HomeMy WebLinkAboutPR 19047: RENEWAL OF THE DEPT. OF STATE HEALTH SERVICES PUBLIC HEALTH EMERGENCY PREPAREDNESS PROGRAM FOR FY 2016 Arts
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DATE: June 26, 2015
To: Brian McDougal, City Manager
From: Judith A. Smith, RN, BSN (�
RE: P.R. No. 19047 Renewal of the Department of State Health Services Public Health
Emergency Preparedness Program for FY 2016
Nature of the Request: This contact renewal for FY 2016 between the City of Port Arthur and
the Department of State Health services Public Health Emergency Preparedness Program will
continue to allow the City of Port Arthur Health Department to perform and support activities
and develop interventions to prevent human illness related to chemical, biological, radiological
agents, naturally occurring health threats and other public health emergencies. The contract term
is from July 1, 2015 through June 30, 2016. This award is for $100,296 and includes a 10%cash
or in-kind match.
Staff Analysis, Considerations: This funding supports salaries and fringe for one full time
employee.
Recommendations: It is recommended that the City Council approve P.R.No.19047 authorizing
the City Manager and the City Health Director to execute the contract between the City of Port
Arthur and the Department of State Health Services Public Health Emergency Preparedness
Program in the amount of$100,296.
Budget Considerations: This will be no effect to the city budget and the 10%match will be in-
kind.
"REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHUR"
P.O. BOX 1089•PORT ARTIIUR,TX 77641-1089.409/983-8101•FAX 409/982-6743
P. R. NO. 19047
06/26/15-js
RESOLUTION NO.
A RESOLUTION APPROVING THE FY 2015-2016 CONTRACT
BETWEEN THE CITY OF PORT ARTHUR AND THE
DEPARTMENT OF STATE HEALTH SERVICES FOR THE
PUBLIC HEALTH EMERGENCY PREPAREDNESS PROGRAM
IN THE AMOUNT OF $100,296.00
WHEREAS, the contract between the City of Port Arthur and the Department of
State Health Services provides financial assistance to the Port Arthur City Health
Department to supplement the delivery of public health services; and,
WHEREAS, the FY 2015-2016 contract will allow the City of Port Arthur to
prepare and respond to bioterrorism, outbreaks of infectious disease, and other public
health threats and emergencies in accordance with an established set of public health
preparedness capabilities; and,
WHEREAS, the contract award is $100,296 for the period July 1, 2015 through
June 30, 2016 and requires a 10%cash or in-kind match of$10,029.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF PORT ARTHUR:
Section 1. That, the facts and opinions are true and correct.
Section 2. That, the City Council of the City of Port Arthur hereby approves
the contract between the City of Port Arthur and the Department of State Health Services
for the Public Health Preparedness Program.
P.R.NO. 19047
06/26/2015-js
Section 3. That, the City Council deems it is in the best interest of the City to
approve and authorize the City Manager and the Director of the City's Health
Department to execute the contract between the Department of State Health Services and
the City of Port Arthur, Texas, in substantially the same form as attached hereto as
Exhibit "A".
Section 4. 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 July, 2015.
A.D., at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the
following Vote:
AYES: Mayor:
Council members:
NOES:
Mayor
ATTEST:
Sherri Bellard, City Secretary
P. R. NO. 19047
Page 3
APPROVE 1 AS TO FORM:
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V: Tizeno, City A4 ey
APPROVED FOR ADMINISTRATION:
9,cuitik .jn mai')
Brian McDougal, City Manager *With A. Smith, RN, BSN
Director of Health Services
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DEPARTMENT OF STATE HEALTH SERVICES
CONTRACT 2016-001230-00
This Contract is entered into by and between the Department of State Health Services (DSHS or
the Department), an agency of the State of Texas, and Port Arthur Health Department (Contractor),
a Governmental, (collectively, the Parties) entity.
1. Purpose of the Contract: DSHS agrees to purchase, and Contractor agrees to provide,
services or goods to the eligible populations.
