HomeMy WebLinkAboutPR 19205: TO ACCEPT A ONE TIME DISCRETIONARY ADDITIONAL GRANT FUNDS FROM THE TDSHS, PREPAREDNESS rswv
City of
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Texas
DATE: October 26, 2015
To: Brian McDougal, City Manager
From: Judith A. Smith, RN, BSN
RE: Authorization to Accept One Time Discretionary Unique Grant Funds from the Texas
Department of State Health Services.
Nature of the Request: The Texas Department of State Health Services is releasing funds for a
PHEP Supplement to help fund activities that aligns with one or more of the 15 Public Health
Emergency Preparedness capabilities. These capabilities are listed on page 2 of the contract. This
is a one-time discretionary grant funding. The total amount of this contract is $38,717 and will
run from 11/05/2015 to 06/30/2016. The health department will utilize these funds for supplies
and contractual fees to host a Public Health Emergency Symposium scheduled for 2016.
Staff Analysis, Considerations: None
Recommendations: It is recommended that the City Council approve P.R. No.19205,
authorizing the City of Port Arthur Health Department to accept additional grant funding from
the Texas Department of State Health Services to help fund activities that aligns with one or
more of the (15) fifteen Public Health Emergency Preparedness capabilities.
Budget Considerations: None
"REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHURP.O.BOX 1089•PORT ARTHUR,IX 77641-1089•
409/983-8101•FAX 409/982-6743
P. R. NO. 19205
10/26/2015-js
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE CITY OF PORT
ARTHUR TO ACCEPT A ONE TIME DISCRETIONARY
ADDITIONAL GRANT FUNDS FROM THE TEXAS
DEPARTMENT OF STATE HEALTH SERVICES PUBLIC
HEALTH PREPAREDNESS SECTION IN THE AMOUNT OF
$38,717.00.
WHEREAS, the Texas Department of State Health Services encouraged the local
health departments to apply for this one-time discretionary unique funding to help fund
activities that aligns with the (15) fifteen Public Health Preparedness capabilities. This
contract begins November 05, 2015 and ends June 30, 2016; and,
WHEREAS, the City of Port Arthur has been awarded one-time discretionary
grant funds in the amount of$38,717.00 that will be utilized to purchase additional public
health emergency supplies and host a regional Public Health Emergency Symposium that
will be scheduled for 2016.
NOW THEREFORE,BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF PORT ARTHUR:
Section 1. That,the facts and opinions in the preamble are true and correct.
Section 2. That, the City Council of the City of Port Arthur hereby authorizes
the acceptance of one-time discretionary unique grant funds in the amount of $38,717,
and authorizes the City Manager to execute this contract, in substantially the same form
as Exhibit "A."
P. R. NO. 19205
Page 2 —js
Section 3. 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 November 2015
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:
Mayor
ATTEST:
Sherri Bellard, City Secretary
APPROVED AS TO FORM:
\c'41 Tiz o, ity Attorney
APPROVED FOR ADMINISTRATION:
guctAlk intia RIYAS10
Brian McDougal, City Manager Judith Smith, RN, BSN,
Director of Health Services
DEPARTMENT OF STATE HEALTH SERVICES
CONTRACT 2016-004050-00
• r •
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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 $38,717.00.
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 11/05/2015 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: As applicable, DSHS enters into this Contract under the authority of Texas Health
and Safety Code Chapters 12 or 1001 or Texas Government Code Chapters 531, 771, 791 or
2155.
6. Program Name: CPS/OT-UNIQUE CPS —One Time Discretionary Unique Contracts
Page 1 of 16
7. Statement of Work:
STATEMENT OF WORK:
A. The Contractor will complete one time funding activities during the term of this Contract that aligns with
one or more of the 15 PHEP capabilities by performing activities that support the Public Health Emergency
Preparedness Cooperative Agreement (Funding Opportunity Number CDC-RFA-TP12-120104CONT15)
from the Centers for Disease Control and Prevention (CDC).
The total amount of this Contract will not exceed $38,717.00.
Contractor will perform the activities required under this Contract in the Service Area designated in the
most recent version of Section 8. "Service Area" of this contract.
