HomeMy WebLinkAboutAgreement A-19-121-1 with FCSS.pdf1 FIRST AMENDMENT TO AGREEMENT
2 THIS FIRST AMENDMENT TO AGREEMENT (hereinafter "Amendment") is made and
3 entered into this 24 1h day of March, 2020, by and between COUNTY OF FRESNO, a Political
4 Subdivision of the State of California, Fresno, California (hereinafter "COUNTY"), and FRESNO
5 COUNTY SUPERINTENDENT OF SCHOOLS, a California Educational Organization, whose address is
6 1111 Van Ness Avenue, Fresno, California, 93721, hereinafter referred to as "CONTRACTOR".
7 WITNESSETH:
8 WHEREAS, COUNTY and CONTRACTOR entered into Agreement number A-19-121, dated
9 March 12, 2019 (hereinafter "Agreement"), pursuant to which CONTRACTOR agreed to provide
10 physical activity (PA) and nutritional trainings, technical assistance, resources and referral organizations
11 to Early Care and Education (ECE) partners to increase the number of ECE sites to adopt and practice
12 nutritional and PA standards to COUNTY, through its Department of Public Health (Department); and
13 WHEREAS, COUNTY and CONTRACTOR now desire to amend the Agreement in order to
14 modify the Compensation/Invoice terms and amend the Scope of Work timeline.
15 NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which
16 is hereby acknowledged, COUNTY and CONTRACTOR agree as follows:
17 1. That all references in existing COUNTY Agreement No. A-19-121 to "Exhibit A" shall be
18 changed to read "REVISED Exhibit A," attached hereto and incorporated herein by reference.
19 2.That all references in existing COUNTY Agreement No. A-19-121 to "Exhibit B" shall be
20 changed to read "REVISED Exhibit B," attached hereto and incorporated herein by reference.
21 3. That all references in existing COUNTY Agreement No. A-19-121 to "Exhibit C" shall be
22 changed to read "REVISED Exhibit C," attached hereto and incorporated herein by reference.
23 4. Section Five (5) of the Agreement, located on page Three (3), Line Twenty-Two (22)
24 beginning with the word "CONTRACTOR" and ending on Page Three (3), Line Twenty-Four (24) with
25 the word "Analyst", be deleted in its entirety and replaced with the following:
26 " CONTRACTOR shall invoice COUNTY monthly, by the thirtieth (30 th ) day of each month
27 for the prior month's expenditures, addressed to the County of Fresno, Department of Public Health,
28 OHPW-SPAN, P.O. Box 11867, Fresno, CA 93775, Attention: OHPW-CDC SPAN Staff Analyst.
- 1 -
Agreement No. 19-121-1
1 Invoices shall detail line items as specified in Revised Exhibit C, including original budget amount(s),
2 current month's expenses, year-to-date expenses, and budget balances. In addition, invoices shall also
3 include all relevant supporting documentation including but not limited to copies of original statements,
4 program expense receipts, payroll records and mileage claims."
5 5. Section Nineteen (19) of the Agreement, located on page Eleven (11 ), Line Twenty-One
6 (21) and ending on Page Twelve (12), Line One (1), be deleted in its entirety and replaced with the
7 following:
8 "19. SINGLE AUDIT CLAUSE
9 COUNTY and CONTRACTOR, their officers, consultants, subcontractors,
10 agents, and employees shall comply with all applicable State, Federal, and local laws and regulations
11 governing projects that utilize Federal Funds including those identified in Exhibit F, attached hereto
12 and incorporated herein by reference.
13 A.If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars ($750,000)
14 or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual
15 audit in accordance with the requirements of the Single Audit Standards as set forth in Office of
16 Management and Budget (0MB) Title 2 of the Code of Federal Regulations Part 200. CONTRACTOR
17 shall submit said audit and management letter to COUNTY. The audit must include a statement of
18 findings or a statement that there were no findings. If there were negative findings, CONTRACTOR
19 must include a corrective action plan signed by an authorized individual. CONTRACTOR agrees to
20 take action to correct any material non-compliance or weakness found as a result of such audit. Such
21 audit shall be delivered to COUNTY's Department of Public Health, Business Office, for review within
22 nine (9) months of the end of any fiscal year in which funds were expended and/or received for the
23 program. Failure to perform the requisite audit functions as required by this Agreement may result in
24 COUNTY performing the necessary audit tasks, or at COUNTY's option, contracting with a public
25 accountant to perform said audit, or, may result in the inability of COUNTY to enter into future
26 agreements with CONTRACTOR. All audit costs related to this Agreement are the sole responsibility
27 of CONTRACTOR.
28 B. A single audit report is not applicable if all CONTRACTOR's Federal contracts
-2 -
1 do not exceed the Seven Hundred Fifty Thousand Dollars ($750,000) requirement. If a single audit is
2 not applicable, a program audit must be performed and a program audit report with management letter
3 shall be submitted by CONTRACTOR to COUNTY as a minimum requirement to attest to
4 CONTRACTOR's solvency. Said audit report shall be delivered to COUNTY's Department of Public
5 Health, Business Office, for review no later than nine (9) months after the close of the fiscal year in
6 which the funds supplied through this Agreement are expended. Failure to comply with this Act may
7 result in COUNTY performing the necessary audit tasks or contracting with a qualified accountant to
8 perform said audit. All audit costs related to this Agreement are the sole responsibility of
9 CONTRACTOR who agrees to take corrective action to eliminate any material noncompliance or
10 weakness found as a result of such audit. Audit work performed by COUNTY under this paragraph
11 shall be billed to the CONTRACTOR at COUNTY cost, as determined by COUNTY's Auditor-
12 Controller/Treasurer-Tax Collector."
13 5. Except as otherwise provided in this First Amendment, all other provisions of the
14 Agreement remain unchanged and in full force and effect.
15 COUNTY and CONTRACTOR agree that this Amendment is sufficient to amend the
16 Agreement and, that upon execution of this Amendment, the Agreement and this Amendment together
17 shall be considered the Agreement.
