HomeMy WebLinkAboutResolution - 2023-R0441 - Amendment No. 3, HHSC Contract No. HHS001081400001, SA/Prevention - 09/12/2023Resolution No. 2023-R0441
Item No. 5.36
September 12, 2023
M��1]5111 IL[U�I
BE IT RESOLVED BY THE CITY COUNCIL O�' Ti-iE CTTY O�' LUBBOCK:
THAT the acts of the Mayor of the City of Lubbock in executing, on behalf of the City of
Lubbock, Amendment No. 3 to the Health and Human Scrvices Commission Contract No.
HHS001081400001, under the Substance Abuse Prevention and Behavioral Health Promotion
Grant Program (Sf1/Prevention), by and between the City of Lubbock and the State of Texas'
Health and Human Services Commission, and related documents are hereby ratified in full. Said
Amendment is attached hereto and incorporated in this resolution as if fully set forth herein and
shall be included in the minutes of the City Council.
Passed by the City Council on
September 12, 2023
TRf1�
ATTEST:
Cou ney Paz, City Secreta
APPROVED AS TO CONTEN'1':
��
,�
►
Bill Howerton, Deputy City Manager
: ' 7Z�l�f � : �T�lOT�77T�
iRachael Foster,
City Attorney
RES.HHSC Contract No. HHS001081400001 Amendment No3 Ratification
8.30.23
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
Resolution No. 2023-RO441
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT NO. HHS001081400001
AMENDMENT NO.3
The HEALTH AND HUMAN SERVICES COMMISSION ("HHSC" or "System Agency") and CITY OF
LUBBOCK ("Grantee"), who are collectively referred to herein as the "Parties" to that certain
Substance Abuse Prevention and Behavioral Health Promotion Grant Programs (SA/Prevention)
Contract effective September 1, 2021, and denominated HHSC Contract No. HHS001081400001
("Contract"), as amended, now desire to further amend the Contract.
WHEREAS, the Parties desire to add additional funding in State Fiscal Year ("FY")
2024 to the Community Coalition Partnership-COVID (SA/CCP-COV) and
Prevention Resource Centers (SA/PRC) Programs;
WHEREAS, the Parties desire to replace the following previous attachments: "Revised
Attachment A: Revised General Statement of Work (September 2022)"; "Attachment
A-2: Community Coalition Partnership Statement of Work"; "Attachment A-3:
Prevention Resource Centers Statement of Work"; "Revised Attachment B: Revised
Fiscal Requirements (September 2022)"; "Revised Attachment B-1: Approved
Revised Categorical Budget (September 2022)"; and "Revised Attachment C:
Revised Deliverables and Performance Measures (September 2022)";
WHEREAS, the Parties desire to incorporate a new Federal Funding Accountability
and Transparency Act (FFATA) Certification Form; and
WHEREAS, the Parties desire to update certain Contract terms.
NOW, THEREFORE, the Parties hereby amend the Contract as follows:
ARTICLE IV of the Contract Signature Document, titled "Budget," is hereby
amended to add state FY 2024 state -allotted funding in the amount of $78,571.00. The
HHSC state FY 2024 funding for each Prevention Program, as well as the state FY
Total Contract Value, is documented in the table below:
Program ID
FY 2024 HHSC
Share
FY 2024
Added
funding
FY 2024
Match
FY New Total
Contract Value
SAIYPS
$0.00
$0.00
$0.00
$0.00
SAIYPU
$0.00
$0.00
$0.00
$0.00
SAIYPI
$0.00
$0.00
$0.00
$0.00
SA/CCP
$250,000.00
$0.00
$12,500.00
$262,500.00
SA/CCP-COV
$50,825.00
$53,571.00
$0.00
$104,396.00
SAIPRC
$250,000.00
$25, 000.00
$13, 750.00
$288, 750.00
HHSC Solicitation No. N-A
HHSC Contract No. HHS001081400001
Amendment No. 3
Page I of 4
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
Total 1 $550,825.00 1 $78,571.00 1 $26,250.00 1 $655,646.00
2. Agency Share total reimbursements will not exceed $2,046,978.00 for the period from
September 1, 2021 through August 31, 2024. Fiscal year allocations are documented in
Attachment B, Fiscal Requirements. Grantee is required to contribute a 5% match
requirement, per fiscal year, in accordance with Attachment B. Grantee's budgeted
match requirement for the period from September 1, 2021 through August 31, 2024 is
$76,250.00. The total amount of this Contract including applicable match will not
exceed $2,123,228.00.
3. "REVISED ATTACHMENT A: REVISED GENERAL STATEMENT OF WORK (SEPTEMBER
2022)" is hereby deleted in its entirety and replaced with "ATTACHMENT A: REVISED
GENERAL STATEMENT OF WORK (SEPTEMBER 2023)."
4. "ATTACHMENT A-2: COMMUNITY COALITION PARTNERSHIP STATEMENT OF WORK"
is hereby deleted in its entirety and replaced with "ATTACHMENT A-2: REVISED
COMMUNITY COALITION PARTNERSHIP STATEMENT OF WORK (SEPTEMBER 2023)."
5. "ATTACHMENT A-3: PREVENTION RESOURCE CENTERS STATEMENT OF WORK" is
hereby deleted in its entirety and replaced with "ATTACHMENT A-3: REVISED
PREVENTION RESOURCE CENTER STATEMENT OF WORK (SEPTEMBER 2023)."
6. "REVISED ATTACHMENT B: REVISED FISCAL REQUIREMENTS (SEPTEMBER 2022)" is
hereby deleted in its entirety and replaced with "ATTACHMENT B-2: REVISED FISCAL
REQUIREMENTS (SEPTEMBER 2023)."
7. "REVISED ATTACHMENT B-1: APPROVED REVISED CATEGORICAL BUDGET
(SEPTEMBER 2022)" is hereby deleted in its entirety and replaced with "ATTACHMENT
B-3: APPROVED REVISED CATEGORICAL BUDGET (SEPTEMBER 2023)."
8. "REVISED ATTACHMENT C: REVISED DELIVERABLES AND PERFORMANCE MEASURES
(SEPTEMBER 2022)" is hereby deleted in its entirety and replaced with "ATTACHMENT
C-1: REVISED DELIVERABLES AND PERFORMANCE MEASURES (SEPTEMBER 2023)."
9. "ATTACHMENT 1-2: FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT
(FFATA) CERTIFICATION FORM" is incorporated as part of the Contract and requires
Grantee to complete the Certification Form to meet the federal requirement.
10. The U.S. Health and Services Commission, Substance Abuse and Mental Health Services
Administration (SAMHSA) revised the name of the "Substance Abuse Prevention and
Treatment Block Grant (SABGISAPT)" (assistance listing number 93.959) to the
"Substance Use Prevention, Treatment and Recovery Services (SUPTRS) Block Grant."
Therefore, all references in the executed agreement that reference "SABG" or "SAPT"
are replaced with: "Substance Use Prevention, Treatment and Recovery Services
(SUPTRS) Block Grant."
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
Page 2 of 4
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
11. This Amendment shall be effective on September 1, 2023, provided both Parties have
signed below before then.
12. Except as modified by this Amendment, all terms and conditions of the Contract, as
amended, shall remain in full force and effect.
13. Any further revisions to the Contract shall be by written agreement of the Parties.
SIGNATURE PAGE FOR AMENDMENT NO. 3
HHSC CONTRACT No. HHS001081400001
HEALTH AND HUMAN SERVICES
COMMISSION
By: rDocuSigned by -
so'-tl Gauvxs
Sonja Gaines
Deputy Executive Commissioner
August 30, 2023
Date of Signature:
CITY OF LUBBOCK
Er
cuSigned by:
By: Paul''`'`'
Tray Payne
Mayor
August 30, 2023
Date of Signature:
THE FOLLOWING DOCUMENTS ARE ATTACHED AND INCORPORATED AS PART OF THE
CONTRACT:
• ATTACHMENT A: REVISED GENERAL STATEMENT OF WORK (SEPTEMBER 2023).
• ATTACHMENT A-2: REVISED COMMUNITY COALITION PARTNERSHIP STATEMENT OF
WORK (SEPTEMBER 2023).
• ATTACHMENTA-3: REVISED PREVENTION RESOURCE CENTERS STATEMENT OF WORK
(SEPTEMBER 2023).
• ATTACHMENT B-2: REVISED FISCAL REQUIREMENTS (SEPTEMBER 2023).
• ATTACHMENT B-3: APPROVED REVISED CATEGORICAL BUDGET (SEPTEMBER 2023).
• ATTACHMENT C-1: REVISED DELIVERABLES AND PERFORMANCE MEASURES
(SEPTEMBER 2023).
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
Page 3 of 4
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
• ATTACHMENT I-2: FEDERAL FINANCIAL ACCOUNTING AND TRANSPARENCY ACT
(FFATA) CERTIFICATION FORM.
HHSC Solicitation No. N'A
HHSC Contract No. HHS001081400001
Amendment No. 3
Page 4 of 4
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65780056827E
ATTACHMENT A:
REVISED GENERAL STATEMENT OF WORK
(SEPTEMBER 2023)
I. PURPOSE
A. To provide prevention and behavioral health promotion strategies for programs
referenced in Contract Signature Document. Grantee is required to adhere to the
requirements within the Prevention and Behavioral Health Promotion (PBHP) Program
Guidance document (hereafter referred to as the "Program Guide"):
https:Hhhs.texas. gov/about-hhs/process-improvement/improving-services-
texans/behavioral-health-services/substance-use-misuse-prevention .
II. GOAL
To prevent substance use and misuse and promote behavioral health and wellness in youth,
families, and communities across Texas. Grantees will implement the following strategies
as outlined in the Program Guide:
A. Prevention Education;
B. Information Dissemination;
C. Positive Alternatives;
D. Problem Identification and Referral;
E. Community -Based Processes; and
F. Environmental and Social Policies.
III. GENERAL RESPONSIBILITIES
Grantee shall:
A. Provide prevention services and activities in accordance with the rules in Title 26 of
the Texas Administrative Code (TAC), Chapter 321(A) and as outlined in this
agreement and the Program Guide.