CDC's five-year PHEP— Hospital Preparedness Program (HPP) Cooperative Agreement seeks to align
PHEP and HPP programs by advancing public health and healthcare preparedness.
B. The Contractor will address the following CDC PHEP Capabilities that are specific to the Funding
Award.
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 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 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.
Page 2 of 16
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
vaccination) to the identified population in accordance with public health guidelines and/or
recommendations.
9. Capability 9—Medical Material Management and Distribution is the ability to acquire, maintain (e.g.,
cold chain storage or other storage protocol), transport distribute, and track medical material (e.g.,
pharmaceuticals, gloves, masks, and ventilators) during an incident and to recover and account for unused
medical material, 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 is 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.
C. Contractor will not exceed the total amount of this Contract..
D. 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.
Page 3 of 16
E. The Parties have the authority under Texas Government Code Chapter 791 to enter into this Interlocal
Cooperation Contract.
F. The following documents and resources are incorporated by reference and made a part of this Contract:
1. DSHS and CDC Public Health Emergency Preparedness Cooperative Agreement, Funding Opportunity
Number: CDC-RFA-TP12-120102CONT14;
2. Public Health Preparedness Capabilities: National Standards for State and Local Planning, March
2011:
http://www.cdc.gov/phpr/capabilities/DSLR_capabilities_July.pdf;
3. Presidential Policy Directive 8/PPD-8, March 30, 2011:
http://www.hlswatch.com/wp-content/u ploads/2011/04/PPD-8-Preparedness.pdf;
4. Homeland Security Exercise and Evaluation Plan (HSEEP) Documents:
https://hseep.dhs.gov/pages/1001_HSEEP7.aspx;
5. Ready or Not? Have a Plan; Surviving Disaster: How Texans Prepare (videos):
http://www.texasprepares.org/survivingdisaster.htm; and
6. Preparedness Program Guidance(s) as provided by DSHS and CDC.
G. 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
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.
H. 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.
Page 4 of 16
I. 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 the previous PHEP cooperative agreement and that
are not performing critical duties in the jurisdiction served to the affected area of the state upon receipt of a
written request from DSHS. This provision is not applicable if the Contractor is an institution of higher
education or a poison control center.
J. Contractor will inform DSHS in writing if Contractor will not continue performance under this Contract
within thirty 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.
K. 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.
L. 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. If applicable, vacant positions existing after ninety days may result
in a decrease in funds.
M. 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
necessary to accomplish the objectives of this contract and to monitor compliance; and
2. Submit reports as requested by DSHS to satisfy information-sharing Requirements set forth in Texas
Government Code, Sections 421.071 and 421.072 (b) and (c).
If Contractor is legally prohibited from providing such reports, Contractor will immediately notify DSHS in
writing.
N. In the event of a local, state, or federal emergency the Contractor has the authority to utilize
approximately five percent of the Contractor's staff's time supporting this Contract for response efforts.
DSHS will reimburse Contractor up to five percent of this Contract funded by CDC for personnel costs
responding to an emergency event. Contractor will maintain records to document the time spent on
response efforts for auditing purposes. Allowable activities also include participation of drills and
exercises in the pre-event time period. Contractor will notify the Assigned Contract Manager in writing
when this provision is implemented.
O. For the purposes of this Contract, the Contractor may not use funds for fundraising activities, lobbying,
research, construction, major renovations, and reimbursement of pre-award costs, clinical care, purchase
of vehicles of any kind, funding an award to another party or provider who is ineligible, backfilling costs for
staff or the purchase of incentive items.
P. Contractor may transfer cumulative budget line items of 25% or less among direct cost categories, other
than equipment and indirect without prior approval from DSHS or a written amendment.
PERFORMANCE MEASURES:
Page 5 of 16
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 the current PHEP base awards.
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) and Match Reimbursement
Certification (B-13A) on a quarterly basis. Vouchers, supporting documentation, Financial Status Reports,
and Match Reimbursement Certification should be mailed or submitted by fax or email to the
addresses/number below.
