HomeMy WebLinkAbout2000 S Health -Renewal of State Consolidated Contract with Health Department RETURN THIS COPY TO THE CLERK'S
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CONSOLIDATED CONTRACT
BETWEEN
THE STATE OF NORTH CAROLINA
AS REPRESENTED BY
THE STATE HEALTH DIRECTOR
(Hereinafter called the "State")
AND
Orange County Local Health Department
(Hereinafter called the "Department')
FOR THE PURPOSE OF
M� NTA1NING AND PROMOTING THE ADVANCEMENT OF
HEALTH IN NORTH CAROLINA
This Contract Shall Cover a Period From
July 01, 2000 to June 30, 2001
NOW, THEREFORE, the State and the Department agree that the provisions and
clauses herein set forth shall be incorporated in and constitute the terms and
conditions.applicable for the following activities involving State funding. (State funding
or funds means State, federal, and/or special funding or funds throughout this
contract.)
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A. WORK TO BE PERFORMED BY THE DEPARTMENT
1. The Department shall perform activities in compliance with applicable program
rules contained in the North Carolina Administrative Code as well as all applicable
Federal and State laws and regulations.
2. The Department shall perform the activities specified in the Program Contract
Addenda for State funded budgets.
3. The Department shall administer and enforce all rules that have been adopted by
the Commission for Health Services or approved by the State and adopted by the
Local Board of Health.
4. The Department shall provide to the State copies of rules adopted by the Local
Board of Health pursuant to G.S. 130A-39 and Public Health Ordinances adopted
by the County Commissioners, within 30 days of adoption.
5. The Department shall provide to the State a Community Diagnosis Prioritization of
Problems every biennium. The Department shall also provide a Community
Diagnosis narrative, when completed in association with the Comprehensive
Community Assessment/Diagnosis.
B. FUNDING STIPULATIONS
1. Funding for this contract is subject to the availability of State, Federal, and Special
Funds for the purpose set forth in this Contract.
2. During the period of this Contract, the Department shall not use State, Federal or
Special Project funds received under this Contract to reduce locally appropriated
funds as reflected in the Local Health Department Budgets.
3. The Department shall not use personal health program funds to support
environmental health personnel nor use environmental health program funds to
support personal health programs.
4. Fees generated by the Food and Lodging Fees Collection Program may only be
used to support State and Local food, lodging, and institution sanitation programs.
and activities.
5. Funds for Childhood Lead Poisoning Prevention may be used to support both
environmental health and child health activities.
6. The Department shall comply with Standards for Mandated Public Health
Services, 15A NCAC 25, Section .0200; and Administrative Procedures Manual
for Federal Block Grant Funds, 1 NCAC 3.3, Sections .0100- .1502.
7. The Department shall maintain monthly employee time records to document
employee salaries and fringe benefits charged to state funds. The percentage of
time each employee spends in each activity shall be converted to dollars based
upon the employee's salary and benefits.
8. The Department participating in Medicaid Reimbursement shall:
a. Comply with the terms of the Medicaid Interagency Agreement and the
Provider Participation Agreement effective October 1, 1992 and any
subsequent approved addenda or new Agreement approved and
established during the period of this contract.
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b. Make every reasonable effort to collect its cost in providing services, for
which Medicaid reimbursement is sought, through public or private third
party payors except where prohibited by Federal regulations or State law.
No one shall be refused services solely because of an inability to pay.
9. Subject to the approval of the appropriate Section, a local health department may
seek reimbursement for services covered by a program operating under 15A
NCAC 24A rules when those services are not supported by other state or federal
funds. All payment program rules and procedures as specified in the Purchase of
Medical Care Services Manual must be followed.
10. Programs and services supported in whole or in part with federal funds must
provide interpreter services at no charge to non-English speaking clients. Only
those programs and services funded entirely with state and/or local funds, unless
prohibited by State law or rule, may charge non-English speaking clients for
interpreter services.