18 The Agreement, as hereby amended, is ratified and continued. All provisions, terms,
19 covenants, conditions and promises contained in the Agreement and not amended herein shall remain
20 in full force and effect.
21 Ill
22 Ill
23 Ill
24 Ill
25 Ill
26 Ill
27 Ill
28 Ill
- 3 -
1 EXECUTED AND EFFECTIVE as of the date first above set forth.
2
3 CONTRACTOR:
Fresno County Superintendent of Schools
4
5
6
7
8
9
Dr. athryn Catania, Deputy Superintendent
10 Jim A Yovino, Superintendent
Print Name & Title
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
1111 Van Ness Avenue, Fresno, CA 93721
Mailing Address
FOR ACCOUNTNG
USE ONLY:
ORG No.:
Account No.:
Fund/Subclass:
SA
56201555
7295
0001/10000
-4-
COUNTY OF FRESNO:
-Board
of Supervisors of the County of Fresno
ATTEST:
Bernice E Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
By:
Deputy
REVISED Exhibit A
Work Plan -Year One
Overarching Strategy 3: Implement & Integrate Nutrition & Physical Activity Standards into Statewide Early Care and Educ�tion (ECE) Systems
Short-Term Outcome Intermediate Outcome ;
Demonstrated progress on ECE nutrition and physical activity Increased number of ECE state and local systems with e,nbedded nutrition and PA
standards standards across four counties reaching up to 25,000 c ildren
Outcome Measures: Increased number of ECEs that have implemented and integrated nutrition and physical activity standards into policies and/or
professional development plans. I
Strategy 1 Milestone I Completion Date
Collaborate with one partners to assess the number of ECEs Implementation of nutrition standards (inclusive of BF I September 29, 2020
I that implement nutrition and PA standards in Fresno County. supports) and PA standards.
Settings: LHDs Statewide working in ECE settings
Partners: Fresno County, CCFP Roundtable, CA State ECE Partnership, Resource & Referral Network (R&R Network) i
Activity Timeline
Activity 2: Collect sample policies addressing nutrition and PA standards in ECEs. Q2
Activity 3: Collaborate with state and local partners to determine a system and process to identify the number of ECEs Q3
(i.e. centers and family day care homes) in targeted counties that have nutrition and PA policies in place, and the
strength of those policies. (In year-two, will review and document best practices.)
Activity 4: Coordinate with partners to assess the training and TA needs of ECEs to implement nutrition and PA Q3
standards and policies.
Activity 5: Based on the results of the assessment, work with partners to develop content for trainings, webinars, I Q4
and/or identify resources to assist in the implementation of nutrition and PA standards in ECE sites. i
1
REVISED Exhibit A
Activity 7: Evaluation Activity: Assess the number of ECEs in Fresno County that have implemented nutrition and PA Q4
standards.
Strategy 2 Milestone Completion Date
Work with the CA Child Care R&R Network and CCFP Training interventions provided to county R&Rs across September 29, 2020
Roundtable to improve PA and nutrition content in CA include evidence-based PA and nutrition content
professional development trainings. and materials.
Settings: ECE sites, ECE trainings, R&R Network training opportunities; CCFP Roundtable meetings
Partners: CA R&R Network; CCFP Roundtable member organizations; Fresno County LHD
Activity Timeline
Activity 1: In collaboration with partners, map systems of influence for ECE professional development standards and Q2-Q3
training guidance. Use this to inform future activities.
Activity 4: Work with up to two partners to assess provider PA and nutrition trainings needs and interests. Q3
Activity 5: Work with CA R&R Network and CCFP staff to assess what additional training materials and resources can be Q3-Q4
used in providing trainings in year two for county R&Rs and that can be integrated into Roundtable training materials.
Inclusive of resources for parents and children.
Activity 8: Evaluation Activity: Assess changes in knowledge of and intent to implement PA and Nutrition policies and Q4
practices among training recipients.
2
REVISED Exhibit A
Strategy 3 Milestone Completion Date
Provide Nutrition and PA technical assistance (TA) to up to Work with one ECE county R&R organization and two September 29, 2020
three ECE county R&R organizations, and up to three individual ECS sites to increase ECE adoption and
individual ECE sites to increase ECE adoption and practice of practice of PA and nutrition standards.
PA and nutrition standards
Settings: County R&Rs; ECE sites in Fresno County
Partners: CA R&R Network; CCFP Roundtable
Activity Timeline
Activity 1: Survey ECE county R&R sites and ECEs to determine which ones would like to receive nutrition and/or PA Q2
training or TA per specified topics. Provide requested TA.
Activity 2: Provide training and/or TA per assessment results. CDPH PA staff and R&R Network PA leads will provide PA Q3-Q4
TA to county R&R organizations and to individual ECE sites. Similarly, CDPH and R&R Network nutrition staff will provide
nutrition TA.
Activity 4: Evaluation Activity: CDPH PA staff and R&R Network PA leads will work together to draft survey content for Q4
ECEs that receive TA over the course of the grant to determine their satisfaction.
3
REVISED EXHIBIT B SPAN Five Year Work Plan
REVISED WorkPlan-Year One & Two
Overarching Strategy 1: Implement Food Service Guidelines
Strategy 1: Develop Healthy Meeting policy for state and local government agencies.
Each LHD is required to work towards the development of one Healthy Meeting policy during Year 1.
Strategy 2: Assist small retail vendors in adopting healthy food service guidelines in select counties.
Each LHD is required to work with two small retail vendors to assist in the adoption of healthy
food service guidelines during Year 1.
Overarching Strategy 2: Implement Interventions Supportive of Breastfeeding
Strategy 1: Collaborate with partners to assess the number of sites that support BF in select counties.
Each LHD is required to collaborate with two partners to assess the number of sites that
support BF in select counties. Partners include community health clinics (i.e. FQHC's), WIC
clinics and LHDs.
Strategy 2: Promote compliance with federal lactation accommodation laws in targeted (low-
income) worksites.
Each LHD is required to promote compliance with federal lactation accommodation laws in two
targeted worksite.