B. Submit Implementation Plans as set forth in Attachment C-1: Revised Deliverables
and Performance Measures (September 2023) for review and approval by System
Agency detailing how all required services and strategies will be implemented
locally. The Implementation Plan virtual forms can be located at the following links:
a. YP Fall Semester (due 9/1);
b. YP Spring Semester (due 1/15);
c. YP Summer Term (due 5/15); and
d. CCP and PRC Annual (due 9/1).
C. Develop policies and procedures as required by 1 TAC § 392.511 and outlined within
the Program Guide, "Policy and Procedures Guidance" and make them available for
inspection by the System Agency.
D. Follow the National Standards for Culturally and Linguistically Appropriate Services
in Health and Health Care (The National CLAS Standards, 2013) and demonstrate
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
1
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
ATTACHMENT A:
REVISED GENERAL STATEMEN OF WORK
(SEPTEMBER 2023)
good -faith efforts to reach out to under -served populations as detailed within the
Program Guide, "Adherence to CLAS Standards."
E. Secure and maintain community agreements with partners that adhere to the Program
Guide, "Community Agreements" (CAs). CAs may include a Memorandum of
Understanding (MOU), a Letter of Agreement (LOA), Memorandum of Agreement
(MOA) or other agreement as approved by System Agency.
F. Appropriate level staff shall participate in System Agency meetings, trainings, and
state -scheduled calls per requirements in the Program Guide, "Required HHS Meetings
and Communication."
G. Submit additional documentation as requested by the System Agency.
H. Post in a prominent location, legible prohibitions against firearms, weapons, alcohol,
and illegal drugs, illegal activities, and violence at program sites that do not have the
existing prohibitions posted.
I. Conduct and document quarterly fidelity and quality assurance checks of all required
activities.
J. System Agency requires all deliverables excluding the CMBHS deliverables be
submitted within the System Agency submission reporting system and/or by email to
the SUD Mailbox: SUD.Contracts@hhs.texas.gov.. Grantee is required to maintain
access to required systems or platforms for the term of this Contract.
IV. STAFFING AND STAFF COMPETENCY REQUIREMENTS
A. Grantee shall designate two media representatives to assist with the statewide media
campaign as described in the Program Guide. Grantee's participation is required.
B. The Prevention Program Director and all other prevention program staff must complete
the general required trainings as specified in the Program Guide, Section General Staff
Training Requirements. All training and certification documentation must be
maintained within the employees' file for System Agency review upon request.
V. CRIMINAL BACKGROUND VERIFICATION REQUIREMENTS
Grantee shall establish and adhere to policies on conducting criminal background checks
of potential employees, volunteers, and/or subcontractors, which at a minimum must
include:
A. A pre -employment criminal background check for any individual that will have direct
contact with youth, families, or other participants;
B. Standards detailing hiring decisions for employees with a background check finding;
and,
C. Requirements for employees to report post -employment instances that would
negatively impact subsequent background checks.
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
2
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
ATTACHMENT A:
REVISED GENERAL STATEMENT OF WORK
(SEPTEMBER 2023)
VI. CONSENT
Grantees are required to obtain consent from participants and their parents/legal guardians
in accordance with applicable laws. This includes obtaining consent for any youth
prevention program services as well as any activities, including Positive Alternatives, that
occur off -site or involve participant travel. Grantee will document consent using a form or
process created by Grantee. Grantee will maintain all relevant consent documentation on
file.
VII. DOCUMENTATION OF STRATEGIES AND SERVICES
Grantee shall utilize the Prevention Activity Tracking Tool (PATT), or other electronic
tools as required by the System Agency, to document prevention activities as outlined in
the Program Guide, "Documentation of Strategies and Services."
VIII. CLINICAL MANAGEMENT FOR BEHAVIORAL HEALTH SERVICES
(CMBHS) COMPONENTS
A. Grantee shall use the CMBHS components/functionality specified below, in
accordance with the System Agency instructions:
1. Request/maintain user access for appropriate staff, (including access control and
credential maintenance);
2. Provider detail;
3. Performance Measures;
4. Financial Status Reports (FSR);
5. Invoices; and
6. Curriculum Outcome Measures (YPS, YPU, and YPI Programs only).
B. Designate a Security Administrator and a back-up Security Administrator. The Security
Administrator is required to implement and maintain a system for management of user
accounts/user roles to ensure that all the CMBHS user accounts are current.
C. Notify the CMBHS Helpdesk within 10 business days of any change to the designated
Security Administrator or the back-up Security Administrator.
D. In addition to CMBHS Helpdesk notification, Grantee shall submit a signed CMBHS
Security Attestation Form and a list of Grantee's employees, contracted laborers and
sub -Grantees authorized to have access to secure data. The CMBHS Security
Attestation Form shall be submitted electronically on or before the 15th day of
September and March 15th, each fiscal year.
E. Establish and maintain a security policy that ensures adequate system security and
protection of confidential information.
F. Ensure that access to CMBHS is restricted to only authorized users. Grantee shall,
within 24 hours, remove access to users who are no longer authorized to have access
to secure data.
G. Attend System Agency training on CMBHS documentation.
HHSC Solicitation No. N A
HHSC Contract No. HHS001081400001
Amendment No. 3
3
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
ATTACHMENT A:
REVISED GENERAL STATEMENT OF WORK
(SEPTEMBER 2023)
H. Use other CMBHS components and meet CMBHS training requirements per request
by the System's Agency. (The use of CMBHS is not limited to the components and
functionality listed above.)
IX. DELIVERABLE AND REPORTING REQUIREMENTS
A. Grantee shall submit all required reports of monitoring activities to System Agency by
the applicable due dates outlined in Attachment C-1: Revised Deliverables and
Performance Measures (September 2023).
B. The following reports must be submitted to System Agency via email to the SUD
Mailbox, SUD.Contracts(ahhs.texas.gov., by the required due dates and report name
described in the Attachment C-1: Revised Deliverables and Performance Measures
(September 2023):
1. In addition to Clinical Management for Behavioral Health Services (CMBHS),
Grantees are required to submit data, reports, performance measures, and any other
requested information into data systems designated by the System Agency.
2. Grantee will notify the System Agency of any staffing changes within ten (10)
business days of a revision using the System Agency process outlined in the
Program Guide.
3. Grantee shall submit a Financial Status Report (FSR) for each awarded program, in
accordance with Attachment B
4. Grantee shall submit a General Ledger for each awarded program to support each
Program's FSR, in accordance with Attachment B
5. Grantee shall submit a FSR to General Ledger Worksheet for each awarded
program, in accordance with Attachment B.
6. Grantee shall submit monthly invoices in Clinical Management for Behavioral
Health Services (CMBHS) for each awarded program, in accordance with
Attachment B.
7. Grantee shall submit annual Contract Closeout documentation for each awarded
program. This documentation is required each fiscal year by October 15th. The
Final Contract Closeout is due 45 days after the contract end date.
8. Grantee shall submit a CMBHS Security Attestation Form twice a fiscal year.
9. Grantee will report the performance measures for the previous month's activities in
CMBHS by the 15th of the current month for each awarded program.
10. Grantee's duty to submit documents will survive the termination or expiration of
this Contract.
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
4
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
X. PERFORMANCE MEASURE DEFINITIONS AND GUIDANCE
A. Grantee shall reference Program Guide, "Performance Measure Definitions and
Guidance," for the YP, PRC, and CCP performance measure definitions and guidance
regarding the data to report.
B. Grantee shall report the performance measures required by each funded program
documented in Revised Attachment C-1: Revised Deliverables and Performance
Measures (September 2023).
C. System Agency will monitor Grantee's performance of the requirements herein, as well
as in Revised Attachment C-1: Revised Deliverables and Performance Measures
(September 2023).
XI. RENEWALS
No renewal options are available for this Contract.
XII. PROCUREMENT INFORMATION
This Contract is awarded from the System Agency's Request for Application No.
HHS0000776, posted on March 11, 2019. Grantee is awarded the following contracts as a
result of the RFA:
Fiscal Year
Program
Contract Number
Y2020-2021
SA/Prevention
HHSOO1081400001
Y2022-2024
SA/Prevention
HHSOO1081400001
XIII. GRANTEE INFORMATION
Grantee TIN:
17560005906
Contract Determination:
Subrecipient
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
5
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
Payment Method: Cost Reimbursement
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
ATTACHMENTA-2:
REVISED COMMUNITY COALITION PARTNERSHIP
STATEMENT OF WORK
(SEPTEMBER 2023)
I. PURPOSE
The purpose of the Community Coalition Partnership (CCP) is to mobilize the community
to implement evidence -based environmental strategies related to substance use and misuse
prevention and behavioral health promotion. Grantee may take an approach that addresses
the Social Determinants of Health with an effort to produce outcomes that change policies
and influence social norms.
II. GOALS
A. To increase citizen participation and commitment among all sectors of the community
towards reducing substance use and misuse and promoting behavioral health.
B. To create community environments that foster behavioral health and wellness and
address environmental factors that lead to substance use and misuse.
C. To increase community awareness regarding substance use and misuse through the
dissemination of information through community -based processes that includes
presentations, media campaigns, and other distribution networks.
III. SERVICE AREA
A. Grantee shall provide services and focus CCP strategies in the counties (service area)
listed below, as approved by System Agency:
Region: 1
Counties: Armstrong Bailey Briscoe Carson Castro Childress Cochran Collingsworth
Crosby Dallam Deaf Smith Dickens Donley Floyd Garza Gray Hale Hall Hansford
Hartley Hemphill Hockley Hutchinson King Lamb Lipscomb Lubbock Lynn
Moore Motley Ochiltree Oldham Parmer Potter Randall Roberts Sherman Swisher
Terry Wheller Yoakum
B. Grantee may request to add and/or delete counties referenced in Section III (A);
however, all requests for additional counties must be within the same region. The
counties per HHS region are documented at the following link:
https://hhs.texas.gov/sites/default files/documents/about-hhs/hhs-regional-map.pdf
C. Grantee's request to revise the service area shall comply with the following
requirements:
1. Submit email requests to the assigned contract manager and the SA Mailbox,
SUD.Contracts(@hhs.texas.gov.