11. Subject to the availability of funds and approval of the Public Health Nursing and .
Professional Development Unit, a local health department may request
reimbursement for
a. Nursing service personnel participating in the Introduction to Principles
and Practices of Public Health and Public Health Nursing Course.
Reimbursement is limited to no more than $400.00 per participant upon
successful completion of the course.
b. Nursing service personnel participating in the Public Health Nurse
Supervisors Training Course. Reimbursement is limited to no more than
$600.00 per participant upon successful completion of the course.
C. Community Health Assistants and Public Health Nurses attending certain
pre-approved Continuing Education courses offered by the Public Health
Nursing and Professional Development Unit. Reimbursement is limited to
$50.00 per participant per event.
12. The Department shall have an annual audit performed in accordance with The.
Single Audit Act of 1984 as implemented by OMB Circular A-133.The audit report
shall be submitted to the Local Government Commission (LGC) by the County
Administration (if single county health department) or the District Health
Department or Public Health Authority (if so organized)within (six) 6 months
following the close of the contract. Audit findings referred to the DHHS Controller's
Office by LGC will be investigated and findings verified by the DHHS Controller's
Office staff with assistance of the Division of Public Health Program Staff.
13. Equipment is a type of fixed asset consisting of specific items of property that: (1)
are tangible in nature; (2) have a life longer than one year, and (3) have a
significant value.
a. For Inventory Purposes
1. Equipment must be accounted for in accordance with Local
Government Accounting System Procedure No. 15.
2. All equipment with an acquisition cost of$500.00 or more, and
purchased with Women, Infants and Children (WIC) Program
Funds, must be inventoried with the Women's and Children's
Health Section.
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b. For Prior Approval Purposes
1. All equipment purchased or leased with an acquisition cost
exceeding $500.00, where there is an option to purchase with
State/Federal funds, must receive prior written approval from the
appropriate Section.
2. All medical equipment and computer equipment, regardless of cost
and all other equipment with an acquisition cost of$500.00 or
more, purchased with WIC Program Funds, must receive prior
approval from the WIC Program Office.
3. The use of Women's and Children's Health Medicaid fees for
capital improvements requires prior written approval from the
Women's and Children's Health Section.
14. The Department agrees to execute the following Federal Certifications_ attached to
this agreement (applicable-when receiving Federal funds):
a. Certification regarding Lobbying.
b. Certification regarding Debarment.
In addition, the following Federal Certifications shall be executed if required:
c. Certification regarding Drug-Free Workplace Requirements.
d. Certification regarding Environmental Tobacco Smoke
C. FISCAL CONTROL
1. The Department shall comply with the Local Government Budget and Fiscal
Control Act, North Carolina General Statute Chapter 159, Article 3.
a. The Department shall maintain'a purchasing and procurement system in
accordance with generally accepted accounting practices and procedures
set forth by the Local Government Commission.
b. The Department shall execute written agreements with all parties who
invoice the Department for payment for the provision of services to
patients.
C. When subcontracting, the following conditions must be met:
1. The Department is not relieved of any of the duties and
responsibilities provided in this contract.
2. The subcontractor will agree to abide by the standards contained
herein or to provide such information as to allow the Department to
comply with these standards.
3. The subcontractor will agree to allow state and federal authorized
representatives access to any records pertinent to its role as a
subcontractor of the Department.
4. Upon request, the Department will make available to the State a
copy of subcontracts supported with State/Federal funds.
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d. The Department must receive prior written approval from the state to
subcontract when any of the following conditions exist:
1. The Department proposes to subcontract to a single entity
fifty percent (50%) or more of the total state and federal
funds made available through this contract.
2. The Department proposes to subcontract fifty percent
(50%) or more, or$50,000 which ever is greater, of the
total state and federal funds made available through this
contract for a single public health service or program.
