HomeMy WebLinkAboutAgreement A-20-458 with Heluna Health for ELC - CARES.PDF13300 Crossroads Parkway North, Suite 450 | City of Industry, CA | 91746
Phone: 800.201.7320 | Fax: 562.205.2453 | www.helunahealth.org
WORK ORDER AGREEMENT
This Work Order Agreement (this "Agreement") is hereby made by and between Public Health Foundation Enterprises, Inc. DBA Heluna Health, a 501(c)(3)
California nonprofit corporation (hereafter "HELUNA HEALTH", or “Client”), and the Local Health Department identified below (hereafter "Local Health
Department") and sets forth the terms and conditions between Client and Local Health Department, for agreed services, as required by the Client, and as
stated in this Agreement. This Agreement does not designate Local Health Department as the agent or legal representative of HELUNA HEALTH for any
purpose whatsoever. (HELUNA HEALTH and Local Health Department shall be referred to herein individually as a “party” and collectively as the “parties”).
I.IDENTIFIED PARTIES
CLIENT
Heluna Health
13300 Crossroads Parkway North, Suite 450
City of Industry, CA 91746
www.helunahealth.org
ATTN: Rochelle McLaurin, Deputy Director
ELCCOVID19Invoices@helunahealth.org
LOCAL HEALTH DEPARTMENT
County of Fresno
1221 Fulton Street
Fresno, CA 93721
ATTN: David Pomaville, Director, Department of Public Health
DPomaville@fresnocountyca.gov
(559) 600-6405
Grant#: 6NU50CK000539-01-08 DHHS-CDC CFDA#: 93.323 Program#: 0187.1580
II.TERM. Unless otherwise terminated or extended by written notice, the term of this Agreement shall commence on 5/1/2020 and term on 3/31/2022.
III.SERVICES AND COMPENSATION. Local Health Department shall perform the services (the “Services”) described below and as described in Attachment
A, Statement of Work (“SOW”) attached hereto and incorporated herein by this reference. The Services will take place at the location as referenced in
Section 1. Identified Parties for Local Health Department and at such other location as may be set forth in the SOW.
(a) Services. Local Health Department shall perform all services as stated in the SOW. Local Health Department shall perform the Services in
accordance with generally accepted professional standards and in an expeditious and economical manner consistent with sound professional
practices. Local Health Department maintains and shall maintain at all times during the term of this Agreement all applicable federal, state and local
business and other licenses, including any professional licenses or certificates, industrial permits and/or licenses, industry specific licenses, licenses
required by the state(s) and/or locality(s) in which it does business, fictitious business names, federal tax identification numbers, insurance, and
anything else required of Local Health Department as a business operator or to perform the Services.
(b)Payment. HELUNA HEALTH agrees to compensate the Local Health Department on a Cost-Reimbursable Contract. See Attachment A
"Budget" for line item budget detail. Local Health Department shall be compensated only for Services actually performed and required as set
forth herein and any services in excess will not be compensated. The total compensation payable to the Local Health Department hereunder shall
be as set forth below: A total to not exceed $537,756.00.
If for any reason Local Health Department receives an overpayment of amount described above, Local Health Department shall promptly notify
HELUNA HEALTH of such overpayment and repay said amount to HELUNA HEALTH within 10 days of demand for such repayment.
(c)Invoice. Invoices shall be submitted: Monthly, No Later than 30 Days after month end. See Attachment C for “Required Invoice Template.”
Payment for all undisputed amounts of submitted invoices shall be paid no later than 30 days after HELUNA HEALTH’s receipt of the invoice and
required back up documentation. Local Health Department shall submit invoices to the attention of the contact person identified by HELUNA
HEALTH. All final invoices must be received within 45 days of the expiration or termination of this Agreement or within such earlier time period as
HELUNA HEALTH may require. If any invoices are not submitted within such time periods, Local Health Department waives all rights to payment
under such invoices. Local Health Department shall be solely responsible for the payment of all federal, state and local income taxes, social security
taxes, federal and state unemployment insurance and similar taxes and all other assessments, taxes, contributions or sums payable with respect to
Local Health Department or its employees as a result of or in connection with the Services performed by Local Health Department hereunder.
(d)Budget Modifications.
The budget may be modified accordingly:
Informal Budget Modification: Two (2) times throughout the term of this agreement. The informal budget modification must be a change
of <10% of the total budget. The request must be in writing to ELCCOVID19Invoices@helunahealth.org. Any informal budget modification
request must be submitted thirty (30) days before the end of the agreement term.
Formal Budget Modification: Two (2) times throughout the term of this agreement. The formal budget modification must be a change of
10% or greater of the total budget. The request must be in writing on agency letterhead to ELCCOVID19Invoices@helunahealth.org. Any
formal budget modification request must be submitted sixty (60) days before the end of the agreement term.
IV.INSURANCE. Local Health Department, at its sole cost and expense, shall at all times during the term of this Agreement maintain the insurance coverage
set forth on Attachment B, attached hereto and incorporated herein by this reference, on the terms and conditions described therein. Evidence of such
insurance coverage shall be provided to HELUNA HEALTH by Local Health Department prior to commencing performance of the Services under this
Agreement in the form of a Certificate of Insurance or Certificate of Self-Insurance.
Agreement No. 20-458
3 | Work Order Agreement – County of Fresno 0187.1580
7. COMPLIANCE WITH LAWS. Local Health Department shall comply with all
state and federal statutes and regulations applicable to Local Health Department,
the Services and the Program in performing Local Health Department’s
obligations under this Agreement. Local Health Department represents and
warrants that neither Local Health Department nor its principals or personnel are
presently, nor will any of them be during the term of this Agreement, debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any federal department or funding
agency.
8. HIPAA (if applicable). In the event that Local Health Department’s performance
under this Agreement may expose Local Health Department to individually
identifiable health information or other medical information governed by the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as
amended, and any regulations promulgated in connection thereto, then Local
Health Department agrees to execute and deliver a copy of HELUNA HEALTH's
standard Business Associate Agreement or Business Associate sub Local Health
Department Agreement, as applicable, as required by HIPAA.
