HomeMy WebLinkAboutPR 24885: APPROVAL FOR AMENDMENT NO. 5 GRANT RENEWAL WITH DSHS Cu) of
or rthur
Texas
Date: April 06, 2026
To: Ron Burton, CPM, City Manager
From: Judith A. Smith, RN, BSN, Director of Health Services
RE: PR# 24885Approval for Amendment No. 5 Grant Renewal with DSHS and the City of
Port Arthur to support Public Health Emergency Preparedness for FY 2027. This Grant
requires a 10%match of$10,351.00
Nature of the Request: The Department of State Health Services provides funding to local health
departments to help each facility plan and prepare for natural and man-made disasters. The City of Port
Arthur Health Department has received this funding since 2011. The Department provides services which
include community preparedness, community recovery, emergency public information, information
sharing, fatality management, etc.
Staff Analysis, Considerations: This grant covers the salary and fringe for one (1) epidemiologist who
provides surveillance and case reporting for South Jefferson County.
Recommendations: It is recommended that the City Council approve P.R. No. 24885, approving the
contract amendment between the City of Port Arthur and the Department of State Health Services for the
FY 2027 PREP (Public Health Emergency Preparedness) grant. The grant period is from July 1, 2026, to
June 30,2027.
Budget Considerations: The FY 2027 Contract Amendment No. 5 between the city of Port Arthur and
the Department of State Health Services for the Public Health Emergency Preparedness Program for
$103,507.00 of federal funding with a 10% city match of $10,351.00 for a total not to exceed
$113,858.00. The total amount of the contract is $341,574.00, which includes the city's 10% cash match
of$31,053.00. The cash match is budgeted in account 101-23-061-5111-00-50-000.
"REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHUR"P.O.BOX 1089•PORT ARTHUR,TX 77641-1089•
409/983-8101•FAX 409/982-6743
P. R. No.24885
04/06/2026-js - TNR
RESOLUTION NO.
A RESOLUTION APPROVING THE FY 2027 CONTRACT
AMENDMENT NO. 5 BETWEEN THE CITY OF PORT ARTHUR
AND THE DEPARTMENT OF STATE HEALTH SERVICES FOR
THE PUBLIC HEALTH EMERGENCY PREPAREDNESS
PROGRAM FOR $103,507.00 OF FEDERAL FUNDING WITH A
10% CITY MATCH OF $10,351.00 FOR A TOTAL NOT TO
EXCEED $113,858.00. THIS CONTRACT PERIOD STARTS JULY
1 2026 AND EXPIRES JUNE 30, 2027. THE TOTAL AMOUNT OF
THE CONTRACT IS $341,574.00, WHICH INCLUDES THE
CITY'S 10% CASH MATCH OF $31,053.00. THE CASH MATCH
IS BUDGETED IN ACCOUNT 101-23-061-5111-00-50-000.
WHEREAS, the Texas Department of State Health Services ("DSHS") administers the
Public Health Emergency Preparedness ("PHEP") grant program to provide financial assistance
to local health departments for planning, preparedness, response, and recovery related to natural
and man-made public health emergencies; and
WHEREAS, the City of Port Arthur Health Department has participated in the PHEP
program since 2011, providing critical public health services to South Jefferson County,
including epidemiological surveillance, case reporting, community preparedness, emergency
public information, and response coordination; and
WHEREAS, the City Council previously approved the PHEP contract and subsequent
amendments pursuant to Resolution No. 24-182, Resolution No. 25-170, Resolution No. 25-425
(funding reduction amendment), and Resolution No. 25-521 (funding reinstatement amendment);
and
WHEREAS, DSHS has offered a contract amendment for Fiscal Year 2027 to continue
funding under the PHEP program for the grant period of July 1, 2026, through June 30, 2027;
and
WHEREAS, the total grant amount shall not exceed $341,574.00, consisting of
$310,521,00 in DSHS funding and a required City cash match of $31,053.00 (10%), with
$113,858.00 allocated for the current funding increment, inclusive of the applicable match; and
WHEREAS, such funding will support the salary and fringe benefits of one (1)
epidemiologist responsible for disease surveillance and case reporting for South Jefferson
County, thereby enhancing the City's capacity to respond to public health threats; and
P. R. No.24885
04/06/2026-js - TNR
WHEREAS, the City Council finds that participation in the PHEP program and
acceptance of the contract amendment are in the best interest of the City and promote the health,
safety, and welfare of the community.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF PORT ARTHUR, TEXAS:
Section 1. That the facts and opinions are true and correct.
Section 2. The City Council hereby approves the Fiscal Year 2027 contract
amendment between the City of Port Arthur and the Texas Department of State Health Services
for the Public Health Emergency Preparedness (PHEP) Grant Program, for the term of July 1,
2026, through June 30, 2027, in substantially the same form as attached hereto as Exhibit "A."
Section 3. The City Manager and the Director of the Health Department are hereby
authorized to execute the agreement and any related documents necessary to accept and
implement the grant, and to take all actions necessary to comply with its terms and conditions.
Section 4. The total grant funding authorized herein shall not exceed $341,574.00,
consisting of $310,521.00 in grant funds and a required City cash match of $31,053.00. The
City's required cash match and any related expenditures are hereby authorized in accordance
with the adopted budget and applicable funding sources.
Section 5. That a copy of the caption of this Resolution be spread upon the Minutes
of the City Council.
READ, ADOPTED, AND APPROVED, this day of April 2026 A.D., at a
Regular Meeting of the City Council of the City of Port Arthur, Texas by the following Vote:
AYES: Mayor:
Councilmembers:
NOES:
P. R. No.24885
04/06/2026-js
Mayor, Charlotte M. Moses
ATTEST:
Sherri Bellard, City Secretary
APPROVED AS TO FORM:
Roxann Pais Cotroneo, City Attorney
APPROVED' ; DMINISTRATION:
V
VPr
Ron Burton, CPM
City Manager
Ju h A. Smith,RN,BSN
Director of Health Services
APPR D AS T F FUNDS:
Ly oswell, , ICMA-CM
Fi ce Director
EXHIBIT "A"
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DEPARTMENT OF STATE HEALTH SERVICES
CONTRACT No. HHS001439500029
AMENDMENT No. 5
The DEPARTMENT OF STATE HEALTH SERVICES("System Agency" or "DSHS") and CITY OF
PORT ARTHUR("Grantee"), who are collectively referred to as the "Parties" to that certain Public
Health Emergency Preparedness ("PHEP") grant agreement, effective July 1, 2024, and
denominated DSHS Contract No. HHS001439500029 ("Contract"), as amended, now desire to
further amend the Contract.
WHEREAS, the Parties desire to extend the term of the Contract to exercise the second of four(4)
available one-year extension options under the Contract;
WHEREAS, the Parties desire to add funds to the Contract associated with the FY2027 extension
period; and
WHEREAS,the Parties desire to revise certain terms for compliance with applicable law and DSHS
policy;
Now,THEREFORE,the Parties hereby amend the Contract as follows:
1. SECTION III of the Contract, DURATION, is amended to reflect a revised termination date
of June 30,2027.
2. SECTION V of the Contract, BUDGET, is amended to increase funding for FY2027 in the
amount of $113,858.00. The total amount of this Grant Agreement will not exceed
$341,574.00. This includes the System Agency share of $310,521.00 and Grantee's
required match amount of$31,053.00.
The total not-to-exceed amount includes the following:
Total Federal Funds: $310,521.00
Total State Funds: $0.00
Funds will be allocated for each Project Fiscal Year ("FY"), which means the period
beginning July 1 and ending June 30 each year, under this Grant Agreement. All
expenditures under the Grant Agreement must be within the identified FY, and in
accordance with ATTACHMENT B.4,REVISED BUDGET.
3. SECTION VI of the Contract, NOTICE TO PROCEED, is hereby deleted in its entirety and
replaced with the following:
Funding for this Grant Agreement is available each FY, which is the period of July 1,
through June 30, for the contract term in Section III, Duration, and is dependent on the
award of the applicable federal grant.No work may begin,and no charges may be incurred
DSHS Contract No.HHS001439500029
Amendment No.5
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until DSHS issues a written Notice to Proceed("NTP")to Grantee for each FY.Although
the NTP may issue a budget amount less than the total not to exceed amount of the Grant
Agreement,the NTP must not effectuate a total budget of the Grant Agreement that results
in a total not to exceed Grant Agreement amount that exceeds the amount specified in
Section V, Budget, of the Grant Agreement. Such changes to total not to exceed amount
specified in the Grant Agreement must be effectuated by amendment. Any expenditures
made beyond the dollar amounts specified in the NTP(s) will be at Grantee's sole risk.
Notwithstanding the preceding, at DSHS's discretion, Grantee may be eligible to receive
reimbursement for eligible expenses incurred during the period of performance as defined
by 2 CFR § 200.309.
4. SECTION VII of the Contract,REPORTING REQUIREMENTS,is hereby supplemented with
the addition of the following:
Grantee shall submit the reports for FY2027, as identified in the table below, and as
outlined in ATTACHMENT A.5, FY2027 STATEMENT OF WORK, by the due dates and
submission methods specified therein. DSHS may add contractual requirements and revise
reporting due dates throughout the term of this Grant Agreement to comply with
modifications made to the federal grant award.
Project FY2027 DSHS Email or System to
Report Frequency
Due Date(s) Submit Report
FSRs are due
biannually.The first
Financial Status Report- FSR is due on the last
Biannual day of the month invoices@dshs.texas.gov;
following the first FSR fsrgrants(a,dshs.texas.gov;copy
(See SECTION I(U)(10)of period.The second FSR to the System Agency
is due on the last da of p
July 30,2027 January 31,2027 representative identified in
ATTACHMENT A.5,FY 2027 y
STATEMENT OF WORK) the month,thirty(30) SECTION VIII,CONTRACT
calendar days after the REPRESENTATIVES,of the
Contract end date and Grant Agreement
following the second
FSR period.
