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HomeMy WebLinkAboutResolution - 5026 - Auth Mayor To Execute Contract With TDH To Provide HIV Education - 11_09_1995Resolution No. 5026 November 9, 1995 Item #45 RESQLU—TION 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 Grant Application, attached herewith, by and between the City of Lubbock and the Texas Department of Health, HIV Division for HIV counseling and testing, and any associated documents, which Application shall be spread upon the minutes of the Council and as spread upon the minutes of this Council shall constitute and be a part of this Resolution as if fully copied herein in detail. Passed by the City Council this 9 th & FEN W M3 I etty Johns n, City Secretary 1 APPROVED AS TO CONTENT: Doug Good , Director of Health and Commu Services APPROVED AS TO FORM: arence Walker, Assistant City Attorney CW Aakedocs/app-himes October 30, 1995 Resolution No. 502E November 9, 1995 TEXAS DEPARTMENT OF HEALTH Item #45 HIV/STD HEALTH RESOURCES DIVISION APPLICATION FOR FUNDING DATE RECEIVED BY STATE 1 I APPLICANT INFORMATION 1) LEGAL NAME: C i ty of Lubbock Heal th 6) ADDRESS: isW. Add.. P.O. Box Yuajaer. Cary. Carry. shoe. Department ad zip Cam) 2) PAYEE NAME: City of Lubbock 1902 Texas Avenue P.O. Box 2548 3) PROJECT DIRECTOR AND PHONE NOS: Lubbock, TX 79408 a) Office No: (806)767-2939 Lubbock County b) FAX No: (806) - 762-5506 7) PAYEE ADDRESS: (train mm N/A 4) CONTACT PERSON* AND PHONE NO: Tar Fos key (8Qk ))2kZ,-2553 5) FINANCIAL OFFICER AND PHONE NO: 8) TAX C.D. NUMBER: Debra Forte` ®0©ff10®0®E� 0 6 (806) 767-2015 9) TYPE OF APPLICANT: (enter appropriate letter in box:) 0 a) City Health Department f) Private Non -Profit Organization b) County Health Department g) Higher Education c) District Health Department h) Indian Tribe d) Community -Based Organization i) Minority Organization e) Hospital j) Other (specify) 10) TYPE OF APPLICATION: NEW ® CONTINUATION 11) DESCRIPTIVE TITLE OF PROJECT: 12) REQUESTED FUNDING: HIV Counseling, testing, referral: a) Total Charges $33,575 Partner Elicitation b) Indirect Cost 1, 42z c) Total Funding - Requested $ 3 5 , 000 16) LIST ALL COUNTIES TO BE SERVED: 13) START DATE END DATE 01/01r 96 12/3V 96 14) EXECUTIVE DIRECTOR OF AGENCY: Doug Goodman Lubbock t5) a) NAME OF AUTHORIZED REPRESENTATIVE: David R. Langston LE: Mayor • c) TEIA HONE O: (80 67- Y. G UR A ORIZ REPR LATIVE 17) DATE SIGNED: November 9, 1995 R Please list the person Who can answer gueti ns about the apOication. O..,roiaeioc ABSTRACT Name of Applicant: City of Lubbock Health Department Mailing Address: 1902 Texas Avenue, Lubbock, TX 79408 Contact Person: Tammy Foskey Telephone Number: 8o6-767-2953 FAX Number: 806-762-5506 Public Health Region: 1 HSDA: Lubbock State Senatorial District: 28 State Representative District: 82-8 List All Counties Served: Lubbock 3 Congressional District: 84-83 Total Estimated Number to be Served: Total 1 ,60o By Sex: Males 700 Females 900 By Age: Adults over 20 1—,100 Adolescents 13-20 480 Children under 13 20 By Race: White (Non -Hispanic) 70o Black (Non -Hispanic) 400 Hispanic 450 Asian/Pacific Islander 50 Unknown Project Summary: (Narrative overview of the 90a1(0, obiectives, and activities.) The continuation grant for counseling, testing, referral and partner elicitation will work to provide HIV education, preventive measures, counseling and testing for the target groups as determined by the Regional HIV Coalition (MSM: adolescent, college -aged, of color and anglo. IDU: homeless, sex worker, incarcerated. UHS: migrants, gang members and sexual partners of IDUand/or MSM), The City of Lubbock Health Department is the location of the STD Clinic which will continue to be used as an HIV testing site. Other sites for testing are: Texas Tech University, Presbyterian Center Women's Clinic, Lubbock County Jail, Lubbock County Youth Center, the adult theaters/bookstores and the gay club. Collaboration activities include: working with Catholic Family Services in their outreach education eforts to the migrants, adolescents, and female partners of IDU and MSM and working with Insiide/Out whose education efforts involve gang members, IDU, homeless and MSM of color. Testing referrals and/or on -site counseling and testing following a formal HIV education presentatioin will be offered through the City of Lubbock Health Department to CFS and Inside/Out when appropriate and requested. Testing will also be offered as a continuity of service to Impact Tech (a peer education group) when requested to supplement and HIV education presentation. Prevention of HIV infection is to be the main focus of all CTRPE activities and testing is one realm of prevention. Referrals for those testing seropositive will be coordinated through the South Plains ,AIDS Resource Center (SPARC) and a support group for those who are high -risk seronegatives is a goal for the coming year. Deferrals for drug treatment will continue to be made to Lubbock MHNIR and to the AA/NA groups in the Lubbock and surrounding areas when applicable. Budget Summary: Personnel $ 26.396 Fringe Benefits — 6 , 439_� Travel 46o Equipment _ -- Supplies 50 Contractual Other Total Direct Costs $ 33,575 Indirect Cost 1 ,425 Total Requested $ 35,Q00 APPLICATION CHECKLIST NAME OF APPLICANT: City of Lubbock Health Department Instructions. Send all items below with the 1996 application. REQUIRED FORMS/CONTENTS x Application for Funding Form X Abstract =Application Checklist X Table of Contents PROJECT NARRATIVE X Redirection Efforts in 1995 X Workplan X Required Objectives -X-Target Group Chart for Objective BUDGET x Key Personnel Form X Categorical Budget Justification Multiple Funding Sources Form ASSURANCES X Confidentiality Statement X Workplace Guidelines X Compliance with Requirements for Contents of AIDS -Related Written Materials X Conflict of Interest Restrictions X Advocate and Promote Statement x Certification Regarding Lobbying X Physician Supervision X Board Members and Executive Officer OTHER REQUIRED DOCUMENTATION X Board of Directors list APPENDICES: X Indirect cost rate agreement, if applicable Other documentation you deem necessary SUBMISSION OF