9. CONFIDENTIALITY AND NON-DISCLOSURE. HELUNA HEALTH and Local
Health Department agree that during the course of this Agreement, Local Health
Department may be exposed to and become aware of certain unique and
confidential information and special knowledge (hereinafter "Confidential
Information") provided to or developed by HELUNA HEALTH and/or Local Health
Department. Said Confidential Information includes, but is not limited to, the
identity of actual and potential clients of HELUNA HEALTH, client lists, particular
needs of each client, the manner in which business is conducted with each client,
addresses, telephone numbers, and specific characteristics of clients; financial
information about HELUNA HEALTH and/or its clients; client information reports;
mailing labels; various sales and marketing information; sales report forms;
pricing information (such as price lists, quotation guides, previous or outstanding
quotations, or billing information); pending projects or proposals; business plans
and projections, including new product, facility or expansion plans; employee
salaries; contracts and wage information; mailing plans and programs; technical
know-how; designs; products ordered; business methods; processes; records;
specifications; computer programs; accounting; and information disclosed to
HELUNA HEALTH by any third party which HELUNA HEALTH is obligated to
treat as confidential and/or proprietary.
Local Health Department expressly acknowledges that the Confidential
Information constitutes confidential, valuable, special and unique assets of
HELUNA HEALTH or, if applicable, any third-parties who may have disclosed
Confidential Information to HELUNA HEALTH and that the Confidential
Information belongs to and shall remain the property of HELUNA HEALTH and
such third-parties. Local Health Department further expressly acknowledges that
the Confidential Information derives independent actual or potential economic
value from not being generally known to the public or to other persons and Local
Health Department agrees to afford HELUNA HEALTH protection against any
unauthorized use of the Confidential Information or any use of the Confidential
Information in any manner that may be detrimental to HELUNA HEALTH.
Therefore, Local Health Department agrees to hold any and all Confidential
Information in the strictest of confidence, whether or not particular portions or
aspects thereof may also be available from other sources. Local Health
Department shall not disclose Confidential Information in any manner
whatsoever, directly or indirectly, or use it in any way whatsoever, either during
the term of this Agreement or at any time thereafter, except solely for the purpose
of performance under this Agreement, except as required by the California Public
Records Act. Further, Local Health Department shall develop and maintain
procedures and take other reasonable steps in furtherance of HELUNA
HEALTH's desire to maintain the confidentiality of the Confidential Information.
All documents and other items which might be deemed the subject of or related
to Confidential Information of HELUNA HEALTH's business, whether prepared,
conceived, originated, discovered, or developed by Local Health Department, in
whole or in part, or otherwise coming into Local Health Department’s possession,
shall remain the exclusive property of HELUNA HEALTH and shall not be copied
or removed from the premises of HELUNA HEALTH without the express written
consent of HELUNA HEALTH. All such items, and any copies thereof, shall be
immediately returned to HELUNA HEALTH by Local Health Department upon
request at any time and upon termination of this Agreement. This section shall
survive expiration or termination of this Agreement.
10. NON-SOLICITATION OF EMPLOYEES. During the term of this Agreement and
for two years following its termination, Local Health Department shall not induce,
encourage, or advise any person who is employed by or is engaged as an agent
or independent Local Health Department by HELUNA HEALTH to leave the
employment of HELUNA HEALTH or otherwise raid the employees of HELUNA
HEALTH, without the express written consent of HELUNA HEALTH. Nothing
contained in this paragraph shall constitute a waiver by HELUNA HEALTH of any
rights it may have if Local Health Department engages in actionable conduct after
the two-year period referred to above.
11. WORKS FOR HIRE. Local Health Department agrees that all inventions, original
works of authorship, developments, concepts, know-how, discoveries, ideas,
logos, improvements, trade secrets, secret processes, patents, patent
applications, software, platforms, service marks, trademarks, trademark
applications, copyright and copyright registrations, whether or not patentable or
registerable under copyright, trademark or other similar laws, made, conceived or
developed by Local Health Department, in whole or in part, either alone or in
connection with others, that relate to the Services under this Agreement or the
operations, activities, research, investigation, business or obligations of HELUNA
HEALTH (collectively, the "Work Product") are the sole property of the HELUNA
HEALTH and all right, title, interest and ownership in all such Work Product,
including but not limited to copyrights, trademarks, patents, trade secret rights,
trade names, and know-how and the rights to secure any renewals, reissues, and
extensions thereof, will vest in the HELUNA HEALTH. The Work Product will be
deemed to be "works made for hire" under United States copyright law (17 U.S.C.
Section 101 et seq.) and made in the course of this Agreement, and Local Health
Department expressly disclaims any interest in the Work Product.
To the extent that the Work Product may not, by operation of law, vest in the
HELUNA HEALTH or may not be considered to be works made for hire, all right,
title and interest therein are hereby irrevocably assigned to the HELUNA HEALTH.
Local Health Department understands that HELUNA HEALTH may register the
copyright, trademark, patent and other rights in the Work Product in HELUNA
HEALTH's name and Local Health Department grants HELUNA HEALTH the
exclusive right, and appoints HELUNA HEALTH as attorney-in-fact, to execute and
prosecute in Local Health Department’s name as author or inventor or in HELUNA
HEALTH’s name as assignee, any application for registration or recordation of any
copyright, trademark, patent or other right or interest in or to the Work Product, and
to undertake any enforcement action with respect to any Work Product. Local
Health Department hereby agrees to sign such applications, documents,
assignment forms and other papers as the HELUNA HEALTH requests from time
to time to further confirm this assignment and Local Health Department agrees to
give the HELUNA HEALTH and any person designated by the HELUNA HEALTH
any reasonable assistance required to perfect and enforce the rights defined in this
section. Local Health Department further understands that the HELUNA HEALTH
has full, complete and exclusive ownership of the Work Product. In the event the
aforementioned assignment is invalid, Local Health Department grants HELUNA
HEALTH a non-exclusive, worldwide, perpetual, fully paid-up, irrevocable, right
and license to use, reproduce, make, sell, perform and display (publicly or
otherwise), and distribute, and modify and otherwise make derivative works of the
Work Product and to authorize third parties to perform any or all of the foregoing
on its behalf, including through multiple tiers of sublicenses. Local Health
Department agrees not to use the Work Product Property for the benefit of anyone
other than HELUNA HEALTH without HELUNA HEALTH's prior written permission.
All rights, interest and ownership to the Work Product granted or assigned to
HELUNA HEALTH hereunder shall be subject to any rights of the Program under
HELUNA HEALTH’s agreement with the Program and any rights of the United
States Federal Government under applicable laws and regulations.
