HomeMy WebLinkAboutAgreement A-20-353 with CA Dept. of Public Health.pdfCalifornia Department of Public Health
Contractor Certification Clause
CERTIFICATION
Tuberculosis Control Branch
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
By (Authorized Signature)
Federal ID Number
ATTEST :
BERNICE E. SEIDEL
,._e,__...."""""=-/4:...,c___L..""""'-'=::,:___~_,___.'=--"~'--"':....i.--_A-.."""'-=-"""""'"---------Co u~\of F.re ~no , State of al ifornia
c ~ ~ Cler k of the Board of Superv isors
Printed NameandTitlofPersonSignlng By•....:~::::d:~~~~n:=-------
Deputy
Ernest Buddy Mendes , Chairman of the Board of Supervisors of the County of Fresno
Date Executed Executed in the County of
Fresno
CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has , unless exempted , complied with the
nondiscrimination program requirements . (Gov . Code §12990 (a-f) and CCR , Title 2,
Section 11102) (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 CCC 04/2017 1 of 4 February 2020
California Department of Public Health Tuberculosis Control Branch
Darfur Contracting Act
Pursuant to Public Contract Code (PCC) sections 104 75-10481 , 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 104 77(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 .
EBM
Initials
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
Initials section 104 76 , 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
104 77(b) or submit a contract/purchase order. A copy of the written permission from
DGS is included with our bid, proposal or contract/purchase order.
3 .
Initials
CERTIFICATION
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 104 76.
I, the official named below, CERTIFY UNDER PENAL TY 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.
j: Federal ID Number :i Company Name (Printed)
ii County of Fresno
---·--
By (Authorized Signature)
-: . ...=..·----: --=-:.; --_cc~·c -t ~=="-= --co=c-z.. _____ -~----·11
;:~~-~=c-=--=-=·" --~
Printed Name ~nd Titl e ~f PeCn Signing
Ernest Buddy Mendes , Chairman of the Board of Supervisors of the County of Fresno
' Date Ex ecuted
Adapted from CDPH 9067 (7 /17)
·-7 E~ecuted i;
0
th~ C;~nty and State of
;· Fresno ATTEST:
.. -L ·-BERNICE E. SEIDEL
Clerk of the Board of Supervisors
County of Fresno , State of California
By tf-~!lo , r =tJ< Depufy
,,
0 11
ebruary 2020
California Department of Publ ic Health Tuberculosis Control Branch
Certification of Established
Electronic Directly Observed Therapy (eDOT)
Policy and Procedures
J . . . County of Fresno unsd1ct1on:
Local Assistance Subvention Award
The Contactor named above hereby certifies that a policy and procedures document
has been established for the use of electronic directly observed therapy (eDOT) that
includes the minimum requirements listed in the California Department of Public
Health-California Tuberculosis Controllers Association joint guidelines , "Guidelines for
Electronic Directly Observed Therapy (eDOT) Program Protoco ls i n Cal ifornia 2016 ."
Please sign and return this form with your funding request for equipment and
services for use with eDOT. Local assistance award funds cannot be used to
purchase cell phones or computers for use by patients.
~4--<---'-#:-~
Authorized Signature
~~) ~d.. ~
Date
ATTEST :
BERNICE E. SEIDEL
Clerk of the Board of Supervisors
_E_rn_e_s_t_B_u_d_d_y_M_e_n_d_e_s _____________ ~;u(i = s w itornia
Print Name Deputy ~
Chairman of the Board of Supervisors of the County of Fresno
Title
Guidelines for eDOT Program Protocols in California 2016 can be found on the CTCA
website at: https ://ctca.org/wp-content/uploads/2018/11/CDPH_CTCA-eDOT-
Guidelines-Cleared-081116.pdf
Page 1 of 1 February 2020