Overarching Strategy 3 (& 5 Combined): Implement &Integrate Nutrition and Physical Activity
Standards into Statewide Early Care and Education (ECE) Systems
Strategy 1: Collaborate with partners to assess the number of ECEs that implement nutrition and PA
standards in select counties.
Each LHD is required to collaborate with one partner to assess the number of EC Es
that implement nutrition and PA standards in select counties.
Strategy 2: Work with the CA Child Care R &R Network and CCFP Roundtable to improve PA and nutrition
content in professional development trainings.
Each LHD is required to work with one partner to assess PA and nutrition training needs
and interests.
Strategy 3: Provide Nutrition and PA technical assistance to up to five ECE county R&R organizations,
and up to six individual ECE sites to increase ECE adoption and practice of PA and nutrition standards.
Each LHD is required to work with one ECE county R&R organization, and two individual ECE
sites to increase ECE adoption and practice of PA and nutrition standards.
Overarching Strategy 4: Establish New or Improved Pedestrian, Bicycle, and Transit Transportation
Systems.
Page 1 of 3
REVISED EXHIBIT B
SPAN Five Year Work Plan
Strategy 1: Increase community PA by supporting LHD involvement in the development, revision, or
implementation of pedestrian, bicycle, ortransportation plans and/or updating a city or county-wide general
plan's transportation or health element or promoting local policy or infrastructure solutions.
Each LHD is required to work towards the development, revision, or implementation of either
pedestrian, bicycle ortransportation plan or the updating of a city or county-wide general plan's
transportation or health element or promoting local pol icyori nfrastructure solutions.
Strategy 2: Increase community PA through training and TA to LHDs to support the development of
successful application for the CA Department of Transportation's Active Transportation Program ( ATP).
Each LHD is required to participate in one statewide webinar demonstrating the types of
transportation projects and activities fund through the ATP.
Each LHD is required to assist in one evaluation survey assessing changes in knowledge and
confidence in participating in planning processes among involved LHD staff.
Strategy 3: Support selectLHDs to conduct SRTS program activities including promotion of Walking
School Buses, Bicycle Trains, signage and wayfinding to promote family and community PA.
Each LHD is required to participate in the dissemination of Walking School Bus and Bicycle Train
Toolkits and infographics to a minimum oftwo school districts.
Each LHD is required to participate in one statewide webinar on an emerging SRTS
implementation, program or policy strategy.
Each LHD is required to provide assistant in the piloting of one community participatory walkability
audit and subsequent actin planning.
Strategy 4: Collaborate with state-level partners in transportation and planning to include obesity, chronic
disease prevention, and health equity in transportation policy and programming.
Each LHD is required to identify at least one way to enhance collaboration with Cal trans-which
mayinclude be not be limited to participating in Caltrans' AT efforts through eithertheirnewly
created Walk/Bike Technical Advisory Committee or through the existing Active Transportation for
Livable Communities committee (ATLC).
Page 2 of 3
REVISED EXHIBIT B SPAN Five Year Work Plan
Work Plan Overview Years Two-Five
Strategy 1: Implement Food Service Guidelines: Building on the findings and success of year one
activities, work plans for years two through five will include strategies and activities that extend
services to additional counties, settings (healthcare, food banks/pantries) and small retail markets
as possible. Years two and three will focus on supports for local government agency healthy meeting
policy adoption, assisting small grocers toi mp rove healthyfood access, and deepened evaluation
efforts. lnyearsthreetofive, wewill promote new resources statewide and work with partners to
develop trainings and TA to help inform and drive the approaches. The Cal SPAN team will host
convenings, webinars, and/orteleconferencesto support communities of practice. As
organizations implement food service guidelines and policies, the team will develop success stories to
highlight achievements, challenges, and lessons learned.
Strategy 2: Implement Interventions Supportive ofBF: Building on the findings and success of year
one activities, work plans for years two through five will extend services to additional LH Os, FQHCs,
and WIC clinics. Years two and three will focus on existing BF policies in these sites and assessing
training and TA needsofthesecondwaveofLHDsandclinicsastheybegintodevelopand
implement BF supports. In years three-five, CDPH will promote new resources statewide, and work
with partners to develop trainings and TA as per the assessment. we will host convenings,
webinars, and/or teleconferences to support communities of practice. Also, in years two-five, as
organizations implement policies, the Cal SPAN team will work with them to measure progress and
impact and to develop success stories.
Strategies 3 & 5: Implement & Integrate Nutrition & PA Standards into Statewide ECE Systems: Building
on successes in year one, we will develop partnerships to assist assessing EGE centers' readiness
to implement nutrition and PA standards. The responses from county R&Rs and individual ECE
sites will inform and drive the approach for statewide EGE systems, including the state's child care
licensing agency, California's quality rating and improvement systems (ORIS), and a proposal for
an EGE recognition program. CDPH will hostconvenings, webinars, and/orteleconferences to support
communities of practice. In years fourand five, staff will work with the CA child care licensing to
strengthen its PA and nutrition-related requirements for certification. This may include increasing
requirements for continuing education credits and optional trainings in obesity prevention
strategies, including PA, CACFP meal pattern implementation and nutrition best practices. Also, in
years four and five, staff will work with COE to propose revisionstotheexisting EGE learning
standards and frameworks to include stronger PA and nutrition content and on integrating enhanced
PA and nutrition criteria into QRIS for ECE sites to achieve a higher performance rating. Finally,
CDPH will grow evaluation efforts, and communicate lessons learned and promising practices.
Strategy 4: Establish New or Improved Pedestrian, Bicycle, and TransitTransportation Systems: The
Cal SPAN team will build upon the success of year one to include promotion and adoption of the CA-
based Healthy Places Index tool (Southern CA Public Health Alliance) and the CDC's Health and
Transportation Tool, and databases into program guidance, tools, and resources. We will promote
incorporating health equity in AT through creation of infographics and messaging in collaboration
with partners (e.g., Safe Routes to School Partnership, Changelab Solutions, Policylink, etc.). We
will host convenings, webinars, and/or teleconferences to support communities of practice. In years
three to five, we will promote new resources statewide through the SNAP-Ed LHD network. Finally,
we will increase our role as a contributor in the state's AT policy and program work, providing
sustainability for these efforts in the future.