2. The requests must include the following information:
a. Legal Entity Name;
b. Contract number;
c. Program ID;
d. Current service area;
e. Revised service area;
HHSC Solicitation No. N A
HHSC Contract No. HHS001081400001
Amendment No. 3
1
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
ATTACHMENTA-2:
REVISED COMMUNITY COALITION PARTNERSHIP
STATEMENT OF WORK
(SEPTEMBER 2023)
f. Justification for service area change.
D. System Agency may revise the Service area in accordance with Attachment F: HHSC
Additional Provisions, Section 4. Miscellaneous Provisions, A. Minor Administrative
Changes. All revisions to the service area are considered a minor administrative change
and do not require an amendment. System Agency shall provide a written notification
to document revisions to the service area.
IV. TARGET POPULATION
The coalition's sector representation should strategically align with the targeted strategies
as outlined in the Program Guide, https:Hhhs.texas.gov/about-hhs/process-
improvement/improving-services-texans/behavioral-health-services/substance-use-
misuse-prevention.
The CCP should implement strategies to enhance outcomes for the following populations:
A. The primary population is adolescents (ages 12-17) and young adults (ages 18-25)
within the approved service area.
B. The secondary population is the general population across the lifespan within the
approved service area.
V. GRANTEE RESPONSIBILITIES
Grantee shall:
A. Conduct prevention services and activities through the operation of one or
more coalition(s) that utilize(s) the Strategic Prevention Framework (SPF) process as
a guide.
B. Implement the combination of Center for Substance Abuse Prevention (CSAP)
strategies identified in the Program Guide including: information
dissemination, alternative activities; community -based processes; and environmental
strategies to shift related policies, practices, norms and community conditions.
C. Develop, implement, and maintain a policy to reflect the CCP coalition's cultural
competency efforts; maintain current policies and procedures and make them
available for System Agency review upon request.
D. Document application of CLAS (Culturally and Linguistically Appropriate
Services) standards by completing the CLAS section of the Quarterly Reporting
form.
E. Collaborate with the PRCs (Prevention Resource Centers) on Tobacco Retail
Education endeavors as needed to prevent tobacco use.
F. Use supplemental block grant funds awarded to address the negative impact of
COVID-19 on behavioral health, in accordance with the guidance provided by
System Agency in the Program Guide. The COVID-19 funding will be managed
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
2
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
ATTACHMENTA-2:
REVISED COMMUNITY COALITION PARTNERSHIP
STATEMENT OF WORK
(SEPTEMBER 2023)
under the Program ID (CCP-COV) and require separate invoicing and FSR
submissions. At minimum, Grantee shall:
1. Develop and implement community -wide activities that reduce stress, address
trauma, or promote behavioral health and wellness;
2. Develop and implement projects that change physical environment, build
community resilience, or improve systemic processes to enhance behavioral health
and wellness;
3. Document strategies as documented above in Section V. (F 1-2) in the
Implementation Plan for review and approval by System Agency. Grantee will not
implement strategies prior to receiving System Agency approval. Any changes to
strategies will be submitted to System Agency and approved in the Implementation
Plan prior to implementation;
4. Use data to prioritize strategies as documented above in Section V. (F 1-2), detailed
in Program Guide, "COVID-19 Supplemental Funding Guidance";
5. Prioritize behavioral health equity; and
6. Focus services and resources in areas disproportionately impacted by COVID-19.
G. All proposed strategies must be approved by System Agency prior to implementation
and documented in the Implementation Plan.
VI. POLICY/PROCEDURAL REQUIREMENTS
Grantee shall:
A. Operate in accordance with the rules in Title 26 of the Texas Administrative Code
(TAC), Chapter 321
(https:Htexrep-.sos.state.tx.us/public/readtac$ext.ViewTAC?tac view 4&ti 26&12t 1
&ch=321).
B. Ensure all program staff for this contract shall be registered with and have access to
the CCP forum. Staff must request access using procedures outlined in the Program
Guide, "Community Coalition Partnership Program Specific Staffing Requirements".
C. Follow the submission schedule and reporting requirements detailed in Attachment
C-1: Revised Deliverables and Performance Measures (September 2023).
D. Submit required reports to System Agency by the applicable due dates outlined in
Attachment C-1: Revised Deliverables and Performance Measures (September
2023).
E. If the due date for all required deliverables is on a weekend or holiday, the due date is
the following business day.
VII. COMMUNITY COALITION PARTNERSHIP STAFFING REQUIREMENTS
A. In addition to the staffing requirements outlined in the Attachment A-4: Revised
General Statement of Work (September 2023), Community Coalition Partnership
Programs must:
HHSC Solicitation No. N A
HHSC Contract No. HHS001081400001
Amendment No. 3
3
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
ATTACHMENTA-2:
REVISED COMMUNITY COALITION PARTNERSHIP
STATEMENT OF WORK
(SEPTEMBER 2023)
1. Employ a minimum of one Program Director at .25 Full -Time Equivalent (FTE)
per coalition funded.
2. Employ a minimum of one Coalition Coordinator at 1.0 FTE per coalition
funded.
B. CCP staff shall receive coalition competency training as outlined in the Program
Guide.
VIII. PERFORMANCE MEASURES
Grantee shall report in CMBHS all required performance measures documented on
Attachment C-1: Revised Deliverables and Performance Measures (September
2023). Grantee shall ensure all performance measures are submitted by the due date.
IX. DELIVERABLE AND REPORTING REQUIREMENTS
A. Grantee shall submit the CCP program report/deliverables in accordance with
Attachment C-1: Revised Deliverables and Performance Measures (September
2023).
B. The CCP program deliverables described above are as follows:
1. Quarterly Reports: Using approved System Agency template, the Grantee will
document accomplishments and barriers during the implementation of
programmatic activities.
C. The CCP-COV program deliverables described above are as follows:
1. Quarterly Reports: Using approved System Agency template, the Grantee will
document accomplishments, barriers, and evaluation strategies during the
implementation of programmatic activities and projects for the CCP-COV
programs.
2. CCP-COV Final Projects Report: Using approved System Agency template,
the Grantee will provide a summative description and evaluation of the CCP-
COV environmental and systemic change projects and stress -reducing and
trauma -healing activities to be completed by the end of FY24 (August 31, 2024).
The number of required environmental and systemic change projects by the end
of the funding period is a minimum of 3 per coalition receiving CCP-COV
funding.
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
4
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
ATTACIIMENTA-3:
REVISED PREVENTION RESOURCE CENTERS
STATEMENT OF WORK
(SEPTEMBER 2023)
I. PURPOSE
The purpose of the Prevention Resource Centers (PRCs) is to increase the capacity of the
statewide substance misuse prevention system. PRC services seek to enhance community
collaboration, increase community awareness and readiness, provide information and
resources on substance use and related behavioral health data, and support professional
development of the prevention workforce, and strengthen regional compliance with tobacco
and nicotine laws.
II. GOALS
A. To maintain and serve as the primary resource for substance use and related
behavioral health data for the region.
B. To build the prevention workforce capacity through technical support and coordination
of prevention trainings.
C. To increase community awareness of substance use and misuse and the broader social
determinants that impact behavioral health by disseminating information across a wide
variety of media outlets and distribution networks.
D. To strengthen compliance with existing laws on the sale of tobacco and nicotine
products to minors through education and monitoring activities.
III. SERVICE AREA
A. Grantee shall provide services and focus PRC strategies in the counties (service area)
listed below, as approved by System Agency:
Region: 1
Counties: Hockley, Lubbock
B. Grantee may request to add and/or delete counties referenced in Section III (A);
however, all requests for additional counties must be within the same region. The
counties per HHS region are documented at the following link:
https:Hhhs.texas.gov/sites/default/files/documents-about-hhs hhs-regional-map.pdf
C. Grantee's request to revise the service area shall comply with the following
requirements:
1. Submit email requests to the assigned contract manager and the SUD Mailbox,
SUD.Contracts@hhs.texas. go
2. The requests must include the following information:
a. Legal Entity Name;
b. Contract number;
c. Program ID;
d. Current service area;
e. Revised service area;
f. Justification for service area change.
E. System Agency may revise the service area in accordance with Attachment F:
HHSC Additional Provisions, Section 4. Miscellaneous Provisions, A. Minor
HHSC Solicitation No. N A
HHSC Contract No. HHS001081400001
Amendment No. 3
1
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
Administrative Changes. All revisions to the service area are considered a minor
administrative change and do not require an amendment. System Agency shall
provide a written notification to the service area.
IV. TARGET POPULATION
A. The primary target population is all System Agency -funded substance misuse
prevention providers in the region.
B. The target population may also include school administrators and teachers, community
groups and coalitions, education services centers (ESCs), local mental health
authorities (LMHAs), substance use disorder intervention and treatment organizations,
law enforcement, healthcare entities, healthcare providers, pharmaceutical entities that
hold information about substance use or prescription medication, tobacco retailers,
higher education institutions, and community stakeholders including youth, young
adults, parents, and residents in Texas.
V. GRANTEE RESPONSIBILITIES
Grantee shall:
A. Conduct prevention services and activities in accordance with the rules in Title 26 of
the Texas Administrative Code JAC), Chapter 321(A);
B. Implement Center for Substance Abuse Prevention (CSAP) Strategies associated with
each PRC core function outlined in the Program Guide, Section V "Required
Frameworks/Models. The Program guide can be found at the following site:
littps:Hhhs.texas.gov/about-hhs/process-improvement/improving-servicestexans/
behavioral-health-services/substance-use-misuse-prevention.
VI. PRC CORE FUNCTIONS
A. Data Resource Coordination (Data Core)
A goal of each Prevention Resource Center (PRC) is to maintain and serve as the primary
resource for substance use and related behavioral health data for the region. This includes
collecting, analyzing, and synthesizing data for local needs assessments and sharing data
with other funded prevention programs and community members at large as detailed in the
Program Guide. Grantee will also develop and maintain a Regional Epidemiological
Workgroup (REW) and develop a Regional Needs Assessment as outlined in the Program
Guide.