3. The Department proposes to subcontract for services in the
Women, Infants and Children Program.
e. The Department shall retain all budgets, budget revisions, contracts,
contract addenda, and financial records in accordance with the current
Records Disposition Schedule for County and District Health Departments
issued by the NC Division of Archives and History, Department of Cultural
Resources.
2. The Department shall prepare and maintain a budget for each activity covered by
this contract in a manner consistent with instructions provided with Local Health
Department Budget- WIC Form 3370 and Local Health Department Budget Form
2948.
a. The Department shall prepare budget revisions for prior approval of the
State when State funds will be increased or decreased.
b. The Department shall submit all revisions prior to the end of the term
specified in this Contract. Budget revisions received by the State after the
end of the contract period will be returned without action.
3. The Department shall observe the following conditions when budgeting and
reporting earned revenues:
a. Locally appropriated funds may not be supplanted by earned revenues
from persons, or public or private third party payors. Such revenue shall
be used for the activity that generated the revenue, except in the WCH
Section programs where there is some flexibility(see "b" below.)
b. All earned revenue must be budgeted and spent in the program that
earned it except,
1. Revenue generated by WCH Section Programs may be budgeted and
expended in any WCH Section Program activity.
2, Revenue generated by a local clinic or program that has no state
funded activity budget(no state funds) should budget.and expend
those earned revenues in a state program activity that most closely
matches the deliverables of the respective state program.
C. All fees collected shall be used-in the current year or succeeding fiscal
year.
d. Use of program income generated by the expenditure of Federal
categorical funds will be governed by applicable Federal regulations,
including, but not limited to, 45 CFR 74.
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e. When budgeting:
i. Line item 9000 on the program budget form must be used to
budget the total of line items 101, 102 and 103.
ii. Line item 102 on the program budget must be used to budget TXIX
earned revenues.
iii. Line item 103 on the program budget must be used to budget other
earned revenues.
f. When reporting expenditures:
i. Line item 9000 on the Local Expenditure Report must be used to
report the total of line items 101, 102, 103.
ii. Line item 102 on the Local Expenditure Report must be used to
report TXIX earned revenues that were expended.
iii. Line item 103 on the Local Expenditure Report must be used to
report other earned revenues that were expended.
g. A local account shall be maintained for unexpended earned revenues (i.e.,
TXIX fees, private Insurance or private pay (cash). Accounts shall be
maintained in sufficient detail to identify the program source generating the
fees.
h. The amount of Title XIX fees budgeted and expended in FY 2000-2001
must equal or exceed the amount of Title XIX revenues earned during FY
1998-99. The state will not approve program activity budgets that do not
include an amount of Title XIX fees sufficient to meet the requirements of
this section. The Division of Public Health may waive this requirement if
the Department provides sufficient justification.
4. The Department shall submit a monthly report of actual expenditures of the
Department according to instructions provided with Local Expenditure Reports,
Form 2949 and Form 2950.
a. The Department shall submit monthly expenditure reports for all programs
(including WIC, Minority Infant Mortality Reduction, and Healthy Start) to
the State within 20 days from the end of the reporting month. Failure to
meet the reporting deadline will result in an immediate suspension of
payments until the overdue expenditure report is received.
b. The Department shall submit the final Expenditure Report for all programs
(including WIC, Minority Infant Mortality Reduction, and Healthy Start) to
the State within 20 days after the end of the contract period. Report is due
by July 20.
C. The Department shall have up to two (2) months after the end of the
contract period to submit amended or corrected expenditure reports. Any
such reports must be prepared for the specific month to be amended or
corrected. Reports received after August 31 (August 14'h for WIC) will be
returned without action.
d. The Department shall refund to the State all unexpended State funds
within 30 days after notification of overpayment. When payment is not
received by the State within 30 days, future payments to the Department
may be reduced by the amount due or payments may be suspended until
the refund is received by the State.