12. INDEMNITY. Local Health Department hereby agrees to indemnify, hold harmless
and defend HELUNA HEALTH, its board of trustees, officers, directors, agents,
Local Health Departments, subcontractors, employees, affiliated companies,
representatives, and agents (collectively, the “Local Health Department
Indemnified Parties") from and against any and all claims, causes of action, costs,
demands, lawsuits, expenses (including, without limitation, attorney’s fees and
costs), interest, penalties, losses, damages, settlements, liabilities, and any and
all amounts paid in investigation or defense incurred by any of the Local Health
Department Indemnified Parties arising out of or resulting from: (i) Local Health
Department’s (or its agents’, subcontractors’ or employees’) performance of the
Services; (ii) Local Health Department’s (or its agents’, subcontractors’ or
employees’) default, non-performance or breach of this Agreement, including any
representations, warranties, or certifications; (iii) any alleged or actual acts or
omissions of Local Health Department (or its agents, subcontractors or
employees) relating to services provided outside the scope of this Agreement; (iv)
Local Health Department’s (or its agents’, subcontractors’ or employees’) violation
of any federal, state or local law or regulation; or (v) any claims or actions that the
Work Product, or any element thereof, infringes the intellectual, privacy or other
rights of any party.
If any lawsuit, enforcement or other action is filed against any of the Local Health
Department Indemnified Parties Local Health Department for which the Local
Health Department Indemnified Parties are entitled to indemnification pursuant to
this Agreement, Local Health Department and such other Local Health
Department Indemnified Parties may elect to have Local Health Department,
Local Health Department’s sole expense, take control of the defense and
investigation of such lawsuit or action using attorneys, investigators and others
reasonably satisfactory to Local Health Department. The parties shall cooperate
in all reasonable respects with the investigation, trial, and defense of any such
lawsuit or action and any appeal arising from it. The terms of this section shall
survive the termination of this Agreement.
13. RECORD RETENTION AND ACCESS TO RECORDS. Local Health Department
agrees to retain all books, documents, papers, files, accounts, fiscal data, records,
and reports relating to this Agreement or the Services, including, but not limited to,
4 | Work Order Agreement – County of Fresno 0187.1580
evidence pertaining costs and expenses, payment information, accounts of
services provided and any other information or documentation related to Local
Health Department’s performance under this Agreement. Local Health Department
shall retain all such records for a period of not less than seven (7) years after final
payment is made under this Agreement and all pending matters are closed or
longer if required by (i) HELUNA HEALTH’s record retention policy, (ii) the
Program, or (iii) any other applicable laws or regulations, including under the
Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards issued by the federal Office of Management Budget codified at 2
CFR Part 200 (“Uniform Guidance”) and Federal Acquisition Regulation (FAR)
System regulations at 48 CFR 4.700 et seq. Notwithstanding the foregoing, in the
event any litigation, claim, negotiation, audit or other action is commenced prior to
the expiration of the aforementioned retention period, all records related to such
litigation, claim, negotiation, audit or other action shall be retained until full
completion and resolution of the litigation, claim, negotiation, audit or other action.
Local Health Department agrees that HELUNA HEALTH, the Program, the U.S.
Comptroller General and their respective authorized representatives or designees
shall have the right, upon demand, to access, examine, copy, audit or inspect any
and all of the records described in this section, including on-site audits, reviews
and copying of records. The terms of this section shall survive expiration or
termination of the Agreement.
14. AMENDMENTS. Amendments to this Agreement shall be in writing, signed by the
party to be obligated by such amendment and attached to this Agreement.
15. GOVERNING LAW; VENUE. This Agreement shall be interpreted, construed and
governed by, in accordance with and consistent with the laws of the State of
California without giving effect to its conflicts of laws principals. The sole, exclusive
and proper venue for any proceedings brought to interpret or enforce this
Agreement or to obtain a declaration of the rights of the parties hereunder shall be
Los Angeles County, California. Each of the parties hereto submits to the
exclusive personal jurisdiction of the courts located in Los Angeles County,
California and waives any defense of forum non conveniens.
16. EQUITABLE RELIEF. In light of the irreparable harm to HELUNA HEALTH that a
breach by Local Health Department of Sections 9, 10 and 11 of these Terms and
Conditions would cause, in addition to other remedies set forth in this Agreement
and other relief for violations of this Agreement, HELUNA HEALTH shall be entitled
to enjoin Local Health Department from any breach or threatened breach of such
Sections, to the extent permitted by law and without bond.
17. FAIR INTERPRETATION. The language appearing in all parts of this Agreement
shall be construed, in all cases, according to its fair meaning in the English
language, and not strictly construed for or against any party hereto. This
Agreement has been prepared jointly by the parties hereto after arm’s length
negotiations and any uncertainty or ambiguity contained in this Agreement, if any,
shall not be interpreted or construed against any party, but according to its fair
meaning applying the applicable rules of interpretation and construction of
contracts.
18. NO WAIVER. No failure or delay by any party in exercising a right, power or
remedy under the Agreement shall operate as a waiver of any such right or other
right, power or remedy. No waiver of, or acquiescence in, any breach or default of
any one or more of the terms, provisions or conditions contained in this Agreement
shall be deemed to imply or constitute a waiver of any other or succeeding or
repeated breach or default hereunder. The consent or approval by any party
hereto to or of any act of the other party hereto requiring further consent or
approval shall not be deemed to waive or render unnecessary any consent or
approval to or of any subsequent similar acts.
19. NOTICES. Any notice given in connection with this agreement shall be in writing
and shall be delivered either by hand to the party or by certified mail, return receipt
requested, to the party at the party's address stated in Section 1: Identified Parties.
Any party may change its address stated herein by giving notice of the change in
accordance with this paragraph.
20. REMEDIES NON-EXCLUSIVE. Except where otherwise expressly set forth
herein, all remedies provided by this Agreement shall be deemed to be cumulative
and additional and not in lieu of or exclusive of each other or of any other remedy
available to the respective parties at law or in equity.
21. SEVERABILITY. If any term, provision, condition or other portion of this
Agreement is determined to be invalid, void or unenforceable by a forum of
competent jurisdiction, the same shall not affect any other term, provision,
condition or other portion hereof, and the remainder of this Agreement shall remain
in full force and effect, as if such invalid, void or unenforceable term, provision,
condition or other portion of this Agreement did not appear herein.
22. NON-ASSIGNABILITY. This agreement shall not be assigned, in whole or in part,
by Local Health Department without the prior written approval and consent of
HELUNA HEALTH.