August 31,2026
September 30,2026
Invoices/Requests for The last business day of October 30,2026
Reimbursement the month following the November 30,2026 invoices(a,dshs.texas.gov;
month in which December 31,2026 CMSinvoices(a,dshs.texas.gov;
(See SECTION III(A)of expenses were incurred January 29,2027 copy to the System Agency
ATTACHMENT A.5,FY2027 AND thirty(30) February 26,2027 representative identified in
STATEMENT OF WORK) calendar days following March 31,2027 SECTION VIII,CONTRACT
the expiration date of April 30,2027 REPRESENTATIVES,of the
the Grant Agreement. May 31,2027 Grant Agreement
June 30,2027
July 30,2027
Property Inventory Report
(Form GC-11) FSOequip a,dshs.texas.gov;
Once per FY October 15,2026 copy to the System Agency
(See SECTION I(T)(3)of representative identified in
ATTACHMENT A.5,FY2027 SECTION VIII,CONTRACT
STATEMENT OF WORK)
DSHS Contract No.HHS001439500029
Amendment No.5
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REPRESENTATIVES,of the
Grant Agreement
Initial Work Plan
(See SECTION I(U)(1)of Once per FY July 31,2026 Qualtrics System
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
Jurisdictional Risk
Assessment(JRA)
(See SECTION I(U)(2)of Once per FY June 15,2027 Qualtrics System
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
Capacity Indicators
(See Section I(U)(3)of Once per FY July 31,2026 Qualtrics System
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
Multi-Year Integrated
Preparedness Plan
("MYIPP")
Once per FY May 1,2027 Qualtrics System
(See SECTION 1(U)(4)of
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
After-Action
Review/Improvement Plan No later than 120 days
("AAR/IP") after the exercise or
Once per FY thirty(30)days Qualtrics System
(See SECTION I(U)(5)of following the Contract
ATTACHMENT A.5,FY2027 expiration(6/30/2027).
STATEMENT OF WORK)
Programmatic Mid-Year
Performance Report
Once per FY January 31,2027 Qualtrics System
(See SECTION I(U)(6)of
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
Programmatic End-of-
Year Performance Report
Once per FY July 30,2027 Qualtrics System
(See SECTION I(U)(7)of
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
DSHS Contract No.I1IS001439500029
Amendment No.5
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Jurisdictional Evaluation
Tool(JET)-Only for
Regions 2/3&4/5N
Once per FY June 30,2027 Qualtrics System
(See Section I(U)(8)of
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
Capacity Indicators Survey
(See SECTION I(U)(9)of Once per FY July 31,2026 Qualtrics System
ATTACHMENT A.5,FY2027
STATEMENT OF WORK)
5. The Contract is amended to add ATTACHMENT A.5, FY2027 STATEMENT OF WORK,
which is attached to this Amendment and incorporated into the Contract for all purposes.
6. ATTACHMENT B.3 of the Contract, REVISED BUDGET(NOv.2025),is hereby deleted in
its entirety and replaced with ATTACHMENT B.4,REVISED BUDGET,which is attached to
this Amendment and incorporated into the Contract for all purposes.
7. ATTACHMENT C.1 of the Contract, HHS CONTRACT AFFIRMATIONS, VERSION 2.5,
EFFECTIVE NOVEMBER 2024, is hereby deleted in its entirety and replaced with
ATTACHMENT C.2, HHS CONTRACT AFFIRMATIONS, VERSION 2.8, EFFECTIVE
DECEMBER 2025,which is attached to this Amendment and incorporated into the Contract
for all purposes.
8. ATTACHMENT F.1 of the Contract, FY2026 FFATA, is hereby supplemented with the
addition of ATTACHMENT F.2, FY2027 FFATA,which is attached to this Amendment
and incorporated into the Contract for all purposes.
9. This Amendment is effective immediately upon execution by the last Party to sign below.
Operations and funding for Fiscal Year 2027 begin on July 1, 2026. Except as modified
by this Amendment, all existing terms of the Contract, including the current Statement of
Work, shall remain in full force and effect until and unless modified by written agreement
of the Parties.
10. Except as modified by this Amendment, all terms and conditions of the Contract, as
amended, shall remain in effect.
11. Any further revisions to the Contract shall be by written agreement of the Parties.
12. Each Party represents and warrants that the person executing this Amendment on its behalf
has full power and authority to enter into this Amendment.
SIGNATURE PAGE FOLLOWS
DSHS Contract No.HHS001439500029
Amendment No.5
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SIGNATURE PAGE FOR AMENDMENT No.5
DEPARTMENT OF STATE HEALTH SERVICES CONTRACT No.HHS001439500029
DEPARTMENT OF STATE HEALTH SERVICES CITY OF PORT ARTHUR(HEALTH
DEPARTMENT)
By: By:
Name: Name:
Title: Title:
Date of Signature: Date of Signature:
DSHS Contract No.HHS001439500029
Amendment No.5
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ATTACHMENT A.5
FY2027 STATEMENT OF WORK
GRANTEE RESPONSIBILITIES
A. Grantee shall perform activities in support of the Public Health Emergency Preparedness
("PHEP") Cooperative Agreement between the Centers for Disease Control and Prevention
("CDC") and the Department of State Health Services ("System Agency") to advance public
health emergency preparedness.
B. Grantee shall perform the activities required under this Grant Agreement in the following
cities, counties, or groups of counties (cumulatively, Grantee's "Jurisdiction"): Jefferson.
C. Grantee shall provide System Agency with situational awareness data generated through
interoperable networks of electronic data systems.
D. Grantee shall coordinate with System Agency program staff to develop a preparedness activity
plan for the Grantee's Jurisdiction. At minimum,the Grantee shall ensure the following public
health emergency preparedness capabilities are all addressed in its workplan:
1. Capability 1 — Community preparedness is the ability of communities to prepare for,
withstand, and recover from public health incidents in both the short-term and long-term.
2. Capability 2—Community recovery is the ability of communities to identify critical assets,
facilities, and other services within public health, emergency management, health care,
human services, mental/behavioral health, and environmental health sectors that can guide
and prioritize recovery operations.
3. Capability 3 — Emergency operations coordination is the ability to coordinate with
emergency management and to direct and support an incident or event with public health
or health care implications by establishing a standardized, scalable system of oversight,
organization, and supervision that is consistent with jurisdictional standards and practices
and the National Incident Management System("NIMS").
4. Capability 4 — Emergency public information and warning is the ability to develop,
coordinate, and disseminate information, alerts, warnings, and notifications to the public
and incident management personnel.
5. Capability 5 —Fatality management is the ability to coordinate with partner organizations
and agencies to provide fatality management services to ensure the proper recovery and
preservation of remains;identification of the deceased; determination of cause and manner
of death;release of remains to an authorized individual;and provision of mental/behavioral
health assistance for the grieving. The role also may include supporting activities for the
identification, collection, documentation, retrieval, and transportation of human remains,
personal effects, and evidence to the examination location or incident morgue.
6. Capability 6 — Information sharing is the ability to conduct multijurisdictional and
multidisciplinary exchange of health-related information and situational awareness data
among federal, state, local, tribal, and territorial levels of government and the private
sector. This capability includes the routine sharing of information,as well as the issuing of
public health alerts to all levels of government and the private sector in preparation for,
and in response to, events or incidents of public health significance.
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
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7. Capability 7 — Mass care is the ability of public health agencies to coordinate with and
support partner agencies to address, within a congregate location (excluding shelter-in-
place locations), the public health, health care, mental/behavioral health, and human
services needs of those impacted by an incident. This capability includes coordinating
ongoing surveillance and public health assessments to ensure that health needs continue to
be met as the incident evolves.
8. Capability 8 — Medical countermeasure dispensing and administration is the ability to
provide medical countermeasures to targeted population(s)to prevent, mitigate,or treat the
adverse health effects of a public health incident, according to public health guidelines.
This capability focuses on dispensing and administering medical countermeasures, such as
vaccines, antiviral drugs, antibiotics, and antitoxins.
9. Capability 9 — Medical materiel management and distribution is the ability to acquire,
manage, transport, and track medical materiel during a public health incident or event and
the ability to recover and account for unused medical materiel, such as pharmaceuticals,
vaccines, gloves, masks, ventilators, or medical equipment after an incident.
10. Capability 10 — Medical surge is the ability to provide adequate medical evaluation and
care during events that exceed the limits of the normal medical infrastructure of an affected
community. It encompasses the ability of the health care system to endure a hazard impact,
maintain or rapidly recover operations that were compromised,and support the delivery of
medical care and associated public health services, including disease surveillance,
epidemiological inquiry, laboratory diagnostic services, and environmental health
assessments.
11. Capability 11 —Non-pharmaceutical interventions are actions that people and communities
can take to help slow the spread of illness or reduce the adverse impact of public health
emergencies. This capability focuses on communities, community partners, and
stakeholders recommending and implementing non-pharmaceutical interventions in
response to the needs of an incident, event, or threat. Non-pharmaceutical interventions
may include isolation; quarantine; restrictions on movement and travel advisories or
warnings; social distancing; external decontamination; hygiene; and precautionary
protective behaviors.
12. Capability 12 — Public health laboratory testing is the ability to implement and perform
methods to detect, characterize, and confirm public health threats. It also includes the
ability to report timely data,provide investigative support, and use partnerships to address
actual or potential exposure to threat agents in multiple matrices, including clinical
specimens, and food, water, and other environmental samples. This capability supports
passive and active surveillance when preparing for, responding to, and recovering from
biological, chemical, and radiological (if a Radiological Laboratory Response Network is
established)public health threats and emergencies.
13. Capability 13 —Public health surveillance and epidemiological investigation is the ability
to create,maintain, support, and strengthen routine surveillance and detection systems and
epidemiological investigation processes.It also includes the ability to expand these systems
and processes in response to incidents of public health significance.
14. Capability 14—Responder safety and health is the ability to protect public health and other
emergency responders during pre-deployment, deployment, and post-deployment.
15. Capability 15 — Volunteer management is the ability to coordinate with emergency
management and partner agencies to identify, recruit, register, verify, train, and engage
volunteers to support the jurisdictional public health agency's preparedness, response, and
recovery activities during pre-deployment, deployment, and post-deployment.