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e. The Department shall submit expenditure reports for Mosquito Control
activity in accordance with 15A NCAC 1813, Sections .0104 and .0107.
f. The Department shall submit requests for payment for services provided
under 15A NCAC 24 A rules to the Claims Processing Unit, Purchase of
Medical Care Services, DHHS.
g. The Department shall submit requests for reimbursement for nurse
training to the Public Health Nursing and Professional Development Unit.
Form 3300 - Public Health Nurse Training Activity must be used as the
invoice for payment.
5.. The Department shall submit on an annual basis Staff Time Activity Report, 3389,
Environmental Health Report, 3738, and Food and Lodging Report, 3888. The
reports shall accompany the final expenditure report and must be received by the
State within 20 days after the end of the contract period.
D. PERSONNEL POLICIES
1. The Department shall adhere to and fully comply with State personnel policies as
found in North Carolina General Statute, Chapter 126, and 1 NCAC 8. Such
policies include, but are not limited to, the following:
a. Equal employment opportunity,
b. Affirmative action,
C. Policies for local government employment subject to the State Personnel
Act,
d. "Local Classification and Salary Range,"
e. "Compensation Policy for Local Competitive Services Employees," and
f. 'Recruitment and Selection Policy and Procedures."
2. Environmental Health Specialists employed by the Department shall be delegated
authority by the State to administer and enforce State environmental health rules
and laws as directed by the State pursuant to G.S. 130A-4(b). This delegation
shall be done according to 15A NCAC 10. 0100.
a. Local health departments are responsible for sending their newly
employed environmental health specialists (intems) to centralized training
within 180 days from date of employment.
b. Arrangements for centralized training for newly-employed environmental
health specialists will be handled by the Education and Training Staff,
Division of Environmental Health.
C. A local health department which is contracting with an environmental
health specialist employed by another department shall be responsible for
assuring that all original documents, correspondence, and other public
records be maintained in the health department using the contractor and
the contract shall stipulate that the contractor shall be available for
consultation to the public being served.
3. The Department shall comply with Minimum Standard Health Department Staffing
15A NCAC Section .0301(c), and shall assure that all nursing staff who provide public
health services funded by this contract comply with this rule.
-1
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E. CONFIDENTIALITY
All information as to personal facts and circumstances obtained by Department personnel
in connection with the provision of services or other activity under this Contract shall be
privileged communication, shall be held confidential, and shall not be divulged without the
responsible person's written consent except as may be otherwise required by applicable
law or regulation. Such information may be disclosed in summary, statistical, or other
form which does not directly or indirectly identify particular individuals. Department
Employees must sign confidentiality pledges documenting the knowledge of and the
agreement to maintain personal and medical confidentiality.
F. CIVIL RIGHTS
1. The Department shall assure that no person, on the grounds of race, color, age,
religion, sex, marital status, immigration status, or national origin (unless
otherwise medically indicated) or otherwise qualified handicapped individual solely
by reason of his/her handicap be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under any program or activity
covered by this Contract.
2. The Department shall complete HHS Form 690, Assurance of Compliance with
Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of
1973; Title IX of the Education Amendments of 1972, and the Age Discrimination
Act of 1975.
3. The American with Disabilities Act 1990 (ADA) makes it unlawful to discriminate in
employment against a qualified individual with a disability and outlaws
discrimination against individuals with disabilities in State and local government
services and public accommodations. The Department certifies that it and its
principals and subcontractors will comply with regulations in A.D.A. Title 1
(Employment), Title II (Public Services), and Title III (Public Accommodations) in
fulfilling the obligations under this agreement.
G. RESPONSIBILITIES OF THE STATE
1. The State shall provide to the Department upon request technical assistance in
the preparation of the Consolidated Contract, Activity Budgets and Contract
Addenda.
2. The State shall provide an approved signed copy of the budget to the Department
within forty-five (45) days after receiving an acceptable activity budget from the
Department.
3. The State shall provide funds to the Department upon approval of the Contract
Addenda, activity budgets, and signing of this contract. Payment will be made to
the Department on/or about the 25"' of each month.
4. The State shall assist the Department to comply with all applicable laws,
regulations, and standards relating to the activities covered in this contract.
