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Resolution - 2005-R0416 - Contract - DSHS - Population Based Services - 09/08/2005
Resolution No. 2005-RO416 September 8, 2005 Item 17 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock a Contract Change No. 11 to a Contract with the Texas Department of State Health Services (DSHS Document No. 7560005906 2005) for CHS Population Based Services for public health preventive services and any associated documents by and between the City of Lubbock and the Texas Department of State Health Services, a copy of which Contract Change No. 11 and associated documents are attached hereto and which shall be spread upon the minutes of this Council and as spread upon the minutes of this Council shall constitute and be a part hereof as if fully copied herein in detail. Passed by the City Council this 8th day o f September , 2005. GAL, MAYOR ATTEST: Rebecca Garza, City Secretary APPROVED AS TO CONTENT: Tommy Carne ,Health Director APPROVED AS TO FORM: i "' 7 G. Vandiver, AttdrMey D Dres/TDHconO5Chg9Res August 22, 2005 Resolution No. 2005-R4416 DEPARTMENT OF STATE HEALTH SERVICES 1100 WEST 49TH STREET AUSTIN, TEXAS 78756-3199 STATE OF TEXAS COUNTY OF TRAVIS DSHS Document No. 7560005906 2005 Contract Change Notice No. 11 The Department of State Health Services, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing with LUBBOCK CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto now desire to amend such contract attacnment(s) as tollows: SUMMARY OF TRANSACTION: ATT NO. 03A : CHS - POPULATION BASED SERVICES All terms and conditions not hereby amended remain in full force and effect. EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN. CITY OF LUBBOCK HEALTH DEPARTMENT Authorized Contracting Entity (type above if different from PERFORMING AGENCY) for and in behalf of: PERFORMING AGENCY: LUBBOCK CITY MiALTH DEPARTMENT of to sign) MARC MCDOUGAL, MAYOR (Name and Title) Date: 9 - 6 -©s RECOMMENDED: By: t� 6 / wed (PERFORMI AGENCY Director, if different from person authorized to sign contract RECEIVING AGENCY: DEPARTMENT OF STATE HEALTH SERVICES By: (Signature of person authorized to sign) Bob Burnette, Director Client Services Contracting Unit s (Name and Title) Date: /d -3-or KR CSCU - Rev. 6105 A 1#ppi oved as to form:ATTEST: SII �`. u : pity Attorney Cover page 1 Reb CCa Garza, Czty EC tart' DETAILS OF ATTACHMENTS Att/ DSHS Program ID/ Term Financial Assistance Direct Total Amount Amd DSHS Purchase Assistance (DSHS Share) No. Order Number Begin End Source of Amount Funds* 01C IMM/LOCALS 01/01/04 08/31/05 State 93.268 230,440.00 0.00 230,440.00' 0000001776 HIV/SURV 02 C038578000 09/01/04 08/31/05 State 50,251.00 0.00 50,251.00 CHS/POP 03A 0038805000 09/01/04 12/31/05 93.994 61,303.00 0.00 61,303.00 ZOONOSIS 04 C038061000 09/01/04 08/31/05 State 10,886.00 0.00 10,886.00 OPHP/LPHS OS C039236000 09/01/04 08/31/05 State 93.991 118,554.00 0.00 118,554.00 06B CPS/BIOTERR 09/01/04 08/31105 93.283 697,101.00 0.00 697,101.00 0000300707 DSHS Document No.7560005906 2005 Totals $1,168,535.00 $ 0.00 $1,168,535.00 Change No. 11 11 *Federal funds are indicated by a number from the Cataleg of Federal Domestic Assistance (CFDA), if applicable. REFER TO BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS. Cover Page 2 Resolution No. 2005-RO416 September 8, 2005 cop 1*40" Item 17 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock a Contract Change No. 11 to a Contract with the Texas Department of State Health Services (DSHS Document No. 7560005406 2005) for CHS—Population Based Services for public health preventive services and any associated documents by and between the City of Lubbock and the Texas Department of State Health Services, a copy of which Contract Change No. I I and associated documents are attached hereto and which shall be spread upon the minutes of this Council and as spread upon the minutes