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
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E. Grantee shall coordinate with System Agency program staff to develop a preparedness activity
plan for the Grantee's Jurisdiction. CDC released the Public Health Response Readiness
Framework that defines excellence in response operations. The Grantee shall be
knowledgeable of the following items and ensure the items are addressed throughout the
deliverables in Section I (U):
1. Prioritize a risk-based approach — to all-hazards planning that addresses evolving threats
and supports medical countermeasure logistics;
2. Enhance partnerships—(federal and nongovernmental organizations)to effectively support
community preparedness efforts;
3. Expand local support — to improve jurisdictional readiness to effectively manage public
health emergencies;
4. Improve administrative and budget preparedness systems — to ensure timely access to
resources for supporting jurisdictional responses;
5. Build workforce capacity — to meet jurisdictional surge management needs and support
staff recruitment,retention,resilience, and mental health;
6. Modernize data collection and systems—to improve situational awareness and information
sharing with healthcare systems and other partners;
7. Strengthen risk communications activities — to improve proficiency in disseminating
critical public health information and warnings and address mis/disinformation;
8. Incorporate practices — to enhance preparedness and response support for communities
experiencing differences in health status due to structural barriers;
9. Advance capacity and capability of public health laboratories —to characterize emerging
public health threats through testing and surveillance; and
10. Prioritize community recovery efforts — to support health department reconstitution and
incorporate lessons learned from public health emergency responses.
F. Grantee shall match funds awarded under this Grant Agreement with costs or third-party
contributions that are not paid by the federal government under another award, except where
authorized by federal statute to be used for cost-sharing or matching. The non-federal
contributions ("match")may be provided directly or through donations from public or private
entities and may be in cash or in-kind donations, fairly evaluated, including plant, equipment,
or services. The costs that the Grantee incurs in fulfilling the matching or cost-sharing
requirement are subject to the same requirements, including the cost principles, that apply to
the use of federal funds, including prior approval requirements and other rules for allowable
costs as described in 45 Code of Federal Regulations ("CFR") 74.23 and 45 CFR 92.24, as
amended.
Grantee shall provide matching funds in the amount of ten percent(10%) of the DSHS Direct
Costs and Indirect Costs amount as outlined in ATTACHMENT B.4,REVISED BUDGET. "Cash
match"is defined as an expenditure of cash by the Grantee on allowable costs under this Grant
Agreement that are borne by the Grantee. "In-kind match" is defined as the dollar value of
non-cash contributions by a third party given in goods, commodities, or services that are used
in activities that benefit this Grant Agreement's project,and that are contributed by non-federal
third parties without charge to the Grantee. The criteria for a match must:
1. Be an allowable cost under the applicable federal cost principle;
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
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2. Be necessary and reasonable for the efficient accomplishment of project or program
objectives;
3. Be verifiable within the Grantee's (or subgrantee's) records;
4. Be documented, including methods and sources, in the approved budget (applies only to
cost reimbursement contracts);
5. Not be included as contributions toward any other federally assisted project or program
(match can count only once);
6. Not be paid by the federal government under another award, except where authorized by
federal statute to be used for cost-sharing or match;
7. Conform to other provisions of governing circulars/statutes/regulations as applicable for
the Grant Agreement;
8. Be adequately documented;
9. Follow procedures for generally accepted accounting practices as well as meet audit
requirements; and
10. Value the in-kind contributions reported and be supported by documentation reflecting the
use of goods and/or services during the Grant Agreement term.
G. Grantee shall, in the event of a public health emergency involving a portion of the state,
mobilize and dispatch staff or equipment purchased with funds from previous PREP
cooperative agreements, and not currently performing critical duties in the Grantee's
Jurisdiction, to the affected area of the state upon receipt of a written request from System
Agency.
H. Grantee shall, in the event of a local, state, or federal incident, emergency or disaster,have the
option to request from System Agency the United States Department of Health and Human
Services ("HHS") emPower Individual Data Set (hereinafter, the "CMS data") for PHEP
services. To access CMS data, Grantee shall submit to System Agency a written request that
describes how the CMS data will be used to perform emergency planning for identifying and/or
conducting outreach to at-risk Medicare beneficiaries to ensure they have the necessary
medical resources and assistance throughout and during recovery from the incident,emergency
or disaster. System Agency reserves the right to request additional information from Grantee.
System Agency will review Grantee's request and provide a written approval or denial.
Grantee's access to and use of the CMS data and any derivative data is provided to allow
Grantee to perform specified and System Agency-approved public health activities under the
Grant Agreement.
When accessing the CMS data or derivative data,Grantee shall:
I. Ensure Confidential Information is handled in compliance with the HHS Data Use
Agreement and the Centers for Medicare and Medicaid Services Data Use Agreement and
any associated DUA Addendum;
2. Employ appropriate administrative, technical, and physical safeguards to protect the
confidentiality of the CMS data and/or derivative data. Such protections shall include, but
not be limited to measures that prevent unauthorized use of or access to such data; logon
protocols and passwords for electronic access to such data; encryption of such data at rest
and in transit; permanent deletion of internet histories when using third-party resources;
redaction of information when fully identifiable information is not required;and the use of
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
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sufficient overwriting to ensure permanent deletion of electronic copies of such data or the
physical destruction of such data in accordance with terms of this section;
3. Only utilize CMS data and derivative data to perform public health activities and only for
the purposes specifically requested and approved by System Agency and not for any other
purpose;
4. Ensure CMS data or derivative data is not entered into any type of registry,unless approved
in writing by System Agency;
5. Destroy all source data and derivative data within thirty (30) calendar days from the date
of disclosure. In the event the incident, emergency, or disaster extends past the thirty (30)
calendar days, Grantee may request a thirty (30)-day extension to continue the response
and outreach by submitting a written request to System Agency with justification for the
continued use of the data. Grantee shall submit written attestation to System Agency
certifying that destruction of all data was completed;
6. Ensure Grantee staff who have access to CMS data or any derivative data complete HIPAA
training prior to accessing any data set. Grantee shall produce evidence of completed
training to System Agency upon request;
7. Ensure Grantee staff who have access to CMS data or any derivative data obtain role-based
access to the CMS data or any derivative data; and
8. Attest that each staff member accessing the CMS data does not have a criminal background
or disqualifying criminal history record information or is not otherwise prohibited from
accessing the CMS data as set forth in state or federal law or rule, including CMS
requirements.
I. Grantee shall coordinate activities and response plans within Grantee's Jurisdiction with the
state, regional, and other local jurisdictions, among local agencies, and with hospitals and
major health care entities, and Councils of Government.
J. Grantee shall inform System Agency in writing if Grantee will not continue performance under
this Grant Agreement within thirty (30) calendar days of receipt of System Agency's
notification of an amended standard(s) or guideline(s). In such event, System Agency may
terminate this Grant Agreement immediately or within a reasonable period of time, as
determined by System Agency.
K. Grantee shall develop, implement, and maintain a timekeeping system for accurately
documenting staff time and salary expenditures for all staff funded through this Grant
Agreement, including partial full-time employees and temporary staff.
L. Grantee shall complete and submit programmatic reports as directed by System Agency in a
format specified by System Agency and as needed to satisfy information-sharing requirements
set forth in Texas Government Code Sections 421.071 and 421.072(b) and(c). Grantee must
provide System Agency with other reports, including financial reports, that System Agency
determines necessary to accomplish the objectives of this Grant Agreement and to monitor
compliance.
M. Grantee shall conduct all exercises in accordance with Homeland Security Exercise Evaluation
Program("HSEEP") guidance, and have plans,processes, and training in place to meet NIMS
compliance requirements.
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
Page 5of11
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N. Grantee shall coordinate all planning, training, and exercises performed under this Grant
Agreement with other Local Health Entities, the Texas Division of Emergency Management
("TDEM"),or other points of contact at the discretion of System Agency,to ensure consistency
and coordination of requirements at the local level and eliminate duplication of effort between
the various domestic preparedness funding sources in the state.
O. Grantee shall coordinate preparedness risk communication activities as needed with the System
Agency Communications Unit.
P. Grantee shall work with the DSHS Public Health Region and their Regional Health Care
Coalition to develop comprehensive preparedness strategies by participating in meetings,
trainings, and exercises.
Q. Grantee shall comply with all state and System Agency guidance and standards, including the
following:
Texas Grant Management Standards, located at the following URL:
https://comptroller.texas.gov/purchasing/grant-management/.
R. Grantee shall comply with all applicable federal and state laws, rules, and regulations, as
amended, including,but not limited to, the following:
1. Texas Government Code Chapter 418;
2. Public Law 116-22, Pandemic and All-Hazards Preparedness and Advancing Innovation
Act ("PAHPAI");
3. Public Law 109-417, Pandemic and All-Hazards Preparedness Act("PAHPA");
4. Texas Health and Safety Code Chapter 81;
5. Section 319 C-1 of the Public Health Service ("PHS") Act (47 USC § 247d-3a), as
amended; and
6. 2 CFR Part 200.
S. Grantee shall comply with all requirements related to purchases made with grant funds and
uses of grant funds under this Grant Agreement. The requirements regarding purchases made
with grant funds and uses of grant funds under this Grant Agreement include the following:
1. Grantee may not use funds for research, clinical care, fundraising activities or lobbying,
construction or major renovations, reimbursement of pre-award costs, to supplant existing
state or federal funds for activities,payment or reimbursement of backfilling costs for staff,
purchase of vehicles of any kind,uniforms,buildings or real property, or funding an award
to another party or provider who is ineligible.
2. Grantee may not use funds made available under this Grant Agreement to promote or
advocate the legalization or practice of prostitution or sex trafficking. Nothing in the
preceding sentence shall be construed to preclude the provision to individuals of palliative
care, treatment, or post-exposure pharmaceutical prophylaxis, and necessary
pharmaceuticals and commodities, including test kits, condoms, and, when proven
effective, microbicides.