B. Training and Professional Development Coordination (Training Core)
A goal of the PRC Training Core is to build the prevention workforce capacity through
technical support and coordination of prevention trainings. This goal will be addressed
through the implementation of the CSAP strategy of Community -Based Processes, which
is designed to enhance the ability of the community to more effectively provide prevention
services. Grantee will conduct and document activities within the PRC Training Core in
accordance with requirements in the Program Guide. This includes but is not limited to
working with the System Agency -funded training entity and other community -based
organizations to: host trainings; identify training locations; and promote/coordinate
regional trainings.
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
2
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
C. Media Awareness Activities Coordination (Media Core)
A goal of each Prevention Resource Center (PRC) is to increase awareness of the
community regarding substance use and misuse through Media Awareness Activities.
Media Awareness Activities are marketing efforts that serve the target population. As part
of this requirement, grantees will implement strategies as outlined in the Program Guide,
including but not limited to: developing messaging; promoting messaging; maintaining
social media accounts; and participating in the Statewide Media Campaign.
D. Tobacco -Specific Prevention Activities Coordination (Tobacco Prevention Core)
A goal of the PRCs is to strengthen compliance with existing laws on the sale of tobacco
and nicotine products to minors through education and monitoring activities. This will be
conducted in accordance to the Program Guide including but not limited to: conducting onsite,
voluntary checks with tobacco retailers to assess compliance with tobacco laws;
providing education to tobacco retailers in the region; and conducting follow-up visits for
retailers with tobacco -related violations.
Grantees that accepted the additional HR133 expansion funds to assist with tobacco
enforcement in Texas must track the number of compliance checks completed using the
additional funds. The increase in performance measures related to the HR133 expansion are
specifically for FY24 Quarter I and II. Grantee may review the base performance measures in
Attachment C-1: Revised Deliverables and Performance Measures (September 2023) to
determine the performance measure increase. These funds must only be used for tobacco
compliance checks and tobacco compliance check -related expenditures such as:
1. increase in staffing and/or personnel costs, specifically conducting tobacco compliance
checks;
2. conducting onsite, voluntary checks with tobacco retailers to assess compliance with
tobacco laws; and
3. providing education to tobacco retailers in the region; and conducting follow-up visits for
retailers with tobacco -related violations.
VII. POLICY/PROCEDURAL REQUIREMENTS
Grantee shall:
A. Submit required reports of monitoring activities for PRC program to System Agency
by the applicable due dates outlined in Attachment C-1: Revised Deliverables and
Performance Measures (September 2023).
B. Designate the number of Media Representatives described in the Program Guide.
C. Register for and maintain access to the PRC forum in accordance with the Program
Guide "Required HHS Meetings and Communications". Staff must request access
using procedures outlined by the System Agency.
VIII. DELIVERABLE AND REPORTING REQUIREMENTS
A. Grantee shall submit all PRC reports/deliverables by the due dates, in accordance with
Attachment C-1: Revised Deliverables and Performance Measures (September 2023).
B. The PRC program deliverables described above are as follows:
1. Mid -year Report: In this report, the Grantee indicates their progress toward their
fiscal year performance measures and other goals, provide reasons for any
HHSC Solicitation No. N A
HHSC Contract No. HHS001081400001
Amendment No. 3
3
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65760056827E
difficulties in reaching targets, and describe successes and challenges faced.
2. Regional Needs Assessment: Using a template developed by the System Agency
in consultation with the PRCs, the Grantee shall collect, present, and analyze
primary and secondary data relevant to prevention and behavioral health
promotion.
3. Post Regional Needs Assessment to website: The Grantee will post a PDF of their
completed Regional Needs Assessment to their organization's website.
IX. PRC STAFFING REQUIREMENTS
A. In addition to the staffing requirements outlined in Attachment A-4: Revised General
Statement of Work (September 2023), PRC Programs must employ a:
I . Program Director at a minimum of .50 Full -Time Equivalent (FTE) to oversee
program and ensure compliance with implementation requirements.
2. Data Coordinator, at a minimum of 1 FTE, who will conduct prevention program
services focused on the Data Core requirements of this Contract.
3. Public Relations Coordinator, at a minimum of I FTE, who will conduct prevention
program services focused on the Media and Training Prevention Core requirements
of this Contract.
4. Tobacco Prevention Coordinator, at a minimum of I FTE, who will conduct
prevention program services focused on the Tobacco Prevention Core
requirements of this Contract.
B. PRC staff shall complete prevention resource training(s) and tobacco law training
outlined in the Program Guide "Prevention Resource Center Specific Staff Training
Requirements". Grantee shall ensure the trainings are held within the timeframes
documented in the Program guide.
X. PERFORMANCE MEASURES
A. Grantee's performance will be measured in part on the achievement of the PRC
Program performance measures.
B. Grantee shall report these performance measures monthly through CMBHS under the
Measures component.
C. The PRC program Performance Measures can be referenced in Attachment C-1:
Revised Deliverables and Performance Measures (September 2023).
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
4
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827ET -HMENT B-2:
REVISED FISCAL REQUIREMENTS
(SEPTEMBER 2023)
Grantee shall ensure compliance to the fiscal requirements of the Contract, as follows:
A. Contract is funded from the United States Health & Humans Services (HHS), Substance
Abuse and Mental Health Services Administration (SAMSHA), Substance Use
Prevention, Treatment and Recovery Services (SUPTRS), Assistance Listing Number
(ALN) 93.959.
B. Compliance with the following Code of Federal Regulation (CFR):
1. SUPTRS Block Grant: 45 CFR Part 96, Subpart C, link: 45 CFR Part 96.
2. Federal Uniform Grant Guidance for Title 2, Grants and Agreements, Subtitle A. Office
of Management and Budget Guidance for Grant and Agreements, Chapter II Office of
Management and Budget Guidance, Part 200 Uniform Administrative Requirements,
Cost Principles, and Audit Requirements for Federal Awards for , link:
https://www.hhs.texas.gov/business/grants/federal-uniform rg ant -guidance
C. Compliance with the following Grant requirements, located at System Agency's website:
https://www.hhs.texas.gov/business/ rg ants
1. Federal Funding Accountability and Transparency Act Reporting Requirements.
2. Indirect Cost Rates.
D. Compliance with Texas Grant Management Standards, located at Texas Comptroller of
Public Accounts, link: https:Hcomptroller.texas.gov purchasing/grant-management
E. Access the Transactions List report in CMBHS to identify the amount of federal funds
allocated to this award for each transaction.
F. Grantee is required to contribute five (50 0) percent matching of funds. However, the CCP-
COV Program is funded by COVID-19 supplemental funding, which does not require a
matching of funds.
G. Any unexpended balance associated with any other System Agency -funded contract may
not be applied to this Contract.
H. Invoice and Payment requirements:
1. Grantee shall submit monthly invoices to the System Agency utilizing CMBHS.
Monthly invoices are required for all Programs awarded funding by the 151h of the
month.
HHSC Solicitation No. N A
HHSC Contract No. HHS001081400001
Amendment No. 3
1
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E— -HMENT B-2:
REVISED FISCAL REQUIREMENTS
(SEPTEMBER 2023)
2. After the closure of each Fiscal Year documented in Article IV., BUDGET, of the
Contract Signature Page and/or executed amendments, System Agency shall
conduct contract close-out activities. Grantee shall ensure all invoices for all Programs
awarded funding, for each year (September — August) are submitted in CMBHS by
October 15th. Invoices submitted after October 15th may be denied.
3. All invoices for September service period for all Programs awarded funding must be
submitted by October 15th. The invoices submitted after this date may be denied due
to the grant budget period being closed.
4. System Agency may request additional supportive documentation to support the
invoices. All requests for additional information shall be provided by the deadline
requested.
Funding:
1. System Agency's share of total reimbursements is not to exceed $2,046,978.00 for the
Contract term of September 01, 2020 through August 31, 2025.
2. The required Grantee match for the same period is $76,250.00. Grantee is required to
contribute five percent matching of funds.
J. The Cost Reimbursement Budget:
1. The Attachment B-3: Approved Revised Categorical Budget (September 2023)
documents all approved and allowable expenditures and is incorporated into the
Contract. Grantee shall only utilize the funding detailed in Attachment B-3: Approved
Revised Categorical Budget (September 2023) for approved and allowable costs.
2. If needed, Grantee may revise Attachment B-3: Approved Revised Categorical
Budget (September 2023), which documents the approved budget for each allocated
Program. The requirements for each allocated Program are as follows:
a. Grantee may transfer funds from the budgeted direct categories only, with the
exception of the Equipment Category. Grantee may transfer up to twenty-five
(2 5 %) percent of the allocated fiscal year Program amount without System Agency
approval. Budget revisions exceeding the ten percent requirement require System
Agency's written approval.
b. Grantee may request revisions to the approved Cost Reimbursement budgeted
direct categories that exceed the twenty-five (25%) percent requirement stated in
Attachment B-3: Approved Revised Categorical Budget (September 2023),
excluding "Equipment" and/or "Indirect Cost" categories, by submitting a written
request to the assigned contract manager. This change is considered a minor
administrative change and does not require an amendment, in accordance with
Section 4.A. ("Minor Administrative Changes") of Attachment F: HHSC
Additional Provisions. System Agency will provide written notification of the
approval or denial of the request. The budget revisions are not authorized, and funds
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
2
DocuSign Envelope ID: 78831D41-219C4557-A8A9-657B0056827ET 'HMENT B-2:
REVISED FISCAL REQUIREMENTS
(SEPTEMBER 2023)
cannot be utilized until Grantee receives written approval.
c. Grantee may request transferring funds between awarded Programs by submitting
a written request to the assigned Contract Manager. This change is considered a
minor administrative change and does not require an amendment, in accordance
with Section 4.A. ("Minor Administrative Changes") of Attachment F: IIHSC
Additional Provisions. System Agency will provide written notification of the
approval or denial of the request. The budget revisions are not authorized, and
funds cannot be utilized until Grantee receives written approval.
d. Grantee may revise the Cost Reimbursement budget `Equipment' and/or `Indirect
Cost' categories, however a formal Amendment is required. Grantee shall submit
to the assigned contract manager a written request to revise the budget, which
includes a justification for the revisions. The assigned Contract Manager shall
provide written notification stating if the requested revision is approved. If the
revision is approved, the budget revision is not authorized, and funds cannot be
utilized until the Amendment is executed and signed by both parties.