of this Council shall constitute and be a part hereof as if fully copied herein in detail. Passed by the City Council this 8th day of September )2005. UGAL, MAYOR ATTEST: Rebecca Garza, City Secretary APPROVED AS TO CONTENT: "- �'Iv� IL44 --, Tommy Came , Health Director APPROVED AS T4 FORM: G. Vandiver, Attorney of DDres/TDHcon05Chg9Res August 22, 2005 W7 +CITY OF LUBBOCK MEMO 1'0: LOU FOX, CITY MANAGER FROM: TOMMY CAMDEN, HEALTH DEPARTMENT DIRECTOR SUBJECT: AGENDA COMMENTS - September S, 2005 CITY COUNCIL MEETING DATE: AUGUST 26, 2005 ITEM# / SUBJECT: Consider a resolution authorizing and directing the Mayor to execute for and on behalf of the City of Lubbock a Change No. 11 to a Contract with the Texas Department of State Ilealth Services (DSI -IS Document No. 7560005906 2005) for CHS—Population Based Services for public health preventive services and any associated documents by and between the City of Lubbock and the Texas Department of State Health Services. BACKGROUND/ DISCUSSION: This contract change amends the initial FY05 contract approved by Council on August 16, 2004 with Resolution No. 2004-R-0393. This FY05 annual contract with the Department of State Health Services (formerly Texas Department of Health), DSHS Document No. 7560005906 2005, provides financial assistance for maternal and child health education and extends the current contract by an additional 3 months and now covers the period between September 1, 2004 thru December 31, 2005. The contract will become competitive in 2006. This attachment for $61,303 in financial assistance provides full salary and fringe benefits for a Health Educator and partial funding for a part-time data entry assistant. The two employees are currently assigned to the Health Education Section. Significant funding reductions from last year will continue to prevent or reduce activities planned and organized in the past such as anti -tobacco pep rallies, child safety seat checkpoints, child abuse prevention workshops, health and safety fairs, and substance abuse education. For the past 7 years, the City of Lubbock Health Department has been a facilitator for the '1.'exas Department of Health's Title V Program. During this time, the grant money= has built a strong maternal and child health infrastructure within the Health Education 'Team (1-mr). The activities planned for the 2004-2005 grant include Motherhood and Prenatal Education in underserved neighborhoods as well as facilitating the prenatal parenting classes. Classes will focus on the development of parenting skills and will target at -risk .)SHS Contract Title V Extension teen mothers, as well as the general population. Another initiative will be a collaborative effort with the City of Lubbock's Prevention 'Section, the Fire Department, and HET, in which immunizations and education are provided at reduced cost. The final objective of this program is to reduce the percentage of children under 4 years of age that are not restrained in appropriate child safety seats. This will be achieved through child safety seat inspections as well as distributing child safety seats to low-income families. FISCAL IMPACT The $61,303.00 total represents an increase of $15,326 from the initial amount of $45,977 approved by council on August 16, 2004, SUMMARY/RECOMMENDATION. Chis program fulfills a Core Mission of Public Health, which is Health Education. Without the funding from the Department of State Health Services contract, our local public health efforts would be greatly impaired. Therefore, Health Department staff recommends approval of the resolution. 