APPLICATION: X ORIGINAL AND TWO COPIES OF APPLICATION TO AUSTIN TDH ADDRESS X SEND ONE COPY OF APPLICATION TO REGIONAL HIV COORDINATOR. TABLE OF CONTENTS Page No. I. Application for Funding Form 1 II. Abstract 2 III. Application Checklist 3 IV. Table of Contents 4 V. Redirection Efforts in 1995 5-6 VI. Process Objectives and Workplan 7-10 VII. Target Group Chart for Objective I 11 VIII. Key Personnel Form 12 IX Categorical Budget Justification 13 X. Assurances I. Confidentiality Statement 14 2. Workplace Guidelines 15 3. Compliance with Requirements for Contents of AIDS -Related Written Materials 16 4. Conflict of Interest Restrictions 17 5. Advocate and Promote Statement 18 6. Certification Regarding Lobbying 19 7. Physician Supervision 20 8. Board Members and Executive Officer 21-22 XI. Appendices 23-30 1. STDIHIV High Risk Questionnaire 23 2. Female STD Record 24 3. Male STD Record 25 4. Collaboration Agreement with TTUniversity 26 5. Collaboration Agreement with Inside/Out 27 6, Collaboration Agreement with Catholic Family Services 28 7. Collaboration Agreement with Presbyterian Clinic 29 8. Tracking and Referral Form 30 REDIRECTION EFFORTS IN 1995 Redirection efforts began in January 1995 when the City of Lubbock Health Department was placed on provisional status for funding. Additional funding for the six month period (June -December 1995) would be awarded if redirection efforts were made to meet the risk groups established by the Texas Department of Health. These high -risk groups consisted of: men who have sex with men, men and women of color, injecting drug users, and women who have partners who are injecting drug users and/or have sex with men. The Sexually Transmitted Disease clinic at the Health Department was testing some individuals of the stated high -risk groups but there was an identified need for other testing locations. In looking for additional areas where high -risk individuals would congregate, the adult bookstore/theater locations and gay club were considered (MSM). The HIV counselor has made contact with the management of the above businesses and has made prevention -oriented materials available. Testing was provided on several occasions at the above establishments, although the number of individuals seeking testing was lower than hoped. The management at all locations has provided continued support of Health Department activities. They have been willing to place posters regarding the need for testing and in recognizing the importance of testing in the prevention of further HIV infections. Testing has begun recently (October 1995) for the female trustees of the County Jail. Prior testing had been done by University Medical Center (the county hospital) but, due to lag time between testing and results, the trustees most often were released or transferred before receiving results. Therefore, the City of Lubbock Health Department offered their services to provide inmates with test results prior to release into the community as well as educational and preventive measures for contracting or potentially transmitting an HIV infection (IDUs, sex workers, sexual partners ofbi-sexual or IDU men). Testing has been used by the Lubbock County Youth Center through the STD Clinic at the Health Department. It is now being offered on -site to eliminate staff time transporting youth to and from the Health Department for the testing and, again, for quick results. Individualized risk assessment, education, and preventive measures regarding HIV are given to each adolescent. Once the risk assessment, education, and preventive measures are assessed and discussed, the adolescent is given the choice whether he/she requests the HIV test (IDUs, gang members, MSM, unprotected heterosexual sex while using non - injecting drugs). The City of Lubbock Health Department will begin assisting the Community Health Center of Lubbock, through Presbyterian Center Women's Clinic, to provide HIV counseling, testing and referral to all high - risk prenatal clients in an effort to comply with the new laws for prenatal testing. Referrals from private physicians and clinics are also being made to the Health Department if insurance companies are not yet paying for the HIV testing or ff anonymity is being sought by the patient (IDUs, sexual partners of bi- sexual and/or IDU men, unprotected heterosexual sex while using non -injecting drugs). Testing continues to be offered at Texas Tech University through Student Health. The HIV counselor is working with Impact Tech, a peer education group, to provide testing to students living in residence halls, fraternities and sororities, and other organizations after the formal HIV presentations (MSM, IDU, sexual partners of bi-sexual and/or IDU men., unprotected heterosexual sex while under the influence of non - injecting drugs). The City of Lubbock Health Department will be working with the Inside Out program that seeks to provide HIV prevention messages to gang members and injecting drug users. They are funded to provide education programs only and will coordinate with the Health Department to provide testing or referrals for testing when needed to the individuals they are working with. Coordination with Catholic Family Services to provide testing to the migrant population on -site are being explored (MSM, IDU, unprotected heterosexual sex under the influence of non -injecting drugs, men of color). Referrals to early intervention services are coordinated between the City of Lubbock Health Department and SPARC to provide continuity of care. The Early Intervention clinic is located at the City of Lubbock Health Department and appointments are coordinated through the case managers at SPARC. Referrals for high -risk seronegatives is an area that needs to be developed. The HIV Counselor has plans to work with other organizations in the Lubbock area to assess the need for and to implement a high risk seronegative support group(s). There is the probability of working with volunteers to assist in the organization of such a support group(s) when the needs have been addressed by those who will make referrals. OBJECTIVES AND WORKPLAN CTRPE 1996 PROCESS OBJECTIVE 1: By December 31, 1996, the CTRPE program will provide 1600 HIV pretest counseling and testing sessions, according to TDHICDC guidelines, to the target groups defined in the regional Target Group Chart form. ACTIVITY MEASURES: A. Maintain current STD site for counseling and testing. 