3. The budgeted indirect cost amount is provisional and subject to change. The System
Agency reserves the right to negotiate Grantee's indirect cost amount, which may
require Grantee to provide additional supporting documentation to the assigned
contract manager.
K. Budget Program Adjustment Requests Requirements
Grantee may request revisions to the approved categorical budget by completing a
Budget Program Adjustment (BPA) Form and submitting to the System Agency
Contract Manager and the SUD Mailbox at SUD.ContractsRmhhs.texas.gov or the
System Agency required submission system location.
2. The types of BPA revisions Grantee may request are:
a. Budget changes for direct categories that exceed the allowable variance.
b. Budget changes to the indirect cost categories, in compliance with the System
Agency approved rate.
c. Budget changes to the direct category, Equipment.
d. Requesting additional funding.
e. Request to transfer funding between awarded Programs.
System Agency will review the request to determine if the request is allowable under
the RFA, if applicable, and if the request is approved or denied. The estimated timeline
for System Agency to review and provide written communication on the results of the
BPA request is 30 days from receiving an accepted form.
4. Each Fiscal Year (FY), the deadline to submit BPA's is March 1"t
L. Financial Status Report Requirements
HHSC Solicitation No. N A
HHSC Contract No. HHS001081400001
Amendment No. 3
3
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65780056827ET -HMENT B-2:
REVISED FISCAL REQUIREMENTS
(SEPTEMBER 2023)
Grantee shall submit quarterly Financial Status Report (FSR) in CMBHS to document
all expenditures, for each Program ID referenced in the Contract Signature Page. The
Reports shall be submitted by the due date documented in Attachment C-1: Revised
Deliverables and Performance Measures (September 2023).
2. Grantee shall submit the following supportive documentation for each quarterly FSR.
The documentation shall be submitted by the due date and submission system
documented in Attachment C-1: Revised Deliverables and Performance Measures
(September 2023).
a. General Ledger: The general ledger that documents all expenditures to support the
data reported in the FSR.
b. General Ledger Worksheet: The worksheet shall provide an analysis of the General
Ledger by documenting the expenses into the categorial budget category. The
Worksheet shall be completed on the System Agency template.
HHSC Solicitation No. NIA
HHSC Contract No. HHS001081400001
Amendment No. 3
4
DocuSign Envelope ID 78831D41-219C-4557-A8A9.657B0056827E
ATTACHMENT B-3
APPROVED CATEGORICAL BUDGET
Organization Name:
Contract Number:
Prevention Program(s) Contracted to Provide:
Total Contract Value (System
Date Submitted to HHSC:
Master Budget Roll -Up
Budget Categories
System Agency Funds
Requested
Cash Match
Non System Agency
funds
Category Total
Personnel
$286,536.00
$0.00
$0.00
$286,636.00
Fringe Benefits
$97,004.00
$0.00
$0.00
$97,004.00
Travel
$48,900.00
$0.00
$0.00
$48,900.00
Equipment
$0.00
$0.00
$0.00
$0.00
Supplies
$17,455.00
$0.00
$0.00
$17,465.00
Contractual
$122,600.00
$0.00
$0.00
$122,600.00
Other
$56,901.00
$26,250.00
$0.00
$83,151.00
Total Direct Costs
$629,396.00
$26,250.00
$0.00
$655,646.00
Indirect Costs
$0.00
$0.00
$0.00
$0.00
Totals
$629,396.00
$26,250.00
$0.00
$656,646.00
Subcontracting
Subcontracting Percentage 18.7%
DoouSign Envelope ID 78831041-219C-4557-A8A9.65780056827E
Match Contributions
Program Income
ATTACHMENT B-1
APPROVED CATEGORICAL BUDGET
Required Match Percentage: 5% I Calculated Match Percentage: 4%
Required Match Amount: I $ 31,469.80 I Calculated Match Amount: $ 26,250.00
Source of Cash Match Funds
e Health Department will cover the cost of office space, IT services, and telephone services as the cash
support this contract.
Match Funds
Projected Earnings
Source or
CCP PROGRAM
Budget Summary Detail
Budget Categories
Systemmequestad
Fundspenonral
Cash Match
MdOnd
CalsgorY Tobd
$ 112,6e9 00
$
$ 112,60.00
Fringe B..Ift
S 42,643.00
$
S 42".00
Trawl
$ 33,99C.00
$
$ 33,9100.00
E9ulpm
$
$
$
Supplies
3 1.455.00
$
$ IASSA0
Contractual
$ 45.600.00
$
S 4SA .00
Other
$ 13,023.00
S 12,600.00
$
$ 26,123.00
TOW Direct Coals
$ 250,000.00
$ 12,600.00
t
S 262,Sgo.00
brdhset costa
$
$
$
TotM.
S 250,000A0
$ 12.M.0
S
S 262,100
Organization Name: Clry of Lubbock Neagh Department
Contract Number: l01S001081400001
Fiscal Year: 2021-2024
\
\
\
\
\
\
\
\
\
\
\
\
\
|
|
|
fit
2|�
`|
|
!
�
�
_
.
|
��|||
■
�■�
�
■
,
,
!
!
|
|
|
�
|
|
r
�
|
�
|
|
� �
Fringe Benefits
Enter aW-U. p.—ntgea .en ameiav
Total Fmge Bereft %
a Total Fmge S—MS S
Fringe BamM Nrnpregs
Cesn. S u MS.gO
N NnO Mrim S
Fmge Sen.%Tend S
|
k
|!
|
!
■
�
§
K
k
k
k
!
|!
�
�
|
■
■
\
§
|
f
k
|
k
k
k
k
k
!!
!|
!
||
|
|
k
|
!
■
B
B
`
|
■
■
|!
#!-!
■.
■
|
�
|
|
|
|
§
|
|
MDUP
RdWwuasmdn Rat.
NuM nr of Mbs
MSaaya Cost
Otlwrmb C
F-04M Soup
Tow Coal
f
IS
f
t
$
f
f
t
f
f
f
i
s
t
Total Syabm ASOWcy Fulls or Cash Malty for Oewr/Local TraW
S
Tom IoKWAf r CKIW ILocal TraW
t
TOW for Othm I local TraW
i
Can Taw s u,poAt
In Kwn Mst. Tow i
Tow Tr.W Co.. s u.ttom
Daaea"- of llam
Pp— S AwUScatlaW
NWanbar of Nib
Cast Psr Udt
FWn"Souu
Told Coat
f
i
t
f
Sybwmllpsncy FWmOs or Cah Match T
t
A K6w Match
t
TOW knout RaaocYM br
f
!
�.
2
2
\-\
|
��|
���
���
!
§|
�
|
�
f
|
|
-
|
�|
`|
■�
�|�
�!|
!
��
|
.
�
|
|
�.�
�
|
■
|
.
�
�
■
|
|
�
|I
||
|
|||
!|.
|��
|||
�
,
I
|
|
!
�
|
f
|
|
|
�
�
�
�
�
�
�
f
|
!
,
|
�
�
�
��
|
|
|
�
§
�||
q�
�
�
�
h
;�
��!
�
�
|
�`�
'
� ���
�
�
��
�
�
�
� |
`
��
{
�
�|
�
� �
�
`
|
�
|§
|�
�
� $
q
||
|
�
�
{
q
�
��
q
`
|
�
�
|
�
�
|�
�
|
|
�
�|
||
|�
|
i
||
,
`
||
|�
�
|
|
�
�
�!
2
��
|�
|�
|�
|�
|�
|�
|�
�
�
�
�
d
�
�
|
|
�
|
|
�
■
�
�
aped A—ft wW92
OoverraronW Enity Using a Central Service Cost Rate or Indirect Cost Rate
The organisation's curet Central Service Cost Rate or kldkM Cart Rate based on a rate proposal prepared In accordance with OMS Clrc W r A.A. Attach copy of approved Refs Agreement or
Certification of Cost Allocation Plan of Certification of Indeed Costs. Chy and Coady Dovefraftens vAN a Central Sdvke Cost Rate should also compW, the'Ooveffenend and Non Go—refrenah
Entlry Using a Narrah" Cod Allocation Plan' section Im On Indeed Code of the ChysCounty Deparomn (e.g. Haaph Defsartrnerd) thet System Agency U eonrscling with.
Rate
Type of Cods Included In the Rate
Non Gowan mW Entity Using I nt r et Cop Rats
The wganWMm's mM twcent IndkM cost role approved by a federal cognUam agency or pals AnpM audit coordmdWq owncy. Espked fps agroornems age not acceptable. Anach a copy of me rags ogrocarat to
this form.
Symem Agency Fools or Cask Notch:
IMUnd:�
Total Indirect Costs:
CCP-COV PROGRAM
Budget Summary Detail
Budget Categories
System roams
Funds Requestsd
Cash Match
IMUnd
Category Total
Personnel
$ 23,118.00
$
S 23,118.00
Fringe Benefits
$
$
f
TnW
$
$
f
Equlpm rd
S
S
S
Supplies
$ 18,0D0.00
S
S 16,000A0
Contractual
$ 47,000.00
$
f 47,000.00
Other
S 18.278.00
$
s 18,278.00
Total Dbect Costs
$ 104,396.00
$
$
f 104,398.00
Indirect Costa
$
S
f
Totals
S 1o4,39f.00
S
$
S 10639 .