2. Total Amount: The total amount of this Contract is $100,296.00.
3. Funding Obligation: This Contract is contingent upon the continued availability of funding. If
funds become unavailable through lack of appropriations, budget cuts, transfer of funds between
programs or health and human services agencies, amendment to the Appropriations Act, health
and human services agency consolidation, or any other disruptions of current appropriated funding
for this Contract, DSHS may restrict, reduce, or terminate funding under this Contract.
4. Term of the Contract: This Contract begins on 07/01/2015 and ends on 06/30/2016. DSHS
has the option, in its sole discretion, to renew the Contract. DSHS is not responsible for payment
under this Contract before both parties have signed the Contract or before the start date of the
Contract, whichever is later.
5. Authority: DSHS enters into this Contract under the authority of Health and Safety Code,
Chapter 1001.
6. Program Name: CPS/HAZARDS Public Health Emergency Preparedness (PHEP)
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7. Statement of Work:
A. Contractor shall perform activities in support of the Public Health Emergency Preparedness Cooperative
Agreement(Funding Opportunity Number CDC-RFA-TP12-12010402CONT15) from the Centers for
Disease Control and Prevention (CDC). CDC's five-year Public Health Emergency Preparedness (PHEP)
— Hospital Preparedness Program (HPP) Cooperative Agreement seeks to align PHEP and HPP
programs and advance public health and healthcare preparedness. Contractor shall perform the activities
required under this Program Attachment in the Service Area designated in the most recent version of
Section 8. "Service Area" of this contract.
B. Identify the appropriate jurisdictional partners to address the emergency preparedness, response, and
recovery needs of older adults regarding public health, medical and mental health behavioral needs and
address processes and accomplishments to meet the needs of older adults.
C. Provide DSHS with situational awareness data generated through interoperable networks of electronic
data systems,
D. Contractor shall address public health preparedness capabilities including, but not limited to the
contractor's work plan submitted to DSHS as provided for in Section 7. "Statement of Work" (0) of this
contract.
1. Capability 1 —Community Preparedness is the ability of communities to prepare for, withstand, and
recover— in both the short and long terms—from public health incidents.
2. Capability 2 —Community Recovery is the ability to collaborate with community partners, e.g., healthcare
organizations, business, education, and emergency management) to plan and advocate for the rebuilding
of public health, medical, and mental/behavioral health systems to at least a level of functioning comparable
to pre-incident levels and improved levels where possible.
3. Capability 3— Emergency Operations Center Coordination is the ability to direct and support an event
or incident with public health or medical implications by establishing a standardized, scalable system of
oversight, organization, and supervision consistent with jurisdictional standards and practices with the
National Incident Management System.
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
responders.
5. Capability 5— Fatality Management is the ability to coordinate with other organizations (e.g., law
enforcement, healthcare, emergency management, and medical examiner/coroner) to ensure the proper
recovery, handling, identification, transportation, tracking, storage, and disposal of human remains and
personal effects; certify cause of death, and facilitate access to mental/behavioral health services to the
family members, responders, and survivors of an incident.
6. Capability 6— Information Sharing is the ability to conduct multijurisdictional, multidisciplinary exchange
of health-related information and situational awareness data among federal, state, local, territorial, and
tribal levels of government, and the private sector. This capability includes the routine sharing of information
as well as issuing of public health alerts to federal, state, local, territorial, and tribal levels of government
and the private sector in preparation for and in response to events or incidents of public health significance.
7. Capability 7— Mass Care is the ability to coordinate with partner agencies to address the public health,
medical, and mental/behavioral health needs of those impacted by an incident at a congregate location.
This capability includes the coordination of ongoing surveillance and assessment to ensure that local health
needs to continue to me met as the incident evolves.
8. Capability 8 — Medical Countermeasure Dispensing is the ability to provide medical countermeasures
(including vaccines, antiviral drugs, antibiotics, antitoxin, etc.) in support of treatment or prophylaxis (oral or
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vaccination) to the identified population in accordance with public health guidelines and/or
recommendations.
