__--_Financial Assistance __-__; ; An. ?DR Term ; Source of ; Direct Total Assistance ; No. ; Program ; Begin ; End ; FMnds$ ; Amount ; Assistance ; Amount ITDR Share) ; 01 RIV-LRS ; 91 1191; 8131/91: STATE 33.665.00; .00; 33.665.00; 02 ; CRR-LRS ; 9/ 1/91; 8/31/92: STATE 93.268 ; 91.114.00; 169.552.00: 260.666.00: + + 1 , 03A ; NCR-LRS 9/ 1/91, 8/31/92: STATE 154.045.00: 30.478.00; 284.523.00, 04 RIV-LRS 9/ 1/91; 8/31/92: STATE 36.000.00: .001, 36.000.00 -------------------------------------------- TDR Document No. C2000376 -------------------------------- TOTALS 414.824.00: ..................................... 1 200.030.00: S 614.854.00: Change No. 02 ; $Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance ICFDAI. if applicable. REFER TO BUDGET SECTION OF ANY ZERO ANOUNT AtTACNNENT FOR DETAILS. COVER - Page 2 TEXAS DEPARTMENT OF HEALTH Receiving Agency/Program: MATERNAL & CHILD H Performing Agency: LUBBOCK CITY HEALTH DEPPA TDH Document No. C20W376 Change # Z Term: REVISED CONTRACT BUDGET i-------------- DIRECT ASSISTANCE ---------- ------- ---- Current Approved Change ------------------------ Requested -----1 New or Revised r 1 -------(a)----------------(b)---_ Budget -----(c)----1 -- -------------�_Budget (Personnel (No. Pos. 2) (Travel ' $29,004.00 1 1 $1,474.00 ' 1 $30,478.00 + 1 (Laboratory Support .00 l .00 l .00 .00 l .00 .00 l (STD Drugs ITB .00 1 l 1 .00 1 I .00 1 l Drugs (Vaccines .00 .00 1 .00 1 .00 .00 .00 Other .00 00 .00 TUH irecE Assis�cel I TDH Financial Assist. 255 519.00 i '$Z84 ; 5i3: 0�0 , �U , (11.474.00}I 5254,045.00 i 5z3 . TDH Share UU $ZU4 , uu /---------------------------------------------------------------------------------------\ ASSISTANCE ----------------------- -----__--FINANCIAL 1Object ---------------------------------------------------- Current Approveed ;Change Requested 1 New or Revised Cl lClass CategoriesBudget Budget - ---- - - ---- -- Via. Personnel_---_---- -_ - - ---- - - - -- -- ------ ----+-$179_173.00-;----___-($1_474.00);-------$177,699.00-� -----(b)- _, -----(c) ---1 1b Fringe Benefits ; $43,413.00 .00 ; $43 413.00 ' -----------------;---------------.00-;---------------.00 Ic. Travel �-------------.00 i ld-- Equipment ------------------------------��-=----------------��- e. Supplies $16,733.00 ; .00 ; ---------------'------- -------------------I 16 733.00 1 ------------------------------------------------------------- 1f. Contractual -------------------- ------------------- ; $16,200.00 ; ---.00-------------- .00 ; ------------- $16,200.00 -------------- g__ Other -------------------------------------------------- 1h Total Direct Charges ; $255,519.00 ; ---��--------------------f $254,045.00 f ------------------------------------------.00--------- Ii. Indirect_ Charges ; ; -($1,474.00); ------------ .00 ;.00 1j-- Total ------------------;_---__-5255,519-00- 1k RECEIVING AGENCY share I-'------ ---- ----- -------------------------------------------------- --------(51,474-00);-------5254,----00 ; $255,519.00 ; ($1,474.00); ---� $254,045.00 1 11. PERFORMING AGENCY share' .00 .00 .00 1---(Includes -m_- PI) ------ - �-------------------�-------------------'--------------------1 1--- - m. Program Income -00 -------------------------�� ------------------------------------ Detail on Indirect Charges: Type of Rate (Mark one Box) Provisional Predetermined l - Final - Fixed l Rate 0.00 Base .U0 Total Indirect Charges .00 I--------------------------------------------------------------------------------------1 (EXPLANATION OF CHANGE: l )Increase in direct assistance and decrease in financial assistance for upgrade 1 lof state position. CSA II, LC301-131 to CSA III, LC301-131 effective l 110/01/91. 1 I I Form No. - a Rev. 03/91