3SHS Contract Title V Extension DOCUMENT NO. 7560005906-2005 ATTACHMENT NO. 03A PURCHASE ORDER NO. C038805000 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: COMMUNITY HEALTH SERVICES SECTION TERM: September 01, 2004 THRU: December 31, 2005 It is mutually agreed by and between the contracting parties to amend the conditions of Document No. 7560005906 2005 -03 as written below. All other conditions not hereby amended are to remain in full force and effect. SECTION I. SCOPE OF WORK is replaced with the following: PERFORMING AGENCY shall perform public health preventive services related to women, children, and their families in order to address local health needs; to build the local public health infrastructure; and to improve the health status of women, children, and families. PERFORMING AGENCY shall comply with all applicable federal and state laws, rules, regulations, standards, and guidelines in effect on the beginning date of this contract Attachment unless amended. The following documents are incorporated by reference and made hart of this contract Attachment: • RECEIVING AGENCY'S Family & Community Health Services Grants FY2005 Competitive Request for Proposal (RFP) for Title V Population -Based projects; • PERFORMING AGENCY'S FY2005 Component II, Attachment C application and any revisions; • RECEIVING AGENCY'S Department of State Health Services (DSHS) Standards for Public Health Clinic Services, revised August, 2004; • RECEIVING AGENCY'S Quality Assurance (QA) Title V - Population Based On -Site Evaluation Report (designed to be used with QA Core Tool), which requires monthly time sheets to document staff time on work plan activities, invoices of all expenditures, logs of dated activities with sign -in sheets for public presentations; and, • Title V Policy and Procedures Manual revised for FY2005. Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING AGENCY shall inform RECEIVING AGENCY Program, in writing, if it will not continue performance under this Attachment in compliance with the amended standard(s) or guideline(s). RECEIVING AGENCY may terminate the Attachment immediately or within a reasonable period of time as determined by RECEIVING AGENCY. ATTACHMENT — Page I PERFORMING AGENCY shall implement its approved work plan in consultation with RECEIVING AGENCY'S Health Service Regional (HSR) Title V Coordinator and Central Office Title V Program Manager. RECEIVING AGENCY'S Health Service Regional (HSR) Director, as coordinator of regional services, will assist RECEIVING AGENCY staff in providing direction to PERFORMING AGENCY. RECEIVING AGENCY personnel will provide technical assistance and training to PERFORMING AGENCY, as needed. PERFORMING AGENCY shall cooperate with RECEIVING AGENCY staff to attain the goals of unified community health assessment, policy development, coordinated services, and quality assurance and to prevent unnecessary duplication of services. PERFORMANCE MEASURES The following performance measures will be used to assess, in part, PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment, without waiving the enforceability of any of the other terms of this contract. • PERFORMING AGENCY shall report final performance measure data no later than 60 days after the end of the four-month extended Attachment term. • PERFORMING AGENCY shall submit monthly progress reports, per program policy stated in FY2005 program manual, within thirty (30) days of the end of each month. • PERFORMING AGENCY shall submit quarterly reports on project activities to RECEIVING AGENCY'S Central Office within thirty (30) days of the end of each quarter, and within sixty (60) days of the end of the extension period of September 1, 2005 through December 31, 2005. Quarterly reports shall describe accomplishments, challenges, barriers, impact, and progress in achieving the goals and objectives contained in PERFORMING AGENCY'S FY2005 Title V Application work plan, and any revisions. • The quarterly progress report shall be in the format specified by RECEIVING AGENCY in the Title V Policy and Procedures Manual and through any amended guidelines. For FY2005, there will be an additional progress report for the extension period of September 