9. Capability 9— Medical Materiel Management and Distribution is the ability to acquire, maintain (e.g.,
cold chain storage or other storage protocol), transport distribute, and track medical materiel (e.g.,
pharmaceuticals, gloves, masks, and ventilators) during an incident and to recover and account for unused
medical materiel, as necessary, 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 healthcare system to survive a hazard impact and maintain or rapidly recover operations
that were compromised.
11. Capability 11 — Non-Pharmaceutical Interventions are the ability to recommend to the applicable lead
agency (if not public health) and implement, if applicable, strategies for disease, injury, and exposure
control. Strategies include the following: isolation and quarantine; restrictions on movement and travel
advisory/warnings; social distancing; external decontamination; hygiene; and precautionary behaviors.
12. Capability 12— Public Health Laboratory Testing is the ability to conduct rapid and conventional
detection, characterization, confirmatory testing, data reporting, investigative support, and laboratory
networking to address actual or potential exposure to all-hazards. Hazards include chemical, radiological,
and biological, and biological agents in multiple matrices that may include clinical samples, food, and
environmental samples (e.g., water, air, and soil). This capability supports routine surveillance, including
pre-event incident and post-exposure activities.
13. Capability 13 — Public Health Surveillance and Epidemiological Investigations is the ability to create,
maintain, support, and strengthen routine surveillance and detection systems and epidemiological
investigation processes, as well as to expand these systems and processes in response to incidents of
public health significance.
14. Capability 14— Responder Safety and Health describes the ability to protect public health agency staff
responding to an incident and the ability to support the health and safety needs of hospital and medical
facility personnel, if requested.
15. Capability 15—Volunteer Management is the ability to coordinate the identification, recruitment,
registration, credential verification, training, and engagement of volunteers to support the jurisdictional
public health agency's response to incidents of public health significance.
E. Contractor will not exceed the total amount of this Contract without DSHS prior approval, which will be
evidenced by the Parties executing a written amendment.
F. Contractor will comply with all applicable federal and state laws, rules, and regulations including, but not
limited to, the following:
1. Public Law 107-188, Public Health Security and Bioterrorism Preparedness and Response Act of 2002;
2. Public Law 113-05, Pandemic and All-Hazards Preparedness Reauthorization Act; and
3. Texas Health and Safety Code Chapter 81.
G. Contractor will comply with all applicable regulations, standards and guidelines in effect on the beginning
date of the Term of this Contract.
H. The Parties have the authority under Texas Government Code Chapter 791 to enter into this Interlocal
Cooperation Contract.
I. Funds awarded for this Contract must be matched by 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
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plant, equipment, or services. The costs that the Contractor incurs in fulfilling the matching or cost-sharing
requirement are subject to the same requirements, including the cost principles, that are applicable to the
use of Federal funds, including prior approval requirements and other rules for allowable costs as
described in 45 CFR 74.23 and 45 CFR 92.24.
J. The Contractor is required to provide matching funds for this Contract not less than ten-percent of the
allocation amount. Cash match is defined as an expenditure of cash by the contractor on allowable costs of
this Contract that are borne by the contractor. 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 Contract's project and that are contributed by non-federal third parties without charge to the contractor.
The criteria for match must:
1. Be an allowable cost under the applicable federal cost principle;
2. Be necessary and reasonable for the efficient accomplishment of project or program objectives;
3. Be verifiable within the contractor's (or subcontractor'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 Contract;
8. Be adequately documented;
9. Must follow procedures for generally accepted accounting practices as well as meet audit requirements;
and
10. Value the in-kind contributions reported and must be supported by documentation reflecting the use of
goods and/or services during the Contract term.
K. In the event of a public health emergency involving a portion of the state Contractor will mobilize and
dispatch staff or equipment purchased with funds from previous PHEP cooperative agreements and not
performing critical duties in the jurisdiction served, to the affected area of the state upon receipt of a written
request from DSHS.