Organization Name: City of Lubbock Neafh Department
Contract Number: l01S001081400001
Fiscal Year: 2021-2024
F..GbATft
AutlOcstlon
TOW FTCS
TOW Avg
MM1Sy
StlryN7+0O
Nwnbw of
monft
Fudhq Soap
SMMT)NhbOs
R"U WW br
Projw
Now HkW Ub (PMIQM)
PSRtbr POW to MM%MMWW*OrateWa&*Wh.mootMM FmMbn MkWWWftVmWWb1M HEARD Md WL
OS
f 3,80.00
12
SY�Y
FMW aCSM
MMN
i 27,1/SA0
f
f
i
f
i
i
f
i
i
f
f
f
f
i
i
SytRanAgrry Fatlsa Cash MON TOM
f 23,11SAf
M KMd RUtch TOM
f
SWry Shp TOW
f 23,11fAf
Fringe Benefits
Ent.r either the p—map w cash amount
Total Frnp Banal. %
a Total Fmp Boner. $
Frogs Banatlt A,—ts
t:aah r
M 1(srtl Match 1 a
Fmp BMafns Total . It
Travel Category Detail
/ndlute Poky used p
OrganknO n s Tnvd Poky - - krekd, b.vd poky in r.mwd r.spom. If uMV ory.drau Ws navel poky
SwofT. MvdPoky
C.,ft c.I Wortukop Tr.vd Costs
Cords—sivootdop
J�Mkatkn
��
Num4a ofDaye
Nay
m cm
AMe.
MMab
iod03q
phr Wets
FurdYp 3ouco
TOW
i
1
i
t
i
f
i
/
t
Totd Sytstsrn ApsmyFurdsal Cady MMMtfar Confm of VJwksI
/
Totdkr Wrd Mddrfor Ccn% s/1Wrkdgp
i
Totdfar Ccs*—o/Nbrbk Tm
i
AralMoalbn
MN-P
Nm*w of Miles
MOMP Cop
WMr COW
FY,ftgieup
ToWC.9
Travolwossr.nounfor-W aaltlNtssaWpbtNq
Scu
tICO
f MM.00i
SfS.nO
It
i
f
i
S
S
f
i
f
f
f
S
Total SysWn Apsncy Funds or Cash Ms" for OdwI Local Tn
i
T.4"O"'bM for Oliver I Lootl!!
i
Total far Othar/Local Tra
i
Caen Taal S
In Kind Match Tow i
Total Traval Costs i
Equipment Category Detail
Dascs"ch of Rom
Poll—t.nnafrauan
Nunara Onits
Cost Far unit
FuMYq Sara
Told Cost
s
s
s
s
SyMptnADateyF-ft.CaenMWnT
S
to Kral MOWiT
t
ToWArc-"RogaWAb
S
!
!.
k
k
.
|
/.�
|
�
|�
��|
��|
�
�
�
�
�
!-
h
�|
!,
�
||
��|
�
�
|
|
.
�|||
��f�
�| $$�
||�
|�|!,
|I|||f
#
|
|
I
I
|
■
|
�
�
!
|
i
�
|
`
■
|
|
/|
t
|
`
�»
!
�
!
||�|
|�|
� I|
�t�||
|�
|I
■|�!|
|�
�
!
! z
�
|
||
■
�
�
|
§
|
!
�
!
�
|
.
|
.
�
.
�
��|�|�|�|
I
�
�
�
�
|
i
|
�
i
�
|
!
|
|
�
�
|
�
�
m/ VMV-&M IOW PWl
waw wa w
qww qRo. •pad lwMl WnW2
Governmental Entry UWW a Cenral Service Cost Rate or Indirect Coal Rate
The organution's currant Central Service Cog Rate or eneeat Cop Rate based on a rare proposal prepared In accordance with OMB Circular A47. Attech copy of approved Rate Agreenrnl or
Undkalbn of Cost Allocation Plan or Cernkalbn of Indirect Costs. nnrm Cos. City and County Oovens edth a General Service Cog Rate alnnnd also compNN al the and mW Non Ooverren
Entity Useng a NenaUve Cog Allocation Plan' section for tM InCtrect cogs ofthe CAyX*u,%y Deperenen (e.g. NeaM Departrmnt) that System Agency is co eractIg wML
Rare
Type of Cogs Included In the Real,
Non Governmental Entity Using Indirect CO. Rea.
TM mg+hicealen's most recent In,11— Cost rMe approved by. lederea Coghiant agency or stare single eodh Coordinating agency. Expend me agreements ate not aeeepMWe. Attach a Copy oltlu real, agreemaea to
this loan.
Rat.
Sylstem Agency Fonds or Cash Match:
na4rw:�
Total Indirect Costs:
PRC PROGRAM
Budget Summary Detail
Budget CatapoAas
Funds Regquues�ted
Cash Match
6r-IOna
Cahpory Total
Personnel
S 150 729 00
S
S 150.729.00
Fringe Benefits
$ 54.361.00
S
S $4.381.00
Travel
$ 14 910.00
$
$ 14.910.00
Equipment
$
$
$
Supplies
$
3
$
Contractual
S 30,000.00
$
$ 30.000.00
Other
S 25.000.00
S 13.750.00
S
$ 39,750.00
Total Direct Costs
$ 275.000.00
S 13.750.00
S
S 268,750.00
Indirect Costs
$
S
$
Total.
S 275,000.00
S 13,750.00
S
S M.TSO.00
Organization Name: City of Lubbock Neahh Department
Contract Number: NNS001081400001
Fiscal Year: 2021-2024
|
/
.
.
-
:
\
\
\
\
\
\
\
\
\
\
\
-
-
.
�
)�|
.
■
.
-
-
■
�
■�
��
�
�
z
!
I
ei
TOO
|
!
|
|
|
|
|
!
|
|
Fringe Benefits
EN sKM, tfm pemsatps ac cssb slrauM
ToW Fmys B—fa %
ar ToW Fm3a B—mf $ 1A0
FrIm. Be fft Amotnb
c.ab. 3 1Ao
In IVrk Mma+ 1 $
Fmps Bsasms TaW I 3 1A3
Ud tM tv"s of costs that or -UsUm's b ms bfbs
FICA (7A%)—bwmos(.BOAS W PSY PT.Q.-3mlb%7($I,-W pyWl.•—Ally($13A6WPF pM.M.EO.bn W..M. bf CPS Camltat.n(SW Pf f%Y Pn4
Mtkato Policy used a
Oryni,~s TravN Poky - eaehade travel potty In removal roWisse II us" Organ"WWt trawl POtky
seats of Tom Trawl Poky
Cenlersmo Mar Travel Cops
/Vlbhw
Cowh
at0
c"
NunOaof UtY
Nundw or
E�fhaF�W�
T.Ild Auto
Aphs
Mwb
lntlBbP
Otlw Costs
FUMM Sovie
TOW
Pravarsbn PlorMara M."
Csatrap rspsYso Motrp. Tr" amsi p i75 for msw a dry SM a rAgftW
hOW (aro}urq W).S500 far Ylik srid omp traral tests of SM a dry.
Auto. T%
5
a
t2700
s117
fs,
SYpam AVM
FUMaW—
MMch
i t.t76A0
t
t
i
i
i
t
t
i
i
TOW tyutatr AgsmyFurds wCash MdMitir Conkisfmcs/Mbrtstropi
8.376At
ToW 610M Match for Conhrims l
i
Total hN Ccsft K lWwkhep Tray.4f
t,376A0
Other I Local Travel Costa
,knWcelbn
p sun.
NunEara Miles
MMpa Cost
Other Coab
Fu.tq soya
TOWCotl
Travel costs for Tobacco Con,Ffartes O"m wrWt4r bythe To0soro CoarbMar. A barrel Mutation It necessary esloe parts of Ote MOM Me a 5 tw
AOva horn Lubbock. and aarWRofstated out arMrual--Atw
$0.50
10.000
s SAW=
S73500
System Agancy
Fugsar Cash
Mack
i O.ULGO
s
i
It
t
It
f
It
f
s
s
f
f
Total fysten Agency Foals or Cash Match bar Other l local Travel
f 6A311A0
Tote) hHual tar Other l heel Travel
s
TOM fa OOarr/tacal Travel
$ OHO LN
Cash 7otel i 7Mt0.00
M Nbal Maleh TOM i
7oM Travel Costs 3 1f.Ot0A0
Description of IMM
PrrposeiuWme.gon
NUMera Ualte
CostPa Uelt
FUMftp Sara
Total Cost
i
s
s
s
fytstarn Agency Funds or Cash Match Total
f
M Kind Match Told
i
Total Ambled Ragtwab0 bar EqUIPTAIN
f
f *S+o1 WPtl1uW RWl
s xplu�.waaw
f RWlW1M Vs•'Jb �Puni Rau�BY VMAIR8
peg PPl � f fwvw"i UOPZM W 8 wndAM W41 W W
�
$
s
$
s
�
s
g
�
��y~
��3
y3
3
�y§
3
�°
�
�
�
�
�
�i
E
s
��
ins
���
��
��
�g
p�
g
�
!
�
�
|
|
|
|
|
�
§
!
�
|■|
-
|
|E
|,
■
|
!
■
|
�
|
.
|
,
|
�
MnaW PW1
Indirect Category Detail
Govermwmal Entry Using a Central Sarvbe Cost Rate or bafllect Cost Rala
TM erganlMio 's curent Central Safvice Cost Raw or l dhect Cod Rate based on a rate proposal prepareU In accordance wbb OMB Cireldar "T. ptwcb copy of approved Raw Agrearrom or
Certdbatbn of Cost Allocation Plan or Cemlbstlon of Indbact Cods. Cby and County Govenanems with a Central Service Cost Rate slaold also canpwle the'Gowrmwmal and Non Gosarntne"
EMlty Using a Norratlw Cod ASoeaUm Plan' section for the Indirect cods of the CdyiCoumy Departamem w.g. Health Deparbnent) that System Agency It contracting warn.
