HomeMy WebLinkAboutAgreement A-17-467 with CDPH for ADAP.pdfExhibit F
Security RequirementS,, Protectionst anq Confidentiality Checldist
County of Fresno
Site Name:
----------------------------------~
Site t..Jumber:
I he Contractor shall complete anti return this checldfst wlth tile signed copy of the contract
agreement. To cornpte~e this checklist, the authorized agency administrator or representative
attests by checking the boxes adjacent to the statemenl ana sighing this checklist that the: ·
A.DAP Enrollment Site meets, and shall contlnue td meet thmughotlt the life of tile. con1ract
(Juty 1, 2ot5-June 30, 2019), the regotrelht:;nt$ as identified in the Scope of Work wnlch
includes those identified beloW:
2.
Th'e Contractor ha$ reyie;Ned at:ld a~e,sts that tfiecontrading agenc:y or qrgan'iZEition
meets thB' tequlhementsasv,~ritterl in the "f\J.Ghdiscrt-rnrnalfot:; Cla.Llse 'ocp.:t)" sro 17A
. forfri and has a rooess.in la.de tol:l~aiW!th dlscli.h1h1atioh oomplalhts,
The Colitmclcir can ensure th~ admT11istratTve, physi~at and technical safegue~rds or
protecte:d !1eattJ1 tnforma.tlon .asl'eq!-HtE:d rn the C.DI:)H HIPAA BM 8~14. HI PAr\ Stisiness
Associi:!l9 ~dCJendum
f---"'~'~
4.
5.
The ADAPN.otice of Pfurac.y PractiQes is. posted in an are~raftlle A.DAP Entailment Site
t~aU~ accessi~le an¢ visible to AoAP'e!PiJiicaJ1ts/~Heri~.
r~,e Contractor has.Jnternet access and scanning and uploading capabitTties to a !low for
the creation of electronic AOAP c:ierit files within the;; desr~nated ADAP's Enrollment
Benefits Manage11ent Sf!:!CiUre web"ba~e'd enroltmen~ system.
The C(lrrtractor l1as desktop computers with ir:1~rnet·ac;;ce!;~ available for ali site personnel
(shared orindivrdual)who VL~III:ie perform]ng.ADAP ~nrollments13Mces.
l'he comractor ha:s faXmach!rre/s ~nd sc;a,i"lnerls u~~a'rotransmtt~ntl/or retefV$::1 ADAP
6, cHemt enrollmentlnf6rmatlon/dbcumenfation located lira secure area at thlsADAP ,__,_..__Et]rOfli:rienlS!te, , ·· · · . · '·· ·· ' · · · ·
All of the reqltir(]ments !isi.ed abf)vti rrmst be mrt~ 'f11 order (o 6tJcim1rJ <W i!t5AP E?r1rollme.m Sf( a,
Bria11 Pacheco
Signature
Chairman, Boa,rd of supeN,Tsers
Tftfe
Dat.e
ATTEST:
BERNICE E. SEIDEL, Clerk
Board of Supervisors
.
By cj\_,J)o .~·#
De ty
CCC-3Q7
CERTIFICATION
1. the t)fficial named below, CERTIFY U~'DER PENAL TV OF PERJURY that lam duly
authorized to legally bind tbepros!Jleetive Contractor to the elausc(s) Bstecl below. This
certification is made under the lavvs of the State ofCalitbntia.
Fede.ral lD Number
sy (/1f:}~!)ignanrreJ
t~~~"'-""'"*'"'~w:>.~~'i'r;..-'{;~=0',W.:~;r"'~;t_-;it;;:;·,;,';ZWU{,&;'~;;::,~~':t:w:;;;,.,;:7;~~~~~~-;;;,,~~M1
ATTEST:
BERNICE E. SEIDEL, Clerk
Board of Supervisors il Printed !Vame and Title o,{Person Bignlng
!srian Pachec0, Chairmat1 1 Board of Supervisors By d.~-~ uty
Dt'lte Executed
Q \ \1)...\ 'U)" ;;:'"e¢ulc?c/ in the CrJunty of
Fresno
CQNTR;\CTOR CER1'D'lCATION f!L\.lJSE:S
J. STATE?\~lENT OF COMPUANCE; Conn·aptorhas, unless cxe!,;pt<?d. complk>:Q with
the. nondiscdnJimition pt'6e,ram requi(eJhents. (do:v. c'o{le '§ 12990 {~~t) and CCR, Title.2)
Section 81 OS) (Not applicable to public enti~les;)
2.DRUG,.PREE' WORKPLACE REQUJREMENTS:ConhtttctorwHI comply .with the
requ.iremen~s.pfthe Dnm~Free Wor)<place :A.crot: 1990 ~ntl will provide a drug-I:i·ee
'~'ork)}lace by taki11g the f~lloydr!g actions:
a. Publish~ sMement notifying en'ipi:Oy!;lesS that unla~,-~{u[nutnufapture, distr.ibuLi(>n,
dispensation, possession or use ofa CC>litrolle.d sqfrsrance is pl;ohibited ~i.nd :Specifying
.actions to be 1akc11 agait1S1.employees tbr violations.
b. Es.tri.blish a Dhtg~Eree Awat'ene:Ss Program to inform employees about:
1) the dangers o.l dt'Llg abuse iit the wot'l<J)lace;
2) the pet·son's or organ[:zation 1S poliCy ofmaintttininga drug-free \vmkplace~
3) any available: eounscllrrg, tch~1bl Litation.ancl c1i1ployee assisian<.:~e p(ograms; and,
4) penalties that may be impos:ed upon (:l'i1ployees fm· ckug r!bLise vic1latimis.