23. COUNTERPARTS. This Agreement may be executed in two or more counterparts,
each of which shall be deemed an original and all of which together shall constitute
one instrument. Any signed counterpart delivered by electronic mail or facsimile
shall be deemed for all purposes to constitute such party’s good and valid
execution and delivery of this Agreement.
24. FEDERAL TERMS AND CONDITIONS.
A. Equal Employment Opportunity. Except as otherwise provided under 41 CFR
Part 60, to the extent this Agreement meets the definition of a “federally
assisted construction contract” as set forth in 41 CFR Part 60-1.3, Local Health
Department agrees at all times during the term of this Agreement to comply
with and abide by the following: (i) the equal opportunity clause (“Equal
Opportunity Clause”) in 41 CFR 60-1.4(b) in accordance with Executive Order
11246, as amended by Executive Order 11375 and that the Equal Opportunity
Clause is a part of this Agreement and incorporated herein by this reference;
and (ii) the regulations implementing the Equal Opportunity Clause at 41 CFR
Part 60 and that such implementing regulations are a part of this Agreement
and incorporated herein by this reference.
B. Davis-Bacon Act and Copeland “Anti-Kickback” Act. To the extent this
Agreement is for construction services (new construction or repair), Local
Health Department agrees at all times during the term of this Agreement to
comply with and abide by: (i) the terms of the Davis-Bacon Act, codified at 40
U.S.C. 3141 et seq., as supplemented by regulations at 29 CFR Part 5, and
that such terms and regulations are a part of this Agreement and incorporated
herein by this reference; and (ii) the terms of the Copeland “Anti-Kick Back”
Act, codified at 40 U.S.C. § 3145 et seq., as supplemented by 29 CFR 3, and
that such terms and regulations are a part of this Agreement and incorporated
herein by this reference
C. Contract Work Hours and Safety Standards Act. To the extent this Agreement
is in excess of $100,000 and involves the employment of mechanics or
laborers, Local Health Department agrees at all times during the term of this
Agreement to comply with and abide by the terms of the Contract Work Hours
and Safety Standards Act, codified at 40 U.S.C. 3701 et seq., as
supplemented by regulations at 29 CFR Part 5, and that such terms and
regulations are a part of this Agreement and incorporated herein by this
reference.
D. Clean Air Act and Federal Water Pollution Control Act. To the extent this
Agreement is in excess of $150,000, Local Health Department agrees at all
times during the term of this Agreement to comply with and abide by the
standards, orders or regulations issued pursuant to the Clean Air Act, codified
at 42 U.S.C. 7401 et seq. and the Federal Water Pollution Control Act codified
at 33 U.S.C. 1251 et seq. Local Health Department further agrees to report
any violations of the foregoing to HELUNA HEALTH and the Regional Office
of the Environmental Protection Agency.
E. Debarment and Suspension Certification. Local Health Department certifies
that neither Local Health Department nor any of Local Health Department’s
agents, sub Local Health Departments or employees who may perform
services under this Agreement are debarred, suspended or excluded from
participation in any federal assistance programs in accordance with Executive
Orders 12549 and 12689 and its implementing guidelines. Local Health
Department agrees to immediately notify HELUNA HEALTH if Local Health
Department or any of Local Health Department’s agents, sub Local Health
Departments or employees who may perform services under this Agreement
become debarred, suspended or excluded from participation in federal
assistance programs or federal contract transactions.
F. Byrd Anti-Lobbying Amendment Certification. To the extent this Agreement is
in excess of $100,000, Local Health Department certifies that neither Local
Health Department nor any of Local Health Department’s agents, sub Local
Health Departments or employees who may perform services under this
Agreement have not used and will not use any Federally appropriated funds
to pay any person or organization for influencing or attempting to influence an
officer or employee of any agency, a member of Congress, officer or employee
of Congress, or an employee of a member of Congress in connection with
obtaining any Federal contract, grant or any other award covered by 31 U.S.C.
1352. Local Health Department agrees to immediately notify HELUNA
HEALTH if Local Health Department or any of Local Health Department’s
agents, sub Local Health Departments or employees who may perform
services under this Agreement influence or attempt to influence any officer or
employee of any agency, a member of Congress, officer or employee of
Congress, or an employee of a member of Congress in connection with
obtaining any Federal contract, grant or any other award covered by 31 U.S.C.
1352.
5 | Work Order Agreement – County of Fresno 0187.1580
ATTACHMENT A
Statement of Work (SOW), Budget, and Reporting
Statement of Work
Activity 1: Establish or enhance ability to aggressively identify cases, conduct
contact tracing and follow up, as well as implement recommended containment
measures.
Activity 1 -
Milestone 1
Planned Activity
(Provide a title for this
milestone)
Expand contact tracing workforce
Implementation Plan
(Bulleted items or brief
sentences)
Fresno County has a population of approximately
1,000,000 residents and should have at least 150 trained
staff. Contact tracing capabilities are currently below
recommended and the FCDPH is in the process of
increasing personnel, training, and infrastructure to
follow federal and state guidelines of 15:100,000 to
continue to meet community needs as cases rise.
Contact tracing division track cases using RedCap and
Cal-Redie data management platforms to easily share
information between investigators and epidemiologists.
In efforts to increase community commitment, the
FCDPH is recruiting personnel from stakeholder entities
to assist with contact tracing to build a robust tracing
team of 150 personnel.
Applicant capacity: What is
the current capacity to perform
this milestone?
As of June 20, 2020 approximately 95 county employees
have been trained to conduct contact tracing and follow
up with individuals who have been in contact with
positive cases. Training of the other 70 individuals for
surge capacity will be completed by December 2020.
Expected Achieve By Date
(select from drop down)
December 2020
Activity 1: Establish or enhance ability to aggressively identify cases, conduct
contact tracing and follow up, as well as implement recommended containment
measures.
Activity 1 -
Milestone 2
Planned Activity
(Provide a title for this
milestone)
Adopt and implement the State contact tracing platform
Implementation Plan
(Bulleted items or brief
sentences)
When the contact tracing platform, CalConnect, is
available, Fresno County public health and information
technology staff will implement the system and train
public health staff and contact tracers to use the system,
once all recordable data points are updated in software
updates.
6 | Work Order Agreement – County of Fresno 0187.1580
Applicant capacity: What is
the current capacity to
perform this milestone?