1, 2005 through December 31, 2005. • PERFORMING AGENCY shall provide public health preventative services to women, children, and their families who live or receive services in the following counties/area: Lubbock. PERFORMING AGENCY shall submit a comprehensive final report on FY2005 work plan activities, including the extension period of September 1, 2005 through December 31, 2005, on or before February 28, 2006. This final report shall include the findings of an evaluation to determine the effectiveness of project activities in addressing local health ATTACHMENT — Page 2 needs, in building the local public health infrastructure, and in improving public health status. SECTION II. SPECIAL PROVISIONS is replaced with the following: General Provisions, Reports Article, second paragraph, is replace with the following: For each Attachment, PERFORMING AGENCY shall submit a Financial Status Report, State of Texas Supplemental Form 269A (Form GC -4a) within thirty (30) days following the end of each of the first four (4) quarters. PERFORMING AGENCY shall submit a final financial report on State of Texas Supplemental Form 269A (Form GC -4a), not later than sixty (60) days following the end of the Attachment term. PERFORMING AGENCY shall submit a State of Texas Purchase Voucher (Form B-13), or any other form designated by RECEIVING AGENCY, with the final financial report if all costs have not been recovered, or PERFORMING AGENCY shall refund excess monies if costs incurred were less than funds received. General Provisions, Reports Article, is revised to include the following: PERFORMING AGENCY shall submit monthly, quarterly and year-end financial reports, in the format specified by RECEIVING AGENCY Program, within thirty (30) days of the end of each month and quarter, and within sixty (60) days of the end of the contract Attachment term detailing the activities performed and the objectives achieved with the funding provided under this contract Attachment. PERFORMING AGENCY shall submit other reports as deemed necessary by RECEIVING AGENCY Program. General Provisions, Inspections Article, is revised to include the following: In addition to the site visits authorized by the Inspections Article of the General Provisions, PERFORMING AGENCY shall allow RECEIVING AGENCY to conduct on-site quality assurance reviews as deemed necessary by RECEIVING AGENCY. Unsatisfactory review findings may result in implementation of General Provisions, Sanctions Article. PERFORMING AGENCY shall notify RECEIVING AGENCY Program immediately in the event of any significant change affecting PERFORMING AGENCY'S identity, ownership or control, name, governing board membership, vendor identification, medical or program director, or address. Failure to disclose the required information or inaccurate disclosure by PERFORMING AGENCY may be treated as a material breach of this contract Attachment and may be grounds for termination. ATTACHMENT — Page 3 General Provisions, Terms and Conditions of Payment Article, is revised to include the following: Funds made available in the initial contract term of September 1, 2004 through August 31, 2005 must be used for services performed on or after September 1, 2004 through August 31, 2005..Any funds that are not expended for services performed during that period are not available for services performed after August 31, 2005. PERFORMING AGENCY shall submit all vouchers and supporting document for dates of service between September 1, 2004 and August 31, 2005 to RECEIVING AGENCY no later than October 15, 2005. Funds made available by this contract amendment for the period of September 1, 2005 through December 31, 2005 must be used for services performed on or after September 1, 2005 through December 31, 2005. Any funds that are not expended for services performed during that period are not available. PERFORMING AGENCY shall submit all vouchers and