Page 3 of 3
CDC SPAN Grant Budget REVISED Exhibit C
Fresno County Superintendent of Schools
Year(l) Year(2) Year (3) Year(4) Year(S) Total
A Salaries and Wages wos,tron I ttre SOW Referent Annual Sala11 .. c 11u<1get .. c 11u<1get .. c IIU<lget , . IIU<lget r C 11u<1get
Coordinator, Cyndi Dean OA53, 1·3 $83,820.06 0.11 $5,344.93 0.12 $10,860.28 0.12 $10,058.41 0.12 $10,058.41 0.12 $10,058.41 $46,380.43
Total Salaries and Wages $5,344.93 $10,860.28 $10,058.41 $10,058.41 $10,058.41 $46,380.43
Fringe Benefits 20% $1,069.01 20% $2,172.06 20% $2,011.68 20% $2,011.68 20% $2,011.68 $9,276.11
Total Personnel $6,413.94 $13,032.33 $12,070.09 $12,070.09 $12,070.09 $55,656.53
D Equipment Reference
SPARK -promote healthy, active lifestyle -1-day workshop@ $2,699 + $7,214.20 $7,214.20 7 curriculums (school sites)@ $399 each= $2,793-Total for workshop OAS3, 1·3
and curriculums = $5,492
NASCO -Physical Activity & Nutrition Message to promote healthy OAS3, 1·3 $151.08 $5,892.02 $3,021.55 $3,021.55 $3,021.55 $15,107.75
lifestyle - 7 school sites x 1 Kit @ $431.65 = $3,021.55
Harvest of the Month Rate the Taste -HOTM produce@ $32.10 per OAS3, 1·3 $4,494.00 $2,247.00 $2,247.00 $2,247.00 $11,235.00
class x 35 classes x 2 months= $2,247
Nutrition education materials to promote healthy lifestyles -200 OA53, 1·3 $538.74 $1,061.26 $800.00 $800.00 $800.00 $4,000.00
students x 1 events x $4. = $800 each event X 5 years.
Family Connection Nights -Food tor Taste Testing -Parent/Child
learning classes & staff trainings -$325 per FCN @ 6 sites= $1,950 x 5 OAS3, 1-3 $1,300.38 $1,950.00 $1,950.00 $1,950.00 $7,150.38
years
CATCH -Physical Activity on-line access & Early Childhood Curriculum OAS3, 1·3 $3,157.42 $2,280.00 $2,280.00 $2,280.00 $9,997.42 on-line access and Teacher's Manual -12 curriculums@ $190 each=
$2,280
Skillastics Early Childhood Physical Activity Pack@ $50 per 2-year on-OAS3, l-3 $1,319.00 $1,319.00 $1,319.00 $1,319.00 $5,276.00 line access plus 2-year on-line access Curriculum & Teacher's manual @
$140 = $190 total package x 12 sites= $1,319.40
Total Equipment $689.82 $24,438.28 $11,617.55 $11,617.55 $11,617.55 $59,980.75
Supplies Reference
Office Supplies -paper, pens, copy paper, envelopes, folders, etc. OAS3, 1·3 895.69 1,332.73 670.27 670.27 670.27 4,239.23
Total Supplies $895.69 $1,332.73 $670.27 $670.27 $670.27 $4,239.23
Travel Reference
Conference or IDEA World Conference travel to Anaheim Marriott and
parking for project implementation. Mileage= 251 miles (1-way) @ OA53, 1·3 $288.26 $577.42 $345.59 $345.59 $345.59 $1,902.45 54.5 rate x 2 (502 miles round trip)= $273.59 plus Parking= 4-days@
$18 = $ 72. Total $345.59
Total Travel $288.26 $577.42 $345.59 $345.59 $345.59 $1,902.45
CDC SPAN Grant Budget REVISED Exhibit C
Fresno County Superintendent of Schools
Year (1) Year(2) Year (3) Year(4) Year (5) Total
G Other Reference
1 Coordinator -Childhood Obesity Conference -Beyond Obesity:
Tackling Root Cases, Anaheim -Registration@ $375, 3-night stay@ OAS3, 1-3 $963.44 $1,137.94 $1,137.94 $3,239.32 $189 per night x 3 = $567 =tax= $610.94, and Per Diem @ $38 per day
x 4 = $152. Total $1,137.94
1 Coordinator -IDEA World Conference -Ignite the Fire, Anaheim -
Registration @ $375, 3-night stay@ $189 per night x 3 = $567 =tax= OAS3, 1·3 $1,137.94 $1,137.94 $2,275.88
$610.94, and Per Diem @$38 per day x 4 = $152. Total $1,137.94
Total Other $963.44 $1,137.94 $1,137.94 $1,138 $1,138 $5,515.20
Total Direct Costs $9,251.15 $40,518.70 $25,841.44 $25,841.44 $25,841.44 $127,294.16
INDIRECT COST 11% $957.09 11% $4,457.06 11% $2,842.56 11% $2,842.56 11% $2,842.56 $13,941.82
Total Annual Budget $10,208.24 $44,975.76 $28,684.00 $28,684.00 $28,684.00 $141,235.99
California Department of Public Health
EXHIBIT F-Federal Terms
Exhibit F
Federal Terms and Conditions
(For Federally Funded Grant Agreements)
The use of headings or titles throughout this exhibit is for convenience only and shall not be used to interpret or to
govern the meaning of any specific term or condition.
This exhibit contains provisions that require strict adherence to various contracting laws and policies.