Currently, all contact tracing is conducted through
CalREDIE.
Expected Achieve By Date
(select from drop down)
December 2021
Activity 2: Improve morbidity and mortality surveillance
Activity 2 -
Milestone 1
Planned Activity
(Provide a title for this
milestone)
Community- based surveillance
Implementation Plan
(Bulleted items or brief
sentences)
The Population of Fresno County is 978,130. To meet 1.5 tests per 1,000
Fresno County
capacity needs to be 1467 tests per day. The total capacity through all
testing sites
and facilities in Fresno Co. equals 1500.
Fresno County has dramatically increased testing across the entire
health care system
and that capacity continues to increase. The framework for testing
includes multiple
providers, access points, and geographic diversity throughout Fresno
County. The
limiting factor to expand capacity has been specimen collection kits.
Fresno County
is now receiving 11,000 kits per allotment increasing our capacity to
1500 per day.
Applicant capacity: What is
the current capacity to
perform this milestone?
Current Testing Capacity Optum Serve Sites 132 - Fresno 132 - Sanger
Community Health Clinic's; A third site is in development for west Fresno;
Discussions for an additional fourth site are ongoing; 500 – Across 7 large
and distributed clinic systems Hospitals 400 - Across 7 hospitals Fresno
County Department of Public Health 150 - Remote Clinics, Emergency
Responders, Home Health Providers 200- Skilled Nursing Facilities Testing
locations are located across Fresno County and in all incorporated cities.
Expected Achieve By Date
(select from drop down)
December 2020
Activity 2: Improve morbidity and mortality surveillance
Activity 2 -
Milestone 2
Planned Activity
(Provide a title for this
milestone)
Provide accurate accounting of COVID-19 associated deaths
Process to review all deaths to verify if associated with COVID-19.
Provide accurate information in a timely manner.
7 | Work Order Agreement – County of Fresno 0187.1580
Implementation Plan
(Bulleted items or brief
sentences)
Applicant capacity: What is
the current capacity to
perform this milestone?
CSMIT with epidemiology team reviews records of deaths for accurate
reporting
Expected Achieve By Date
(select from drop down)
Activity 3: Enhance laboratory testing and reporting capacity.
Activity 3 -
Milestone 1
Planned Activity
(Provide a title for this
milestone)
Fresno County Public Health Laboratory facilities were flooded for a
total lost in October 2018. We are rebuilding a new facility and are
expected to open in October 2020. Currently, we have temporary
COVID PCR only testing occurring at Fresno State University's lab
facilities.
Implementation Plan
(Bulleted items or brief
sentences)
Expand Fresno State Capacities from 66 daily COVID PCR tests to 266
daily testing. Complete construction of new lab facility.
Applicant capacity: What is
the current capacity to
perform this milestone?
Facilities and equipment we have full capacity. We currently have 2 vacant
Public Health Microbiologist positions. We are looking to fill within the next
14 days.
Expected Achieve By Date
(select from drop down)
December 2020
Activity 3: Enhance laboratory testing and reporting capacity.
Activity 3 -
Milestone 2
Planned Activity
(Provide a title for this
milestone)
Ensure adequate inventory of specimen collection kits
Maintain a daily minimum inventory of 1,000 collection kits on hand.
Distribute to healthcare facilities, skilled nursing facilities, etc. upon
8 | Work Order Agreement – County of Fresno 0187.1580
Implementation Plan
(Bulleted items or brief
sentences)
request if their inventories run low. Request additional kits through
MHOAC as needed.
Applicant capacity: What is
the current capacity to
perform this milestone?
Fully capable, depending on supply chain availability
Expected Achieve By Date
(select from drop down)
December 2020
Activity 3: Enhance laboratory testing and reporting capacity.
Activity 3 -
Milestone 3
Planned Activity
(Provide a title for this
milestone)
Provide adequate data entry staff for lab reporting
Implementation Plan
(Bulleted items or brief
sentences)
Continue to expand available lab data entry staff and maintain staffing
levels throughout the response term
Applicant capacity: What is
the current capacity to
perform this milestone?
7 staff assigned currently, need additional 5 staff for a total of 12 data entry
staff
Expected Achieve By Date
(select from drop down)
September 2020
Activity 3: Enhance laboratory testing and reporting capacity.
Activity 3 -
Milestone 4
Planned Activity
(Provide a title for this
milestone)
Expand FQHC and rural health clinics surveillance
Execute contracts with participating clinics to approx. 200 individuals
per week per site. Develop mobile PCR testing with UCSF to provide
9 | Work Order Agreement – County of Fresno 0187.1580
Implementation Plan
(Bulleted items or brief
sentences)
surveillance (asymptomatic) testing in rural and metropolitan areas.
Coordinate locations with participating clinic sites and local
jurisdictions.
Applicant capacity: What is
the current capacity to
perform this milestone?
Expected Achieve By Date
(select from drop down)
March 2021
Activity 3: Enhance laboratory testing and reporting capacity.
Activity 3 -
Milestone 5
Planned Activity
(Provide a title for this
milestone)
Serology Testing
Implementation Plan
(Bulleted items or brief
sentences)
When viable serology testing is available, conduct serology testing at
DPH and through local participating clinics, with an emphasis on high-
risk individuals including healthcare and other critical infrastructure
workers.
Utilize existing contracts with mobile units, FQHCs and rural providers
to collect specimens and coordinate testing protocols as appropriate
(either Public Health or commercial laboratory)
Applicant capacity: What is
the current capacity to
perform this milestone?
None
Expected Achieve By Date
(select from drop down)
September 2021
Activity 4: Control COVID-19 in high-risk settings and protect vulnerable or high-risk
populations.
Activity 4 -
Milestone 1
Planned Activity
(Provide a title for this
milestone)
Assess and monitor infections in skilled nursing facilities
10 | Work Order Agreement – County of Fresno 0187.1580
Implementation Plan
(Bulleted items or brief
sentences)
Fresno County has 32 Skilled Nursing Facilities listed below. The
Fresno County
Department Health has been coordinating with the State of California
Department
of Public, Licensing and Certification Branch since late February.
• Weekly calls with key Department staff
• Coordination of PPE requests through the MHOAC
• Targeted investigations
• Support for Testing and Tracing
• Technical assistance and training
• The Department of Public Health has deployed a COVID19 Medical
Investigation Team focused specifically on this population
Applicant capacity: What is
the current capacity to
perform this milestone?