5. The State reserves the right to conduct reviews to determine compliance with the
terms of this contract.
6. The State shall be assured that the Department maintains expenditure of locally
appropriated funds (MOE) for maternal health, child health, and family planning
program activities equal to, or greater than, that reported on the Staff Time
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Activity Report for the period beginning July 1, 1984, and ending June 30, 1985.
This figure will be increased for the first time based on a federally accepted
inflation index, effective with FY 2000-2001 Contract. This revised baseline figure
for 2000-2001 will be calculated and provided to Departments for use in budget
preparation. After this initial inflation adjustment, the MOE amount will be
adjusted annually. This MOE shall be measured by salary equivalencies that are
to be maintained in accordance with Section B.7 of this contract and monitored by
Women's and Children's Health Section Program Staff.
H. DISBURSEMENT OF FUNDS
The State shall disburse funds to the Department as follows:
1. Provided the Consolidated Contract and the appropriate program budgets are
executed and received; a payment equal to total approved Program Budget
divided by the number of effective months of the budget shall be made in the first
effective month of a budget.
2. All subsequent monthly payments for each budget will be based on monthly
expenditures reported (due on the 20th of each month), and shall be adjusted
either upward or downward accordingly. The May, June, and Final payments will
be reimbursement based. Reimbursement of approved expenditures for any
report month cannot exceed one month's quotient of the total budget for the
contract period.
3. For departments receiving Rural Obstetrical Care Incentive funds, payment of
such funds shall be made in one lump sum the month following receipt and
approval of the activity budget.
4. Food and lodging fees will be disbursed to the department in one sum the month
following receipt and approval of the activity budget and any subsequent budget
revisions.
5. Funds for Childhood Lead Poisoning Prevention will be disbursed once per year.
The number of confirmed cases identified in each county will determine the
amount. A separate contract addendum must be submitted with budget page in
order to receive these funds. Funds for training will be disbursed upon request.
6. Subsequent to an approved revision of a program budget, increases or decreases
in monthly payments amount will be reflected in the month following the
completion of the revision.
7. Payments shall be suspended when expenditure reports are not received by the
time specified in C. 4. a, b. Payments will resume on, or about, the 25th of the
month following the receipt of the delinquent expenditure reports.
8.. Total payment by program activity is limited to the total amount of the budget.
9. Final payments will be made based on the Final monthly (June) expenditure
report. Final payments will be equal to the difference between approved reported
expenditures and the sum of previous payments. Final payments should be made
not later than September 25th provided that an original signed copy of an
expenditure report for each month has been received by the DHHS Office of the
Controller, and that the Staff Time Activity Report, 3389, Environmental Health
Report, 3788, and Food and Lodging, 3888 have been received by the State.
Months when Final Expenditure Reports are due may vary depending on the
applicable fiscal year of the funding source (i.e., June, or September, or March for
example.)
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I. AMENDMENT OF CONTRACT
Amendments, modifications, or waivers of this contract may be made at any time by
mutual agreement of all parties. Amendments shall be in writing and signed by
appropriate authorities.
J. PROVISION OF TERMINATION
Either party may terminate this contract for reasons other than non-compliance upon
sixty- (60) days written notice. If termination should occur, the Department shall receive
payment only for allowable expenditures.
The State may withhold payment to the Department until the State can determine whether
the Department is entitled to further payment or whether the State is entitled to a refund.
K. COMPLIANCE
1. The State shall respond to non-compliance with all terms of this contract as
follows:
a. Upon determination of non-compliance, the State shall give the
Department sixty (60) days written notice to come into compliance. If the
deficiency is corrected, the Department shall submit a written report to the
State that sets forth the corrective action taken.
b. If the above deficiencies should not be corrected to the satisfaction of the
State after the sixty- (60) day period, disbursement of funds for the
particular activity may be temporarily suspended pending negotiation of a
plan of corrective action.