3. Grantee must initiate the purchase of all equipment approved in writing by System Agency,
as applicable. Failure to timely initiate the purchase of equipment may result in the loss of
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
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availability of funds for the purchase of equipment. Requests to purchase equipment must
be submitted to the assigned System Agency Contract Representative.
4. At the expiration or termination of this Grant Agreement for any reason, title to any
remaining equipment and supplies purchased with funds under this Grant Agreement
reverts to System Agency. Title may be transferred to another party at the sole discretion
of System Agency. System Agency may, at its option and to the extent allowed by law,
transfer the reversionary interest to such property to Grantee.
5. Grantee shall not use System Agency funds to lease buildings or real property without prior
written approval from System Agency.Further,Grantee shall not use System Agency funds
for the purchase of buildings or real property under any circumstance.
6. System Agency reserves the right, where allowed by legal authority, to redirect funds in
the event of financial shortfalls.
7. System Agency will monitor Grantee's expenditures on a monthly basis. If expenditures
are below the amount projected in Grantee's total FY amount, Grantee's budget may be
subject to a decrease for the remainder of the FY.
T. Grantee shall comply with requirements related to the cost reimbursement budget under this
Grant Agreement. The cost reimbursement budget requirements include the following:
1. Grantee's approved cost reimbursement budget must document all approved and allowable
expenditures.
2. Grantee shall only utilize funding under this Grant Agreement for approved and allowable
costs. If Grantee requests to utilize funds for an expense not documented in the approved
cost reimbursement budget, Grantee shall notify the System Agency Contract
Representative,in writing,and request approval prior to utilizing the funds. System Agency
shall provide written notification whether the requested expense is approved or denied.
3. DSHS-approved budget may be revised by Grantee in accordance with the following
requirements:
4. For any transfer between budget categories, Grantee shall submit a revised Categorical
Budget using the Budget Template to the DSHS Contract Representative, highlighting the
areas affected by the budget transfer and written justification for the transfer request. After
DSHS review, the designated DSHS Contract Representative will provide notification of
acceptance, rejection, or the need for a Contract Amendment to the Grantee by email.
5. For transfer of funds between direct budget categories, other than the `Equipment' and
`Indirect Cost' categories, for less than or equal to a cumulative twenty-five (25) percent
of the total value of the respective Contract budget period, Grantee shall submit timely
written notification to DSHS Contract Representative using the Revised Budget Form and
request DSHS approval.If a budget revision for less than or equal to the cumulative twenty-
five(25)percent is approved for transfer of funds between direct budget categories,DSHS
Contract Representative will provide notification of acceptance to Grantee by email, upon
receipt of which, the funds can be utilized by the Grantee.
6. For transfer of funds between direct budget categories, other than the `Equipment' and
`Indirect Cost' categories, that cumulatively exceeds twenty-five (25) percent of the total
value of the respective Contract budget period, Grantee shall submit timely written
notification to DSHS Contract Representative using the Revised Budget Form and request
DSHS approval. If the revision is approved, the budget revision is not authorized, and the
funds cannot be utilized until an amendment is executed by the Parties.
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
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7. Any transfer between budget categories that includes `Equipment' and/or `Indirect Cost'
categories must be approved by amendment to the Contract. Grantee shall submit timely
written notification to DSHS Contract Representative using the Revised Budget Form and
request DSHS approval. If the revision is approved, the budget revision is not authorized,
and the funds cannot be utilized until an amendment is executed by the Parties.
8. Grantee shall maintain an inventory of equipment, supplies defined as Controlled Assets,
and real property. Submit an annual cumulative report of the equipment and other property
on HHS System Agency Grantee's Property Inventory Report to
FSOequip ar,dshs.texas.2ov, with a copy to the assigned System Agency Contract
Representative by email not later than October 15 of each year. Controlled Assets include
firearms, regardless of the acquisition cost, and the following assets with an acquisition
cost of $500 or more, but less than $10,000: desktop and laptop computers (including
notebooks, tablets and similar devices), non-portable printers and copiers, emergency
management equipment, communication devices and systems, medical and laboratory
equipment, and media equipment. Controlled Assets are considered Supplies.
U. Grantee shall comply with the reporting requirements and due dates established in this
STATEMENT OF WORK and SECTION VII, REPORTING REQUIREMENTS, of the Grant
Agreement. Unless stated otherwise in this Grant Agreement,Grantee must submit the reports
via Qualtrics, a web-based system, according to instructions provided by System Agency.
Programmatic reports satisfy the information-sharing requirements set forth in Texas
Government Code, Sections 421.071 and 421.072(b) and (c). The reporting requirements
include the following:
1. Grantee must prepare an Initial Work Plan each FY and submit it to System Agency via
Qualtrics, using a URL provided by System Agency. For FY2027, Grantee must submit
the Initial Work Plan to System Agency by July 31, 2026. This requirement must be
reviewed and approved by System Agency to receive credit.
2. Grantee must prepare and submit a Jurisdictional Risk Assessment ("JRA") to System
Agency via Qualtrics, using a URL provided by System Agency. For FY2027, Grantee
must submit a Jurisdictional Risk Assessment to System Agency by June 15, 2027. Must
include disproportionately impacted populations or access and functional needs.Previously
completed JRAs can be submitted if they are not more than five (5) years old. The next
JRA will be due within the next five (5) years from the submitted JRA date. This
requirement must be reviewed and approved by System Agency to receive credit.
3. Grantee must prepare and submit a self-assessment on Capacity Indicators each FY via
Qualtrics. For FY2027, Grantee must submit the Capacity Indicators Form to System
Agency by July 31, 2026. System Agency will provide a template to Grantee, which will
identify the information that Grantee must provide in its Capacity Indicators Survey. This
requirement must be reviewed and approved by System Agency to receive credit.
4. Grantee must prepare and submit a current Multi-Year Integrated Preparedness Plan
("MYIPP") each FY, which must include at least five (5) years of progressive exercise,
planning and training, to System Agency via Qualtrics. For FY2027, Grantee must submit
the MYIPP to System Agency by May 1, 2027. The MYIPP must be based on the results
of the Grantee's training needs assessment and the evaluations of previous exercises and
responses, including the After-Action Review/Improvement Plan. The MYIPP must
include a description of:
a) Summary of the MYIPP Workshop;
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
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b) The proposed location,month(s), and year(s) of future exercise(s);
c) The type(s) of future exercise(s)that will take place; and
d) The partnering entities.
MYIPP must include one access and functional needs or underserved populations (FEMA
Definition), training to support a ready responder workforce (WHF-B, AHA-G, LOC-B),
and recovery operations (REC-A). This requirement must be reviewed and approved by
System Agency to receive credit.
5. Grantee must implement an exercise program to include three (3) discussion-based
exercises and one(1) Functional or Full-Scale Operational Exercise over the five (5)-year
Performance Period. Real world incidents can count as a full-scale exercise with prior
approval from the System Agency. This includes completing After-Action Reports(AAR),
Corrective Action and Improvement Plans.The exercises should utilize scenarios that meet
the priority jurisdictional risks identified in the JRA. Submit the After-Action
Review/Improvement Plan("AAR/IP")for each exercise no later than 120 days after the
exercise or thirty (30) days following the Contract expiration, via Qualtrics. This
requirement must be reviewed and approved by System Agency to receive credit.
6. For FY2027, the Grantee must submit the Programmatic Mid-Year Performance
Report to the System Agency by January 31, 2027, via Qualtrics. The System Agency
will provide a template to the Grantee,which will identify the information that the Grantee
must provide in its Programmatic Mid-Year Performance Report. This requirement must
be reviewed and approved by System Agency to receive credit.
7. For FY2027, the Grantee must submit the Programmatic End-of-Year Performance
Report to the System Agency by July 30, 2027. The System Agency will provide a
template to the Grantee to identify the information that the Grantee must provide in its
Programmatic End-of-Year Performance Report. This requirement must be reviewed and
approved by System Agency to receive credit.
8. For FY2027, if the Grantee is located in DSHS Public Health Regions 2/3 and 4/5N,
Grantee must submit the Jurisdictional Evaluation Tool("JET") to the System Agency
by June 30, 2027. The System Agency will provide a template to the Grantee to be
completed using Qualtrics. This requirement must be reviewed and approved by System
Agency to receive credit. If the Grantee is Project Public Health Ready ("PPHR")
accredited, they may submit supporting PPHR documentation in lieu of completing
applicable sections of the JET survey, as determined by System Agency.
9. Grantee must complete and submit the Capacity Indicators Survey in Qualtrics by July
31,2026.The System Agency will provide a template to the Grantee to be completed using
Qualtrics. This requirement must be reviewed and approved by System Agency to receive
credit.
10. Grantee must submit biannual Financial Status Reports ("FSRs)". Grantee's FSRs are
due biannually. The first FSR is due on the last day of the month following the first FSR
period. The second FSR is due on the last day of the month, thirty (30) days after the
Contract end date and following the second FSR period. The first FSR, for the period July
1, 2026, through December 31, 2026, is due by January 31, 2027. The second FSR, for
the period January 1, 2027, through June 30, 2027, is due by July 30, 2027. Grantee shall
electronically submit FSRs to invoices@dshs.texas.gov and fsrgrantsa,dshs.texas.gov,
with a copy to the System Agency Contract Representative identified in SECTION VIII,
CONTRACT REPRESENTATIVES, of this Grant Agreement. As directed by System Agency,
Grantee must submit FSR reports by mail or fax as follows:
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
Page 9 of 11
Docusign Envelope ID:2E543BDC-8683-45A6-8FF3-D6EB14660FDD
a. For submission by mail,use address below:
Department of State Health Services
Claims Processing Unit
P.O. Box 149347, MC 1940
Austin, TX 78714-9347
b. For submission by fax, use the number below:
(512)458-7442
11. Grantee must maintain an inventory of equipment, supplies defined as"Controlled Assets"
(see definition in the form titled, "DSHS Contractor's Property Inventory Report (Form
GC-11),"link below), and real property. Grantee shall submit an annual cumulative report
of the above-stated items on Form GC-11, located at the following
URL:https://www.dshs.texas.gov/hiv-std-program/dshs-tb-hiv-std-section-thisis/contract-
management-section-prevention. Grantee will submit the Form GC-11, via email, to
FSOequip(aidshs.texas.gov, with a copy to the System Agency Contract Representative
identified in SECTION VIII,CONTRACT REPRESENTATIVES, of this Grant Agreement, no
later than October 15th of each calendar year.