1. Federal Funds
Index of Special Terms and Conditions
2. Federal Equal Employment Opportunity Requirements
3. Debarment and Suspension Certification
4. Covenant Against Contingent Fees
5. Air or Water Pollution Requirements
6. Lobbying Restrictions and Disclosure Certification
7. Additional Restrictions
8. Human Subjects Use Requirments
9. Financial and Compliance Audit Requirements
10. Audit and Record Retention
11. Federal Requirements
CDPH (rev. 07/16) Page 1 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
1. Federal Funds
(Applicable only to that portion of an agreement funded in part or whole with federal funds.)
a. It is mutually understood between the parties that this Grant may have been written before ascertaining
the availability of congressional appropriation of funds, for the mutual benefit of both parties, in order to
avoid program and fiscal delays which would occur if the Grant were executed after that determination
was made.
b. This Grant is valid and enforceable only if sufficient funds are made available to the State by the UnitedStates Government for the fiscal years covered by the term of this Grant. In addition, this Grant is subject
to any additional restrictions, limitations, or conditions enacted by the Congress or any statute enacted by
the Congress which may affect the provisions, terms or funding of this Grant in any manner.
c. It is mutually agreed that if the Congress does not appropriate sufficient funds for the program, this Grant
shall be amended to reflect any reduction in funds.
d. CDPH has the option to invalidate or cancel the Grant with 30-days advance written notice or to amend
the Grant to reflect any reduction in funds.
2. Federal Equal Opportunity Requirements
(Applicable to all federally funded grants entered into by the California Department of Public Health (CDPH)
formerly known as California Department of Health Services (CDHS).)
a. The Grantee will not discriminate against any employee or applicant for employment because of race,
color, religion, sex, national origin, physical or mental handicap, disability, age or status as a disabled
veteran or veteran of the Vietnam era. The Grantee will take affirmative action to ensure that qualified
applicants are employed, and that employees are treated during employment, without regard to their race,
color, religion, sex, national origin, physical or mental handicap, disability, age or status as a disabled
veteran or veteran of the Vietnam era. Such action shall include, but not be limited to the following:
employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination;
rates of pay or other forms of compensation; and career development opportunities and selection for
training, including apprenticeship. The Grantee agrees to post in conspicuous places, available to
employees and applicants for employment, notices to be provided by the Federal Government or CDPH,
setting forth the provisions of the Equal Opportunity clause, Section 503 of the Rehabilitation Act of 1973
and the affirmative action clause required by the Vietnam Era Veterans' Readjustment Assistance Act of
1974 (38 U.S.C. 4212). Such notices shall state the Grantee's obligation under the law to take affirmative
action to employ and advance in employment qualified applicants without discrimination based on their
race, color, religion, sex, national origin physical or mental handicap, disability, age or status as a disabled
veteran or veteran of the Vietnam era and the rights of applicants and employees.
b. The Grantee will, in all solicitations or advancements for employees placed by or on behalf of the Grantee,
state that all qualified applicants will receive consideration for employment without regard to race, color,
religion, sex, national origin physical or mental handicap, disability, age or status as a disabled veteran or
veteran of the Vietnam era.
c. The Grantee will send to each labor union or representative of workers with which it has a collective
bargaining agreement or other contract or understanding a notice, to be provided by the Federal
Government or the State, advising the labor union or workers' representative of the Grantee's
commitments under the provisions herein and shall post copies of the notice in conspicuous places
available to employees and applicants for employment.
d. The Grantee will comply with all provisions of and furnish all information and reports required by Section
503 of the Rehabilitation Act of 1973, as amended, the Vietnam Era Veterans' Readjustment Assistance
Act of 1974 (38 U.S.C. 4212) and of the Federal Executive Order No. 11246 as amended, including by
Executive Order 11375, 'Amending Executive Order 11246 Relating to Equal Employment Opportunity,'
and as supplemented by regulation at 41 CFR part 60, "Office of the Federal Contract Compliance
Programs, Equal Employment Opportunity, Department of Labor,'' and of the rules, regulations, and
relevant orders of the Secretary of Labor.
CDPH (rev. 07/16) Page 2 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
e. The Grantee will furnish all information and reports required by Federal Executive Order No. 11246 as amended, including by Executive Order 11375, 'Amending Executive Order 11246 Relating to Equal
Employment Opportunity,' and as supplemented by regulation at 41 CFR part 60, "Office of the Federal
Contract Compliance Programs, Equal Employment Opportunity, Department of Labor," and the
Rehabilitation Act of 1973, and by the rules, regulations, and orders of the Secretary of Labor, or pursuantthereto, and will permit access to its books, records, and accounts by the State and its designatedrepresentatives and the Secretary of Labor for purposes of investigation to ascertain compliance with such
rules, regulations, and orders.
f. In the event of the Grantee's noncompliance with the requirements of the provisions herein or with anyfederal rules, regulations, or orders which are referenced herein, this Agreement may be cancelled,
terminated, or suspended in whole or in part and the Grantee may be declared ineligible for further federaland state contracts in accordance with procedures authorized in Federal Executive Order No. 11246 asamended and such other sanctions may be imposed and remedies invoked as provided in Federal
Executive Order No. 11246 as amended, including by Executive Order 11375, 'Amending Executive Order
11246 Relating to Equal Employment Opportunity,' and as supplemented by regulation at 41 CFR part 60, "Office of the Federal Contract Compliance Programs, Equal Employment Opportunity, Department ofLabor," or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law.
g. The Grantee will include the provisions of Paragraphs a through g in every subcontract or purchase orderunless exempted by rules, regulations, or orders of the Secretary of Labor issued pursuant to Federal
Executive Order No. 11246 as amended, including by Executive Order 11375, 'Amending Executive Order
11246 Relating to Equal Employment Opportunity,' and as supplemented by regulation at 41 CFR part 60,
"Office of the Federal Contract Compliance Programs, Equal Employment Opportunity, Department ofLabor," or Section 503 of the Rehabilitation Act of 1973 or (38 U.S.C. 4212) of the Vietnam Era Veteran's
Readjustment Assistance Act, so that such provisions will be binding upon each subGrantee or vendor.The Grantee will take such action with respect to any subcontract or purchase order as the Director of theOffice of Federal Contract Compliance Programs or CDPH may direct as a means of enforcing such
provisions including sanctions for noncompliance provided, however, that in the event the Granteebecomes involved in, or is threatened with litigation by a subGrantee or vendor as a result of suchdirection by CDPH, the Grantee may request in writing to CDPH, who, in turn, may request the United
States to enter into such litigation to protect the interests of the State and of the United States.