C. If the deficiency is still not corrected within the next thirty- (30) days
following temporary suspension of funding, program funds may be
permanently suspended until the Department can provide evidence that
the deficiencies have been corrected.
d. In the event of the Department's non-compliance with clauses of this
contract, the State may cancel, terminate, or suspend this contract in
whole or in part and the Department may be declared ineligible for further
State contracts or agreements. Such terminations for non-compliance
shall not occur until (1) the provisions of Section K-1 (a-c) have been
followed, documented, and have failed to provide a resolution, (2) all other
reasonable administrative remedies have been exhausted.
2. If the Department or the State should be determined out of compliance with the
provisions of the contract, either party may file a formal appeal with the Office of
Administrative Hearings.
Signature Page attached
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IN WITNESS WHEREOF, the Department and the State have executed this
agreement in duplicate originals, one of which is retained by each of the parties.
LOCAL SIGNATURES
Health Dire r
Date
Finance Office/ E56te
4�&�
hairman of County Co m i i hers Date
(When required)
STATE OF NORTH CAROLINA
B Y f. -O 4
—
State Health Vrector Dat
or Authorized Agent
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
CERTIFICATION REGARDING LOBBYING
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 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,continuation,renewal,amendment,or modification of any Federal
contract,grant,loan,or cooperative agreement
2.If any funds other than Federal appropriated fiords 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,an
officer or employee of Congress,or an employee of a Member of Congress in connection with this
Federally funded contract,grant,loan,or cooperative agreement,the undersigned shall complete and
submit Standard Form SF-LLL;"Disclosure of Lobbying Activities,"in accordance with its instructions.
3.The undersigned shall require that the language of this certification be included in the award document
for subawards at all tiers(including subcontracts,subgrants,and contracts under grants,loans,and
cooperative agreements)who receive federal funds of$100,000.00 or more 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 malting 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 than$10,000.00 and not more than$100,000,00
for each such failure.
Health Director
Signature Title
Orange County Health Dept.
Agency/Organization Date
(Certification signature should be same as Contract signature.)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH .
CERTIFICATION REGARDING DEBARMENT,SUSPENSION,INELIGIBILITY AND
VOLUNTARY EXCLUSION-LOWER TIER COVERED TRANSACTIONS
(Note: The phrase"prospective lower tier participant," means providers under contract
with the Division.)
1.By signing and submitting this document,the prospective lower tier participant is providing the
certification set out below.
2.The certification in this clause is a material representation of the fact upon which reliance was placed
when this transaction wtentered into.If it is later determined that the prospective lower tier participant
knowingly rendered an et.-oneous certification,in addition to other remedies available to the Federal
Government,the department or agency with which this transaction originate may pursue available
remedies,including suspension and/or debarment.
3.The prospective lower tier participant will provide immediate written notice to the person to which this
proposal is submitted if at any time the prospective lower tier participant learns that its certification was
erroneous when submitted or has become erroneous by reason of changed circumstances.
4.The terms "covered transaction,""debarred,""suspended," "ineligible,"'lower tier covered transaction,"
"participant,""person,""primary covered transaction,""principal,""proposal,"and"voluntarily excluded,"
as used in this clause,have the meanings set out in the Definitions and Coverage sections of rules
implementing Executive Order 12549,45 CFR Part 76.You may contact the person to which this proposal
is submitted for assistance in obtaining a copy of those regulations.
5.The prospective lower tier participant agrees by submitting this proposal that,should the proposed
covered transaction be entered into,it shall not knowingly enter any lower tier covered transaction with a
person who is debarred,suspended,determined ineligible or voluntarily excluded from participation in this
covered transaction unless authorized by the department or agency with which this transaction originated.
6.The prospective lower tier participant further agrees by submitting this document that it will include the
clause titled "Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion--
Lower Tier Covered Transaction,"without modification,in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
7.A participant in a covered transaction may rely upon a certification of a prospective participant in a
lower tier covered transaction that is not debarred,suspended,ineligible,or voluntarily excluded from
covered transaction,unless it knows that the certification is erroneous.A participant may decide the method
and frequency of which it determines the eligibility of its principals.Each participant may,but is not
required to,check the Nonprocurement List.