1. Document HIV risk assessment in STD chart. (Appendix A) 2. CTRPE trained nursing staff will be available to do on -site counseling and testing for high -risk individuals when the HIV counselor is unavailable. 3. Maintain availability of HIV pamphlets in the STD clinic lobby area. B. Maintain testing site at Texas Tech University (on -site) eight hours a week. Provide testing for Impact Tech (peer educators) when requested following formal HIV presentation. (MSM, IDU, female partners of MSM and/or IDU) (Appendix B) C. Collaborate with Inside/Out (HERR) to provide testing for individuals (IDU, MSM, MSM of color, MSM adolescents, gang members) off -site, Referrals will also be made to the City of Lubbock Health Department when needed. (Appendix C) D. Collaborate with Catholic Family Services (HERR) to provide testing for individuals (migrants, homeless, IDU, MSM adolescents, female partners of MSM and/or IDU) off -site. (Appendix D) E. Continue to work with the management of adult theaters/bookstores to provide prevention materials and on -site testing. (MSM, MSM of color) F. Continue to work with the management of gay club to provide on -site testing and referrals for testing to the City of Lubbock Health Department. (MSM, MSM of color) G. Continue to provide on -site testing for female inmates at the Lubbock County Jail. (IDU, sex workers, sexual partners of MSM and/or IDU). H. Provide on -site testing for prenatal clients of Presbyterian Clinic Women's Center (IDU, homeless, migrants, sexual partners of MSM and/or IDU). (Appendix E) EVALUATION OF OBJECTIVE: Monthly and quarterly reports will indicate the number of individuals receiving pretest counseling and those individuals being tested for HIV. Number of individuals within specific target groups receiving pretest counseling and testing will be documented on monthly and quarterly reports. EVALUATION FORMULA: #pretest counseled and #testing PROCESS OBJECTIVE 11: By December 31, 1996, the CTRPE program will provide posttest counseling to a minimum of 75% of the 1600 individuals who test for HIV infection. ACTIVITY MEASURES: A. Due to confidentiality laws, emphasis is placed on the importance of returning for results in person. B. Maintain adequate and varied hours for scheduling appointments for results. C. Posttest counseling is documented. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will indicate the percentages of individuals returning for test results. EVALUATION FORMULA: # receiving posttest counseling/#HIV tested x 100 PROCESS OBJECTIVE III: By December 31, 1996, the CTRPE program will provide posttest counseling to a minimum of 85% of the individuals who test seropositive for HIV infection. ACTIVITY MEASURES: A. Emphasize the need to obtain test results in person. B. if confidential testing is selected, obtain locating information to assist in notification of individual should he/she test seropositive for an HIV infection. C. Emphasize the confidentiality of results and importance of knowing serostatus to make important life and health decisions. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will indicate the number of individuals testing seropositive and the number returning for test results that are seropositive. EVALUATION FORMULA: # receiving seropositive results/#iesting seropositive PROCESS OBJECTIVE IV: By December 31, 1996, the CTRPE program will document that a minimum of 90% of seropositive individuals receiving posttest counseling are under case management for early intervention services. ACTIVITY MEASURES: A. A packet of information will be reviewed with the counselor and given to each person. B. An appointment will be made at the early intervention clinic located at the City of Lubbock Health Department. C. A list of private physicians will also be available for those who are desiring more confidentiality and anonymity. D. A follow-up appointment will be scheduled to assess individual's needs and implementation of further referrals. E. Referral will be made to the South Plains AIDS Resource Center for social and support services. F. Referral to the Immunization clinic for immunization update and TB testing. EVALUATION OF OBJECTIVE: A tracking system was developed to provide agencies a :method that is consistent in making appropriate referrals for early intervention medical services, and social and support services. (Appendix F) Monthly and quarterly reports will document progress towards this objective. EVALUATION FORMULA: #referred for early intervention)#seropositives x 100 PROCESS OBJECTIVE V: By December 31, 1996, the CTRPE program will elicit at least one sex and/or needle sharing partner for health department notification (local/regional STD program) from a minimum of 50% of their seropositive individuals receiving posttest counseling. ACTIVITY MEASURES: A. Introduce partner elicitation during pretest counseling session. B. At the time of seropositive posttest counseling session, address the issue of the importance of notification of partners. If unable to elicit partners at the time, arrange for a follow-up appointment to discuss this and any other issues. C. Work with DIS (Disease Intervention Specialist) to arrange follow-up field visit if necessary. D. All trained HIV counselors will be trained in Partner Elicitation course offered by TDH. E. The Wellness coordinator at the Early Intervention clinic will also work to elicit names and re- emphasize the importance of partner notification during the counseling session.. EVALUATION OBJECTIVE: Monthly and quarterly reports will be the tools for evaluation. The form developed by TDH will be submitted immediately following a seropositive posttest counseling session. EVALUATION FORMULA: #seropositive clients requesting assistance/ #seropositive clients x 100 PROCESS OBJECTIVE VI: All women (100%) testing HIV positive who are identified as pregnant will be referred for prenatal care. ACTIVITY MEASURES: A. Emphasize the importance of returning for test results for the health of the mother and child. B. Obtain locating information on all pregnant women testing through the City of Lubbock Health Department for notification if needed of seropositive results. C. Physician referrals will be made for women testing seropositive and follow-up will be made by the HIV counselor to assure that the prenatal appointment(s) is kept. D. Materials documenting the evidence of AZT in the prevention of HIV in infants will be made available. Breast feeding and plans for delivery (vaginal or C-section) will also be discussed and information made available. E. Partner Elicitation/Prenatal Referral Report Form will be submitted to TDH within 2 working days of the seropositive posttest counseling session. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will document the progress. EVALUATION FORMULA: #seropositive pregnant women referred for prenatal care/ #seropositive pregnant women PROCESS OBJECTIVE VII: Collaborate with other agencies serving high -risk seronegatives to form a support group(s) to address issues dealing with staying HIV negative. ACTIVITY MEASURES: A. Work with SPARC, Lubbock M[flVK Presbyterian Center, Catholic Family Services, Inside/Out, and the management of the adult theaters/bookstores and gay club to determine the needs of the community that is at high -risk for HIV. B. Work with Texas Tech University students as volunteers for organizing the format and publicity of the support group(s). C. Gather material from other programs in the state that have seronegative support groups to use in forming one in the Lubbock area. EVALUATION OBJECTIVE: Monthly and quarterly reports will document the progress. CTRPE OBJECTIVE 1: TARGET GROUP CHART REGION 1 By December 31, 1996, the CTRPE program will provide 1600 total number) 141V pretest counseling and testing sessions, according to TDH/CDC Ruidelines, to the target groupi defined below: G, W m E MSM Adolescent H 120 7.5 LCYC, work with Inside/Out(HERR) College -aged H 100 6.25 TTU, club, theaters/.bookstores MSM of color H 100 6.25 club, theaters/bookstores,InsideOu Anglo M 75 4.69 club, theaters, bookstores IDU Homeless H 60 3.75 Jail, Presbyterian, Inside/Out Sex worker H 60 3.75 Jail Incarcerated M 100 6.25 Jail, LCYC UHS Migrants H 200 12.5 work with Catholic Family Srvs.(HE Gangs M 50 3.13 LCYC, Inside/Out. IDU 'Fpm.qlp Partnels MSM M. 200 12.5 TTU, Presbyterian, CFS OTHER Dther 11 535 33..-44--- clinic based TOTAL 1600 100% KEY PERSONNEL Annual Number % Total Name and Position Title Salary Months Time Amount Rate Required (1) (2) (3) (4) Tammy Foskey $ 2,199.67 12 100 $ 26,396.00 2,199.67 $ 26,396.00 TOTAL Rev 10CV94 HIV COUNSELING, TESTING, REFERRAL AND PARTNER ELICITATION BUDGET JUSTIFICATION A. PERSONNEL HIV Counselor (Tammera Foskey) 100% counseling 2199.67/monthly x 100% time x 12 months = $26,396.00 This refunded position will continue to provide counseling, testing, referral and partner elicitation in Lubbock county for STD clients, female trustees, women of child-bearing age who are partners of men who have sex with men or use injecting drugs, gang members, men who have sex with men and others seeking testing for HIV at the City of Lubbock Health Department, B. FRINGE (25%) FICA: rate x salaries Insurance: cost per mo x FTE's (Health ins. 2,245 Life ins, 16 Dental ins. 171 Retirement 2,009) Worker's Comp: rate x salaries Unemployment: rate x salaries Total Fringe Rate C. TRAVEL Expenses for HIV counselor to attend one state conference Mileage @ $.275 x 800 miles round trip = $220 Per Diem @ $55 x 3 days = $165 Meals @ $25 x 3 days = $ 75 D. SUPPLIES Funds are requested for the purpose of general office supplies $50 E. OTHER Funds are requested for educational supplies $185 Registration for one conference $45 F. TOTAL DIRECT COSTS G. TOTAL INDIRECT COSTS (UGCMS) H. TOTAL BUDGET $1,978.00 $4,441.00 20.00 00.00 25.00% $26,396.00 $6,439.00 $460.00 50.00 230.00 $33,575.00 $1,425,00 $35,000.00 CONFIDENTIALITY STATEMENT The applicant agency and its employees or subcontractors, if applicable, provide assurance to the Texas Department of Health that: Confidentiality of all records shall be maintained. No information obtained in connection with the examination, care, or provision of programs or services to any person with HIV shall be disclosed without the individual's consent, except as may be required by law, such as for the reporting of communicable diseases. Information may be disclosed in statistical or other summary form, but only if the identity of the individuals diagnosed or provided care is not disclosed. We are aware that the Health and Safety Code, §81.103, provides for both civil and criminal penalties against anyone who violates the confidentiality of persons protected under the law. Furthermore, all employees and volunteers who provide direct client care services or handle direct care records wherein they may be informed of a client's HIV status or any other information related to the client's care, are required to sign a statement of confidentiality assuring compliance with the law. An entity that does not adopt a confidentiality policy as required by law is not eligible to receive state funds until the policy is developed and implemented. Nnvemher 9 , i 995 Date Rev 9195 ASSURANCE OF COMPLIANCE with the HIV/AIDS MODEL WORKPLACE GUIDELINES PROVIDERS OF DIRECT CARE, SERVICES, OR PROGRAMS By signing and submitting this proposal, the applicant agency certifies that its Project Director and Authorized Business Official have: 1) received a copy of the HIV/AIDS Model Workplace Guidelines, Providers of Direct Care, Services, or Programs, Amended Final Rules, Texas Board of Health, January 27, 1990; 2) have read them; 3) accept them; and 4) agree to adopt and implement workplace policies on HIV/AIDS to include at a minimum: a) the provision of education for employees and clients concerning HIV, its related conditions, and AIDS; b) confidentiality of AIDS and HIV -related and all other medical information for employees, clients, inmates, patients, and residents served by the applicant agency; and c) an