3. Debarment and Suspension Certification
a. By signing this Grant, the Grantee agrees to comply with applicable federal suspension and debarment
regulations including, but not limited to 7 CFR Part 3017, 45 CFR 76, 40 CFR 32 or 34 CFR 85.
b. By signing this Grant, the Grantee certifies to the best of its knowledge and belief, that it and its principals:
(1)Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarilyexcluded by any federal department or agency;
(2)Have not within a three-year period preceding this application/proposal/agreement been convicted ofor had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local)transaction or contract under a public transaction; violation of Federal or State antitrust statutes orcommission of embezzlement, theft, forgery, bribery, falsification or destruction of records, makingfalse statements, or receiving stolen property;
(3)Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State or local) with commission of any of the offenses enumerated in Paragraph b(2) herein;
and
(4)Have not within a three-year period preceding this application/proposal/agreement had one or more
public transactions (Federal, State or local) terminated for cause or default.
(5)Shall not knowingly enter into any lower tier covered transaction with a person who is proposed fordebarment under federal regulations (i.e., 48 CFR part 9, subpart 9.4), debarred, suspended, declaredineligible, or voluntarily excluded from participation in such transaction, unless authorized by the State.
CDPH (rev. 07/16) Page 3 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
(6) Will include a clause entitled, "Debarment and Suspension Certification" that essentially sets forth the
provisions herein, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
c. If the Grantee is unable to certify to any of the statements in this certification, the Grantee shall submit an
explanation to the CDPH Program Contract Manager.
d. The terms and definitions herein have the meanings set out in the Definitions and Coverage sections of
the rules implementing Federal Executive Order 12549.
e. If the Grantee knowingly violates this certification, in addition to other remedies available to the Federal
Government, the CDPH may terminate this Agreement for cause or default.
4. Covenant Against Contingent Fees
The Grantee warrants that no person or selling agency has been employed or retained to solicit/secure this Grant upon an agreement of understanding for a commission, percentage, brokerage, or contingent fee, except bona fide employees or bona fide established commercial or selling agencies retained by the Grantee
for the purpose of securing business. For breach or violation of this warranty, CDPH shall have the right to
annul this Grant without liability or in its discretion to deduct from the Grant price or consideration, or otherwise
recover, the full amount of such commission, percentage, and brokerage or contingent fee.
5. Air or Water Pollution Requirements
Any federally funded grant and/or subgrants in excess of $100,000 must comply with the following provisions
unless said grant is exempt under 40 CFR 15.5.
a. Government Grantees agree to comply with all applicable standards, orders, or requirements issued
under section 306 of the Clean Air Act [42 U.S.C. 1857(h)], section 508 of the Clean Water Act (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency regulations ( 40 CFR part 15).
b. Institutions of higher education, hospitals, nonprofit organizations and commercial businesses agree to comply with all applicable standards, orders, or requirements issued under the Clean Air Act (42 U.S.C. 7401 et seq.), as amended, and the Federal Water Pollution Control Act (33 U.S.C. 1251 et seq.), as
amended.
6. Lobbying Restrictions and Disclosure Certification
(Applicable to federally funded grants in excess of $100,000 per Section 1352 of the 31, U.S.C.)
a. Certification and Disclosure Requirements
(1) Each person (or recipient) who requests or receives a grant, subgrant, which is subject to Section
1352 of the 31, U.S.C., and which exceeds $100,000 at any tier, shall file a certification (in the form set forth in Attachment 1, consisting of one page, entitled "Certification Regarding Lobbying") that the recipient has not made, and will not make, any payment prohibited by Paragraph b of this provision.
(2) Each recipient shall file a disclosure (in the form set forth in Attachment 2, entitled "Standard Form-
LLL 'disclosure of Lobbying Activities'") if such recipient has made or has agreed to make any payment using nonappropriated funds (to include profits from any covered federal action) in connection with a grant or any extension or amendment of that grant, which would be prohibited under
Paragraph b of this provision if paid for with appropriated funds.
(3) Each recipient shall file a disclosure form at the end of each calendar quarter in which there occurs
any event that requires disclosure or that materially affect the accuracy of the information contained in any disclosure form previously filed by such person under Paragraph a(2) herein. An event that
materially affects the accuracy of the information reported includes:
(a) A cumulative increase of $25,000 or more in the amount paid or expected to be paid for
influencing or attempting to influence a covered federal action;
CDPH (rev. 07/16) Page 4 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
(b) A change in the person(s) or individuals(s) influencing or attempting to influence a covered federal
action; or
(c) A change in the officer(s), employee(s), or member(s) contacted for the purpose of influencing or
attempting to influence a covered federal action.
( 4) Each person ( or recipient) who requests or receives from a person referred to in Paragraph a( 1) of
this provision a grant or subgrant exceeding $100,000 at any tier under a grant shall file a certification,
and a disclosure form, if required, to the next tier above.
(5) All disclosure forms (but not certifications) shall be forwarded from tier to tier until received by the
person referred to in Paragraph a(1) of this provision. That person shall forward all disclosure forms to CDPH Program Contract Manager.
b. Prohibition
Section 1352 of Title 31, U.S.C., provides in part that no appropriated funds may be expended by the
recipient of a federal contract or agreement, grant, loan, or cooperative agreement to pay 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 any of the
following covered federal actions: the awarding of any federal contract or agreement, the making of any
federal grant, the making of any federal loan, entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract or agreement, grant,
loan, or cooperative agreement.
7. Additional Restrictions
Grantee shall comply with the restrictions under Division F, Title V, Section 503 of the Consolidated
Appropriations Act, 2012 (H.R. 2055), which provides that:
"SEC. 503.(a) No part of any appropriation contained in this Act or transferred pursuant to
section 4002 of Public Law 111-148 shall be used, other than for normal and recognized
executive-legislative relationships, for publicity or propaganda purposes, for the preparation,
distribution, or use of any kit, pamphlet, booklet, publication, electronic communication, radio,
television, or video presentation designed to support or defeat the enactment of legislation
before the Congress or any State or local legislature or legislative body, except in presentation
to the Congress or any State or local legislature itself, or designed to support or defeat any
proposed or pending regulation, administrative action, or order issued by the executive branch
of any State or local government, except in presentation to the executive branch of any State or
local government itself.