Claims Processing Unit, MC1940
Texas Department of State Health Services
1100 West 49th Street
PO Box 149347
Austin, TX 78714-9347
Fax: (512) 458-7442
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
Page 6 of 16
8. Service Area
Jefferson County
Page 7 of 16
This section intentionally left blank.
Page 8 of 16
10. Procurement method:
Non-Competitive Interagency/Interlocal
GST-2016-Solicitation-00044 RLHS FY16 OT-Unique LHD NEW CONTRACT
11. Renewals:
Number of Renewals Remaining: 0 Date Renewals Expire: 06/30/2016
12. Payment Method:
Cost Reimbursement
13. Source of Funds:
93.069
14. DUNS Number:
137134909
Page 9 of 16
15. Programmatic Reporting Requirements:
Report Name Frequency Period Begin Period End Due Date
Financial Status Quarterly 11-5-2015 12-31-2015 1-31-2016
Report (FSR)
Financial Status Quarterly 1-1-2016 3-31-2016 4-30-2016
Report(FSR)
Financial Status Quarterly 4-1-2016 6-30-2016 8-15-2016
Report (FSR)
Submission Instructions:
Contractors are required to provide specific information to have an acceptable e-signature. The name and
title of the certifying official must be printed in the designated areas at the bottom of the FSR. The e-mail
with the FSR attached must then be sent by the certifying official name as stated on that FSR. Anything else
will not be accepted.
FSR: invoices@dshs.state.tx.us & Php.vouchersupport@dshs.state.tx.us & FSRGrants@dshs.state.tx.us
Page 10 of 16
expended by the end of the contract term must be refunded to DSHS.
Contractors will repay all or part of advance funds at any time during the Contract's term. However, if the
advance has not been repaid prior to the last three months of the Contract term, the contractor must deduct
at least one-third of the remaining advance from each of the last three months' reimbursement requests. If
the advance is not repaid prior to the last three months of the Contract term, DSHS will reduce the
reimbursement request by one-third of the remaining balance of the advance.
E. General Provisions, Access and Inspection Article X, Section 10.01 is revised to include the following:
In addition to the site visits authorized by this Article of the General Provisions, Contractor will allow DSHS to
conduct on-site quality assurance reviews of Contractor. Contractor will comply with all DSHS
documentation requests and on-site visits. Contractor will make available for review all documents related to
the Contract, upon request by the DSHS Program staff.
F. General Provisions, Program Equipment and Supplies Article XXII, Section 22.01, 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 and supplies must be received no later than 45 calendar days following
the end of the Contract term.
G. General Provisions, General Terms Article XIV, Amendment Section 14.12, 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 Contract.
Page 12 of 16
16. Special Provisions
SPECIAL PROVISIONS:
The Parties agree to the following changes to DSHS FY 2016 General Provisions (Core/Subrecipient).
A. General Provisions, Compliance and Reporting Article II, Applicable Laws and Regulations Regarding
Funding Sources, Section 2.06, is amended by deleting Section 2.06 in its entirety and replacing it with the
following:
When applicable, federal statutes, regulations and/or federal grant requirements applicable to funding
sources and any updates to such will apply to this Contract. Contractor agrees to comply with applicable
laws, executive orders, regulations and policies, as well as Office of Management and Budget (OMB)
Circulars (as codified in Title 2, 200 of the Code of Federal Regulations (CFR) and 45 CFR 75) the Uniform
Grant and Contract Management Act of 1981 (UGMA), Tex. Gov. Code Chapter 783, and Uniform Grant
Management Standards (UGMS), as revised by federal circulars and incorporated in UGMS by the
Comptroller of Public Accounts, Texas Procurement and Support Services Division. UGMA and UGMS can
be located through web links on the DSHS website at http://www.dshs.state.tx.us/contracts/links.shtm.
Contractor also shall comply with all applicable federal and state assurances contained in UGMS, Part III,
State Uniform Administrative Requirements for Grants and Cooperative Agreements §_.14. If applicable,
Contractor shall comply with the Federal awarding agency's Common Rule, and the U.S. Health and Human
Services Grants Policy Statement, both of which may be located through web links on the DSHS website at
http://www.dshs.state.tx.us/contracts/links.shtm. For contracts funded by block grants, Contractor shall
comply with Tex. Gov. Code Chapter 2105.