anti -discrimination policy assuring all privileges and opportunities for any employee or client with a communicable disease, unless based on accurate scientific information. November 9x_1995 Date Rev 9/95 ASSURANCE OF COMPLIANCE with the REQUIREMENTS FOR CONTENTS OF AIDS -RELATED WRITTEN MATERIALS, PICTORIALS, AUDIOVISUALS, QUESTIONNAIRES, SURVEY INSTRUMENTS, AND EDUCATIONAL SESSIONS, AND ITS PREFACE By signing and submitting this proposal, the applicant agency certifies that its Project Director and Authorized Business Official: 1) have received a copy of the Requirements for Contents of AIDS -Related Written Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, and Educational Sessions in Centers for Disease Control Assistance Programs, dated June, 1992, and its Preface; 2) have read them; 3) accept them; 4) agree to comply with all particulars and specifications set forth; 5) and agree that all specified materials shall be submitted to the program materials review panel and subject to the CDC Basic Principles set forth. Following are the names, occupations, affiliations and addresses of the proposed panel members: (use attachment page if needed.) Name Liz Inskip-Faulk Soila Reyes Leonard Jarmon Ben Morales Patsy Camunes Doug Stroupe �w of Lubbock t Agen y Si Clature of Auth ze+ Rev 9/95 Occupation Health Educator HIV Educator Minister/SAcounselor Manager LVN Manager lth Department Affiliation and Address LCHD, 1902 Texas Ave. Lubbock, TX CFS, 102 Ave. J, Lubbock, TX Inside/Out, 1409 23rd, Lubbock, TX Crystal Cinema, 1408 N Ave. Y Lbb, Presbyterian Clinic, 1318 Broadway Lubbock, TX THE PLACE, 2401 Main St.,Lubbock, T November 9 1995 Date , ASSURANCE OF COMPLIANCE WITH CONFLICT OF INTEREST RESTRICTIONS The applicant agency and its employees or subcontractors, if applicable, provide assurance to the Texas Department of Health that: No person who is an employee, agent, consultant, officer, or elected or appointed official of this agency, and, therefore, in a position to obtain a financial interest or benefit from an activity, or an interest in any contract, subcontract, or agreement with respect thereto, or the proceeds thereunder, either for himself or herself or for those with whom he or she has family or business ties, during his or her tenure or for one year thereafter shall participate in the decision making process or use inside information with regard to such activity. Furthermore, this agency will adopt procedural rules which require the affected person to withdraw from his or her functions and responsibilities or the decision -making process with respect to the specific assisted activity from which they would derive benefit. 11-9-95 We Rev 9/91 ADVOCATE AND PROMOTE STATEMENT Applicant agency certifies that it does not advocate or promote conduct that violates state law, in compliance with the HIV Services Act, Texas Health and Safety Code, Section 85.011, as follows: "Grants may not be awarded to an entity or community organization that advocates or promotes conduct that violates state law. This subsection does not prohibit the award of a grant to an entity or community organization that provides accurate information about ways to reduce the risk of exposure to or transmission of HIV." -9-95 Rev. 9/95 CERTIFICATION REGARDING LOBBYING 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 the 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-1 It. "Disclosure Form to Report Lobbying," in accordance with its instructions. (See Appendix of Program Guidance for this form and 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 agreement; 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. 1 1-9-95 Date Rev. W9S ASSURANCE OF COMPLIANCE WITH THE TEXAS HEALTH AND SAFETY CODE SUBCHAPTER D. TESTING PROGRAMS AND COUNSELING SEC. 85.085 PHYSICIAN SUPERVISION OF MEDICAL CARE By Signing and submitting this form, the applicant agency certifies that its project staff and volunteers are working under the standing delegation order of a licensed practicing physician when providing HIV counseling and testing services as required in part by the Texas Health and Safety Code, Sec. 85.085. City of Lubbock Health Department 4 V/�1t,2- A Mo Signature of Licensed Physician 4 '1 �Ds License Number Rev. 9/95 11-9-95 ite /� Date BOARD MEMBER AND EXECUTIVE OFFICERS ASSURANCES FORM City of Lubbock Health Department 1902 Texas Avenue, Lubbock, TX 79408 (NAME & ADDRESS OF ORGANIZATION) The persons signing on behalf of the above named organization certify that they are duly authorized to sign this Assurances Form on behalf of the organization. 1) The undersigned acknowledges that an annual budget has been approved for each contract with TDH. 2) The Board of Directors convenes on a regularly scheduled basis (no less than quarterly) to discuss the operations of the organization. 3) Actual income and expenses are being compared with the approved budget, variances are noted, and corrective action taken as needed (with board approval). 4) Timely and accurate financial statements are presented by the designated financial officer on a regular basis to the board. 5) Any required financial reports and forms whether federal or state are being filed on a current and timely basis. 6) Adequate internal controls are in place to ensure fiscal integrity and accountability and to safeguard assets. 7) The Treasurer of the Board has been fully informed of his or her responsibilities as Treasurer. 8) The Board has Audit and/or Finantx Committees that convey regularly and communicate effectively with the Board Treasurer and other board members in understanding and responding to financial developments. 9) The organization observes Generally Accepted Accounting Principles when .preparing financial statements and fund accounting practices are observed to ensure integrity among specific contracts or grants. 