(b)No part of any appropriation contained in this Act or transferred pursuant to section
4002 of Public Law 111-148 shall be used to pay the salary or expenses of any grant or
contract recipient, or agent acting for such recipient, related to any activity designed to
influence the enactment of legislation, appropriations, regulation, administrative action, or
Executive order proposed or pending before the Congress or any State government, State
legislature or local legislature or legislative body, other than for normal and recognized
executive-legislative relationships or participation by an agency or officer of a State, local or
tribal government in policymaking and administrative processes within the executive branch of
that government.
(c) The prohibitions in subsections (a) and (b) shall include any activity to advocate or promote any proposed, pending or future Federal, State or local tax increase, or any proposed, pending, or future
requirement or restriction on any legal consumer product, including its sale or marketing, including but not
limited to the advocacy or promotion of gun control."
8. Human Subjects Use Requirements
CDPH (rev. 07/16) Page 5 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
(Applicable only to federally funded agreements in which performance, directly or through a subcontract/subaward, includes any tests or examination of materials derived from the human body.)
By signing this Agreement, Contractor agrees that if any performance under this Agreement or any
subcontract or subagreement includes any tests or examination of materials derived from the human body for
the purpose of providing information, diagnosis, prevention, treatment or assessment of disease, impairment, or health of a human being, all locations at which such examinations are performed shall meet the
requirements of 42 U.S.C. Section 263a (CLIA) and the regulations thereunder.
9. Financial and Compliance Audit Requirements
By signing this Agreement, the Contractor/Subcontrac tor agrees to abide by all requirements specified in 2
CFR 200, et seq., 2 CFR 400, et seq., and 45 CFR, 75, et seq., as applicable, including but not limited to
obtaining an annual audit, and any subsequent federal regulatory additions or revisions.
a. The definitions used in this provision are contained in Section 38040 of the Health and Safety Code, which
by this reference is made a part hereof.
b. Direct service contract means a contract or agreement for services contained in local assistance or
subvention programs or both (see Health and Safety [H&S] Code section 38020). Direct service contracts
shall not include contracts, agreements, grants, or subventions to other governmental agencies or units of
government nor contracts or agreements with regional centers or area agencies on aging (H&S Code
section 38030).
c. The Contractor, as indicated below, agrees to obtain one of the following audits:
(1)If the Contractor is a nonprofit organization (as defined in H&S Code section 38040) and receives
$25,000 or more from any State agency under a direct service contract or agreement; the Contractor
agrees to obtain an annual single, organization wide, financial and compliance audit. Said audit shall
be conducted according to Generally Accepted Auditing Standards. This audit does not fulfill the audit
requirements of Paragraph c(3) below. The audit shall be completed by the 15th day of the fifth
month following the end of the Contractor's fiscal year, and/or
(2)If the Contractor is a nonprofit organization (as defined in H&S Code section 38040) and receives less
than $25,000 per year from any State agency under a direct service contract or agreement, the
Contractor agrees to obtain a biennial single, organization wide financial and compliance audit, unless
there is evidence of fraud or other violation of state law in connection with this Agreement. This auditdoes not fulfill the audit requirements of Paragraph c(3) below. The audit shall be completed by the
15th day of the fifth month following the end of the Contractor's fiscal year, and/or
(3) If the Contractor is a State or Local Government entity or Nonprofit organization (as defined in 2CFR
Part 200) and expends $750,000 or more in Federal awards, the Contractor agrees to obtain an
annual single, organization wide, financial and compliance audit according to the requirements
specified in 2CFR Part 200. An audit conducted pursuant to this provision will fulfill the audit
requirements outlined in Paragraphs c( 1) and c(2) above. The audit shall be completed by the end of
the ninth month following the end of the audit period. The requirements of this provision apply if:
(a) The Contractor is a recipient expending Federal awards received directly from Federal awarding
agencies, or
(b) The Contractor is a subrecipient expending Federal awards received from a pass-through entity
such as the State, County or community based organization.
(4)If the Contractor submits to CDPH a report of an audit other than a single audit, the Contractor must
also submit a certification indicating the Contractor has not expended $750,000 or more in federal
funds for the year covered by the audit report.
d. Two copies of the audit report shall be delivered to the CDPH program funding this Agreement. The audit
report must identify the Contractor's legal name and the number assigned to this Agreement. The auditreport shall be due within 30 days after the completion of the audit. Upon receipt of said audit report, the
CDPH (rev. 07/16) Page 6 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
CDPH Program Contract Manager shall forward the audit report to CDPH's Audits and Investigations Unit
if the audit report was submitted under Section 16.c(3), unless the audit report is from a City, County, or
Special District within the State of California whereby the report will be retained by the funding program.
e. The cost of the audits described herein may be included in the funding for this Agreement up to the
proportionate amount this Agreement represents of the Contractor's total revenue. The CDPH program
funding this Agreement must provide advance written approval of the specific amount allowed for said
audit expenses.
f.The State or its authorized designee, including the Bureau of State Audits, is responsible for conducting
agreement performance audits which are not financial and compliance audits. Performance audits are
defined by Generally Accepted Government Auditing Standards.
g. Nothing in this Agreement limits the State's responsibility or authority to enforce State law or regulations,
procedures, or reporting requirements arising thereto.
h. Nothing in this provision limits the authority of the State to make audits of this Agreement, provided
however, that if independent audits arranged for by the Contractor meet Generally Accepted
Governmental Auditing Standards, the State shall rely on those audits and any additional audit work and
shall build upon the work already done.
i. The State may, at its option, direct its own auditors to perform either of the audits described above. The
Contractor will be given advance written notification, if the State chooses to exercise its option to perform
said audits.
j.The Contractor shall include a clause in any agreement the Contractor enters into with the audit firm doing
the single organization wide audit to provide access by the State or Federal Government to the working
papers of the independent auditor who prepares the single organization wide audit for the Contractor.
k. Federal or state auditors shall have "expanded scope auditing" authority to conduct specific program
audits during the same period in which a single organization wide audit is being performed, but the audit
report has not been issued. The federal or state auditors shall review and have access to the current audit
work being conducted and will not apply any testing or review procedures which have not been satisfied by
previous audit work that has been completed.