8.Nothing contained in the foregoing shall be construed to require establishment of a system of records in
order to render in good faith the certification required by this clause.The knowledge and information of a
participant is not required to exceed that which is normally possessed by a;prudent person in the ordinary
course of business dealings.
9.Except for transactions authorized in paragraph 5 of these instructions,if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended,
debarred,ineligible,or voluntarily excluded from participation in this transaction,in addition to other
remedies available to the Federal Government,the department or agency with which this transaction
originated may pursue available remedies,including suspension,and/or debarment.
r
Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion—Lower Tier
Covered Transactions
(l)The prospective lower tier participant certifies,by submission of this document,that neither it nor its
principals is presently debarred,suspend,proposed for debarment,declared ineligible,nor voluntarily
excluded from participation in this transaction by any Federal department or agency.
(2)Where the prospective lower tier participant is unable to certify to any of the statements in this
certification,such prospective participant shall attach an explanation to this proposal.
Health Director
Signature Title
Orange County Health Dept.
Agency/Organization Date
(Certification signature should be same as Contract signature.)
r '
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
1.By execution of this Agreement the Contractor certifies that it will provide a drug-free workplace by:
A.Publishing a statement notifying employees that the unlawful manufacture,distribution,dispensing,
possession or use of a controlled substance is prohibited in the Contractor's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
B.Establishing a drug-free awareness program to inform employees about:
(1)The dangers of drug abuse in the workplace;
(2)The Contractor's policy of maintaining a drug-free workplace,
(3)Any available drug counseling,rehabilitation,and employee assistance programs;and
(4)The penalties that may be imposed upon employees for drag abuse violations occurring in the
workplace;
C.Making it a requirement that each employee be engaged in the performance of the agreement be given a
copy of the statement required by paragraph(a);
D.Notifying the employee in the statement required by paragraph(a)that,as a condition of employment
under the agreement,the employee will:
(1)Abide by the terms of the statement;and
(2)Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace
no later than five days after such conviction;
E.Notifying the Department within ten days after receiving notice under subparagraph(d)(2)from an
employee or otherwise receiving actual notice of such conviction;
F.Taking one of the following actions,within 30 days of receiving notice under subparagraph(d)(2),with
respect to any employee who is so convicted:
(1)Taking appropriate personnel action against such an employee,up to and including termination;or
(2)Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal,State,or local health,law enforcement,or other
appropriate agency;and
Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs(a),(b),(c),(d),(e),and(fl•
1
• II.The site(s)for the performance of work done in connection with the specific agreement are listed below:
1. 300 W Tryon St
(Street address)
Hillsborough NC 27278
(City,county,state,zip code)
2. 2501 Homestead Rd.
(Street address)
Chapel Hill NC 27516
(City,county,State,Zip code)
Contractor will inform the Department of any additional sites for performance of work under this
agreement.
False certification or violation of the certification shall be grounds for suspension of payment,suspension
or termination of grants,or government-wide Federal suspension or debarment(Section 4 CFR Part 85,
Section 85.615 and .620).
EXECUTED BY /V Health Director
CONTRACT AUTHORIZED OFFICER
300 W. Tryon St. Zi
ADDRESS DATE
Hillsborough NC 27278
(Certification signature should be same as Contract signature.)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DMSION OF PUBLIC HEALTH
CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Certification for Contracts,Grants,Loans and Cooperative Agreements
Public Law 103-227,Part C-Environmental Tobacco Smoke,also known as the Pro-Children Act of 1994
(Act),requires that smoking not be permitted in any portion of any indoor facility owned or leased or
contracted for by an entity and used routinely or regularly for the provision of health,day care,education,
or library services to children under the age of 18,if the services are funded by Federal programs either
directly or through State or local governments,by Federal grant,contract,loan,or loan guarantee.The law
does not apply to children's services provided in private residences,facilities funded solely by Medicare or
Medicaid funds,and portions of facilities used for inpatient drug or alcohol treatment.Failure to comply
with the provisions of the law may result in the imposition of a civil monetary penalty of up to$1,000.00
per day and/or the imposition of an administrative compliance order on the responsible entity.