To remain compliant with AFL 20-53 and 20-55, all SNFs within Fresno
County will have initial testing performed and notification will be sent to the
State Licensing and Credentialing Board no later than June 30, 2020. Serial
or surveillance testing of at least 25% of the SNF will be required weekly
thereafter.
Expected Achieve By Date
(select from drop down)
December 2021
Activity 4: Control COVID-19 in high-risk settings and protect vulnerable or high-risk
populations.
Activity 4 -
Milestone 2
Planned Activity
(Provide a title for this
milestone)
Health care worker return to work
Implementation Plan
(Bulleted items or brief
sentences)
The following applies to workers in professions
related to health care and hospitals; skilled nursing facilities and long-
term facilities;
hospice; dialysis; infant care; settings which treat
immunocompromised individuals; and
all first responder agencies. An excluded worker may return to work
when:
i. At least 7 days have passed since recovery defined as resolution of
fever
without the use of fever-reducing medications and improvement in
respiratory
symptoms (e.g., cough, shortness of breath); and,
ii. At least 14 days have passed since symptoms first appeared.
Applicant capacity: What is
the current capacity to
perform this milestone?
As of June 25, 2020 local health care facilities are experiencing staff
shortages due to COVID-19 interventions. We will continue to assist facilities
with resources and to bridge lines of communication to the State for
continued awareness and requests for assistance.
Expected Achieve By Date
(select from drop down)
March 2022
Activity 4: Control COVID-19 in high-risk settings and protect vulnerable or high-risk
populations.
11 | Work Order Agreement – County of Fresno 0187.1580
Activity 4 -
Milestone 3
Planned Activity
(Provide a title for this
milestone)
Monitoring of Food processing facilities and agriculture stakeholders
Implementation Plan
(Bulleted items or brief
sentences)
Investigation of COVID-19 food processing facilities and agriculture
stakeholders. Mobile swabbing based on geographical location of
workers.
Applicant capacity: What is
the current capacity to
perform this milestone?
Two personnel from the FCDPH Environmental Health Division are
embedded with the MIT section to assist with investigations in food
processing facilities. FCDPH coordinates for mobile swabbing locations.
Expected Achieve By Date
(select from drop down)
March 2022
Activity 5: Monitor and mitigate COVID-19 introductions from connected jurisdictions
(i.e., neighboring cities, states; including air travel).
Activity 5 -
Milestone 1
Planned Activity
(Provide a title for this
milestone)
Regional Public Health Consortium Calls
Implementation Plan
(Bulleted items or brief
sentences)
On a weekly basis, participate in San Joaquin Valley Public Health
Consortium calls with other Central Valley counties to:
• assess current standings throughout the region
• coordinate regional containment and mitigation strategies
• ensure cohesive messaging to drive voluntary compliance with
containment measures
• update on status of availability PPE, test kits, etc.
Applicant capacity: What is
the current capacity to
perform this milestone?
Currently participating in calls
Expected Achieve By Date
(select from drop down)
12 | Work Order Agreement – County of Fresno 0187.1580
Activity 5: Monitor and mitigate COVID-19 introductions from connected jurisdictions
(i.e., neighboring cities, states; including air travel).
Activity 5 -
Milestone 2
Planned Activity
(Provide a title for this
milestone)
Hospital Association/Medical Provider Calls
Implementation Plan
(Bulleted items or brief
sentences)
On a weekly basis, participate in Hospital Council calls with other
Central Valley medical providers to:
• assess current standings throughout the region
• coordinate regional containment and mitigation strategies
• update on status of availability PPE, test kits, etc.
Applicant capacity: What is
the current capacity to
perform this milestone?
Currently participating in calls
Expected Achieve By Date
(select from drop down)
Activity 5: Monitor and mitigate COVID-19 introductions from connected jurisdictions
(i.e., neighboring cities, states; including air travel).
Activity 5 -
Milestone 3
Planned Activity
(Provide a title for this
milestone)
Elected Officials Calls
Implementation Plan
(Bulleted items or brief
sentences)
On a bi-weekly basis, participate in calls with local, state and national
elected officials to:
• assess current standings throughout the region
• coordinate regional containment and mitigation strategies
• ensure cohesive messaging to drive voluntary compliance with
containment measures
• update on status of availability PPE, test kits, etc.
Applicant capacity: What is
the current capacity to
perform this milestone?
Currently participating in calls
Expected Achieve By Date
(select from drop down)
13 | Work Order Agreement – County of Fresno 0187.1580
Activity 6: Work with healthcare system to manage and monitor system capacity.
Activity 6 -
Milestone 1
Planned Activity
(Provide a title for this
milestone)
Assisting stakeholders with supplies
Implementation Plan
(Bulleted items or brief
sentences)
The County Medical Health Operational Area Coordinator (MHOAC) has
developed an inventory of PPE available for use by County employees
and partners, as well as assessed all suppliers and sources for ordering.
Applicant capacity: What
is the current capacity to
perform this milestone?
Our assessment indicates we have sufficient PPE on hand and available for
day-to- day needs, as well as in the event of an outbreak or surge.
Expected Achieve By Date
(select from drop down)
December 2021
Activity 6: Work with healthcare system to manage and monitor system capacity.
Activity 6 -
Milestone 2
Planned Activity
(Provide a title for this
milestone)
Monitoring bed capacities
Implementation Plan
(Bulleted items or brief
sentences)
There are seven general acute care hospitals (GACH) in Fresno County.
All
these facilities maintain emergency operation, surge, and pandemic
plans and are
required to train on these at least twice annually per Centers for
Medicaid and
Medicare (CMS) guidelines. Each facility has a staffing matrix to ensure
adequate
staffing and available on-call resources. This plan can accommodate a
minimum of 35% surge due to COVID-19 cases.
The plan outlines both the existing bed capacity within our hospitals, as
well as the
ability to activate an Alternate Care Site (ACS) at the Fresno Convention
Center.
The bed capacity within hospitals is 1750, and the number of beds at the
Convention Center ACS site adds 250 beds for a total of 2000 beds in
our county
dedicated to hospitalized patients.
14 | Work Order Agreement – County of Fresno 0187.1580
Applicant capacity: What
is the current capacity to
perform this milestone?
