HomeMy WebLinkAboutAgreement A-15-407 Retroactive Award Allotment.pdfACCEPTANCE OF AWARD
County of Fresno, Department of Public Health
Funding Period: July 1, 2015 through June 30,2016
Base Award: $308,674
Food, Shelter, Incentives and Enablers Allotment: $18,662
Agreement No. 15-407
I hereby accept this award. By accepting this award, I agree to the requirements as
described in the Standards and Procedures Manual for FY 2015-2016 and any other
conditions stipulated by the California Department of Public Health, Tuberculosis
Control Branch.
Deborah A. Poochigian
Print Name
ATTEST:
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By ~.j :;.\c. ; c~ ~ (
· De uty
Chairman, Board of Supervisors
Title
State of Calffomia-Heallh and Human Services Agency California Department of PubHc Health
Contracts and Purchasing Services Section
Darfur Contracting Act
Pursuant to Public Contract Code (PCC) sections 10475-10481, the Darfur Contracting Act's intent is to
preclude State agencies from contracting with scrutinized companies that do business in the African nation of
Sudan. A scrutinized company is a company doing specified types of business in Sudan as defined in PCC
section 10476. Scrutinized companies are ineligible to, and cannot, contract with a State agency for goods or
services (PCC section 10477(a)) unless obtaining permission from the Department of General Services
according to the criteria set forth in PCC section 10477(b).
Therefore, to be eligible to contract with the California Department of Public Health, please initial one of the
following three paragraphs and complete the certification below:
1.
2.
3.
DAP
Initials
Initials
Initials
CERTIFICATION
We do not currently have, or we have not had within the previous
three years, business activities or other operations outside of the United States.
OR
We are a scrutinized company as defined in Public Contract Code
section 10476, but we have received written permission from the Department of General
Services (DGS) to submit a bid or proposal pursuant to Public Contract Code section
10477(b) or submit a contracUpurchase order. A copy of the written permission from
DGS is included with our bid, proposal or contracUpurchase order.
OR
We currently have, or we have had within the previous three years,
business activities or other operations outside of the United States,
but we certify below that we are not a scrutinized company
as defined in Public Contract Code section 10476.
I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind this
company to the clause listed above. This certification is made under the laws of the State of California.
Company Name (Printed)
County of Fresno
CDPH 9067 (4/09)
Board of Su ervisors
Federa/10 Number
94-6000-512
ATIEST:
BERNICE E. SEIDEL~Cier1<
Board of Supervisors
By =-t,/)C,· < OAetl
D :>q{y
Executed in the County and State of
Fresno, CA
California Department of Public Health Tuberculosis Control Branch
Contractor Certification Clauses
CERTIFICATION
I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly
authorized to legally bind the prospective Contractor to the clause(s) listed below. This
certification is made under the laws of the State of California.
Contractor/Bidder Firm Name (Printed)
County of Fresno
Deborah A. Poochigian, Cha~rman, Board of.Supervisors
Date xecuted Executed in the County of
Fresno
NTRACTOR ·CERTIFJCATION CLAUSES
Federa/10 Number
94-6000-512
ATTEST:
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By :i.. "" 'C~ ; c ~ofp~y-
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with
the nondiscrimination program requirements. (Gov. Code §12990 (a-t) and CCR, Title 2,
Section 8103) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the
requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free
workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance is prohibited and
specifying actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement; and,
Adapted from DGS form CCC-307 (0312812007)
Page 1 of4
February 2014
V91!1V!I!!GI f<I!CIL191\IIII!CIIfl VI I UUJI\,e I !C9!UI I UU'OH • .UIU~tO) \(VI UIUI U!911\.olf
STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
CERTIFICATION REGARDING LOBBYING
The undersigned certifies, to the best of his or her knowledge and belief, that:
Attachment 1
(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 an agency, a Member of Congress,
an officer or employee of Congress, or an employee of a Member of Congress in connection with the making,
awarding or entering into of this Federal contract, Federal grant, or cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of this Federal contract, grant, 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 of the United States Government, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with this Federal contract, grant, or cooperative agreement, the undersigned shall complete and submit
Standard Form 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
documents for all subawards at all tiers (including subcontractors, subgrants, and contracts under grants and
cooperative agreements) of $100,000 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 making or entering into this transaction
imposed by Section 1352, Title 31, U.S.C., any person who fails to file the required certification shall be subject to
a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
County of Fresno
Name of Contrador
Date
After execution by or on behalf of Contractor, please return to:
California Department of Public Health
Tuberculosis Control Branch
850 Marina Bay Parkway, Building P, Second Floor
Richmond, CA 94804-8403
Deborah A. Poochigian
Printed Name of Person Signing for Con
Chairman, Board of Supervisors
Tille
ATIEST:
BERNICE E. SEIDEL, Cieri<
Board of Supervisors
d\~~~puty
CDPH reserves the right to notifiy the contractor in writing of an alternate submission address.
Adapted from CDPH Exhibit D(F) (10114) Page 24 of26 03-2015