10) This form will be discussed in detail at the next official Board meeting and that discussion and a copy of this form will included in the tes of the meeting. Richard Oiler Chairman of the Board S' ture Date Doug Goodman Executive Officer Signature rDat Rev 9/14/95 BOARD OF HEALTH DATE DATE HOME/OFFICE PHONE TERM TERM NAME ADDRESSES NUMBERS BEGINS EXPIRE Barry Bartee 3234 64th (0) 792-2311 (0) 02/21 /94 02/21 /97 D.D.S. Lubbock 79413 Vernon Farthing 3502 9th (0) 762-8461 (0) 06124/93 02/21/96 M.D. Suite 170 Lubbock 79415 Richard Oiler P.O. Box 53423 (0) 799-0075 (0) 02/27/92 02/21/98 P.E. Lubbock 79453 799-3142 ( FAX) Gary Schwede 5201 13th Street (0) 793-2863 (0) D.V.M. Lubbock 79416 Lorraine Stiggers 1926 East Baylor (H) 744-3359 (H) N.D. Lubbock 79403 Kelly Waggoner P.O. Box 1241 (0) 798-8844 (0) Lubbock 79408 Mark Madison 8200-C Nashville (0) 794-6805 (0) Suite 202 Lubbock 79423 Chairperson: Rich Oiler Secretary: Kelly Waggoner Staff Liaison: Doug Goodman 12/31/93 12/31 /96 01 /27/94 01 /27/97 06/09/94 02121 /98 03/23/95 03/23/98 S.T.D.IHIV HIGH RISK QUESTIONNAIRE This is a questionnaire to find out if you may need HIV testing as part of your Sexually Transmitted Disease screening. Your answers will be reviewed by the clinician in the clinic and kept confidential. Please read and answer each question to the best of your knowledge. Circle "Y" for YES; Circle "Nu for NO Y N Have you ever been the victim of a sexual assault or of sexual abuse? Y N Are you employed in a setting with a risk to HIV exposure? Y N Have you ever had sex with someone who is HIV positive? Y N Have you received a blood transfusion or tattoo prior to 1985? Y N Have you ever been diagnosed with a sexually transmitted disease such as gonorrhea, chlamydia, genital warts, syphilis, herpes, etc. Y N Have you ever used IV drugs? Y N Have you ever traded sex for drugs and/or money? Y N Have you ever had sex while under the influence of drugs and/or alcohol? Y N Have you ever had sex with someone who uses IV drugs? Y N Have you ever had sex with a male who had sex with a male? Y N Do you travel and do seasonal work? Y N Are you or have you ever been homeless? When do you use condoms? Always _Occasionally Never Y N Do you know how to put on a condom correctly? What risks do you have that are not stated on this questionnaire? Please list: When is the last time you had an HIV test? Date? Y N Would you like to have an HIV test as part of your STD exam today? CITY OF LUBBOCK HEALTH DEPARTMENT Fernale STD Record Name:` " Chart # Druguse in 'past 2 weeiGs Allergies: date. Drug(s), Drug Abuser` ©C1B For: " Reason fat Visit Pr4h}ern History A. 1) Volunteer A. [ } Nona A. Last sex solivity B. {) Ct to B. ` [ } Discharge _ _Days B, Nod ptrs 30/60/90 days .. C. 1 } Rx for (Me ()White [) Purulent C. .. ONO. male D. 1.).. TDC GC ()Sct ()Mod.: { }Hvy ()Odor D. [) No. fsnials E. i 3 FIU C [ } .. D ow% E. l }Oral 1 f And F 11STS rttths. D 0 : Pain F. [ }prt. problem - Ca, [ ) Agency fief. E.. 1 } ; . Lesion a. LW Paper H. !) Physician:Ref . F. 0 : Rash Contraception (} Yes 1. 0 Other G. [) itching Type H. [ ) Other : Pregneno. t) Yes. 1) no EDC H. Last douched .. riot S i3 Physical Assessment Describe Abhor rtai i=indirip Disaass (N1Y) Last Episode NME ABN NO. A. Gonorrhea' { } .:.. Skin [ ) [) 1 } B, Chlamydia ; [) Lymph Nodes C. Syphilis 1 ? ,. inguirial {) {) 1 D. Herpes 2 [ ). ;, Femoral E..HPV Other F. Other [ } .... Oral Cavity [ ). [) { } Pubic Area [) 1 } 1 } Disease intervention Activy External Genitalia A. Patient counseled for risk. Vagina t) [ } 1 } reduction. and partner Cervix [ ) [) { ) referral by: Discharge Yes [ } No { } [ } Clinician 1) DI$ Amount SM 1) MOD 1) LRG ; ) B Condoms Character CL () WHITE [ } PUR;) . [ } Given 0 Refused 1 } Has HIV risk l } Discused 1. ) Counseled [ } Tested Call: RTC: Ref: Counselor Initial D..: interviewed by cis Clinician. Signature: 0 Yes ()No DIS Initial Di.aRrtflss:i Treatment by Standing Order/Comments: Medication Instruction Given [ ) Verball) Prlotedl) Understood. . Immunization )) Referred { } Current Year Case Conference { ) Nurse() Physician[ } Other Physician Order/Cornments; Patient Education }Yes:l}No; Roferenoo Care Plan i# Chart Review Physician: hiursa: Data Date*•' STD 908-F Revised 4193 No Text COLLABORATION AGREEMENT Texas Tech University/Impact Tech agrees to collaborate with the City of Lubbock Health Department to provide testing for HIV when applicable in the scope of providing HIV Education and Prevention. Coordination with the City of Lubbock Health Department will make the continuity of services and referrals possible and more individuals aware of their HIV status. Testing is also made available at Thompson Hall (Student Health) ten hours a week to provide more anonymity for those seeking testing. Ufa 5 C uub-"t 4-'a� (A ncy Representative) (Agency) (Date) COLLABORATION AGREEMENT Inside Out agrees to collaborate with the City of Lubbock Health Department to provide testing for HiV when applicable in the scope of providing HIV Education and Prevention. Funding is made available for HIV Education to our organization, but funding is not available for testing. Coordination with the City of Lubbq&F4ealth Department will make the continuity of services and referrals possible and more aware o(their HIV status. (Agency Repre I 0 /,.?O/q (Date) (Agency) COLLABORATION AGREEMENT Catholic Family Services agrees to collaborate with the City of Lubbock Health Department to provide testing for HIV when applicable in the scope of providing HIV Education and Prevention. Funding is made available for HIV Education to our organization, but funding is not available for testing. Coordination with the City of Lubbock Health Department will make the continuity of services and referrals possible and more individuals aware of their HIV status. W6V�OhIIVA,l Ceholf1c'...rool- (Agency Representative) (Agency) 161d gA75 (Date) COLLABORATION AGREEMENT Presbyterian Center Women's Clinic agrees to collaborate with the City of Lubbock Health Department to provide testing for HIV to the prenatal clients in the scope of providing HIV education and prevention. Coordination with the City of Lubbock Health Department will make the continuity of services and referrals possible and compliance with the Texas state laws regarding HIV prenatal testing possible. CC7r— C ErtCfrn ( ency epr entativ (Agency) I C-) - S�4- q-� (Date) LUBBOCK,TEXAS HIV POSITIVE REFERRAL TRACKING CLIENT NAME/CDC NUMBER: REFERRAL MADE TO: PRIVATE PHYSICIAN SPARC WEMm LA CLINICA IMMUNIZATION CLINIC (CITY OF LUBBOCK HEALTH DEPARTMENT) OTHER REFERRAL CONCLUSION: DATE VERIFIED: TEST SITE LOCATION AND CODE #: COUNSELOR AND CODE #: DATE: GRANT PROPOSAL EVALUATION FORM Page 1 DEPARTMENT: CONTACT: TODAY'S DATE: APP. DUE DATE: :CONTRACT AMOUNT: 1. Is this grant 2. Is a match required? Health Department Judy Hen er5Qn 10-24-95 11-22-95 If yes: Is it: GRANT TITLE: GRANTING AGENCY: CONTRACT PERIOD: FEDERAL CFDA 0: . PASS-THRU GRANTORS #: New Yes Percentage In -kind Source CTRPI TDH 01/96-12/31/96 Continuing XX Number of Years 6.5 No XX Amount OR Cash 3. Are there any indirect costs, i.e. building use, computer time, administrative supervision, associated with the grant? Yes XX _ No If yes, please fist the estimated costs. $1 425.00 4. If there are indirect costs, are they reimbursed by the grant? 