At this time, we have used approximately 1000 beds for COVID and non-
COVID patients, including 25/150 ICU beds. Therefore, we believe that we
have the
capacity to absorb a mild-to-moderate increases in the number of hospitalized
COVID cases of 35-50% from the present volume and still maintain the
standard of
care level of medical treatment for all other patients. Each facility has specific
plans for reassigning beds and opening additional
spaces for patient care such as other treatment areas not traditionally used as
bed
space. Operating theaters can also be used to house ICU beds. Community
Regional Medical Center Hospital has developed a plan for overflow of
medical
surgical patients during a COVID-19 surge and would make requests to the
MHOAC
program, through logistics in the County EOC, to assist with supplies and set
up an
additional 30 to 50 beds on or adjacent to their campus if needed. Our ACS
capacity substantially augments our in-hospital surge capacity.
Expected Achieve By Date
(select from drop down)
Activity 7: Improve understanding of jurisdictional communities with respect to
COVID-19 risk.
Activity 7 -
Milestone 1
Planned Activity
(Provide a title for this
milestone)
Helping the homeless population
Implementation Plan
(Bulleted items or brief
sentences)
With the disestablishment of homeless camps, the county is
establishing contracts for housing arrangements for COVID positive
people. Mobile swabbing teams to perform testing in known areas of
habitation throughout the county.
Applicant capacity: What
is the current capacity to
perform this milestone?
The community has developed approximately 500 new beds to assist
individuals
experiencing homelessness and to isolate COVID positive individuals
RH Comm Builders (Agt. No. 20-126) 265
Poverello House (Agt. No. 20-147) 34
RH Comm Builders - Clarion (Lease Agt. 20-151) 15
RH Comm Builders - Travelodge (Lease Agt. 20-152) 20
Other (Lease Agt. 20-150) 40
Trailers (minimum beds listed) 56
Selma 45-60
Sanger 30-40
Expected Achieve By Date
(select from drop down)
December 2020
Activity 7: Improve understanding of jurisdictional communities with respect to
COVID-19 risk.
15 | Work Order Agreement – County of Fresno 0187.1580
Activity 7 -
Milestone 2
Planned Activity
(Provide a title for this
milestone)
Monitor compliance indicators
Implementation Plan
(Bulleted items or brief
sentences)
•Determine measurable indicators the Department has the ability to
track (e.g., food facility data, call line information, successful contact
tracing attempts)
• Establish monitoring and tracking protocol
• Consistently gather and update indicator data
• Determine enforcement actions, as applicable
• Disseminate compliance statistics via website
Applicant capacity: What
is the current capacity to
perform this milestone?
RedCAP data tracking software
Expected Achieve By Date
(select from drop down)
December 2020
Budget
Total not to exceed $537,756.00.
(if available)
Annual
Max # Salary/Hourly Revised Months
Employee of Hours Range Salary/Hourly Total % Total % Position Original
Expenditure Type Expenditure Name Status (if hourly employee)(per budget) Rate Budgeted Budgeted Budgeted Budget
DM Mary Morrisson Manager COVID Response Permanent $132,132 63.53 100% 6 66,066.00$
SPHN Nestor Yalong (under SSU +5%)MIT Investigation Lead Permanent 40 $90,985 43.74 100% 6 45,492.50$
SPHN Lia Vangyi (under SSU +5%)MIT Investigation Lead Permanent 40 $105,314 50.63 100% 6 52,657.00$
SPHN Rebecca Herrera (under SSU +5%)Swabbing lead Permanent 40 $83,050 39.93 100% 6 41,525.00$
Quality Assurance/Training Coordinator TBD Quality Assurance/Training Coo Extra Help 40 $79,997 38.46 100% 5 33,331.88$
CSMIT Lead Angela Perez Congregate Setting Lead Permanent 40 $57,185 27.49 100% 6 28,592.55$
CSMIT Consult/Training TBD CSMIT Consult Lead Permanent 40 $41,864 20.13 100% 6 20,932.20$
Total Salary 288,597.13$
Fringe Benefits @ 78.00% 225,105.76$
Total Personnel 513,702.88$
Supplies
SP - Office Supplies 4,253$
Total Supplies 4,253$
Equipment
Equipment 4,800$
Total Equipment 4,800$
Other Costs
OC - Facilities Operation 15,000$
Total Other Costs 15,000$
Total Direct Cost 537,756$
Total Budget 537,756$
16 | Work Order Agreement – County of Fresno 0187.1580
Reporting
Progress Reports
Progress reports are due quarterly by the 30th/31st of the month following the end of the quarter.
Progress report will be emailed by the due date to ELCCOVID19@helunahealth.org.
Mandatory Grant Disclosures
Required Disclosures for Federal Awardee Performance and Integrity Information System (FAPIIS): Consistent with
45 CFR 75.113, applicants and recipients must disclose in a timely manner, in writing to the CDC, with a copy to
the HHS Office of Inspector General (OIG), all information related to violations of federal criminal law involving
fraud, bribery, or gratuity violations potentially affecting the federal award. Subrecipients must disclose, in a timely
manner in writing to the prime recipient (pass through entity) and the HHS OIG, all information related to violations
of federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the federal award.
Disclosures must be sent in writing to the CDC and to the HHS OIG at the following addresses:
CDC, Office of Grants Services
Tonya M. Jenkins, Grants Management Specialist
Time Solutions LLC
Office of Grants Services (OGS)
Office of Financial Resources (OFR)
Office of the Chief Operating Officer (OCOO)
Centers for Disease Control and Prevention (CDC)
pjo6@cdc.gov | 404-498-2399 office
AND
U.S. Department of Health and Human Services
Office of the Inspector General
ATTN: Mandatory Grant Disclosures, Intake Coordinator
330 Independence Avenue, SW
Cohen Building, Room 5527
Washington, DC 20201
Fax: (202)-205-0604 (Include “Mandatory Grant Disclosures” in subject line) or
Email: MandatoryGranteeDisclosures@oig.hhs.gov
Recipients must include this mandatory disclosure requirement in all subawards and contracts
under this award.
Failure to make required disclosures can result in any of the remedies described in 45 CFR 75.371. Remedies for
noncompliance, including suspension or debarment (See 2 CFR parts
180 and 376, and 31 U.S.C. 3321).