L. Contractor will inform DSHS in writing if Contractor will not continue performance under this Contract
within 30 days of receipt of an amended standard(s) or guideline(s). DSHS may terminate this Contract
immediately or within a reasonable period of time as determined by DSHS.
M. Contractor will develop, implement and maintain a timekeeping system for accurately documenting staff
time and salary expenditures for all staff funded through this Contract, including partial full-time employees
and temporary staff.
N. DSHS reserves the right, where allowed by legal authority, to redirect funds in the event of financial
shortfalls. DSHS will monitor Contractor's expenditures on a quarterly basis. If expenditures are below that
projected in Contractor's total Contract amount, Contractor's budget may be subject to a decrease for the
remainder of the Term of the Contract. Vacant positions existing after ninety days may result in a decrease
in funds.
0. The Contractor will:
1. Submit programmatic reports as directed by DSHS in a format specified by DSHS. Contractor will
provide DSHS other reports, including financial reports, and any other reports that DSHS determines
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necessary to accomplish the objectives of this contract and to monitor compliance;
2. Submit Performance Measures to DSHS within an established timeframe designated by DSHS as
required by the CDC.
3. Submit the Mitigation Plan due to DSHS within an established timeframe designated by DSHS;
4. Submit the Emergency Support Function 8 plans developed in accordance with the Texas Department of
Emergency Management (TDEM) and DSHS Planning Standards within 30 days of request from DSHS.
5. Submit by the last day of every month a list of all reported clusters and information on investigation
findings on the tracking sheet provided by the DSHS
6. Submit a current Multi-Year Training & Exercise Plan that covers FY16 through FY21 to DSHS by July 6,
2015, using the template provided by DSHS. In accordance with HSEEP guidelines, contractors must
conduct or participate in a Multi-year Training and Exercise Workshop with all applicable agencies and
submit an agenda and a participant roster as documentation of attendance.
7. Complete and submit the Operational Readiness Review (ORR) provided by DSHS to DSHS SNS
SharePoint 20 business days prior to review;
a. Provide updated Point of Dispensing (POD) standards data for submission to DSHS SNS SharePoint
by April 1, 2016;
b. Perform and submit metrics on three SNS operation drills (at pre-identified POD locations and existing
call down rosters) and submit After Action Reviews/Improvements sixty days after completion of the drill or
by April 1, 2016. Acceptable drills include:
I. Staff Call Down;
ii. Facility Set-up;
iii. POD Activation;
iv. Dispensing Throughput; and
v. RealOpt usage;
c. Submit above items listed in 7 (b)to PreparednessExercise@dshs.state.tx.us by April 1, 2016.
8. Submit the Mid-Year Report due to DSHS within an established timeframe designated by DSHS.
9. Complete an End-Of-Year performance report in a format specified by DSHS no later than August 15,
2016.
10. Conduct or participate in, at least, one Preparedness Exercise which includes evaluation of capabilities
and objectives in accordance to the Contractor's exercise plan and developed in accordance with
Homeland Security Exercise and Evaluation Program (HSEEP) standards. Contractor will submit to DSHS
an exercise notification following the Concept and Objectives meeting in accordance with timeframes
established in DSHS Exercise Guidance. A joint after action report/improvement plan must be submitted
within 60 days of the exercise to the DSHS Exercise Team mailbox
(preparednessexercise@dshs.state.tx.us). The After Action Report must also include a Corrective Action
Plan. These exercises may include a tabletop exercise, a functional exercise, or a full-scale exercise to test
preparedness and response capabilities, but not associated with Strategic National Stockpile (SNS).
11. Designate a member of the PHEP program to attend, in person, the PHEP all four quarterly meetings
of the contract term. If the designee is unable to attend the first meeting in person, the Contractor must
petition DSHS in writing requesting an exemption and proposal for attending a subsequent quarterly
meeting.