12. Grantee shall provide System Agency with other reports, including financial reports, that
System Agency determines necessary to accomplish the objectives of this Grant Agreement
and to monitor compliance.
13. The Grantee must immediately notify the System Agency in writing if the Grantee is
legally prohibited from providing any report required under this Grant Agreement.
II. PERFORMANCE MEASURES
A. System Agency will monitor the Grantee's performance of the requirements in this
Statement of Work and compliance with the Grant Agreement's terms and conditions.
B. Grantee's failure to meet certain requirements, including, but not limited to the following,
may result in the System Agency withholding a portion of the current Fiscal Year PHEP
award: adherence to PHEP reporting deadlines and the capability to receive, stage, store,
distribute, and dispense materiel during a public health emergency.
C. Upon request by the System Agency,the Grantee shall reasonably revise any performance
measure to the System Agency's satisfaction and with the requirements outlined in this
Grant Agreement.
III. INVOICE AND PAYMENT
A. Grantee shall request monthly payments by the last business day of the month following
the month in which expenses were incurred and shall use the State of Texas Purchase
Vouchers (Form B-13 and Form B-13A) located at
https://www.dshs.texas.gov/contractor-forms. Grantee's fmal invoice will be due thirty
(30) calendar days following the expiration date of the Grant Agreement. The System
Agency will issue reimbursement payments to the Grantee monthly for reported actual
cash disbursements supported by adequate documentation.
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
Page 10of11
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Invoice approval and payment is contingent upon receipt of adequate supporting
documentation that is submitted by electronic mail to invoices@,dshs.texas.gov and
CMSInvoices@,dshs.texas.gov, with a copy to the assigned System Agency Contract
Representative identified in the Grant Agreement.
At a minimum, every invoice should include:
1. Grantee name, address, email address, vendor identification number, and telephone
number;
2. DSHS Contract or Purchase Order number;
3. Identification of service(s)provided;
4. The total invoice amount; and
5. Any additional supporting documentation that is required by this Statement of Work
or as requested by System Agency.
B. System Agency will pay Grantee monthly on a cost reimbursement basis and in
accordance with ATTACHMENT B.4,REVISED BUDGET, of this Grant Agreement. System
Agency will reimburse Grantee only for allowable expenses incurred within the FY and
in accordance with the Statement of Work.
C. System Agency reserves the right, where allowed by legal authority, to redirect funds in
the event of financial shortfall. System Agency will monitor Grantee's expenditures on a
periodic basis. If expenditures are below the amount projected in Grantee's total Grant
Agreement amount, Grantee's budget may be subject to a decrease for the remainder of
the Grant Agreement term. Vacant positions existing after ninety (90) days may result in
a decrease in funds. Grantee must report position vacancies to their assigned Contract
Manager each month until the position is filled.
D. Grantee may request a one-time working capital advance not to exceed twelve percent
(12%)of the total funds allotted per FY.All advances must be expended by the end of the
FY. Advances not expended by the end of the Grant Agreement term must be refunded to
the System Agency. System Agency may require the Grantee to repay all or part of
advanced funds at any time during the Grant Agreement term. However, if the advance
has not been repaid before the last three (3) months of the Grant Agreement term, the
Grantee must deduct at least one-third (1/3) of the remaining advance from each of the
last three(3)months' reimbursement requests. If the advance is not repaid prior to the last
three (3) months of the Grant Agreement term, System Agency will reduce the
reimbursement request by one-third(1/3)of the remaining balance of the advance.
DSHS Contract No.HHS001439500029
Attachment A.5—FY2027 Statement of Work
Page 11 of 11
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ATTACHMENT B.4
REVISED BUDGET
DSHS FUNDING DSHS FUNDING DSHS FUNDING TOTAL
BUDGET CATEGORIES FOR FY2025 FOR FY2026 FOR FY2027 DSHS
(July 1,2024— (July 1,2025— (July 1,2026— FUNDING
June 30,2025) June 30,2026) June 30,2027)
Personnel $74,503.00 $54,285.00 $63,000.00 $191,788.00
Fringe Benefits $29,004.00 $22,800.00 $26,460.00 $78,264.00
Travel $0.00 $3,978.00 $2,839.00 $6,817.00
Equipment $0.00 $0.00 $0.00 $0.00
Supplies $0.00 $21,294.00 $10,508.00 $31,802.00
Contractual $0.00 $0.00 $0.00 $0.00
Other $0.00 $1,150.00 $700.00 $1,850.00
Sum of DSHS Direct Costs $103,507.00 $103,507.00 $103,507.00 $310,521.00
Indirect Costs $0.00 $0.00 $0.00 $0.00
Sum of DSHS Direct Costs $103,507.00 $103,507.00 $103,507.00 $310,521.00
and Indirect Costs
Plus Required Match(Cash or $10,351.00 $10,351.00 $10,351.00 $31,053.00
In-Kind)
Total Contract Amount $113,858.00 $113,858.00 $113,858.00 $341,574.00
FY is defined as the period of July 1 through June 30.
DSHS Contract No.HHS001439500029
Attachment B.4—Revised Budget
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HEALTH AND HUMAN SERVICES
Contract Number HHS001439500029
Attachment C2 CONTRACT AFFIRMATIONS
For purposes of these Contract Affirmations, HHS includes both the Health and Human Services
Commission(HHSC) and the Department of State Health Services (DSHS). System Agency
refers to HHSC, DSHS, or both,that will be a party to this Contract. These Contract
Affirmations apply to all Contractors and Grantees (referred to as"Contractor")regardless of
their business form(e.g., individual,partnership, corporation).
By entering into this Contract, Contractor affirms, without exception, understands, and agrees to
comply with the following items through the life of the Contract:
1. Contractor represents and warrants that these Contract Affirmations apply to Contractor
and all of Contractor's principals, officers, directors, shareholders, partners, owners,
agents, employees, subcontractors, independent contractors, and any other representatives
who may provide services under, who have a financial interest in, or otherwise are
interested in this Contract and any related Solicitation.
2. Complete and Accurate Information
Contractor represents and warrants that all statements and information provided to HHS
are current, complete, and accurate. This includes all statements and information in this
Contract and any related Solicitation Response.
3. Public Information Act
Contractor understands that HHS will comply with the Texas Public Information Act
(Chapter 552 of the Texas Government Code) as interpreted by judicial rulings and
opinions of the Attorney General of the State of Texas. Information, documentation, and
other material prepared and submitted in connection with this Contract or any related
Solicitation may be subject to public disclosure pursuant to the Texas Public Information
Act. In accordance with Section 2252.907 of the Texas Government Code, Contractor is
required to make any information created or exchanged with the State pursuant to the
Contract, and not otherwise excepted from disclosure under the Texas Public Information
Act, available in a format that is accessible by the public at no additional charge to the
State.
4. Contracting Information Requirements
Contractor represents and warrants that it will comply with the requirements of Section
552.372(a)of the Texas Government Code. Except as provided by Section 552.374(c) of
the Texas Government Code,the requirements of Subchapter J(Additional Provisions
Related to Contracting Information), Chapter 552 of the Government Code, may apply to
the Contract and the Contractor agrees that the Contract can be terminated if the
Contractor knowingly or intentionally fails to comply with a requirement of that
subchapter.
Health and Human Services
Contract Affirmations v.2.8
Effective December 2025
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5. Assignment
A. Contractor shall not assign its rights under the Contract or delegate the performance
of its duties under the Contract without prior written approval from System Agency.
Any attempted assignment in violation of this provision is void and without effect.
B. Contractor understands and agrees the System Agency may in one or more
transactions assign, pledge, or transfer the Contract. Upon receipt of System
Agency's notice of assignment, pledge, or transfer, Contractor shall cooperate with
System Agency in giving effect to such assignment, pledge, or transfer, at no cost to
System Agency or to the recipient entity.
6. Terms and Conditions
Contractor accepts the Solicitation terms and conditions unless specifically noted by
exceptions advanced in the form and manner directed in the Solicitation, if any,under
which this Contract was awarded. Contractor agrees that all exceptions to the Solicitation,
as well as terms and conditions advanced by Contractor that differ in any manner from
HHS' terms and conditions, if any, are rejected unless expressly accepted by System
Agency in writing.
7. HHS Right to Use
Contractor agrees that HHS has the right to use,produce, and distribute copies of and to
disclose to HHS employees, agents, and contractors and other governmental entities all or
part of this Contract or any related Solicitation Response as HHS deems necessary to
complete the procurement process or comply with state or federal laws.
8. Release from Liability
Contractor generally releases from liability and waives all claims against any party
providing information about the Contractor at the request of System Agency.
9. Dealings with Public Servants
Contractor has not given, has not offered to give, and does not intend to give at any time
hereafter any economic opportunity, future employment, gift, loan, gratuity, special
discount,trip, favor, or service to a public servant in connection with this Contract or any
related Solicitation, or related Solicitation Response.
10. Financial Participation Prohibited
Under Section 2155.004, Texas Government Code (relating to financial participation in
preparing solicitations), Contractor certifies that the individual or business entity named
in this Contract and any related Solicitation Response is not ineligible to receive this
Contract and acknowledges that this Contract may be terminated and payment withheld if
this certification is inaccurate.
11. Prior Disaster Relief Contract Violation
Under Sections 2155.006 and 2261.053 of the Texas Government Code (relating to
convictions and penalties regarding Hurricane Rita,Hurricane Katrina, and other
disasters), the Contractor certifies that the individual or business entity named in this
Contract and any related Solicitation Response is not ineligible to receive this Contract
Health and Human Services
Contract Affirmations v.2.8
Effective December 2025
Page 2 of 14
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and acknowledges that this Contract may be terminated and payment withheld if this
certification is inaccurate.