c. Bvet'y emrlnyee wl~o woi'ks on th~ proposed Agreement wiH:
l). recd,··e a copy ofthe.·compnny's drug,.fnee •vorkp lace [H'Jlicy statement; and,
2} agree to abide by the terms orthe cmnpany's, statement as a condi1ion of einplo:yment
on the Agreement
Failure. to comJ:'!ly \Yith t11ese·t'equir.enlents n)U:Y: result hi swlJ~ension.Qfpayments under
the Agreement or te1:ininati\ln oftne Agreen1ent,m bcnhailci.Contrae,t€11; 111ay beilleligJqle
for aw:urd. of any ftltme State agreements n~the.d~pa rtmeiJiQetei·miJleS that any ul1he
r~}llowing: has occurred: the Coritractor has made false CI':Wtificatiott ar vio Ia ted tflc
....; -• < • • ' ' • ";,' ,, ' '-"'., ·-"· ' ,,
Darfur Contracting Aqt
Calkmi~ D.oPt1rfmJJnt_ cf PJfJio. Him~}L
Oontrl!«s anrll f",.jrclJ'*,,O Servl~~; 8ooUcn
Pursuant to Pt~bllc Contract Code (PCC) sections 10475·10481, the DariLJr Contracting Act's intent is to
precfude.State·agericies from coritraotirig vJith scrutinized com·panles thatdo.bUsiness.in the-African nation of
$udan. A scrutinize~ .company is a comp<:il1Y -doil}g sp'egifi~d typ~s qfpusif;le~s ih Sudan as defint?¢ in PCC
s~ction 10476 .. Scrutfniz~d 9.Prrip"anfes,are in~l.igtblei!' to, and cannot, c(;)ntract With a St~t~ $'geJ;i!;Y f.or.g:pods or
services (PCC section 10477(a)) unless obh:linltifg perr,rlissiOh from the Department ofGeneial Sen/ices
according to tbe criteria set forth.inPCC section 10477{b}.
Therefore, tO be eligible to contr~ct vvith the Ca.lifocnia O¢pqttm~ntof Public Health_, please thitlal one of the
follovJing three paragraphs ancl:complete.th~ certificatr~m below:
1. BP
Initials
2.
3.
Initials
CERTIFICATION
We do not currently have, or we have not had within the previous
three years, bl1Siness actlvi~ies or otfier ope~edlons outside of tht;l Uni.ted States.
OR
We are a scrutinized company as defined in Public Contract Code
sectfon 1 0476; but we:have receive~ written permtsslon from the Department of General
Services (DG.S) to subthlta bid ot proposal purstlant to Pu~lic·¢ontract Code section
10477(b) or sLibmita ~onkaytfpurchase orQer. A c_opy of the written permissiohfrom
DGS fs included With ol,.Jr bid; propo·S:aJ or contrac\Jpuh:~hase~ order,.
OR
W$ currently hav~ •. or \~t~e have h~d within the. previous three yeats,
business acitlvlti~s or other operation$ -otjtsioe ·ofthe L.Jnlted States;
but we certify below that We are not a scrutinized company
as d~fined ih PLJblic Contract Code section 10476~
I, the official n.amed below, ,CERTIFY UNDER p,ENALTY OF PERJURY that lam duly authorized to legally bind this
company to the clause llste<l above. This certiffoation is made. under the ·Jaws oftlle: State of California.
COPH 9067>(4/09)
ATTEST:
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By ~0.< ~y
STATsOF CI\UFORNlA
'CALIFORNIA cntlL RIGHTS LAWS A iTAChlMENT
DGS oLs'Q4(Rev,DW7) .. . .
I)E!:',li;Rlt~lt;}JT OF 'GENERAL SERVICES
.~J=Fl¢~ OF [EG/ILSE~VICES
Pursua11tto Public. Cc;mtr~ot. Code sec~iPn2.01 0, a, persqn that :submits a bid orproposal to, or
otherNise p(qpos~s to ent~r Into or renew. a t:onfract witl"i; a: state age,ncy wrtll respectto any
contract iii the amouht ·of $1 OQ~OOO or above shall certify, under pe11a1ty perJury, al the time the
bid or proposal Ts sut:lmitted or the ccmtracl is rehi;l.Vifed, all. of the follo,Ning:
1. CALIFORNIA CIVtL RIGHTS LAWS; For cpntracts e;(ecute.d or rene\!ved after Jat'lilary 1,
20~·7, the con:g,actor certifies cemp!iance yvltht~e Unruh Civil Rights. Act (Section 51·ofthe Civil
Code) and'the Fair Employment and Hcusfng Act (S~ction 1 2'960 ofth!!! Government Code);
and
2. EMPLOYER DISCRIMINATORY, POLIGIES: For ct:mtract:; e~ecuted or ren!3Wed after
Ji:inU;:JfY 1, 2017; if a Contractor has. anfnternal policy agaii1st ~ SIZ)Verel§n n~tion o.r peqp)es
recognized by theUntted S,tawsgovemment, the Contr:ac;tor cert,ifjes that such polfq:ies are not
useq 1n vt.olatron of the Unruh Civil Rigl:lts ~ct (Section 51· df the Civil Code) arthe Fair
Employmeht a11d l"lous.ingAct (Section 1~9eo of' the Government Code), ·
CERTiFJCATION