CDC is required to report any termination of a federal award prior to the end of the period of performance due to
material failure to comply with the terms and conditions of this award in the OMB-designated integrity and
performance system accessible through SAM (currently FAPIIS). (45 CFR 75.372(b)) CDC must also notify the
recipient if the federal award is terminated for failure to comply with the federal statutes, regulations, or terms and
conditions of the federal award. (45 CFR 75.373(b))
17 | Work Order Agreement – County of Fresno 0187.1580
ATTACHMENT B
Insurance Coverage Requirements
Local Health Department (and any sub Local Health Department may use if permitted under the Agreement) shall, at its own expense, obtain and
maintain the following self-insurance coverage during all periods while providing services under the Agreement:
General Liability Insurance
(a) Coverage on an occurrence basis of all operations and premises, independent Local Health Departments, products, completed operations,
explosion, collapse and underground hazards, broad form contractual liability, personal injury (including bodily injury and death), broad
form property damage (including completed operations and loss of use) and additional insured endorsement.
(b) The minimum limits of liability under this insurance requirement shall be not less than the following:
(i) General Aggregate Limit $2,000,000
(ii) Each Occurrence $1,000,000
Workers Compensation & Employer’s Liability Insurance
Coverage in accordance with all applicable state laws reflecting the following limits of liability
(b) Workers’ Compensation:
(i) California Statutory Benefits
(b) Employer’s Liability:
(i) $1,000,000 Bodily Injury each Accident
(ii) $1,000,000 Bodily Injury by Disease – Policy Limit
(iii) $1,000,000 Bodily Injury by Disease – Each Employee
Comprehensive Automobile Liability Insurance
Coverage for all owned, hired and non-owned vehicles with limits not less than $1,000,000 combined single limit, bodily injury and property damage
liability per occurrence with no annual aggregate limits.
Professional Liability Insurance
Coverage with minimum limits of liability not less than $1,000,000 each occurrence and $2,000,000 annual aggregate. To the extent coverage is
afforded on a claims made basis, tail coverage for a minimum of three (3) years shall be required.
All insurance policies shall: (i) name HELUNA HEALTH and any related entities identified by HELUNA HEALTH as Additional Insureds on a primary
basis; (ii) stipulate that the insurance is primary and that any insurance carried by any of said Additional Insureds shall be excess and non-contributory
insurance; (iii) be provided by carriers rated by A.M. Best Company as “A- VII” or better and be admitted to conduct insurance business in California;
(iv) not contain a deductible greater than $1,000; (v) provide that thirty (30) days written notification is to be given to HELUNA HEALTH prior to the
non-renewal, cancellation or material alteration of any policy; and (vi) be acceptable to HELUNA HEALTH.
Coverage: The County of Fresno is self-insured for the following coverage:
Type of Coverage Self-Insured Limit
General & Auto Liability:
Personal injury, bodily injury, property
damage, errors and omissions
$2,000,000
Professional Liability $1,000,000 per occurrence
$3,000,000 annual aggregate
Workers Compensation $2,000,000
Terms, Conditions and Special Items
1. The certification of self-insurance provided by this document conforms to the policies of
the County of Fresno, which do not permit the assumption of liability arising from the
negligence of individuals who are not officers or employees of the County. This
document is to be used to support indemnification agreements that do not extend to the
negligence of others.
2. The provisions included in the General Liability section shall apply only with respect to
claims arising out of the negligent acts or omissions of the County of Fresno, or its
officers and employees.
Cancellation
Should any of the above described self-insurance coverages be modified or cancelled
before the expiration date shown below, the County of Fresno will provide 30 days
written notice to the named certificate holder.
Certificate Holder:
Heluna Health
13300 Crossroads Parkway North, Ste. 250
City of Industry, CA 91746
Fresno County Public Health working with Heluna
Health in regard to funding epidemiology and laboratory
capacity improvements for the COVID-19 response
Contract term May 1, 2020 – March 23, 2022
Date Issued: July 21, 2020
Certificate expiration date
June 30, 2021
Hollis Magill
Human Resources Manager
Certificate of Self-Insurance
Risk Management Division, 2220 Tulare St, 16th Fl., Fresno, CA 93721
18 | Work Order Agreement – County of Fresno 0187.1580
ATTACHMENT C
Required Invoice Template
Draft
An example of the required invoice template is attached. The invoice template specific to your agency will be
provided after the agreement is fully executed.
Invoice Instructions
The invoice template will be updated monthly and provided the third week of month for the previous month.
Monthly invoice template and supporting documentation are due within 30 days of month end via email to
ELCCOVID19Invoices@helunahealth.org.
Supporting documentation required: Invoice, proof of payment, receipts, and packing slips for any operating
cost purchases (i.e. equipment, supplies, etc.).
For personnel supporting documentation, please provide payroll register or general ledger detail for
employees and timesheets.
INVOICE Heluna Health
13300 Crossroads Parkway North, Suite 450
City of Industry, CA 91746
(800) 201-7320
ELCCOVID19Invoices@helunahealth.org
Name of Local Health Department
Local Health Department Address
Contact
Telephone #
Email
Program Number: Invoice No:
Period Covered: Date of Invoice:
Final: Yes_____ No_____
Non-Heluna Health Personnel Costs
Position Title $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
Operating Costs
Line 1 $0.00 $0.00 $0.00 $0.00 $0.00
Line 2 $0.00 $0.00 $0.00 $0.00 $0.00
Line 3 $0.00 $0.00 $0.00 $0.00 $0.00
Line 4 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL OPERATING COSTS $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL DIRECT COSTS $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
TOTAL INVOICE $0.00 $0.00 $0.00 $0.00 $0.00
Please submit only one (1) invoice per month.
Due Date: Invoice and supporting documentation are due within 30 days of month end via email to ELCCOVID19Invoices@helunahealth.org.
Supporting documentation required: Invoice, proof of payment, receipts, and packing slips for any operating cost purchases (i.e. equipment, supplies, etc.).
For personnel supporting documentation, please provide payroll register or general ledger detail for employees and timesheets.
I certify that all expenditures reported are for appropriate purposes and in accordance with the terms and conditions of the agreement.
Signature Date
Printed Name and Title
Received on: ________________________________________________________________________________________________
First Review & Date: __________________________________________________________________________________________
Approver & Date: _____________________________________________________________________________________________
Date Sent to Accounting: ______________________________________________________________________________________
********************Heluna Health Use Only********************
ITEM Prior Month
Expended
CURRENT
EXPENSES
Indirect Costs
UNEXPENDED
BALANCE
APPROVED
BUDGET
Total Benefits
Total Salaries
CUMULATIVE
EXPENSES
TOTAL NON-HELUNA HEALTH PERSONNEL COSTS