The term "expanded scope auditing" is applied and defined in the U.S. General Accounting Office (GAO)
issued Standards for Audit of Government Organizations, Programs, Activities and Functions, better
known as the "yellow book".
10. Audit and Record Retention
(Applicable to agreements in excess of $10,000.)
a. The Contractor shall maintain books, records, documents, and other evidence, accounting procedures
and practices, sufficient to properly reflect all direct and indirect costs of whatever nature claimed to have
been incurred in the performance of this Agreement, including any matching costs and expenses. The
foregoing constitutes "records" for the purpose of this provision.
b. The Contractor's facility or office or such part thereof as may be engaged in the performance of this
Agreement and his/her records shall be subject at all reasonable times to inspection, audit, and
reproduction.
c. Contractor agrees that CDPH, the Department of General Services, the Bureau of State Audits, or their
designated representatives including the Comptroller General of the United States shall have the right to
review and to copy any records and supporting documentation pertaining to the performance of this
Agreement. Contractor agrees to allow the auditor(s) access to such records during normal business
hours and to allow interviews of any employees who might reasonably have information related to such
records. Further, the Contractor agrees to include a similar right of the State to audit records and
interview staff in any subcontract related to performance of this Agreement. (GC 8546.7, CCR Title 2,
Section 1896).
CDPH (rev. 07/16) Page 7 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
d. The Contractor shall preserve and make available his/her records (1) for a period of three years from the
date of final payment under this Agreement, and (2) for such longer period, if any, as is required by
applicable statute, by any other provision of this Agreement, or by subparagraphs (1) or (2) below.
(1) If this Agreement is completely or partially terminated, the records relating to the work terminated shall
be preserved and made available for a period of three years from the date of any resulting final
settlement.
(2) If any litigation, claim, negotiation, audit, or other action involving the records has been started before
the expiration of the three-year period, the records shall be retained until completion of the action and
resolution of all issues which arise from it, or until the end of the regular three-year period, whichever
is later.
e. The Contractor shall comply with the above requirements and be aware of the penalties for violations of
fraud and for obstruction of investigation as set forth in Public Contract Code § 10115.10, if applicable.
f. The Contractor may, at its discretion, following receipt of final payment under this Agreement, reduce its
accounts, books and records related to this Agreement to microfilm, computer disk, CD ROM, or other
data storage medium. Upon request by an authorized representative to inspect, audit or obtain copies of
said records, the Contractor and/or Subcontractor must supply or make available applicable devices,
hardware, and/or software necessary to view, copy and/or print said records. Applicable devices may
include, but are not limited to, microfilm readers and microfilm printers, etc.
g. The Contractor shall, if applicable, comply with the Single Audit Act and the audit reporting requirements
set forth in Title 2 of the Code of Federal Regulations, Part 200 (2CFR Part 200).
11. Federal Requirements
Granter agrees to comply with and shall require all subgranteers, if any, to comply with all applicable
Federal requirements including but not limited to the United States Code, the Code of Federal
Regulations, the Funding Opportunity Announcement, the Notice of Award, the funding agreement, and
any memoranda or letter regarding the applicable Federal requirements.
CDPH (rev. 07/16) Page 8 of 11
California Department of Public Health -Federal Terms and Conditions
STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF PUBLIC HEAL TH
CERTIFICATION REGARDING LOBBYING
The undersigned certifies, to the best of his or her knowledge and belief, that:
Exhibit F
Attachment 1
(1)No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, toany 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 subGrantees, 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 Grantee
18-10558
Contract / Grant Number
Date
After execution by or on behalf of Grantee, please return to:
California Department of Public Health
Nutrition Education and Obesity Prevention Branch
7204
7377
Printed Name of Person Signing for Grantee
Signature of Person Signing for Grantee
Title
CDPH reserves the right to notifiy the Grantee in writing of an alternate submission address.
CDPH (rev. 07/16) Page 9 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
Attachment 2
CERTIFICATION REGARDING LOBBYING
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse for public burden disclosure)
Approved by 0MB
0348-0046
1. Type of Federal Action:2. Status of Federal Action:3. Report Type:
[ l a. contract [ l a. bid/offer/application [ l a. initial filingb. grant b. initial award b. material change
C. cooperative agreement C. post-award For Material Change Only: d. loan
e. loan guarantee Year __ quarter_
f. loan insurance date of last report __ .
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name
and Address of Prime: D Prime D Subawardee
Tier _, if known:
Conaressional District If known: Congressional District, If known:
6. Federal Department/Agency 7. Federal Program Name/Description:
CDFA Number, if applicable: __
8. Federal Action Number, if known: 9. Award Amount, if known:
$
10.a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if different from
(If individual, last name, first name, Ml): 10a.
(Last name, First name, Ml):
11. Information requested through this form is authorized by title 31
U.S.C. section 1352. This disclosure of lobbying activities is a material Signature:
representation of fact upon which reliance was placed by the tier Print Name: above when this transaction was made or entered into. This
disclosure is required pursuant to 31 U.S.C. 1352. This information Title: will be available for public inspection. required disclosure shall be
subject to a not more than $100,000 for each such failure. Telephone No.: Date:
Federal Use Only I Authorized for Local ReproductionStandard Form-LLL (Rev. 7-97)
CDPH (rev. 07/16) Page 10 of 11
California Department of Public Health -Federal Terms and Conditions Exhibit F
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a
material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying
entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance
published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and
quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is
the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include
Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example,
Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1 ). If known, enter the full Catalog of Federal Domestic Assistance (CFDA)
number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency).
Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment
for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity
identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and Middle Initial
(Ml).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act. as amended, no persons are required to
respond to a collection of information unless it displays a valid 0MB Control Number.
The valid 0MB control number for this information collection is 0MB No. 0348-0046.
CDPH (rev. 07/16) Page 11 of 11