12. Complete all additional reporting requirements. Due dates will be listed in the most current DSHS
reporting schedule, to be released no later than August 3, 2015.
13. If Contractor is legally prohibited from providing any report under this Contract, Contractor will
immediately notify DSHS in writing.
P. In the event of another local, state, or federal emergency the Contractor has the authority to utilize
approximately five percent of the Contractor's staff's time supporting this Program Attachment for response
efforts. DSHS shall reimburse Contractor up to five percent of this Program Attachments funded by CDC
for personnel costs responding to an emergency event. Contractor shall maintain records to document the
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time spent on response efforts for auditing purposes. Allowable activities also include participation of drills
and exercises in the pre-event time period. Contractor shall notify the Assigned Contract Manager in
writing when this provision is implemented.
Q. For the purposes of this Contract, the Contractor may not use funds for research, clinical care,
fund-raising activities or lobbying, construction or major renovations, for 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, funding an award to another party or provider who is ineligible.
R. Contractor shall only expend funds for reasonable program purposes, including personnel, travel,
supplies, and services, such as contractual.
S. Contractor shall cooperate with DSHS to coordinate all planning, training and exercises performed
under this Program Attachment with local emergency management and the Texas Division of Emergency
Management (TDEM) District Coordinators assigned to the contractor's sub-state region, 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.
T. Contractor shall coordinate all risk communication activities with the DSHS Communications Unit by
using DSHS's core messages posted on the DSHS website, and submitting copies of draft risk
communication materials to DSHS for coordination prior to dissemination.
U. Volunteer Management (Capability 15): If Contractors are using volunteers, such as Medical Reserve
Corps or Strategic National Stockpile (SNS) point of dispensing volunteers, and then Contractors must use
the Texas Disaster Volunteer Registry (TDVR), Texas' version of the Emergency System for the Advanced
Registration of Volunteer Health Professionals (ESAR-VHP) system as their main volunteer management
tool.
PERFORMANCE MEASURES:
A. DSHS will monitor the Contractor's compliance with the requirements in Section 7 and this Contract and
failure to meet these requirements may result in withholding a portion of any subsequent PHEP base
awards.
B. The initial reporting requirements for the performance measures are subject to change as DSHS and
CDC may modify performance measures and due dates. DSHS will provide notification to the Contractor
of any changes under this Section.
BILLING INSTRUCTIONS:
Contractor will request payment using the State of Texas Purchase Voucher(Form B-13) on a monthly
basis and acceptable supporting documentation for reimbursement of the required services/deliverables.
Additionally, the Contractor will submit the Financial Status Report (FSR-269A). Vouchers, supporting
documentation and Financial Status Report should be mailed or emailed to the addresses below.
Claims Processing Unit, MC1940
Texas Department of State Health Services
1100 West 49th Street
PO Box 149347
Austin, TX 78714-9347
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B-13: invoices@dshs.state.tx.us
Php.vouchersupport@dshs.state.tx.us
Support Document: invoices@dshs.state.tx.us
Php.vouchersupport@dshs.state.tx.us
B-13A: invoices@dshs.state.tx.us
Php.vouchersupport@dshs.state.tx.us
FSR: invoices@dshs.state.tx.us
Php.vouchersupport@dshs.state.tx.us
FSRGrants@dshs.state.tx.us
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r ,
8. Service Area
Jefferson County
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10. Procurement method:
Non-Competitive Interagency/Interlocal
GST-2012-Solicitation-00043 RLHS GOLIVE HAZARDS PROPOSAL
11. Renewals:
Number of Renewals Remaining: 1 Date Renewals Expire: 06/30/2017
12. Payment Method:
Cost Reimbursement
13. Source of Funds:
93.069, 93.069
14. DUNS Number:
137134909
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This section intentionally left blank.