12. Child Support Obligation
Under Section 231.006(d)of the Texas Family Code regarding child support,Contractor
certifies that the individual or business entity named in this Contract and any related
Solicitation Response is not ineligible to receive the specified payment and acknowledges
that the Contract may be terminated and payment may be withheld if this certification is
inaccurate. If the certification is shown to be false, Contractor may be liable for
additional costs and damages set out in 231.006(f).
13. Suspension and Debarment
Contractor certifies that it and its principals are not suspended or debarred from doing
business with the state or federal government as listed on the State of Texas Debarred
Vendor List maintained by the Texas Comptroller of Public Accounts and the System for
Award Management(SAM)maintained by the General Services Administration. This
certification is made pursuant to the regulations implementing Executive Order 12549
and Executive Order 12689, Debarment and Suspension, 2 C.F.R. Part 376, and any
relevant regulations promulgated by the Department or Agency funding this project. This
provision shall be included in its entirety in Contractor's subcontracts, if any, if payment
in whole or in part is from federal funds.
14. Excluded Parties
Contractor certifies that it is not listed in the prohibited vendors list authorized by
Executive Order 13224, "Blocking Property and Prohibiting Transactions with Persons
Who Commit, Threaten to Commit, or Support Terrorism,"published by the United
States Department of the Treasury, Office of Foreign Assets Control.'
15. Foreign Terrorist Organizations
Contractor represents and warrants that it is not engaged in business with Iran, Sudan, or
a foreign terrorist organization, as prohibited by Section 2252.152 of the Texas
Government Code.
16. Executive Head of a State Agency
In accordance with Section 669.003 of the Texas Government Code,relating to
contracting with the executive head of a state agency, Contractor certifies that it is not(1)
the executive head of an HHS agency, (2) a person who at any time during the four years
before the date of this Contract was the executive head of an HHS agency, or(3)a person
who employs a current or former executive head of an HHS agency.
17. Human Trafficking Prohibition
Under Section 2155.0061 of the Texas Government Code, Contractor certifies that the
individual or business entity named in this Contract is not ineligible to receive this
Contract and acknowledges that this Contract may be terminated and payment withheld if
this certification is inaccurate.
Health and Human Services
Contract Affirmations v.2.8
Effective December 2025
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18. Franchise Tax Status
Contractor represents and warrants that it is not currently delinquent in the payment of
any franchise taxes owed the State of Texas under Chapter 171 of the Texas Tax Code.
19. Debts and Delinquencies
Contractor agrees that any payments due under this Contract shall be applied towards any
debt or delinquency that is owed to the State of Texas.
20. Lobbying Prohibition
Contractor represents and warrants that payments to Contractor and Contractor's receipt
of appropriated or other funds under this Contract or any related Solicitation are not
prohibited by Sections 556.005, 556.0055, or 556.008 of the Texas Government Code
(relating to use of appropriated money or state funds to employ or pay lobbyists, lobbying
expenses, or influence legislation).
21. Buy Texas
Contractor agrees to comply with Section 2155.4441 of the Texas Government Code,
requiring the purchase of products and materials produced in the State of Texas in
performing service contracts.
22. Disaster Recovery Plan
Contractor agrees that upon request of System Agency, Contractor shall provide copies of
its most recent business continuity and disaster recovery plans.
23. Computer Equipment Recycling Program
If this Contract is for the purchase or lease of computer equipment,then Contractor
certifies that it is in compliance with Subchapter Y,Chapter 361 of the Texas Health and
Safety Code related to the Computer Equipment Recycling Program and the Texas
Commission on Environmental Quality rules in 30 TAC Chapter 328.
24. Television Equipment Recycling Program
If this Contract is for the purchase or lease of covered television equipment, then
Contractor certifies that it is compliance with Subchapter Z, Chapter 361 of the Texas
Health and Safety Code related to the Television Equipment Recycling Program.
25. Cybersecurity Training
A. Contractor represents and warrants that it will comply with the requirements of
Section 2063.104 of the Texas Government Code relating to cybersecurity training
and required verification of completion of the training program.
B. Contractor represents and warrants that if Contractor or Subcontractors, officers, or
employees of Contractor have access to any state computer system or database, the
Contractor, Subcontractors, officers,and employees of Contractor shall complete
cybersecurity training pursuant to and in accordance with Government Code, Section
2063.104.
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26. Restricted Employment for Certain State Personnel
Contractor acknowledges that,pursuant to Section 572.069 of the Texas Government
Code, a former state officer or employee of a state agency who during the period of state
service or employment participated on behalf of a state agency in a procurement or
contract negotiation involving Contractor may not accept employment from Contractor
before the second anniversary of the date the Contract is signed or the procurement is
terminated or withdrawn.
27. No Conflicts of Interest
A. Contractor represents and warrants that it has no actual or potential conflicts of
interest in providing the requested goods or services to System Agency under this
Contract or any related Solicitation and that Contractor's provision of the requested
goods and/or services under this Contract and any related Solicitation will not
constitute an actual or potential conflict of interest or reasonably create an appearance
of impropriety.
B. Contractor agrees that, if after execution of the Contract, Contractor discovers or is
made aware of a Conflict of Interest, Contractor will immediately and fully disclose
such interest in writing to System Agency. In addition, Contractor will promptly and
fully disclose any relationship that might be perceived or represented as a conflict
after its discovery by Contractor or by System Agency as a potential conflict. System
Agency reserves the right to make a final determination regarding the existence of
Conflicts of Interest, and Contractor agrees to abide by System Agency's decision.
28. Fraud,Waste, and Abuse
Contractor understands that HHS does not tolerate any type of fraud, waste, or abuse.
Violations of law, agency policies, or standards of ethical conduct will be investigated,
and appropriate actions will be taken. Pursuant to Texas Government Code, Section
321.022, if the administrative head of a department or entity that is subject to audit by the
state auditor has reasonable cause to believe that money received from the state by the
department or entity or by a client or contractor of the department or entity may have
been lost,misappropriated, or misused, or that other fraudulent or unlawful conduct has
occurred in relation to the operation of the department or entity, the administrative head
shall report the reason and basis for the belief to the Texas State Auditor's Office (SAO).
All employees or contractors who have reasonable cause to believe that fraud,waste, or
abuse has occurred(including misconduct by any HHS employee, Grantee officer, agent,
employee, or subcontractor that would constitute fraud,waste, or abuse) are required to
immediately report the questioned activity to the Health and Human Services
Commission's Office of Inspector General. Contractor agrees to comply with all
applicable laws,rules,regulations, and System Agency policies regarding fraud,waste,
and abuse including, but not limited to, HHS Circular C-027.
A report to the SAO must be made through one of the following avenues:
• SAO Toll Free Hotline: 1-800-TX-AUDIT
• SAO website: http://sao.fraud.state.tx.us/
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All reports made to the OIG must be made through one of the following avenues:
• OIG Toll Free Hotline 1-800-436-6184
• OIG Website: ReportTexasFraud.com
• Internal Affairs Email: InternalAffairsReferral@hhsc.state.tx.us
• OIG Hotline Email: OIGFraudHotline@hhsc.state.tx.us.
• OIG Mailing Address: Office of Inspector General
Attn: Fraud Hotline
MC 1300
P.O. Box 85200
Austin,Texas 78708-5200
29. Antitrust
The undersigned affirms under penalty of perjury of the laws of the State of Texas that:
A. in connection with this Contract and any related Solicitation Response,neither I nor
any representative of the Contractor has violated any provision of the Texas Free
Enterprise and Antitrust Act, Tex. Bus. & Comm. Code Chapter 15;
B. in connection with this Contract and any related Solicitation Response,neither I nor
any representative of the Contractor has violated any federal antitrust law; and
C. neither I nor any representative of the Contractor has directly or indirectly
communicated any of the contents of this Contract and any related Solicitation
Response to a competitor of the Contractor or any other company, corporation, firm,
partnership or individual engaged in the same line of business as the Contractor.
30. Legal and Regulatory Actions
Contractor represents and warrants that it is not aware of and has received no notice of
any court or governmental agency proceeding, investigation, or other action pending or
threatened against Contractor or any of the individuals or entities included in numbered
paragraph 1 of these Contract Affirmations within the five(5) calendar years immediately
preceding execution of this Contract or the submission of any related Solicitation
Response that would or could impair Contractor's performance under this Contract,relate
to the contracted or similar goods or services, or otherwise be relevant to System
Agency's consideration of entering into this Contract. If Contractor is unable to make the
preceding representation and warranty,then Contractor instead represents and warrants
that it has provided to System Agency a complete, detailed disclosure of any such court
or governmental agency proceeding, investigation, or other action that would or could
impair Contractor's performance under this Contract, relate to the contracted or similar
goods or services, or otherwise be relevant to System Agency's consideration of entering
into this Contract. In addition, Contractor acknowledges this is a continuing disclosure
requirement. Contractor represents and warrants that Contractor shall notify System
Agency in writing within five(5)business days of any changes to the representations or
warranties in this clause and understands that failure to so timely update System Agency
shall constitute breach of contract and may result in immediate contract termination.
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31. No Felony Criminal Convictions
Contractor represents that neither Contractor nor any of its employees, agents, or
representatives, including any subcontractors and employees, agents, or representative of
such subcontractors, have been convicted of a felony criminal offense or that if such a
conviction has occurred Contractor has fully advised System Agency in writing of the
facts and circumstances surrounding the convictions.
32. Unfair Business Practices
Contractor represents and warrants that it has not been the subject of allegations of
Deceptive Trade Practices violations under Chapter 17 of the Texas Business and
Commerce Code, or allegations of any unfair business practice in any administrative
hearing or court suit and that Contractor has not been found to be liable for such practices
in such proceedings. Contractor certifies that it has no officers who have served as
officers of other entities who have been the subject of allegations of Deceptive Trade
Practices violations or allegations of any unfair business practices in an administrative
hearing or court suit and that such officers have not been found to be liable for such
practices in such proceedings.