B. General Provisions, Final Invoice/Billing Submission, Section 5.03 is modified to provide that Contractor
will submit final close-out bill or revisions to previous reimbursement request(s) no later than August 15,
2016.
C. General Provisions, Compliance and Reporting, Article II, Section 2.08(a) is modified by deleting it in its
entirety and replacing it with the following language.
a. The following sections or portions of sections of these General Provisions will not apply to interagency or
interlocal contracts:
i. Hold Harmless and Indemnification, Section 14.17;
ii. Independent Contractor, Section 13.05 (delete the third sentence in its entirety; delete the word
"employees" in the fourth sentence; the remainder of the section applies);
iii. Insurance, Section 14.22;
iv. Liability Coverage, Section 25.03;
v. Fidelity Bond, Section 25.02;
vi. Historically Underutilized Businesses, Section 13.02 (Contractor, however, will comply with HUB
requirements of other statutes and rules specifically applicable to that entity);
vii. Debt to State and Corporate Status, Section 4.01;
viii. Application of Payment Due, Section 4.02; and
ix. Article XVI Claims against the Department (This Article is inapplicable to interagency contracts only).
D. General Provisions, Payment Methods and Restrictions, Article V, Section 5.01 is revised to include the
following:
Contractor may request a one-time working capital advance not to exceed 12% of the total amount of the
Contract funded by DSHS. All advances must be expended by the end of the contract term. Advances not
Page 11 of 16
17. Documents Forming Contract. The Contract consists of the following:
a. Contract (this document) 2016-004050-00
b. General Provisions 2016 General & Grant Subrecipient Additional Provisions (LHD)
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
Page 13 of 16
Budget Summary
Organization Name: Port Arthur Health Department Program ID: CPS/OT-UNIQUE
Contract Number: 2016-004050-00
Budget Categories
Budget Categories DSHS Funds Cash Match In Kind Match Category Total
Requested Contributions
Personnel $0.00 $0.00 $0.00 $0.00
Fringe Benefits $0.00 $0.00 $0.00 $0.00
Travel $0.00 $0.00 $0.00 $0.00
Equipment $0.00 $0.00 $0.00 $0.00
Supplies $24,217.00 $3,871.00 $0.00 $28,088.00
Contractual $5,500.00 $0.00 $0.00 $5,500.00
Other $9,000.00 $0.00 $0.00 $9,000.00
Total Direct Costs $38,717.00 $3,871.00 $0.00 $42,588.00
Indirect Costs $0.00 $0.00 $0.00 $0.00
Totals $38,717.00 $3,871.00 $0.00 $42,588.00
Page 14 of 16
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?
Yes X 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
Page 15 of 16
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 Judith A. Smith, RN, BSN
Email judith.smith@portarthurtx.gov
Telephone (409) 983-8832
FFATA Contact Person #2
Name Jerry W. Dale
Email jerry.dale@portarthurtx.gov
Telephone (409) 983-8174
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
Page 16 of 16
RLHS FY16 OT-Unique LHD NEW CONTRACT
Organization: Port Arthur Health Department RLHS-2016-CPS/UNIQUE-00035
Budget Summary
Organization Name: Port Arthur Health Department Program ID: CPS/OT-UNIQUE
Contract Number: 2016-004050-00 Procurement ID: GST-2016-Solicitation-0
0044
Proposal ID: RLHS-2016-CPS/UNIQUE-00035 Procurement Name: RLHS FY16 OT-Unique
LHD NEW CONTRACT
Budget Categories
DSHS Funds
Budget Categories Requested Cash Match In Kind Match Category Total
Personnel $0 $0 $0 $0
Fringe Benefits $0 $0 $0 $0
Travel $0 $0 $0 $0
Equipment $0 $0 $0 $0
Supplies $24,217, $3,871 $0 $28,088
Contractual $5,500 $0 $0 $5,500
Other $9,000 $0 $0 $9,000
Total Direct Costs $38,717 $3,871 $0 $42,588
Indirect Costs $0 $0 $0 $0
Totals: $38,717 $3,871 $0 $42,588
Subcontracting
Subcontracting Percentage: 14.21%
Match Contributions
Applicable Match Amount: $0
Required Match Percentage: 10.00%
Required Match Amount: $0 Calculated Match Amount: $3,871
Source of Cash Match Funds
Supplies used as Match.