5. Are audit costs reimbursed? If yes: 6. What are the audit requirements for this grant? 7. Can this grant be renewed? If yes, how many times? What are the terms of renewal? Yes XX No Percentage 100% Yes XX No Percentage 100% See Attachment Yes X X No Renewal is dependent on funding from CDC to TDH and then a ocated based on requests and need. 8. Does the grant require the City to gradually assume the cost of the program? Yes If yes, what is the timetable? No XX of the grant application and the negotiation process. The projected amount available is approximately $4 million. Contractor budget requests for this application may not exceed 1995 level funding and may be decreased based on availability of funds. V. USE OF FUNDS A. Allowable Use of Funds Grant funds may ae used for personnel, fringe benefits, staff travel, equipment, supplies, contractual services, other direct costs, and indirect costs. Equipment purchases are allowed if justified and approved in advance. All costs are subject to negotiation with the TDH. Grantees are required to adhere to federal principles for determining allowable costs in accordance with the cost principles applicable to the organization incurring the costs. The kinds of organizations and the applicable cost principles are set out in the TDH contract general provisions and in the TDN KInancial Administrruive Procedures Manual which is provided to all first-time TDH grantees. To obtain a copy, please contact the Grants Management Division at 512/458-7470. [applicable f the applicant receives $25,000 or more in total federal/state financial assistance during the scal year, arrangements must be made for agency -wide financial and compliance audits. Audits ust be performed by an independent certified public- accountant in accordance with the OMB Circular and Government Auditing Standards. Costs of the audit can be roportionately charged to this budget. For example, if this project were 10% of the grantee's tal funding, the grantee could include I0% of audit costs in this budget. . Disallowances Program funds may not be used for the following: 1) to make cash payments to intended recipients of services; 2) for acquisition of real property, building construction, alterations, renovations, or other capital improvements; 3) to duplicate services already available to the target group; or 4) to supplant other funding for services already in place. V1. REQUIRED TARGET POPULATIONS Target populations for all TDH HIV Prevention activities, including CTRPE, have been determined through the Community Planning process. Target populations are broadly defined as persons who are at highest risk of contracting HIV through the following behaviors: men who have sex with men (MSM), injecting drug users (IDU), and unprotected heterosexual sex (UHS). These categories were further divided into subpopulations by each regional coalition based on regional needs assessments. Additionally, each_ subpopulation was identified as high priority, medium priority, or low priority within each region. For example, in Region 1, the high priority target groups are HIV -infected MSMs, MSMs of color, homeless IDUs, sex workers who are IDUs, and certain heterosexuals who practice unsafe sex. The heterosexual category in Region 1 is limited to the following 2 GRANT PROPOSAL EVALUATION FORM Page 2 9. Please address whether other agencies are currently administering similar program and whether any other agencies are available to administer this program. Yes, this program is offered by other agencies; however, there are limited -agencies which provide education, testing, & counseling at an affordable rate to the citizens of Lubbock. The City Health epartment not only tocuses on homosexuals but also heterosexuals, teens, college students, incarcera a persons (both teens and adults), gangs, and high risk pregnant females through outreach activities. 10. For the "Current Year", please identify how expenditures are to be made in the following categories and how the program will be funded. If the grant is for an on -going program, please project revenue and expenditures for future years. If the grant is for one year, show any on -going costs to the City, such as the cost of maintenance on equipment purchased by the grans. CURRENT FUTURE YEARS YEAR 19 19_ 19 19 19 EXPENDITURES Personnel Full Time Salary TMRS Social Security Health Life Dental Supplies Maintenance Other Capital TOTAL EXPENDITURES REVENUE Federal Grant State Grant Local Match Other TOTAL REVENUE $26,396 2,009 1,978 2,245 16 171 50 2,135 $35,000 $35,000 $35,000 11. Please list the number and title (s) of personnel funded by this grant Tammy 1=oskey, , H 1 V Counselor 12. Please list -any new positions to be -added: None GRANT PROPOSAL EVALUATION FORM Page 3 13. Please list any capital items to be purchased: None 14. Please discuss how this program will impact current employee allocation and utilization and whether it will have a long-term financial or manpower impact. Attach additional pages if needed. This TDH Grant does fund one full-time person. If the grant is not renewed this person will not have a position with the City of Lubbock. 