supporting document for dates of service between September 1, 2005 and December 31, 2005 to RECEIVING AGENCY no later than February 28, 2006. ATTACHMENT — Page 4 DEPARTMENT OF STATE HEALTH SERVICES RECEIVING AGENCY PROGRAM: COMMUNITY HEALTH SERVICES SECTION PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT CONTRACT TERM: 09/01/04 THRU: 12/31/05 BUDGET PERIOD: 09/01/04 THRU 12/31105 DSHS DOC. NO. 7560005906 200503A CHG. 11 REVISED CONTRACT BUDGET FINANCIAL ASSISTANCE OBJECT CLASS CATEGORIES CURRENT APPROVED BUDGET (A) CHANGE REQUESTED (B) NEW OR REVISED BUDGET (C) Personnel Fringe Benefits Travel Equipment Supplies Contractual Other Total Direct Charges Indirect Charges TOTAL PERFORMING AGENCY SHARE: Program Income Other Match RECEIVING AGENCY SHARE PERFORMING AGENCY SHARE $33,638.00 $11,213.00 $44,851.00 12,339.00 4,113.00 16,452.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 $45,977.00 $15,326.00 $61,303.00 0.00 0.00 0.00 $45,977.00 $15,326.00 $61,303.00 0.00 0.00 0.00 0.00 0.00 0.00 $45,977.00 $15,326.00 $61,303.00 $0.00 $0.00 $0.00 Detail on Indirect Cost Rate Type: Rate 0.00 Base $0.00 Total $0.00 Budget Justification: Increase to extend contract to 12/31105 and increase number to be served. Form No. GC -9 ECPS - Rev. 10104 Financial status reports are due the 30th of December, 30th of March, 30th of June, 30th of November, 30th of December, and the 28th of February. 1100 West 49th Street Austin, Texas 78756-3199 Department of State Health Services FINANCIAL STATUS REPORT FSR269A Fiscal Division/Accounts Payable Phone (512) 458-7435 Contractor Name: LUBBOCK CITY HEALTH DEPARTMENT DSHS Program: CHS/POP DSHS Document # Year Attachment Payee Acct. No.: 7560005906 2005 03A Payee Vendor ID No.: 17560005906001 Basis: I I Cash I I Accrual Payee Name: CITY OF LUBBOCK Address: PO BOX 2000 City, ST, Zip: LUBBOCK, TX 79408-2000 Contract Term: (Month/Day/Year) From: 09/01/2004 To: 12/31/2005 Period Covered by this Report: From: 06/01/2005 To: 08/3112005 PO Number: 003 8 8 05 000 Final Report? I 1 Yes I X No (i) Budget Categories (ii) Approved Budget Project Cost per General Ledger (v) Remaining Budget Balance (ii minus iv) (iii) This Period (iv) Cumulative a. Personnel [ ] 44,851.00 b. Fringe Benefits [ ] 16,452.00 c. Travel [ ] 0.00 d. Equipment [ ] 0.00 e. Supplies [ ] 0.00 f. Contractual [ ] 0.00 g. Other [ ] 0.00 h. Total Direct Charges 61,303.00 i. Indirect Charges [ 0.00 '. Total Charges 61,303.00 LESS:k. Program Income Collected I. Nan-DSHS Funding( ( } } M. ADVANCE:Received (Col. iii)/ Repaid (Col. ivy Balance Owed Col. v n. Total Reimbursement Requested o. Total Reimbursement Received Prepared by: Title: Phone #: CERTIFICATION:1 certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and unliquidated obligations are for the purposes set forth in the award documents. Signature of Authorized Certifying Official Date Submitted: 06/27/2005 Typed or Printed Name and Title nfCertifying Official Telephone DSHS Form GC -4a (269a) Revised 6/04 1100 West 49th Street Austin, Texas 78756-3199 Department of State Health Services FINANCIAL STATUS REPORT FSR269A Fiscal Division/Accounts Payable Phone 15121 45R-74'15 Contractor Name: LUBBOCK CITY HEALTH DEPARTMENT DSHS Program: CHS/POP DSHS Document # Year Attachment # Payee Acct. No.: 7560005946 2005 03A Payee Vendor ID No.: 17560005906001 Basis: I I Cash [ I Accrual Payee Name: CITY OF LUBBOCK Address: PO BOX 2000 City, ST, Zip: LUBBOCK, TX 79408-2000 Contract Term: (Month/Day/Year) From: 09/01/2004 To: I2/31/2005 Period Covered by this Report: From: 09101/2005 To: 11/30/2005 PO Number: C038805000 Final Report? I ] Yes [ XNo (i) Budget Categories (ii) Approved Budget Project Cost per General Ledger (v) Remaining Budget Balance (ii minus iv) (iii} This Period (iv) Cumulative a. Personnel [ ] 44,851.00 b. Fringe Benefits [ ] 16,452.00 c. Travel [ ] 0.00 d. Equipment [ ] 0.00 e. supplies [ ] 0.00 