Source of In Kind Match Funds
Program Income
Projected Earnings: $0
Source of Earnings
10/23/2015 Page 1 of 2
RLHS FY16 OT-Unique LHD NEW CONTRACT
Organization: Port Arthur Health Department RLHS-2016-CPS/UNIQUE-00035
Budget Summary
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
10/23/2015 Page 2 of 2
17. Documents Forming Contract. The Contract consists of the following:
a. Contract (this document) 2016-004050-00
b. General Provisions 2016 General & Grant Subrecipient Additional Provisions (LHD)
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
Page 13 of 16
Budget Summary
Organization Name: Port Arthur Health Department Program ID: CPS/OT-UNIQUE
Contract Number: 2016-004050-00
Budget Categories
Budget Categories DSHS Funds Cash Match In Kind Match Category Total
Requested Contributions
Personnel $0.00 $0.00 $0.00 $0.00
Fringe Benefits $0.00 $0.00 $0.00 $0.00
Travel $0.00 $0.00 $0.00 $0.00
Equipment $0.00 $0.00 $0.00 $0.00
Supplies $24,217.00 $3,871.00 $0.00 $28,088.00
Contractual $5,500.00 $0.00 $0.00 $5,500.00
Other $9,000.00 $0.00 $0.00 $9,000.00
Total Direct Costs $38,717.00 $3,871.00 $0.00 $42,588.00
Indirect Costs $0.00 $0.00 $0.00 $0.00
Totals $38,717.00 $3,871.00 $0.00 $42,588.00
Page 14 of 16
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?
n 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?
Yes n 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
Page 15 of 16
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 Judith A. Smith, RN, BSN
Email judith.smith@portarthurtx.gov
Telephone (409) 983-8832
FFATA Contact Person #2
Name Jerry W. Dale
Email jerry.dale@portarthurtx.gov
Telephone (409) 983-8174
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
Page 16 of 16
RLHS FY16 OT-Unique LHD NEW CONTRACT
Organization: Port Arthur Health Department RLHS-2016-CPS/UNIQUE-00035
Budget Summary
Organization Name: Port Arthur Health Department Program ID: CPS/OT-UNIQUE
Contract Number: 2016-004050-00 Procurement ID: GST-2016-Solicitation-0
0044
Proposal ID: RLHS-2016-CPS/UNIQUE-00035 Procurement Name: RLHS FY16 OT-Unique
LHD NEW CONTRACT
Budget Categories
DSHS Funds
Budget Categories Requested Cash Match In Kind Match Category Total
Personnel $0 $0 $0 $0
Fringe Benefits $0 $0 $0 $0
Travel $0 $0 $0 $0
Equipment $0 $0 $0 $0
Supplies $24,217 $3,871 $0 $28,088
Contractual $5,500 $0 $0 $5,500
Other $9,000 $0 $0 $9,000
Total Direct Costs $38,717 $3,871 $0 $42,588
Indirect Costs $0 $0 $0 $0
Totals: $38,717 $3,871 $0 $42,588
Subcontracting
Subcontracting Percentage: 14.21%
Match Contributions
Applicable Match Amount: $0
Required Match Percentage: 10.00%
Required Match Amount: $0 Calculated Match Amount: $3,871
Source of Cash Match Funds
Supplies used as Match.
Source of In Kind Match Funds
Program Income
Projected Earnings: $0
Source of Earnings
10/23/2015 Page 1 of 2
RLHS FY16 OT-Unique LHD NEW CONTRACT
Organization: Port Arthur Health Department RLHS-2016-CPS/UNIQUE-00035
Budget Summary
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
10/23/2015 Page 2 of 2