15. In narrative form, please provide a brief description of the program, including the need which will be addressed, the goals and objectives of the program, the target population to be served, and any other significant aspects of the application. Attach additional pages if needed. See Attachment FIRST ASSISTANT CITY <`- _9� DATE DA kT DA DATE In the reorganization of the Health Department, several clinics were eliminated and the focus of the Health Department reassessed. Prevention of disease and the spread of disease became one of the major areas targeted by the City of Lubbock Health Department with the approval of the City Council. HIV is a preventable disease and the City of Lubbock plays a critical role in the education and prevention of HIV infection to the citizens of Lubbock through the position of a funded HIV counselor. The counselor works to emphasize the need to take responsibility to protect him/herself from an HIV infection and serves to educate on HIV in an individualized session to specifically address the needs and/or concerns of the person. This is a continuation grant which has been accepted by the City of Lubbock through a contract with the Texas Department of Health for the past six years. State tax dollars are given to the City of Lubbock to be spent to improve the health of the community. The grant allows the City of Lubbock Health Department to provide HIV counseling, testing, referral and partner elicitation through the hiring of one HIV counselor. Funding will not be given to any agency who is not receiving HIV funding for testing currently. The monies will leave the Lubbock community and will be given to another city. HIV has been an on -going health issue for the last ten years and there is no immediate cure or vaccine in sight. The City of Lubbock Health Department serves as an agency that can and does provide HIV testing at a minimal cost, with confidentiality and/or anonymity assured and works closely with other agencies to provide referrals and early intervention to those individuals testing seropositive. Over the past year, (October 1994-October 1995) the City of Lubbock Health Department has provided testing for 1,941 individuals and of those tested, 1,628 returned for posttest counseling (84% return rate). Five individuals tested seropositive. The City of Lubbock Health Department has a very good reputation in the community and continues to be used as a referral source by private physicians and hospitals for services that may not be offered or affordable to many individuals. The central location and/or bus route access to the City of Lubbock Health Department allows for testing of persons at risk for HIV who may not have transportation and/or financial resources. The confidentiality/anonymity that is given to the clients of the City of Lubbock Health Department is crucial to the programs that are offered. There are very few agencies that provide testing and there are many individuals that are uncomfortable at one agency or another; the availability of several testing sites is very important. Testing is made available in the communities through outreach activities to reach those persons who may not seek testing otherwise for various reasons. The HIV counselor will work with various agencies in the Lubbock area to provide continuity of services through collaboration to provide testing after a formal HIV educational presentation (Inside/Out, Texas Tech University Impact Tech, Catholic Family Services). The HIV counselor will also provide testing to the incarcerated female trustees at the Lubbock County Jail and will provide testing at the Lubbock County Youth Center. Testing will continue to be offered on -site at the Health Department and off -site at Texas Tech University's Student Health.. Collaboration with Presbyterian Clinic of the Community Health Center of Lubbock to provide high -risk prenatal testing for HIV in compliance with state laws will begin in November 1995. The HIV counselor will continue to work with the management of the adult theaters/bookstore and gay club to provide preventive materials, testing on -site and/or referral for testing to the City of Lubbock Health Department. The target populations are determined in part by the Texas Department of Health in coordination with the Regional HIV Coalition that works to assess the needs of the community and determines where there is a need for continued work. The target populations for FY96 are: men who have sex with men (adolescents, college -aged, men of color and anglo); injecting drug users (incarcerated, sex workers, homeless); unprotected heterosexual sex (migrants, gangs and female partners of injecting drug users and/or men who have sex with men). There is also a target group, considered to be at risk, but at a significantly lower risk than those listed above. This group will consist of: individuals having more than one sexual partner, individuals with an STD history, persons having unprotected sex (heterosexual) while under the influence of non -injecting drugs (including alcohol), victims of rape, persons experiencing an occupational risk (needlesticks, etc.), women who are pregnant, and others who feel at risk but may be undisclosing of his/her risk. The hope for a cure or vaccine continues, but at this point, will not be a reality for ten or more years. The testing for HIV can be very costly and for those individuals that are the targeted populations the financial resources are limited and the testing would not be sought. The City of Lubbock Health Department serves to help our citizens prevent infections and maintain a healthy lifestyle. The HIV CTRPE program is a vital part of this goal. HfV is a health issue that can result in thousands of dollars in health care costs and can be transmitted to many more during the incubation period (7-10 years average) if testing is not available to determine an infection with HIV before symptoms start to exhibit. Education, prevention, and testing are crucial to help prevent further infections from occurring. If the City of Lubbock is assisting in the prevention of even one infection, then it is important to the citizens of Lubbock. The persons who have tested at the City of Lubbock Health Department are thankful that the City Council has seen the importance of this program and its need.