Role
Type of Cods lochmed in tha Rate
Non Goverrmreat Eudy Ushg Indirect Cost Rate
The wyantn.pn•s most r—rd Indirect cots rate approved by a lederat—grs:em agency or state single aWA eoordbutfng apency. Expired rate agreen eves are not acceptable. Attach a copy of dw rate agrecmeu to
Wsft—
Rate
Sytatem Agency Furda at C-h Match:
"nd:�
TeW Indirect Costs:
Dxu6lpn Ewe pe 1076931 D41-216C-4557AM965780056627E
Attachment C-1
Deliverables and Performance Measures
I All deliverables for the Contract are listed in the below deli erable table. Grantee is required to submit all deliverablaes for the Attachment A, General Statement of Work
Attachment B, Fiscal Requirements, and for all Prevention Programs (YP's, PRC, CCP) awarded in accordance with the Contract Signature Document
2 Grantee shall ensure all required deliverables are submitted as follows
a The deliverables submitted shall be named the deliverable name refemced in column "Report Name".
b Reports are submitted by the due date in column "Due Dale" Note Deliverables due on the weekend and'or holiday are due the next business day
c Report are submitted by the submission system documented in the column "submission system"
d All reports required to be submitted to the SUD Mailbox at SUD Contracts@hhs texas gov require the eniad subject line to utilize the follow mg naming convention
IFY for Reporll Deliverable (Name of Reportl IProgram IDI [Contract No.l
e System Agency may request deliverables to be submitted through an alternate submission system
3 Grantee is required to submit performance measures in CMBHS for all Prevention Programs awarded Grantee shall ensure compliance to die following requirements
a CCP, PRC and YP performance measures are submitted in CMBHS by the l5th of the current month Grantee shall report the previous months activities
b Performance will be measured in part on the achievement of the key performance measures
c Guidance concering each performance measure can be found in the Program Guide. "Performance Measure Definitions and Guidance "
Requirement
Report Name
Due Date-
Submission System
Attach A, General
Program Staffing Report
Per fiscal year:
Prevention Activity Tracking Tool (PATT)
Statement of Work
September 15 and within 10 business days of a revision
Attach A, General
CMBHS Security Attestation Form and Listing of
Per fiscal year:
SUD Mailbox
Statement of Work
Authorized Users
September 15w & March 15'
SUD Contracts n hhs texas gov
Per fiscal year, quarterly report schedule
Q I reporting period, due December 31 st
Attach B, Fiscal
FSR to GL Workshect (for each funded Program)
Q2 reporting period, due March 31st
SUD Mailbox
SUD Contracts@hhs
Requirements
texas gov
Q3 reporting period, due June 30th
Q4 reporting period, due October 15th
Per fiscal year, quarterly report schedule
QI reporting period, due December 31st
Attach B, Fiscal
Requirements
General Ledger for each funded program)
S ( P g
Q2 reporting period, due March 31"
SUD Mailbox
SUD Contracts@hhs texas gov
Q3 reporting period, due Arne 301h
Q4 reporting period, due October 1 Sth
Per fiscal year, quarterly report schedule for Financial Status
Report (FSR) report
QI reporting period, due December 31 st
Attach A, General
Financial Status Reports (FSRs) (for each funded
CMBHS
Statement of Work
program)
Q2 reporting period, due March 31 °
Q3 reporting period, due June 301h
Q4 reporting period, due October ISth
D—Sign Emelo" ID 788311)41319C4557AB496576aNW27E
Attachment C
Deliverables and Performance Measures
Attach A, General
Performance Measures (for each funded program)
Report previous month's activities due on the 15th of the
CMBHS or other system designated by
Statement of Work
current month
System Agency
Attach A. General
FY Closeout documents (for each funded program)
FY closeout documents due October 15th
SUD Mailbox
Statement of Work
SUD Contracts rdhhs texas go,
Attach A, General
Final Closeout documents (for each funded program)
Final closeout documents due 45 days after contract end date
SUD Mailbox
Statement of Work
SUD Contracts , hhs texas gov
Attachment A.1, YP SOW Reporting uirements
Attach A -I, YP
Due within 20 calendar days after the curriculum cycle has
CMBHS or other system designated by
Statement of Work
Curriculum Outcome Measures Reports
been completed Submit each individual curriculum cycle and
System Agency
the associated outcomes
Virtual Form
https forms office com/Pages/ResponseP
YP Fall Semester Implementation Plan September 1st each
age aspxvid Mnf5m7mCmOmxagk-
fiscal year
r1Ta66jj7mjhNpKtFuPNB7Y27hUQTdL
MFNI3NVE1 WVo3VUQySIAyWIpHUVh
QRy4u
Virtual Form
https forms office com/Pages/ResponseP
Attach A-1, YP
YP Spring Semester Implementation Plan Due January 151h
age aspx?id Mnf5m7mCmOmxagk-
Statement of Work
PBHP YP Implementation Plans
each fiscal year
jrl Ta66jj7mjhNpKtFuPWB7Y27hURUtR
W UOzT V YyOTIPNkpUNEJGOTdFMzJ W
Mr4u
Virtual Fort
https 'forms office com/Pages/ResponseP
YP Summer Term Implementation Plan Due May 15th each
age aspx7id Mnf5m7mCmOmxagk-
fiscal year
Irl Ta66jj7mjhNpKtFuPWB7Y27hUQl oy
RkFONUZZN V pLSj V PSU9 V RIRCME9D
WC4u
Attachment A-2, CCP Reporting Requirements
Attach A-2, CCP
Community Needs Assessment (CNA)
SubmittedSUD
SUD Mailbox
Statement of Work
Contracts hhs texas gov
Attach A-2, CCP
Logic Model
Submitted
SUD Mailbox
Statement of Work
SUD Contracts r hhs texas gov
Attach A-2, CCP
Five -Year Strategic Plan
Submitted
SUD Mailbox
Statement of Work
SUD Contracts hhs texas gov
Attach A-2, CCP
Initial Evaluation Plan
Submitted
SUD Mailbox
Statement of Work
SUD Contracts hhs texas gov
Virtual Form
https "forms office com/Pages/ResponseP
Attach A-2, CCP
PBHP CCP Annual Implementation Plan
Due September 1 st each fiscal year
age aspx9id Mnf5m7mCmOmxagk-
Statement of Work
r I Ta66jj7nijhNpKtFuP W B7Y27hUNl Y5
TIQ4VkdNTjdURVRPWjQ2l,IlhSQzhUR
Per fiscal year, quarterly report schedule as follows
Q I reporting period, due December I Slh
Attach A-2, CCP
Quarterly Reports - CCP and CCP-COV
Q y P
2 reporting
Q P g Period, due March I Sth
SUD Mailbox:
Statement of Work
SUD.Contmcts@hhs texas gov
Q3 reporting period, due June 151h
Q4 reporting period, due September 15th
Attach A-2, CCP
CCP-COV Final Project Report
Due August 31, 2024
SUD Mailbox
tatement Sof Work
SUD. Contracts@hhs texas gov
Attachment A-3. PRC SOW Reporting Requirements
Attach A-3, PRC
Mid -year Report
Each Fiscal Year, due March 31st
SUD Mailbox
Statement of Work
SUD.Contracts hhs texas gov
Virtual Form
https://fomis.otfice coni/Pages/Respons
Attach A-3, PRC
PBHP PRC Annual Implementation Plan
Due September 1 st each fiscal year
ePage.aspx?id= Mnf5m7mCmOmxagk-
Statement of Work
jrITa66jj7mjhNpKtFuPWB7Y27hUNl
Y5TIQ4%rkdNTjdURVRP WJQ2MIhSQ
zhURC4u
SUD Mailbox
Attach A-3, PRC
Regional Needs Assessiiient
Each Fiscal Year. August 31st
Statement of Work
SUD Contracts hhs texas gov
Attach A-3, PRC
Post Regional Needs Assessment to website
Each Fiscal Year, August 31 st
SUD Mailbox
Statement of Work
SUD Contracts r hhs texas gov
Note Deliverables due on the we and/or holiday are due dale is the next business day
DocuSign Envelope ID: 78831D41.219C.4557-ABA9-65780056827E
3D. Number of media awareness activities (not including social
Sept -Nov
Dec -Feb
Mar -May Jun -Aug Annual
CCP 1
media) focused on prevention and behavorial health promotion.
3E. Number of social media messages focused on prevention
CCP 2
and behavorial health promotion messaging and the statewide
media campaign.
4A. Number of community -based processes focused on
CCP 3
prevention and behavorial health promotion.
4B. Number of adults attending community -based processes
CCP 4
focused on prevention and behavorial health promotion.
4C. Number of youth attending community -based processes
CCP 5
focused on prevention and behavorial health promotion.
5A. Number of changed policies and social norms related to
CCP 6
prevention and behavorial health promotion.
COVID SupplementalPerformance
S2. Number of youth attending stress reduction/trauma healing
activities.
S3. Number of adults attending stress reduction/trauma healing
activities.
Total CCP FTEs:
o
i
:�
Yy
6n
i
p
��
�
�
�
�
�
��
_
��
Y�
��
�
�
$$�g
F
Si
t6�
��
_
�p
■
'�7
=E
�
f
�
�
W
��
�
E
�
V
�S
F
_
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
TEXAS Form 8040-A
�$ August 2022-E
Sealth rvices
and Human Federal Funding Accountability and Transparency Act FFATA
Services 9 tY P Y ( )
Certification Form
The certifications enumerated below represent material facts upon which HHSC relies when reporting information to the federal government
required under federal law. If HHSC later determines that the contractor knowingly rendered an erroneous certification, HHSC may pursue all
available remedies in accordance with Texas and U.S. laws. The signer further agrees that they will provide immediate written notice to HHSC
if at any time they learn that any of the certifications provided for below were erroneous when submitted or have since become erroneous by
reason of changed circumstances. Note: If the signer cannot certify all of the statements contained in this section, they must provide written
notice to HHSC detailing which of the below statements they cannot certify and why.
Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax year?
0 Yes — Skip questions A, B and C and continue to section D. ® No — Answer questions A and B.
A. Certification Regarding Percent of Annual Gross from Federal Awards
Did your organization receive 80% or more of its annual gross revenue from federal awards during the preceding fiscal year?