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16. Special Provisions
A. Contractor will submit final close-out bill or revisions to previous reimbursement request(s) no later than
August 15, 2016. No expenditures with service dates from July 1, 2015 to June 30, 2016 will be paid after
August 15, 2016 from the Budget Period 4(BP4) allocation. This Subsection supersedes Section 4.03 of
the Fiscal Year 2016 Department of State of Health Services General Provisions (Core/Sub Recipient).
B. DSHS will monitor Contractor's billing activity and expenditure reporting on a quarterly basis. Based on
these reviews, DSHS may reallocate funding between contracts to maximize use of available funding.
C. General Provisions, Access and Inspection Article XI, Access Section 11.01 is hereby revised to include
the following:
In addition to the site visits authorized by this Article of the General Provisions, Contractor shall allow DSHS
to conduct on-site quality assurance reviews of Contractor. Contractor shall comply with all DSHS
documentation requests and on-site visits. Contractor shall make available for review all documents related
to the Program Attachment, upon request by the DSHS Program staff.
D. General Provisions, General Business Operations of Contractor Article XIV, Equipment Purchases
(Including Controlled Assets), Section 14.20, is revised as follows:
Contractor is required to initiate the purchase of approved equipment no later than June 30, 2016 as
documented by issue of a purchase order or written order confirmation from the vendor on or before June
30, 2016. In addition, all equipment must be received no later than 45 calendar days following the end of the
Program Attachment term.
E. General Provisions, General Terms Article XV, Amendment Section 15.15, is amended to include the
following:
Contractor must submit all amendment and revision requests in writing to the Division Contract Management
Unit at least 90 days prior to the end of the term of this Program Attachment.
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17. Documents Forming Contract. The Contract consists of the following:
a. Contract (this document) 2016-001230-00
b. General Provisions Subrecipient General Provisions
c. Attachments Budget
d. Declarations Certification Regarding Lobbying, Fiscal Federal Funding
Accountability and Transparency Act (FFATA) Certification
e. Exhibits
Any changes made to the Contract, whether by edit or attachment, do not form part of the Contract
unless expressly agreed to in writing by DSHS and Contractor and incorporated herein.
18. Conflicting Terms. In the event of conflicting terms among the documents forming this Contract, the
order of control is first the Contract, then the General Provisions, then the Solicitation Document, if any, and
then Contractor's response to the Solicitation Document, if any.
19. Payee. The Parties agree that the following payee is entitled to receive payment for services rendered
by Contractor or goods received under this Contract:
Name: Port Arthur City Health Dept
Vendor Identification Number: 17460018850
20. Entire Agreement. The Parties acknowledge that this Contract is the entire agreement of the Parties
and that there are no agreements or understandings, written or oral, between them with respect to the
subject matter of this Contract, other than as set forth in this Contract.
I certify that I am authorized to sign this document and I have read and agree to all parts of the contract,
Department of State Health Services Port Arthur Health Department
By: By:
Signature of Authorized Official Signature of Authorized Official
Date Date
Name and Title Name and Title
1100 West 49th Street
Address Address
Austin, TX 78756-4204
City, State, Zip City, State, Zip
Telephone Number Telephone Number
E-mail Address E-mail Address
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Budget Summary
Organization Name: Port Arthur Health Department Program ID: CPS/HAZARDS
Contract Number: 2016-001230-00
Budget Categories
Budget Categories DSHS Funds Cash Match In Kind Match Category Total
Requested Contributions
Personnel $62,796.00 $0.00 $0.00 $62,796.00
Fringe Benefits $28,899.00 $0.00 $0.00 $28,899.00
Travel $5,713.00 $4,179.00 $0.00 $9,892.00
Equipment $0.00 $0.00 $0.00 $0.00
Supplies $250.00 $5,098.00 $0.00 $5,348.00
Contractual $0.00 $0.00 $0.00 $0.00
Other $2,638.00 $753.00 $0.00 $3,391.00
Total Direct Costs $100,296.00 $10,030.00 $0.00 $110,326.00
Indirect Costs $0.00 $0.00 $0.00 $0.00
Totals $100,296.00 $10,030.00 $0.00 $110,326.00
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CERTIFICATION REGARDING LOBBYING
Organization Name: Port Arthur Health Department
Contract Number: 2016-001230-00
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief that:
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or an employee of any agency, a
member of congress, an officer or employee of congress, or an employee of a member of congress
in connection with the awarding of any federal contract, the making of any federal grant, the making
of any federal loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a member of congress
federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit,
an officer or employee of congress, or an employee of a member of congress in connection with this
Standard Form-11, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to
file the required certification shall be subject to a civil penalty of not less that$10,000 and not more
than $100,000 for each such failure.