f. Contractual [ ] 0.00 g. Other [ ] 0.00 h. Total Direct Charges 61,303.00 i. Indirect Charges [ ] 0.00 '. Total Charges 61,303.00 LESS:k. Program Income Collected 1. Non-DSHS Funding ( } ( ) m. ADVANCE:Received (Col. iii)/ Repaid (Col. ivy Balance Owed Col. v n. Total Reimbursement Requested o. Total Reimbursement Received Prepared by: Title: Phone #: CERTIFICATION:I certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and unliquidated obligations are for the purposes set forth in the award documents. Signature of Authorized Certifying Official Date Submitted: Typed or Printed Name and Title of Certifying Official Telephone DSHS Form GC -4a (269a) Revised 6/04 1100 West 49th Street Austin, Texas 78756-3199 Department of State Health Services FINANCIAL STATUS REPORT FSR269A Fiscal Division/Accounts Payable Phone (512) 458-7435 Contractor Name: LUBBOCK CITY HEALTH DEPARTMENT DSHS Program. CHS/POP DSHS Document # Year Attachment # Payee Acct. No.: 7560005906 2005 03A Payee Vendor ID No.: 17560005906001 Basis: I I Cash [ I Accrual Payee Name: CITY OF LUBBOCK Address: PO BOX 2000 City, ST, Zip: LUBBOCK, Tai 79408-2000 Contract Term: (Month/Day/Year) From: 09/01/2004 To: 12/31/2005 Period Covered by this Report: From: 12/01/2005 To: 12/31/2005 PO Number: 0038805000 Final Report? [ }[Yes [ I No (i) Budget Categories (ii) Approved Budget Project Cost per General Ledger (v) Remaining Budget Balance (ii minus iv) (iii) This Period (iv) Cumulative a. Personnel [ ] 44,851.00 b. Fringe Benefits [ ] 16,452,00 c. Travel [ ] 0,00 d. E ui ment [ ] 0.00 e. -Supplies [ ] 0.00 f. Contractual [ ] 0.00 g. Other [ ] 0.00 h. Total Direct Charges 61,303.00 i. Indirect Charges 0.00 '. Total Charges 61,303.00 LESS:k. Program Income Collected 1. Non-DSHS Funding m. ADVANCE:Received (Col, iii)/ Repaid (Col. ivy Balance Owed Col, v ( ) ( ) } n. Total Reimbursement Requested o. Total Reimbursement Received Prepared by: Title: Phone #: CERTIFICATION) certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and unliquidated obligations are for the purposes set forth in the award documents. Signature of Authorized Certifying Official Date Submitted: Typed or Printed Name and Title of Certifying Oficial Telephone DSHS form GC4a (269a) Revised 6/04 a Contract #: 6334 Change Order #: Requisition #: ITB# 1 RF P# 1 RFQ# (Ir Applicable): CONTRACT COVER SHEET See Step -by -Step Contracting Process on CLIC for Instructions (Type or Print all information with the creeption of Signatures and Signature Dates) Forward the complete contract package to Contract Management, Municipal Building Suite 204, for review, approval and cnntract execution. The complete package includes one (1) copy of the conVicted Contract Cover Sheet (Cor internal City use only); rrunimum of three (3) originals of the contract or amendment; and minimum of three (3) originals of all other certifications and contract addenda. Attached Contract must be "Approved as to Content" by Director and "Approved as to Form" by Legal. The following signatures are required to process Cont, t_C;nvcr , IMPORTANT: Bach person who signs the Conlract Comer Sheet must carefully revicn the atracitrd contract doe the conlrac ver sheet. Risk Manager: Ins Cert Reqd: (�0 Date: C� C7 S - Dir of Fiscal Policy Date: Asst City ManagedChiet Date: Originating Dept and Individual Respo a for Ensuring Contract Terms and Contract Compliance: Department: Health Name: Tommy Camden Phone Number: 808-775-2899 Title: Public Health Director information Ior venuorit-ontraciorlAgency or viner r,nnty l.lty of LnDDOCB Is l.ontracung witn: Contract Information: Brief Description of Goods or Services or arrangements covered by the terms of the contract Improve and drengthen local public heath infrastructure through delivery d essential publichealth services Effedive Date: ❑ Upon Execution by Authorized Signatories OR Other (Speedy Date): 9/112004 End Date: Notice To Proceed + (Specify # of Days) OR Other (Specify Date): 12/3112006 Financial Information Cost Center. 