By signing and submitting this application,the Contractor certifies that it will comply with the
requirements of the Act.The Contractor further agrees that it will require the language of this certification
be included in any subawards that contain provisions for children's services and that all subgrantees shall
certify accordingly.
df,L�� Health Director
Signature 0
/ /Title
Orange County Health Dept. 'T
Agency/Organization Date
(Certification signature should be same as Contract signature.)
ASSURANCE OF COMPLIANCE
ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964,SECTION 544 OF THE REHABILITATION ACT OF
1973,TITLE IX OF THE EDUCATION AMENDMENTS OF 1972,AND THE AGE DISCRIMINATION ACT OF 1975
The Applicant provides this assurance in consideration of and for the purpose of obtaining Federal grants,bans,contracts. property,discounts
or other Federal financial assistance from the Depariment of Health and Human Services.
THE APPLICANT HEREBY AGREES THAT IT WILL COMPLY WITH:
1. Tide VI of the Civil Rights Act of 1964 (Pub. L W352), as amended. and all requirements Imposed by or pursuant to the Regulation
of the Department of Health and Human Services (45 C.F.R. Part 80), to the end that, in accordance with Title Vt of that Act and the
Regulation, no person in the United States shelf, on the ground of race. Rio. or national origin, be excluded from participation in, be
denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives
Federal financial assistance from the Department.
2. Section 504 of the Rehabilitation Act of 1973 (Pub. L 93-112), as amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R. Part 84). to the end that. In accordance with Section 504 of
that Act and the Regulation, no otherwise qualified handicapped individual in the United States shall, solely by reason of his handicap,
be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity
for which the Applicant receives Federal finandai assistance from the Department.
3. Title IX of the Educational Amendments of 1972 (Pub. L 92.318). as amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R. Part 86), to the and that, in accordance with Tide IX and the
Regulation, no person in the United States shah, on the basis of sex, be excluded from participation in, be denied the benefits of, or
be otherwise subjected to discrimination under any education program or activity for which the Appiicarht receives Federal financial
assistance from the Department.
4. The Age Discrimination Act of 1975 (Pub. L 94135), as amended, and all requirements imposed by or pursuant to the Regulation of
the Department of Health and Human Services (45 C.F.R. Part 91). to the end that. in accordance with the Act and the Regulation, no
person-in the United States shah, on the basis of age, be denied the benefits of. be excluded from participation in, or be subjected to
discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department.
The Applicant agrees that compliance with this assurance constitutes a condition of continued receipt of Federal financial assistance,and that it
is binding upon the Applicant. its successors.transferees and assignees for the period during which such assistance is provided. If any real
property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department,
this assurance shall obligate the Applicant, or in the case of any transfer of such property,any transferee, for the period during which the real
property or structure is used for a purpose for which the Federal financial assistance is extended or for another purpose involving the provision
of similar services or benefits. if any personal property is so provided.this assurance shall obligate the Applicant for the period during which it
retains ownership or possession of the property.The Applicant further recognizes and agrees that the United States shall have the right to seek
judicial enforcement of this assurance.
The person or persons whose signature(s) appear(s) below istare authorized to sign this assurance. and commit the Applicant to the above
provisions.
j�.—�t>vc3 iir Co. Board of
Date Signature arx!Title of Authorized Offidnt CawnssiWrs
Orange County Health De rtI1 nt
Name of Applicant or Recipient
300 W. Tryon St.
street
Hillsbrough NC 27278
City.state.Zip Code
Form NHS-M
5197