33. Entities that Boycott Israel
Contractor represents and warrants that(1)it does not, and shall not for the duration of
the Contract,boycott Israel or(2)the verification required by Section 2271.002 of the
Texas Government Code does not apply to the Contract. If circumstances relevant to this
provision change during the course of the Contract, Contractor shall promptly notify
System Agency.
34. E-Verify
Contractor certifies that for contracts for services, Contractor shall utilize the U.S.
Department of Homeland Security's E-Verify system during the term of this Contract to
determine the eligibility of:
1. all persons employed by Contractor to perform duties within Texas; and
2. all persons, including subcontractors, assigned by Contractor to perform work
pursuant to this Contract within the United States of America.
35. Former Agency Employees—Certain Contracts
If this Contract is an employment contract, a professional services contract under Chapter
2254 of the Texas Government Code, or a consulting services contract under Chapter
2254 of the Texas Government Code, in accordance with Section 2252.901 of the Texas
Government Code, Contractor represents and warrants that neither Contractor nor any of
Contractor's employees including,but not limited to, those authorized to provide services
under the Contract,were former employees of an HHS Agency during the twelve(12)
month period immediately prior to the date of the execution of the Contract.
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36. Disclosure of Prior State Employment—Consulting Services
If this Contract is for consulting services,
A. In accordance with Section 2254.033 of the Texas Government Code, a Contractor
providing consulting services who has been employed by, or employs an individual
who has been employed by, System Agency or another State of Texas agency at any
time during the two years preceding the submission of Contractor's offer to provide
services must disclose the following information in its offer to provide services.
Contractor hereby certifies that this information was provided and remains true,
correct, and complete:
1. Name of individual(s)(Contractor or employee(s));
2. Status;
3. The nature of the previous employment with HHSC or the other State of Texas
agency;
4. The date the employment was terminated and the reason for the termination; and
5. The annual rate of compensation for the employment at the time of its
termination.
B. If no information was provided in response to Section A above, Contractor certifies
that neither Contractor nor any individual employed by Contractor was employed by
System Agency or any other State of Texas agency at any time during the two years
preceding the submission of Contractor's offer to provide services.
37. Abortion Funding Limitation
Contractor understands, acknowledges, and agrees that,pursuant to Article IX of the
General Appropriations Act(the Act),to the extent allowed by federal and state law,
money appropriated by the Texas Legislature may not be distributed to any individual or
entity that, during the period for which funds are appropriated under the Act:
1. performs an abortion procedure that is not reimbursable under the state's Medicaid
program;
2. is commonly owned, managed, or controlled by an entity that performs an abortion
procedure that is not reimbursable under the state's Medicaid program; or
3. is a franchise or affiliate of an entity that performs an abortion procedure that is not
reimbursable under the state's Medicaid program.
The provision does not apply to a hospital licensed under Chapter 241, Health and Safety
Code, or an office exempt under Section 245.004(a)(2), Health and Safety Code.
Contractor represents and warrants that it is not ineligible, nor will it be ineligible during
the term of this Contract, to receive appropriated funding pursuant to Article IX.
38. Funding Eligibility
Contractor understands, acknowledges, and agrees that, pursuant to Chapter 2273 of the
Texas Government Code, except as exempted under that Chapter,HHSC cannot(1)
contract with(a) an abortion provider or an affiliate of an abortion provider; or(b) an
abortion assistance entity for the purpose of providing an abortion or abortion assistance;
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or(2) contract or appropriate or spend money to provide any person logistical support for
the express purpose of assisting a woman with procuring an abortion or the services of an
abortion provider. Respondent certifies that it is not ineligible to contract with System
Agency under the terms of Chapter 2273 of the Texas Government Code and certifies
that the contract is not a taxpayer resource transaction, appropriation, or expenditure of
money prohibited by Chapter 2273 of the Texas Government Code.
39. Gender Transitioning and Gender Reassignment Procedures and Treatments for
Certain Children—Prohibited Use of Public Money; Prohibited State Health Plan
Reimbursement.
Contractor understands, acknowledges, and agrees that, pursuant to Section 161.704 of
the Texas Health and Safety Code(eff. Sept. 1, 2023), public money may not directly or
indirectly be used, granted,paid, or distributed to any health care provider, medical
school,hospital, physician, or any other entity, organization, or individual that provides
or facilitates the provision of a procedure or treatment to a child that is prohibited under
Section 161.702 of the Texas Health and Safety Code. Contractor also understands,
acknowledges, and agrees that, pursuant to Section 161.705 of the Texas Health and
Safety Code(eff. Sept. 1, 2023), HHSC may not provide Medicaid reimbursement and
the child health plan program established under Chapter 62 may not provide
reimbursement to a physician or health care provider for provision of a procedure or
treatment to a child that is prohibited under Section 161.702 of the Texas Health and
Safety Code. Contractor certifies that it is not ineligible to contract with System Agency
under the terms of Chapter 161, Subchapter Y, of the Texas Health and Safety Code.
40. Prohibition on Certain Telecommunications and Video Surveillance Services or
Equipment(2 CFR 200.216)
Contractor certifies that the individual or business entity named in this Response or
Contract is not ineligible to receive the specified Contract or funding pursuant to 2 CFR
200.216.
41. COVID-19 Vaccine Passports
Pursuant to Texas Health and Safety Code, Section 161.0085(c), Contractor certifies that
it does not require its customers to provide any documentation certifying the customer's
COVID-19 vaccination or post-transmission recovery on entry to, to gain access to, or to
receive service from the Contractor's business. Contractor acknowledges that such a
vaccine or recovery requirement would make Contractor ineligible for a state-funded
contract.
42. Entities that Boycott Energy Companies
Pursuant to Section 2276.002 of the Texas Government Code(relating to prohibition on
contracts with companies boycotting certain energy companies), Contractor represents
and warrants that: (1) it does not, and will not for the duration of the Contract,boycott
energy companies or(2) the verification required by Section 2276.002 of the Texas
Government Code does not apply to the Contract. If circumstances relevant to this
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provision change during the course of the Contract, Contractor shall promptly notify
System Agency.
43. Entities that Discriminate Against Firearm and Ammunition Industries
In accordance with Senate Bill 19, Acts 2021, 87th Leg., R.S.,pursuant to Section
2274.002 of the Texas Government Code(relating to prohibition on contracts with
companies that discriminate against firearm and ammunition industries), Contractor
verifies that: (1)it does not, and will not for the duration of the Contract, have a practice,
policy, guidance, or directive that discriminates against a firearm entity or firearm trade
association or(2)the verification required by Section 2274.002 of the Texas Government
Code does not apply to the Contract. If circumstances relevant to this provision change
during the course of the Contract, Contractor shall promptly notify System Agency.
44. Security Controls for State Agency Data
In accordance with Senate Bill 475,Acts 2021, 87th Leg., R.S., pursuant to Texas
Government Code, Section 2054.138, Contractor understands, acknowledges, and agrees
that if,pursuant to this Contract, Contractor is or will be authorized to access,transmit,
use, or store data for System Agency, Contractor is required to meet the security controls
the System Agency determines are proportionate with System Agency's risk under the
Contract based on the sensitivity of System Agency's data and that Contractor must
periodically provide to System Agency evidence that Contractor meets the security
controls required under the Contract.
45. Cloud Computing State Risk and Authorization Management Program (TX-RAMP)
Pursuant to Texas Government Code, Section 2063.408, Contractor acknowledges and
agrees that, if providing cloud computing services for System Agency, Contractor must
comply with the requirements of the state risk and authorization management program
and that System Agency may not enter or renew a contract with Contractor to purchase
cloud computing services for the agency that are subject to the state risk and
authorization management program unless Contractor demonstrates compliance with
program requirements. If providing cloud computing services for System Agency that are
subject to the state risk and authorization management program, Contractor certifies it
will maintain program compliance and certification throughout the term of the Contract.
46. Contract for Professional Services of Physicians,Optometrists, and Registered
Nurses
In accordance with Senate Bill 799,Acts 2021, 87th Leg., R.S., if Texas Government
Code, Section 2254.008(a)(2)is applicable to this Contract, Contractor affirms that it
possesses the necessary occupational licenses and experience.
47. Foreign-Owned Companies in Connection with Critical Infrastructure
If Texas Government Code, Section 2275.0102(a)(1) (relating to prohibition on contracts
with certain foreign-owned companies in connection with critical infrastructure) is
applicable to this Contract,pursuant to Government Code Section 2275.0102, Contractor
certifies that neither it nor its parent company,nor any affiliate of Contractor or its parent
company, is: (1) majority owned or controlled by citizens or governmental entities of
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China, Iran,North Korea, Russia, or any other country designated by the Governor under
Government Code Section 2275.0103 or(2)headquartered in any of those countries.
48. Critical Infrastructure Subcontracts
For purposes of this Paragraph,the designated countries are China, Iran,North Korea,
Russia, and any countries lawfully designated by the Governor as a threat to critical
infrastructure. Pursuant to Section 117.002 of the Business and Commerce Code,
Contractor shall not enter into a subcontract that will provide direct or remote access to or
control of critical infrastructure, as defined by Section 117.001 of the Texas Business and
Commerce Code, in this state, other than access specifically allowed for product warranty
and support purposes to any subcontractor unless (i)neither the subcontractor nor its
parent company, nor any affiliate of the subcontractor or its parent company, is majority
owned or controlled by citizens or governmental entities of a designated country; and(ii)
neither the subcontractor nor its parent company,nor any affiliate of the subcontractor or
its parent company, is headquartered in a designated country. Contractor will notify the
System Agency before entering into any subcontract that will provide direct or remote
access to or control of critical infrastructure, as defined by Section 117.001 of the Texas
Business &Commerce Code, in this state.
49. Enforcement of Certain Federal Firearms Laws Prohibited
In accordance with House Bill 957, Acts 2021, 87th Leg., R.S.,if Texas Government
Code, Section 2.101 is applicable to Contractor, Contractor certifies that it is not
ineligible to receive state grant funds pursuant to Texas Government Code, Section
2.103.