Q Yes ® No — Skip question C.
B. Certification Regarding Amount of Annual Gross from Federal Awards
Did your organization receive $25 million or more in annual gross revenues from federal awards in the preceding fiscal year?
® Yes p No — Skip question C.
If your answer is Yes to both questions A and B, you must answer question C.
If your answer is No to either question A or B, skip question C and continue to section D.
C. Certification Regarding Public Access to Compensation Information
Does the public have access to information about the highly compensated officers/senior executives in your business or organization (including
parent organization, all branches and all affiliates worldwide) through periodic reports filed under Section 13(a) or 15(d) of the Securities
Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or Section 6104 of the Internal Revenue Code of 1986?
e Yes Q No — Provide the names and total compensation of the top five highly compensated officers/senior executives.
Name of Officer or Senior Executive
Total Compensation
1.
2.
3.
4.
5.
D. Signatures
As the duly authorized representative (signer) of the contractor, I hereby certify that the statements made by me in this certification form are
true, complete and correct to the best of my knowledge.
CDocuSlgned by:
1ra., � August 30, 2023
787 FF32"T'
Signature of Authorized Representative Date
Printed Name of Authorized Representative
Tray Payne
Title of Authorized Representative
Mayor
Legal Name of Contractor
Unique Entity Identifier
City of Lubbock
Applicable HHSC Contract No.(s):
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-657B0056827E
TEXAS
o PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
U.0 Services
Section
New Contract Number
Amendment Number
❑ HHS001081400001
❑x 3
New Work Order Number
Amendment Number
❑
❑
Contractor Legal Business Name:
CITY OF LUBBOCK
Total Contract Value (Including Renewals)
Note: Contract value is defined as the estimated dollar amount that the agency may be obligated to pay
$2,123,228.00
pursuant to the contract and all executed and proposed amendments, extensions and renewals of the contract.
Requesting Agency/Program
HHSC MSS-SUDCMU
Contract Manager Name
Contract Manager Email
Contract Manager Phone
Cristina Bunyard
cristina.bunyard@hhs.texas.gov
N/A
Purchaser/Buyer Name
Purchaser/Buyer Email Purchaser/Buyer Phone
SectionApprovals
section contains all contract -specific approvers
as designated by Program. These individuals will be inserted into the CAPPS Financials approval process. The minimUrn
required approvers listed in Section 2 must include
contracts.This
.approvers,DocuSign,
CAPPS Financials. CAPPS approvals Must occur in
the contract manager, program staff, and legal approval; legal approval may be provided by email for boilerplate template
must be listed in this section. approve the contract
• order list-.
Is this a legal approved boilerplate template? ® Yes ❑ No If "Yes" attach Proof of Approval
Approver Title
Approver Name
Approver E-mail Address
1.
Contract Analyst
F ;i7stina Bunyard
cristina.bunyard@hhs.texas.gov
2.
Contract Administration M4
[Angela Perkins
angela.perk!ns@hhs.texas.gov
3.
Legal
[Steven M. Gonzalez
steven.gonzalez0l@hhs.texas.gov
4.
1
F
5.
IF
-
6.
7.
8.
9.
1
F
10.1
11.
Effective 10/23/2017 - 1 - Revised 01/13/2022
DocuSign Envelope ID: 78831 D41-21 9C-4557-A8A9-657130056827E
TEXAS
E Heath 1. PCS 515 CONTRACT ROUTING AND APPROVAL REQUESTU. a
servluesndHuman
DocuSign Routing Path Begins
Section 3: Internal Required DocuSign .. .
In addition to the approvals in Section 2 the following approvers are needed consistent with the chart below.
HHSC Contracts
Approver Name E-mail Address
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Chief Financial Officer
Trey.Wood@hhs.texas.gov
System Contracting Director
ffAndyMarker
Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen. Ray@hhs.texas.gov
01G Contracts
00 000 up to $19,999,999
Approver
Name
E-mail Address
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
nd over
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen. Ray@hhs.texas.gov
DSHS Contracts
L20,000,001:LtaI49,999,999
Approver
Name
E-mail Address
System Contracting Director
Andy Marker
Edward.Marker@hhs.texas.gov
DSHS General Counsel
Cynthia Hernandez
Cynthia.Hernandez3@hhs.texas.gov
I IM off .
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen. Ray@hhs.texas.gov
Effective 10/23/2017 - 2 - Revised 01/13/2022
DocuSign Envelope ID: 78831D41-219C-4557-A8A9-65780056827E
TEXAS
PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
LL Services
Section 4: DocuSign Signatories
Signatory
Name
E-mail Address
Contractor Signature Authority
Tray Payne
TrayPayne@mylubbock.us
Additional Contractor Signature
Authority
Gloria DIdZ
gdldZ@mylUbbOCk.US
Contractor Signature cc
HHS Signature Authority
Sonja Gaines
sonja.gaines@hhs.texas.gov
HHS Signature Authority cc
SA Mailbox
SUD.Contracts@hhs.texas.gov
General Inbox cc
Cristina Bunyard
cristina.bunyard@hhs.texas.gov
* If adding an additional contractor signature authority, please provide instructions on which documents need to be completed by this individual.
CC: Katherine Wells at kwells@mylubbock.us
Effective 10/23/2017 - 3 - Revised 01/13/2022
DocuSign Envelope ID: 7883lD41-219C-4557-A8A9-65760056827E
TEXAS
PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
0 Services
U.
INSTRUCTIONS
PURPOSE
To direct HHS contracts, work orders, amendments, renewals, and extensions through the routing and approval process.
WHEN TO PREPARE THIS FORM
This form shall be completed for any document requiring CAPPS Financials approval routing and for DocuSign contract signature routing.
Program area shall adhere to any HHS Circular-046 requirements to complete the form prior to submission to Procurement and
Contracting Services Quality Assurance ("PCS QA").
PROCEDURE TO COMPLETE PCS SIS
Section 1: To be completed by Program.
This section contains necessary contract information.
Section 2: To be completed by Program.
This section contains all contract -specific approvers as designated by Program. These individuals will be inserted into the CAPPS
Financials approval process. The minimum required approvers listed in Section 2 must include the contract manager, program staff, and
legal approval. All contract -specific approvers, except for the contract signatory who will review and approve in DocuSign, must
be listed in this section to approve the contract in CAPPS Financials. CAPPS approvals must occur in the order listed in Section 2.
DocuSign Routing Path Begins
Section 3: Required Approvals.
This section contains all required Office of Chief Counsel and Chief Financial Officer approvals based on contract value.
Section 4: To be completed by Program.
This section shall contain all required contract signatory information. These individuals will be inserted into the DocuSign routing path.
Effective 10/23/2017 - 4 - Revised 01/13/2022
Certificate Of Completion
Envelope Id: 78831D41219C4557A8A9657B0056827E
Subject: Amending $2,123,228 00; HHS001081400001; CITY OF LUBBOCK A-3; HHSC/MSS-SUDCMU
Procurement Number:
Source Envelope:
Document Pages: 84 Signatures: 3
Certificate Pages: 2 Initials: 0
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC-06:00) Central Time (US & Canada)
Record Tracking
Status: Original
8/17/2023 11:17:04 PM
Security Appliance Status: Connected
Storage Appliance Status: Connected
Signer Events
Tray Payne
TrayPayne@mylubbock.us
Mayor
City of Lubbock
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Sonja Gaines
Sonja. Gaines@hhs.texas.gov
Deputy Executive Commissioner
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Editor Delivery Events
Agent Delivery Events
Intermediary Delivery Events
Certified Delivery Events
Holder: Texas Health and Human Services
Commission
PCS_DocuSign@hhsc.state.tx.us
Pool: FedRamp
Pool: Texas Health and Human Services
Commission
Signature
DOCUSig-d by:
C 761 E3 CI14B D
Signature Adoption: Pre -selected Style
Using IP Address: 208.84.91.41
ED—Sig-d by.
Otn1a Gauint S
443409418
Signature Adoption: Pre -selected Style
Using IP Address: 167.137.1.13
Signature
Status
Status
Status
Status
Carbon Copy Events Status
Cristina Bunyard COPIED
cristina. bunyard @hhs.texas.gov
Contract Specialist IV
Security Level: Email, Account Authentication
(None)
DocuSign
Status: Completed
Envelope Originator:
Texas Health and Human Services Commission
1100 W. 49th St.
Austin, TX 78756
PCS—DocuSign@hhsc.state.tx.us
IP Address: 168.60.253.53
Location: DocuSign
Location: DocuSign
Timestamp
Sent: 8/17/2023 11:24:23 PM
Resent: 8/29/2023 9:26:58 PM
Viewed: 8/30/2023 8:18:04 AM
Signed: 8/30/2023 8:19:02 AM
Sent: 8/30/2023 8:19:06 AM
Viewed: 8/30/2023 8:22:19 AM
Signed: 8/30/2023 8:22:39 AM
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Sent: 8/17/2023 11:24:22 PM
Carbon Copy Events Status
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Gloria Diaz CO PI E D
gdiaz@mylubbock.us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Katherine Wells CO PI E D
kwells@mylubbock.us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
SA Mailbox COPIED
SUD.Contracts@hhs.texas.gov
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Timestamp
Sent: 8/29/2023 9:26:51 PM
Viewed: 8/30/2023 8:01:07 AM
Sent: 8/29/2023 9-26:51 PM
Sent: 8/25/2023 3:21:45 PM
Viewed: 8/27/2023 9:16:54 PM
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
8/17/2023 11:24:22 PM
Envelope Updated
Security Checked
8/25/2023 3:21:45 PM
Envelope Updated
Security Checked
8/29/2023 9:26:50 PM
Envelope Updated
Security Checked
8/29/2023 9:26:50 PM
Envelope Updated
Security Checked
8/29/2023 9:26:50 PM
Certified Delivered
Security Checked
8/30/2023 8:22:19 AM
Signing Complete
Security Checked
8/30/2023 8:22:39 AM
Completed
Security Checked
8/30/2023 8:22:39 AM
Payment Events
Status
Timestamps