5417 i Account#: 81042 Amount Not To Exceed: $61,303 Other. Will Contract �'— No Project Number (f applicable): Generate If so, amount S Will Contract Be Paid From Grant Funds: Revenue: Yes•Veriiy Availability of f=unds with Budget Notes: . . Jteviewed by Pitrchu,tn-('ontR t.%4anatcr. t.� �ll/t. +i_✓ Date: Z' C �) ContractCuvaSheet.doc (Rev 05/49/05) T Contract Form and Signatory Contract: ° Professional Services Signatory: Mayor Contract Checklist (Nat applicable to Charge Orders or Amendments) ....... •--.. t. Is this individual or owner of this business an officer or employee of the City of Lubbock? No [Note If Yes, City policy may not allow us to write a contract for this individualivendor.] If unsure, check wth Legal. 2. Are all documents In order and submitted at least 5 business days pdorto the start date for services for standard contracts or at least 20 business days prior to start date for services if using a non-standard contract? Yes [Note: If No, and notassocialed with a building repair, complete a'Justification for Untimely Contract Submittal' form.] ..... ............ 3. Does the contract, Licensing Agreement, insurance or other document requiring signature originate from the vendor? Yes - SEE NOTE [Note: If Yes, must be reviewed by Legal. Forward to Purchasing nen Deparbt] _..._.... _ ..._.. _ 4. Does the contfadinvolve work by the contractor on City owned property? No (Note: If Yea, contact Risk Management a (806) 775-2277.) 5. Does the contractirvdve the purchase of hardware, sotware, firmware or computer component acquisition? No [Note: If Yes, A Purchase Requistion from Information Technology is required. Contact IT at (806) 7752374.) 6. Does the contractinvolve a ourchase valued at $2,500 or more? No [Note: If Yes, A Purchase Requistion is required, For assistance, contact your Buyer in the Purchasing Department) 7. Does the contractinvolve arpu chase valued at $25,000 or more? No (Note If Yes, Formai Competitive Sealed Bidding is required. For assistance, contact your Buyerin the Purchasing Department.) 8. Does the contractinvolve Consulting Services valued at $25,000 or more? No [Note: If Yes, requires Request for Qualifications. Contact Purchasing Manager (805) 775.2165.) 9. Does the contractinvolve purchase of construction valued at $25,000 or more? No [Note: if Yes, Requires Payment Bond[ 10. Does the cortract invdye purchasieot construction vdued at $100 000 or more? No (Notes If Ye; contractrequires Performance Bond) . „ __... _ .. _ ........,.. _ ._..._.,..., It. Does the contract include language for Insurarce Requirements? No (Note If Yes, contact Risk Management 1(808) 775.2277.) 12. If state funded does the contract require language for Child Support certification? Not Applicable [Note If Yes, attach Child Support Certification, form OCAS -99-25 for state funded acquisition.] 13. IF federal or side funded, does the contract include dl clauses required by federal or s s and executiveoders and their implementing regulations? Not Applicable 14. If the purchase/transaction Involve purchase, lease, acceptance as eat estate, has an environmental siteass7ent (ESA) been performed cn the pro ? Not Ii [Note If No, contad Environmental Compliance at x2880 or x2113 1 1 r Contract Award by City Council (enter applicable information) Count Date: 1_91W21305 Council Agenda Item # Resolution The complete package includes one (1) copy of the completed Contract Cover Sheet (for internal City use only); minimum of three (3) originals of the contractor amendment; and minimum of three (3) originals of all other certifications and contract addenda. Forward the complete contract package to Contract Management, Municipal Building Suite 204,for review,, approval and contract executlon. ContractCoverSheet.doc (Rev 06/09/05)