50. Prohibition on Abortions
Contractor understands, acknowledges, and agrees that,pursuant to Article II of the
General Appropriations Act, (1) no funds shall be used to pay the direct or indirect costs
(including marketing, overhead, rent,phones, and utilities) of abortion procedures
provided by contractors of HHSC; and(2)no funds appropriated for Medicaid Family
Planning,Healthy Texas Women Program, or the Family Planning Program shall be
distributed to individuals or entities that perform elective abortion procedures or that
contract with or provide funds to individuals or entities for the performance of elective
abortion procedures. Contractor represents and warrants that it is not ineligible, nor will it
be ineligible during the term of this Contract, to receive appropriated funding pursuant to
Article II.
51. Hardening of State Government
Pursuant to Executive Order GA-48, relating to hardening of state government, issued
November 19, 2024, Contractor certifies it is not and, if applicable, any of its holding
companies or subsidiaries is not:
a. Listed in Section 889 of the 2019 National Defense Authorization Act(NDAA);
or
b. Listed in Section 1260H of the 2021 NDAA; or
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C. Owned by the government of a country on the U.S. Department of Commerce's
foreign adversaries list under 15 C.F.R. § 791.4; or
d. Controlled by any governing or regulatory body located in a country on the U.S.
Department of Commerce's foreign adversaries list under 15 C.F.R. § 791.4.
52. Artificial Intelligence Disclosure.
Contractor certifies that it has disclosed in writing to System Agency each artificial
intelligence system it may use to complete any deliverable or a portion of any deliverable
under the Contract. "Artificial intelligence system"means a machine-based system that
for explicit or implicit objectives infers from provided information a method to generate
outputs, such as predictions, content,recommendations, or decisions, to influence a
physical or virtual environment with varying levels of autonomy and adaptiveness after
deployment. Contractor promises not to use an artificial intelligence system to perform
the Contract without the prior written consent of System Agency.
53. Surveillance,Intimidation, and Related Acts.
Contractor certifies that it(and its subcontractors)have not, and if awarded a contract,
will not, either directly or indirectly through a third party, engage in surveillance
targeting or engage in an act of intimidation, coercion, extortion, undue influence, or
other similar conduct intended to influence, silence, or retaliate against:
(1) a member of the state legislature or person employed to support the state
legislature in any capacity;
(2) a family member of a person described by(1);
(3) a state agency employee; or
(4) an individual making a complaint or raising concerns regarding state
agency operations or contracting.
Contractor certifies that it and its subcontractors have not, and if awarded a contract will
not, either directly or indirectly through a third party,use private or confidential
information to manipulate or influence a state contracting decision or proceeding.
Contractor acknowledges that it, its executives and directors, and other associated entities
and individuals could be terminated,barred from state contracts, and penalized up to $2
million for a violation of Government Code, Section 2261.302.
54. False Representation
Contractor understands, acknowledges, and agrees that any false representation or any
failure to comply with a representation,warranty, or certification made by Contractor is
subject to all civil and criminal consequences provided at law or in equity including,but
not limited to, immediate termination of this Contract.
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55. False Statements
Contractor represents and warrants that all statements and information prepared and
submitted by Contractor in this Contract and any related Solicitation Response are
current, complete,true, and accurate. Contractor acknowledges any false statement or
material misrepresentation made by Contractor during the performance of this Contract
or any related Solicitation is a material breach of contract and may void this Contract.
Further, Contractor understands, acknowledges, and agrees that any false representation
or any failure to comply with a representation,warranty, or certification made by
Contractor is subject to all civil and criminal consequences provided at law or in equity
including, but not limited to, immediate termination of this Contract.
56. Permits and License
Contractor represents and warrants that it will comply with all applicable laws and
maintain all permits and licenses required by applicable city, county, state, and federal
rules, regulations, statutes, codes, and other laws that pertain to this Contract.
57. Equal Employment Opportunity
Contractor represents and warrants its compliance with all applicable duly enacted state
and federal laws governing equal employment opportunities.
58. Federal Occupational Safety and Health Law
Contractor represents and warrants that all articles and services shall meet or exceed the
safety standards established and promulgated under the Federal Occupational Safety and
Health Act of 1970, as amended(29 U.S.C. Chapter 15).
59. Signature Authority
Contractor represents and warrants that the individual signing this Contract Affirmations
document is authorized to sign on behalf of Contractor and to bind the Contractor.
Signature Page Follows
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Authorized representative on behalf of Contractor must complete and sign the following:
City of Port Arthur
Legal Name of Contractor
Assumed Business Name of Contractor, if applicable (d/b/a or `doing business as')
Texas County(s)for Assumed Business Name (d/b/a or`doing business as')
Attach Assumed Name Certificate(s)filed with the Texas Secretary of State and Assumed
Name Certificate(s),if any,for each Texas County Where Assumed Name Certificate(s) has
been filed.
Signed by:
itAji{L SKAigiv March 31,2026
`-Stgiinture4of Authorized Representative Date Signed
Judith Smith Director of Health Services
Printed Name of Authorized Representative Title of Authorized Representative
First, Middle Name or Initial, and Last Name
5860 9th Avenue Port Arthur,Texas,77642
Physical Street Address City, State,Zip Code
5860 9th Avenue Port Arthur,Texas,77642
Mailing Address,if different City, State,Zip Code
(409)983-88352 (409)983-8832
Phone Number Fax Number
judith.smith@portarthurtx.gov 13734909
Email Address DUNS Number
174600418550-011 74-6001885
Federal Employer Identification Number Texas Identification Number(TIN)
1-74-6001855-0 17460018850-11
Texas Franchise Tax Number Texas Secretary of State Filing
Number
EMVNEFW2KN4
SAM.gov Unique Entity Identifier(UEI)
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�,* TEXAS Texas Department of State
� �:Health and Human
Z t ' Services Health Services
Fiscal Federal Funding Accountability and
Transparency Act ( FFATA)
The certifications enumerated below represent material facts upon which DSHS relies when
reporting information to the federal government required under federal law. If the Department
later determines that the Contractor knowingly rendered an erroneous certification, DSHS may
pursue all available remedies in accordance with Texas and U.S. law. Signor further agrees that
it will provide immediate written notice to DSHS if at any time Signor learns that any of the
certifications provided for below were erroneous when submitted or have since become
erroneous by reason of changed circumstances. If the Signor cannot certify all of the
statements contained in this section, Signor must provide written notice to DSHS
detailing which of the below statements it cannot certify and why.
Legal Name of Contractor: FFATA Contact: (Name, Email and Phone Number):
City of Port Arthur Lynda Boswell, MA, ICMA-CM
5860 9th Avenue lynda.boswell@portarthurtx.gov
Port Arthur, Texas 77640 (409)983-8186
Primary Address of Contractor: Zip Code: 9-digits required www.usas.com
EMVNEFW2KN4 77642-6011
Unique Entity ID (UEI): This number replaces the DUNS State of Texas Comptroller Vendor Identification Number
www.sam.qov (VIN) - 14 digits:
EMVNEFW2KN4 17460018550-011
Printed Name of Authorized Representative: Signature of Authorized Representative
(—Signed by:
Judith Smith I 1
jttid,l{L S'Wlt{u,
Title of Authorized Representative .BeeteFSit�fi AED30471...
Director of Health Services March 31,2026
1
Department of State Health Services Form 4734—April 2022
Contract Management Section
Docusign Envelope ID:2E543BDC-8683-45A6-8FF3-D6EB14660FDD
Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
As the duly authorized representative (Signor) 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.
Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax
year? Yes No®
If your answer is "Yes", skip questions "A", "B", and "C" and finish the certification. If your answer is "No",
answer questions "A" and "B".
A. Certification Regarding % 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? Yes ❑ No x
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 n No
If your answer is "Yes" to both question "A" and "B", you must answer question "C".
If your answer is "No" to either question "A" or "B", skip question "C" and finish the certification.
C. Certification Regarding Public Access to Compensation Information.
Does the public have access to information about the compensation of the 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? Yes n No
If your answer is "Yes" to this question, where can this information be accessed?
Through Open Records Requests
If your answer is "No" to this question, you must provide the names and total compensation of
the top five highly compensated officers below.
Provide compensation information here:
2
Department of State Health Services Form 4734-April 2022
Contract Management Section
0 docusign
Certificate Of Completion
Envelope Id:2E543BDC-8683-45A6-8FF3-D6EB14660FDD Status:Sent
Subject:Please DocuSign HHS001439500029 City of Port Arthur Amendment 5 CPS-PHEP
Source Envelope:
Document Pages:33 Signatures:2 Envelope Originator:
Certificate Pages:2 Initials:0 CMS Internal Routing Mailbox
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Envelopeld Stamping:Enabled #100
Time Zone:(UTC-06:00)Central Time(US&Canada) Reston,VA 20190
CMS.InternalRouting@dshs.texas.gov
IP Address: 167.137.1.8
Record Tracking
Status:Original Holder:CMS Internal Routing Mailbox Location:DocuSign
3/30/2026 11:31:26 AM CMS.InternalRouting@dshs.texas.gov
Signer Events Signature Timestamp
Judith Smith Signed by: Sent:3/30/2026 11:40:40 AM
judith.smith@portarthurtx.gov ittkitt, SwNttu Viewed:3/30/2026 12:30:41 PM
•—F848504AED3047t.
Director of Health Services Signed:3/31/2026 12:05:03 PM
City of Port Arthur
Security Level:Email,Account Authentication Signature Adoption:Pre-selected Style
(None) Using IP Address:71.40.211.219
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Ron Burton Sent:3/31/2026 12:05:07 PM
ron.burton@portarthurtx.gov
City Manager
City of Port Arthur
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Michael Montgomery
Michael.Montgomery1@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Patty Melchior
Patty.Melchior@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
David Gruber
David.Gruber@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Erika Flores COPIED Sent:3/30/2026 11:40:41 AM
erika.flores@portarthurtx.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
CMS Internal Routing Mailbox
CMS.InternalRouting@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Fred L.Waterman
Fred.Waterman@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 3/30/2026 11:40:41 AM
Payment Events Status Timestamps