x Applicable Non-Applicable
Signature of Authorized Individual Date:
Mrs. Judith Smith 06/19/2015
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Fiscal Federal Funding Accountability and Transparency Act (FFATA) Certification
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.
Organization Name Port Arthur Health Department
Address 449 Austin Avenue State Texas
City Port Arthur Zip Code (9 digit) 77640
Payee Name Port Arthur City Health Dept
Address 449 Austin Ave State TX
City Port Arthur Zip Code (9 digit) 77640-0000
Vendor Identification No. 17460018850 MailCode 011
Payee DUNS No. 137134909
1. Did your organization have a gross income, from all sources, of more than $300,000 in your previous tax
year?
X Yes No
2. 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?
X Yes No
3. 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 X No
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4. 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 No
If Yes, where can this information be found?
If No, you must provide the names and total compensation of the top five highly compensated officers.
Example: John BIum:500000;Mary Redd:50000;Eric Gant:400000;Todd Platt:300000;Sally Tom:300000
Identify contact persons for FFATA Correspondence
FFATA Contact Person #1
Name Deborah Echols
Email deborah.echols@portarthurtx.gov
Telephone (409) 983-8174
FFATA Contact Person #2
Name Judith Smith, RN
Email judith.smith@portarthurtx.gov
Telephone (409) 983-8832
X As the authorized representative of the Organization, I hereby certify that the statements
made by me in this certification form are true, complete and correct to the best of my
knowledge.
E-Signature Date
Mrs. Judith Smith 06/19/2015
Page 17 of 17
IntelliGrants TXDSHS - Document Page Page 2 of 3
BUDGET SUMMARY
Organization Name:Port Arthur Health Department Program ID: CPS/HAZARDS
Contract Number: 2016-001230-00 Procurement ID: GST-2012-Solicitation-00043
Proposal ID: RLHS-2016-CPS/HAZARD-00036 Procurement Name:RLHS GOLIVE HAZARDS PROPOSAL
Budget Categories
Budget Categories DSHS Funds Cash Match In Kind Category Total
Requested Match
rcr
Personnel $62,796 SO $0 $62,796
Fringe Benefits $28,899 SO $0 $28,899
Travel $5,713 $4,179 $0 $9,892
Equipment $0 $0 $0 $0
Supplies $250^ $5,098 $0 $5,348
Contractual $0 $0 $0 $0
Other $2,638 $753 $0 $3,391
Total Direct Costs $100,296 $10,030 $01 $110,326
Indirect Costs $0 $0 $0 $0
Totals: $100,296 $10,030 $0 $110,326
Subcontracting
Subcontracting Percentage: 0.00%
Match Contributions
Required Match Percentage: 10.00% Calculated Match Percentage:10.00%
Required Match Amount: $10,030 Calculated Match Amount: $10,030
Source of Cash Match Funds
Travel,Supplies,and Other costs
33 of 500
Source of In Kind Match Funds
i f
_j
0 of 500
Program Income
Projected Earnings: — $OIL
Source of Earnings
i 1
n
V
0 of 500
Non DSHS Funding
Direct Federal Funds: $0
Other State Agency Funds: $0
Local Funding Sources: $0
Other Funds: $0
Total Projected Non DSHS Funding:$0
https://egrants.dshs.texas.gov/ObjectPage2.aspx?ornnlD=101256&pgeID=19570 6/26/2015